internist’s guide to wound care · angiogram •tibioperoneal trunk- tandem severe stenoses...

INTERNIST’S GUIDE TO WOUND CARE

HOW TO PREVENT AMPUTATION, AVOID LITIGATION

WHILE KEEPING YOUR HANDS CLEAN

Thank you Dr Byrns

ADVISORY

• WHILE YOU DO NOT HAVE TO ‘TOUCH’ ANY OF THE FOLLOWING WOUNDS

YOU DO HAVE TO LOOK AT THEM

And make sure you have

a resident/medical

student/nurse/colleague

who WILL at least

dress/undress the wound

PLAN FOR TODAY

• CASE PRESENTATIONS of common wounds

•

• VASCULAR ULCERS

• DIABETIC FOOT ULCERS

• PRESSURE ULCERS

PLAN FOR TODAY

• CASE PRESENTATIONS of common wounds

• BIG FAT RED LEGS

• RED HOT SWOLLEN FEET

• RED WHERE THERE SHOULDN’T BE

PLAN FOR TODAY

• PRINCIPLES OF DIAGNOSIS and TREATMENT

• MYTH BUSTING (dispelling ‘fake’ science)

• QUIZ TIME! NAME THAT WOUND!

2 GOALS

1) PREVENT AMPUTATION

2) AVOID LITIGATION

67-year-old male with a poorly controlled diabetes presents to ED with c/o increased pain w/ambulation , weeping of his leg

• 12/26/18 -2 days of symptoms

-Patient is blind, therefore was

unable to assess this by himself

-noticed that there was some

weeping and reported pain

-

ED EVAL what do you want to know?

• HISTORY: fever? Anticoag? Prior DVT? Prior cellulitis? DM? trauma? Denies fevers, chills,

• Denies known trauma

• EXAM • Leg temp side to side • Girth • PULSES

• Labs; ESR, CRP, WBC, Creat • HgA1C/BG

• C&S

12/26/18

CULTURE TECHNIQUE?

CULTURE RESULTS

• GRAM STAIN: FEW PMN

• 3+ GRAM POSITIVE COCCI

• CULTURE RESULTS:

• 1. STREPTOCOCCUS GROUP C - Quantity: 3+

•

• 2. STAPHYLOCOCCUS AUREUS - Quantity: 3+

•

• 3. KLEBSIELLA OXYTOCA - Quantity: RARE

•

• 4. PROTEUS MIRABILIS - Quantity: RECOVERED FROM BROTH ONLY.

DIAGNOSTICS

12/26/18 ED

• BG 501

• Creat 1.19

• CRP 5.7

• ESR 18

• WBC 13.4 ->11.3 ->9.5 -> 8.0

• 12/30/18

• CRP 5.6

• WBC 7.5

12/26/18 12/27/18

TREATMENT? 4 key interventions

TMT

• 1) IV ANTB; broad spectrum ->targeted

• BG management

• 2) COMPRESSION

• 3) DEBRIDE

• 4) WOUND CARE; • DRESSINGS: drainage management, topical antimicrobial

• d/c 1/2/19 -> SNF

• RTC 1/8/19

VENOUS LEG DISEASE

• >80 million americans suffer from vein disease

• VLU care costs an estimated $3 billion annually

• Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014;130(4):333–46.

Post-Thrombotic Syndrome

• One of every three patients with DVT in lower extremities or pelvic area will develop post-thrombotic sequelae within 5 years

• PTS is one of most common causes of chronic venous insufficiency

VENOUS DISEASE

BIG FAT RED LEGS

•PEARLS • Stasis dermatitis vs cellulitis

• RARELY is cellulitis symmetrical and/or bilateral

• OK to do short duration antb if you are unsure

• Stasis Dermatitis = topical steroid BID + COMPRESSION

WHICH OF THE

FOLLOWING

PHOTOS IS NOT

COMPRESSION

TED SOCKS

UNNA

BOOT

TUBI GRIP

SUMERIAN

MEDICAL

CARE B

C

D

TED Technology Entertainment Design ……no…..wait……

Thrombotic Embolic Deterrent

• Intended for ‘at rest’ or supine patients

TRUE or FALSE

UNNA’S BOOTS are a good method of

compression for hospitalized patients

UNNA

BOOT

C

•FALSE

• UNNA BOOTS ARE ONLY EFFECTIVE IN PATIENTS WHO AMBULATE

• Not for wheelchair bound or supine patients

• Relies on calf muscle to effect circulation

When not to compress?

