TABLES AND QUICK-AIDES

djshin — Sun, 19 Jul 2009 13:24:56 +0000

QUICK ASSESSMENT MNEMONIC

In general, factors that adversely affect wound healing can be remembered by using the mnemonic device DIDN’T HEAL, as follows¹:

D = Diabetes: The long-term effects of diabetes impair wound healing by diminishing sensation and arterial inflow. In addition, even acute loss of diabetic control can affect wound healing by causing diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis.
I = Infection: Infection potentiates collagen lysis. Bacterial contamination is a necessary condition but is not sufficient for wound infection. A susceptible host and wound environment are also required. Foreign bodies (including sutures) potentiate wound infection.
D = Drugs: Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis.
N = Nutritional problems: Protein-calorie malnutrition and deficiencies of vitamins A, C, and zinc impair normal wound-healing mechanisms.
T = Tissue necrosis, resulting from local or systemic ischemia or radiation injury, impairs wound healing. Wounds in characteristically well-perfused areas, such the face and neck, may heal surprisingly well despite unfavorable circumstances. Conversely, even a minor wound involving the foot, which has a borderline blood supply, may mark the onset of a long-term nonhealing ulcer. Hypoxia and excessive tension on the wound edges also interfere with wound healing because of local oxygen deficits.
H = Hypoxia: Inadequate tissue oxygenation due to local vasoconstriction resulting from sympathetic overactivity may occur because of blood volume deficit, unrelieved pain, or hypothermia, especially involving the distal extent of the extremities.
E = Excessive tension on wound edges: This leads to local tissue ischemia and necrosis.
A = Another wound: Competition between several healing areas for the substrates required for wound healing impairs wound healing at all sites.
L = Low temperature: The relatively low tissue temperature in the distal aspects of the upper and lower extremities (a reduction of 1-1.5°C [2-3°F] from normal core body temperature) is responsible for slower healing of wounds at these sites.

1. Richard M Stillman, MD, FACS
Wound Care: eMedicine General Surgery (19 July 2009)

http://emedicine.medscape.com/article/194018-overview

http://snipurl.com/nj1obhttp://emedicine.medscape.com/article/194018-overview

OTHER TABLES AVAILABLE:

STAGING OF PRESSURE ULCERS AND TREATMENT²

Stage	Definition	Appearance	Appropriate topical treatment	Average healing time (d)
I	Nonblanchable erythema of intact skin	Pink skin that does not resolve when pressure is relieved; discoloration; warmth; induration	DuoDerm q2-3d	14
II	Partial-thickness skin loss involving epidermis and/or dermis	Cracking, blistering, shallow crater, abrasion	Cleanse with saline; DuoDerm/Tegaderm dressing	45
III	Full-thickness skin loss into subcutaneous fatty tissues or fascia	Distinct ulcer margin; deep crater (in general, 2.075 mm or deeper [the thickness of a nickel])	Debride; irrigate with saline; apply DuoDerm/Tegaderm	90
IV	Full-thickness skin loss with extensive tissue involvement of underlying tissues	Extensive necrosis; damage to underlying supporting structures, such as muscle, bone, tendon, or joint capsule	Surgically debride; irrigate with saline (possibly under pressure); apply advanced topical dressings; consider antibiotics	120

MEDICARE CLASSIFICATION/COVERAGE OF SUPPORT SURFACES:

A class I support surface is a simple pressure pad device that is required as follows:

For patients who cannot independently change their body position to effectively alleviate pressure
For patients who have any stage of pressure ulcer on the trunk or pelvis, plus impaired nutritional status, fecal or urinary incontinence, altered sensory perception, or compromised circulatory status

A class II support surface is a pressure-relieving device that reduces pressure over bony prominences to less than 32 mm Hg and that does so for a sustained period. A class II support surface is required as follows:

For patients who have multiple pressure ulcers on the trunk or pelvis that has not improved despite a comprehensive treatment, including a class I support surface for a stage II, III, or IV pressure ulcer for at least 1 month
For patients who have large or multiple stage III or IV pressure ulcers on the trunk or pelvis
For patients who have had a myocutaneous flap or skin graft procedure for a pressure ulcer on the trunk or pelvis within the past 60 days and have been on a class II or III support surface immediately before a recent discharge from a hospital or nursing facility within the past 30 days

A class III support surface is an advanced pressure-relieving device. A class III support surface, that is, an air-fluidized bed, may be used only for failure of a comprehensive conservative treatment plan after 30 days. (Note that an air-fluidized bed is contraindicated for any patient with associated severe pulmonary compromise because the absence of firm back support makes coughing ineffective, and the dry air thickens pulmonary secretions.)

