Introduction to Problem Wound Healing H. Sprague Taveau IV, DO, MBA, FACOFP Medical Director Center for Wound Care and Hyperbaric Medicine Family Medicine Review April 14, 2011

Faculty Disclosure H. Sprague Taveau IV, DO, MBA, FACOFP It is the policy of Diversified Clinical Services and Metroplex Adventist Hospital to ensure balance, independence, objectivity, and scientific rigor in all of its individually sponsored or jointly sponsored educational programs. Dr. Taveau is the Medical Director for Metroplex Adventist Hospital’s Center for Wound Care and Hyperbaric Medicine in Killeen, TX, and is a Regional Medical Director for Diversified Clinical Services. He has no other affiliations nor does he own stock in any company that produces equipment or products discussed in this presentation. REGRETABLY!!

Objectives Become familiar with the fundamental aspects of wound healing and its interrelationship with oxygen Become familiar with the fundamental aspects of wound healing and its interrelationship with oxygen Become familiar with the process of evaluating patients for and instituting hyperbaric oxygen therapy Become familiar with the process of evaluating patients for and instituting hyperbaric oxygen therapy Recognize the physiologic and pharmacologic benefits of hyperbaric oxygen therapy Recognize the physiologic and pharmacologic benefits of hyperbaric oxygen therapy

The Nine Essentials of Wound Healing 1.Adequate Perfusion 2.Elimination of Non-Viable Tissue 3.Control Inflammation or Infection 4.Control Edema 5.Optimize Wound Microenvironment 6.Optimize Tissue Growth 7.Ensure Proper Off-Loading 8.Control Pain 9.Optimize Host Factors

The Nine Essentials of Wound Healing 1.Adequate Perfusion 2. Non-Viable Tissue 3. Inflammation or Infection 4. Edema 5.Wound Microenvironment 6.Tissue Growth Optimized 7.Off-Loading 8.Pain Control 9.Host Factors

If you can’t get water to the garden……the garden won’t grow!!!! The Nine Essentials of Wound Healing

1.Adequate Perfusion 2. Non-Viable Tissue 3. Inflammation or Infection 4. Edema 5.Wound Microenvironment 6.Tissue Growth Optimized 7.Off-Loading 8.Pain Control 9.Host Factors

The Nine Essentials of Wound Healing Wounds Won’t Heal in a SEWER!!

The Nine Essentials of Wound Healing 1.Adequate Perfusion 2. Non-Viable Tissue 3. Inflammation or Infection 4. Edema 5.Wound Microenvironment 6.Tissue Growth Optimized 7.Off-Loading 8.Pain Control 9.Host Factors

The Nine Essentials of Wound Healing Wounds With BUGS Don’t Heal!!

The Nine Essentials of Wound Healing 1.Adequate Perfusion 2. Non-Viable Tissue 3. Inflammation or Infection 4. Edema 5.Wound Microenvironment 6.Tissue Growth Optimized 7.Off-Loading 8.Pain Control 9.Host Factors

The Nine Essentials of Wound Healing Wounds Don’t Heal in a Swamp!!

The Nine Essentials of Wound Healing 1.Adequate Perfusion 2. Non-Viable Tissue 3. Inflammation or Infection 4. Edema 5.Wound Microenvironment 6.Tissue Growth Optimized 7.Off-Loading 8.Pain Control 9.Host Factors

The Nine Essentials of Wound Healing Wounds Don’t Heal Unless The Environment Supports Healing

The Nine Essentials of Wound Healing 1.Adequate Perfusion 2. Non-Viable Tissue 3. Inflammation or Infection 4. Edema 5.Wound Microenvironment 6.Tissue Growth Optimized 7.Off-Loading 8.Pain Control 9.Host Factors

The Nine Essentials of Wound Healing Tissue Growth is OUR Business

The Nine Essentials of Wound Healing 1.Adequate Perfusion 2. Non-Viable Tissue 3. Inflammation or Infection 4. Edema 5.Wound Microenvironment 6.Tissue Growth Optimized 7.Off-Loading 8.Pain Control 9.Host Factors

The Nine Essentials of Wound Healing Wounds Don’t Heal Under Pressure!!

The Nine Essentials of Wound Healing 1.Adequate Perfusion 2. Non-Viable Tissue 3. Inflammation or Infection 4. Edema 5.Wound Microenvironment 6.Tissue Growth Optimized 7.Off-Loading 8.Pain Control 9.Host Factors

The Nine Essentials of Wound Healing Controlled Pain = Better Compliance

The Nine Essentials of Wound Healing 1.Adequate Perfusion 2. Non-Viable Tissue 3. Inflammation or Infection 4. Edema 5.Wound Microenvironment 6.Tissue Growth Optimized 7.Off-Loading 8.Pain Control 9.Host Factors

The Nine Essentials of Wound Healing Wounds Don’t Heal Without Building Blocks!!

Selecting Patients for HBO By ability to reverse specific pathophysiology …of wound healing failure By ability to reverse specific pathophysiology …of wound healing failure By diagnosis By diagnosis

Benefits of Hyperbaric Oxygen Physiologic Effects: Improved leukocyte function and bacterial killing Antibiotic potentiation Enhanced collagen synthesis and cross-linking Pharmacological Effects: Direct antimicrobial effects, toxin synthesis suppression Blunting of systemic inflammatory responses Prevention of leukocyte activation and adhesion PDGF-BB receptor stimulation (multiple effects) VEGF release and angiogenesis Detoxification (CO, CN, H 2 S)

Selecting Patients for HBO By ability to reverse specific pathophysiology …of wound healing failure By ability to reverse specific pathophysiology …of wound healing failure By diagnosis By diagnosis

Emergency/Acute Indications Cerebral Arterial Air or Gas Embolism Cerebral Arterial Air or Gas Embolism Carbon Monoxide Poisoning Carbon Monoxide Poisoning Cyanide Poisoning Cyanide Poisoning Hydrogen Sulfide Poisoning Hydrogen Sulfide Poisoning Clostridial Myositis & Myonecrosis Clostridial Myositis & Myonecrosis Acute Traumatic Ischemia Acute Traumatic Ischemia Crush Injury Crush Injury Compartment Syndrome Compartment Syndrome Replantation Limb/Digits Etc. Replantation Limb/Digits Etc.

Emergency/Acute Indications Decompression Sickness Decompression Sickness Exceptional Blood Loss (Anemia) Exceptional Blood Loss (Anemia) Intracranial Abscess Intracranial Abscess Necrotizing Soft Tissue Infections Necrotizing Soft Tissue Infections Thermal Burns (Not CMS Approved) Thermal Burns (Not CMS Approved) Combined Synergistic Necrotizing STI Combined Synergistic Necrotizing STI Compromised Skin Grafts/Flaps Compromised Skin Grafts/Flaps

Acute Traumatic Ischemia 4 year old slipped and fell into a riding lawn mower, sustaining a mid-calf amputation of his leg. Leg was successfully replanted. 4 year old slipped and fell into a riding lawn mower, sustaining a mid-calf amputation of his leg. Leg was successfully replanted. Ischemic time: 10 hours Ischemic time: 10 hours Tx’d aggressively with HBO Tx’d aggressively with HBO

Acute Traumatic Ischemia Appearance of muscle three days after replantation shows 100% viability as HBO counteracted reperfusion injury.

Acute Traumatic Ischemia Three Months after Injury 2.4 ATA x 90 minutes q8h x 6 Then q12h x 4

Acute Traumatic Ischemia The result was excellent function of the leg. The patient regenerated his nerves and ended up with a sensate foot. He was able to walk and run with the aid of a brace. The result was excellent function of the leg. The patient regenerated his nerves and ended up with a sensate foot. He was able to walk and run with the aid of a brace.

Non-approved Emergent Indications Retinal Artery Insufficiency Retinal Artery Insufficiency Actinomycosis Actinomycosis

Chronic/Elective Indications Problem Wounds Problem Wounds Diabetic Foot Ulcers (Chronic; Wagner III) Diabetic Foot Ulcers (Chronic; Wagner III) Arteriolar Insufficiency Arteriolar Insufficiency Etc. Etc. Chronic Refractory Osteomyelitis Chronic Refractory Osteomyelitis Delayed Radiation Injury Delayed Radiation Injury Soft Tissue Soft Tissue Bony Bony Meleny Ulcer (Invasive Group A Strep) Meleny Ulcer (Invasive Group A Strep)