TABLE OF PRESSURE-RELIEVING SURFACES*:

Class	Type	Principle	Examples
I	Simple	Pressure-relieving pad or mat	3- to 5-inch foam mattress, gel overlay, egg-crate mattress
II	Advanced	Powered air* overlay for mattress with low air loss feature; nonpowered advanced pressure-reducing mattress replacement or powered air* floatation bed with or without low air loss feature	Roho dry floatation mattress system, Pegasus Renaissance mattress
III	Air fluidized	Floatation by filtered air* flow pumped through porcelain beads	Clinitron bed

*Long-term use of powered air devices is relatively contraindicated for patients with chronic obstructive lung disease, such as chronic bronchitis, emphysema, and asthma.

PREVENTION AND TREATMENT OF HEEL PRESSURE ULCERS REQUIRES OFF-LOADING:

Off-loading devices are usually selected based on availability and include the following:

Booties are simple pressure pads that surround the heel with polyester fibers, siliconized fibers, or foam material.
Boots are made from a firm outer shell lined with pressure-relief padding. They can also provide positioning capability to help treat contractures and foot drop.
Pillows made from polyester and sheepskin fleece or special rubber or plastic interpose a conformable soft overlay between the heel and the mattress.
Suspension devices isolate the heel and transfer the weight to the lower leg. These devices also have positioning capabilities that are useful in treating contractures and foot drop.
Inflatable devices made from plastic sheets surround the heel and adjacent tissues.

TABLE OF COMPRESSION BANDAGES FOR VENOUS ULCERS

Type	Description	Examples
Single layer	Single-layer simple tubular woven nylon/elastic bandages may be imprinted with rectangles that stretch to squares when appropriate wrapping tension (30-40 mm Hg) is applied.	ACE bandage, Comperm (Conco Medical), Setopress (Seton Healthcare Group)
Three layer	The layers include a padding absorption layer, a compression bandage layer, and a cohesive compression bandage. Bandages may be left in place for up to 1 week depending on wound exudate.	Dyna-Flex (Johnson & Johnson)
Four layer	The layers include a nonwoven wound contact layer that is permeable to wound exudate and 4 overlying bandages. Bandages may be left in place for up to 1 week depending on exudate volume.	Profore (Smith & Nephew)
Impregnated wrap	The porous flexible occlusive dressing is composed of stretchable gauze and a nonhardening zinc oxide paste.	Unna boot (ConvaTec)

Treatment of venous ulcers includes compression therapy, providing a moist wound environment and debridement of necrotic tissue.³⁶ Most venous ulcers heal with these measures alone. Some require split-thickness skin grafting or application of bioengineered skin (eg, Apligraf, Dermagraft).³⁷ Pentoxifylline (Trental) and horse chestnut seed (available in supermarkets and health food specialty stores) have been shown to expedite healing of venous stasis ulcers. In some cases, compression therapy is inadequate to maintain healing of venous ulcers, and surgical vein stripping or ligation of venous perforators may be helpful.

Surgical options

include skin grafting, application of bioengineered skin substitutes, and use of flap closures.

Skin grafting: Autologous skin grafting is the criterion standard for viable coverage of partial-thickness wounds. The graft can be harvested with the patient under local anesthesia in an outpatient procedure. Meshing the graft allows wider coverage and promotes drainage of serum and blood.
Cadaveric allografting: A cadaveric skin allograft is a useful covering for relatively deep wounds after surgical excision when the wound bed does not appear appropriate for application of an autologous skin graft. The allograft is only a temporary solution.
Application of bioengineered skin substitutes^48,49,43
- Apligraf (Organogenesis; Novartis) is a bilayered skin substitute produced by combining bovine collagen and living cells derived from tissue-cultured human infant foreskins. One study of diabetic foot ulcers demonstrated 12-week healing rates of 39% for patients who received only standard wound care versus 56% for those who were treated by application of an Apligraf after a period of standard wound care.
- Dermagraft (Smith & Nephew, Inc) is human fibroblast-derived dermal substitute manufactured by seeding dermal fibroblasts onto a 3-dimensional bioabsorbable scaffold. It has been marketed for use in the treatment of diabetic foot ulcers, venous ulcers, and pressure sores. A clinical trial showed improved healing rates in diabetic foot ulcers.
- Oasis (Healthpoint, Ltd), a relatively new product, is a xenogeneic acellular collagen matrix derived from porcine small intestinal submucosa in such a way that an extracellular matrix and natural growth factors remain intact. This provides a scaffold for inducing wound healing.⁵⁰ Do not use this in patients with allergies to porcine materials.
- Cultured epithelial autograft (Epicel; Genzyme Tissue Repair, Cambridge, Mass) is an epidermal replacement that is grown in a tissue culture from a skin biopsy taken from the recipient and is cocultured with mouse cells. Preparation of the graft requires about 2 weeks of culture time.
Use of flap closures: Delayed primary closure of a chronic wound requires well-vascularized clean tissues and tension-free apposition.⁵¹ This usually requires undermining and mobilization of adjacent tissue planes by creating skin flaps or myocutaneous flaps.