(Buras and Buras, Harvard Medical School, MGH, Boston) Age associated differences in cellular Proliferation (in vitro)… New born Young adult Old adult

(Buras and Buras, Harvard Medical School, MGH, Boston) Decreased cellular proliferation with diabetes…

(Buras and Buras, Harvard Medical School, MGH, Boston) HBO Dramatically Increases Old Adult Fibroblast Proliferation…

(Buras and Buras, Harvard Medical School, MGH, Boston) HBO Dramatically Increases Diabetic Fibroblast Proliferation…

= Initial healing success = Initial healing failure PtcO 2 As A Predictor of Wound Healing in Diabetic Foot Wounds… Pecoraro, et al. Diabetes 40: , 1991 PtcO2 < 30 mmHg indicated 39 fold increased risk of early healing failure.

Pre Smoking Baseline Post Smoking 2 hours pre…………………………2 hours post

Wagner Classification Diabetic Foot Ulcers Grade 0:Intact skin Grade 0:Intact skin Grade I:Superficial without penetration deeper layers Grade I:Superficial without penetration deeper layers Grade II: Deeper reaching tendon, bone, or joint capsule Grade II: Deeper reaching tendon, bone, or joint capsule Grade III: Deeper with abscess, osteomyelitis, or tendonitis extending to those structures Grade III: Deeper with abscess, osteomyelitis, or tendonitis extending to those structures Grade IV: Gangrene of some portion of the toe, toes, and/or forefoot Grade IV: Gangrene of some portion of the toe, toes, and/or forefoot Grade V:Gangrene involving the whole foot or enough of the foot that no local procedures are possible Grade V:Gangrene involving the whole foot or enough of the foot that no local procedures are possible Wagner FW. Foot & Ankle 1981, Grade I or II w/Infection = Grade III

DFU 10/16/09

DFU 11/20/09

DFU 12/30/09

Soft Tissue Radionecrosis Malignant Fibro- Histiocytoma Malignant Fibro- Histiocytoma Wide excision Wide excision Radiation therapy Radiation therapy 2 months post-op 2 months post-op Dehiscence Dehiscence Radionecrosis Radionecrosis Purulent drainage Purulent drainage

Soft Tissue Radionecrosis Close-up view Close-up view 9 x 6.5 cm 9 x 6.5 cm Stage III/IV Ulceration Stage III/IV Ulceration

Soft Tissue Radionecrosis 1 week post-HBO 2 ATA 90 minutes each Q24h 20 treatments 5 days/week Routine wound care Oral antibiotics

Soft Tissue Radionecrosis 10 days post-STSG 10 days post-STSG Ambulating without difficulty Ambulating without difficulty No further procedures required No further procedures required

Absolute Contraindications Untreated Pneumothorax Untreated Pneumothorax Pregnancy (Almost) Pregnancy (Almost)

Relative Contraindications Upper Respiratory Infections Upper Respiratory Infections Chronic Sinusitis Chronic Sinusitis Emphysema w/CO 2 Retention Emphysema w/CO 2 Retention High Fevers High Fevers History of Seizure Disorder History of Seizure Disorder Pregnancy Pregnancy

Relative Contraindications (Continued) History of Surgery for Otosclerosis History of Surgery for Otosclerosis PE tubes PE tubes Viral Infections Viral Infections Get worse Get worse Congenital Spherocytosis Congenital Spherocytosis Hemolysis in presence of increased PaO 2 Hemolysis in presence of increased PaO 2 History of Optic Neuritis History of Optic Neuritis May be associated with blindness May be associated with blindness

Complications & Side Effects Barotrauma of the Ear Barotrauma of the Ear PE tubes PE tubes CNS Oxygen Toxicity CNS Oxygen Toxicity Pulmonary Oxygen Toxicity Pulmonary Oxygen Toxicity Visual Refractive Changes Visual Refractive Changes

Complications & Side Effects (Continued) Numb Fingers Numb Fingers Dental Problems Dental Problems Occult abcess Occult abcess Claustrophobia Claustrophobia

UT/Hermann Memorial Multiplace

Perry Sigma 40

Perry Sigma 34

Seachrist 3600E

Seachrist 3200

Brooks AFB Research Chamber

Dive Ship Deck HBO “Can”

Hyperbaric Oxygen Therapy Thanks for your attention!