TREATMENT ALGORITHMS

djshin — Sun, 19 Jul 2009 13:23:47 +0000

TABLE OF DRESSINGS¹:

Category	Examples	Description	Applications
Alginate	AlgiSite, Comfeel, Curasorb, Kaltogel, Kaltostat, Sorbsan, Tegagel	Alginate dressings are made of seaweed extract contains guluronic and mannuronic acids that provide tensile strength and calcium and sodium alginates, which confer an absorptive capacity. Some can leave fibers in the wound if they are not thoroughly irrigated. These dressings are secured with secondary coverage.	These dressings are highly absorbent and useful for wounds have copious exudate. Alginate rope is particularly useful to pack exudative wound cavities or sinus tracts.
Hydrofiber	Aquacel, Aquacel-Ag, Versiva	An absorptive textile fiber pad, hydrofiber is also available as a ribbon for packing of deep wounds. This material is covered with a secondary dressing. The hydrofiber combines with wound exudate to produce a hydrophilic gel. Aquacel-Ag contains 1.2% ionic silver that has strong antimicrobial properties against many organisms, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci.	Hydrofiber absorbent dressings used for exudative wounds.
Debriding agents	Hypergel (hypertonic saline gel), Santyl (collagenase), Accuzyme (papain urea)	Various products provide some chemical or enzymatic debridement.	Debriding agents are useful for necrotic wounds as an adjunct to surgical debridement.
Foam	LYOfoam, Spyrosorb, Allevyn	Polyurethane foam has absorptive capacity.	These dressings are useful for cleaning granulating wounds with minimal exudate.
Hydrocolloid	CombiDERM, Comfeel, DuoDerm CGF Extra Thin, Granuflex, Tegasorb	Hydrocolloid dressings are made of microgranular suspension of natural or synthetic polymers, such as gelatin or pectin, in an adhesive matrix. The granules change from a semihydrated state to a gel as the wound exudate is absorbed.	Hydrocolloid dressings are useful for dry necrotic wounds, wounds with minimal exudate and for clean granulating wounds.
Hydrogel	Aquasorb, DuoDerm, Intrasite Gel, Granugel, Normlgel, Nu-Gel, Purilon Gel, KY Jelly	Hydrogel dressings are water-based or glycerin-based semipermeable hydrophilic polymers; cooling properties may decrease wound pain. These gels can lose or absorb water depending upon the state of hydration of the wound. They are secured with secondary covering.	These dressings are useful for dry, sloughy, necrotic wounds (eschar).
Low-adherence dressing	Mepore, Skintact, Release	Low-adherence dressings are made of various materials designed to remove easily without damaging underlying skin.	These dressings are useful for acute minor wounds, such as skin tears, or as a final dressing for chronic wounds that have nearly healed.
Transparent film	OpSite, Skintact, Release, Tegaderm, Bioclusive	Transparent films are highly conformable acrylic adhesive films with no absorptive capacity and little hydrating ability. They may be vapor permeable or perforated.	These dressings are useful for clean, dry wounds with minimal exudate. They also are used to secure an underlying absorptive material, to protect high-friction areas and areas that are difficult to bandage (eg, heels) and to secure intravenous catheters.

1.http://emedicine.medscape.com/article/194018-treatment

http://www.uwcne.org/secure/oned/sessionframe.asp

USER: DRSHIN@DRDJSHIN.COM; PASS:78945612

A SUMMARIZED TABLE

WOUND CARE

CLINCIAL SCIENCES BACKGROUND

djshin — Sun, 19 Jul 2009 12:53:13 +0000

HISTORY OF WOUND MANAGEMENT:

http://www.globalwoundacademy.com/GWA/usa/popup1module9.htm

Collection of WoundCare Sites

TABLES AND QUICK-AIDES

TREATMENT ALGORITHMS

USER: DRSHIN@DRDJSHIN.COM; PASS:78945612

CLINCIAL SCIENCES BACKGROUND