• When you haven’t checked/documented pulses

• When you have ABI < 0.45

• Uncontrolled CHF

CASE FOLLOW UP

1/7/19

RED HOT SWOLLEN FOOT

RED HOT SWOLLEN FOOT DIFFERENTIAL DIAGNOSIS “WAITING’

“WAITING” • W=WOUND

• A=ACUTE CHARCOT (arthropathy)

• I= ISCHEMIA

• T=TRAUMA

• IN=INFECTION (cellulitis, osteomyelitis)

• G=GOUT

OTHER OPTIONS FOR ACRONYMS

• IOWA AG

• CARING U

• IGUAnA

• GrACIOUS

RED HOTE SWOLLEN FOOT DIAGNOSTICS

•LABS •ESR, CRP, CBC/WBC, HgA1C, Creat

•IMAGING •XRAY/MRI/CT Scan

•EXAM •Foot temp •Pulses

CASE #1 RED HOT SWOLLEN FOOT

• 74 y.o. male w/DM presents to ED with left foot pain following a ‘mis-step’ at home several days prior.

• Next step?

CASE #1 RED HOT SWOLLEN FOOT

• HISTORY

• DIAGNOSTICS

• LABS; unremarkable

• Xray = 5th metatarsal fx

• Tmt = placed into a Bledsoe boot to offload and instructed to keep boot on for protection

CASE #1 RED HOT SWOLLEN FOOT Returns to ED 5 days later (continuous use of boot) took it off to shower and noted his foot to be more red and swollen

July 2015

Neuropathic

LOPS =

loss of

protective

sensation

PAD w/ABI

0.65

WAITING=

WOUND

CASE #1 RED HOT SWOLLEN FOOT 74 y.o. male w/DM , 5th metatarsal fx now w/DFU

July 27,

2015

TREATMENT

ANTB

NPWT

Advanced biologics

(amniotic tissue)

Arterial Pump

Off loading

WAITING=

WOUND

July 2015

Sept 2015

Jan 2016

July July 27, 2015

August 2015

CASE #2 RED HOT SWOLLEN FOOT 54YO MALE, DM

8/23/17: PRESENTS TO ED

-LLE (foot and ankle) swollen, red x 4 days w/pain

-DIAGNOSTICS

-BG 180

-DVT neg

-WBC 11.1, Creat 1.0

-DX; Cellulitis

-RX; Antb (Bactrim x 10 days, f/u PCP)

CASE #2 RED HOT SWOLLEN FOOT 54YO MALE, DM

9/4/17: RETURNS TO ED

-LLE (foot and ankle) worsening edema, red x 2 wks w/pain

-Antb; didn’t help

-No fever/chills

-DIAGNOSTICS ; None

-DX; Cellulitis

-RX; new Antb (Keflex? x 10 days, f/u PCP)

-Referral: HRFC

CASE #2 RED HOT SWOLLEN FOOT 54YO MALE, DM

9/8/17: HRFC

-LLE (foot and ankle) edema, red x 2+ wks w/pain

-Antb; didn’t help

-No fever/chills

-EXAM: R foot 86, L foot 97 degrees

-DIAGNOSTICS ; HgA1c 6.9, ESR 10, CRP 0.5

-XRAY

10/2017

1/23/18

4/17/2018

RED HOT SWOLLEN FOOT=

ACUTE CHARCOT PRESENTATION

>10 degrees than other foot

No portal of entry for

infection

No typical trauma, +/- PAIN

DIAGNOSTICS

Xray/MRI

ESR, CRP WBC

TREATMENT

OFF LOAD!!!

WAITING=

ACUTE

CHARCOT

CASE #2 RED HOT SWOLLEN FOOT 54YO MALE, DM

WAITING=

ACUTE

CHARCOT

CASE #3 RED (HOT) SWOLLEN FOOT

WAITING=

• 73 yo NA w/DM presents to ED 11/27/18 w/fever/chills/weak, progressive x 1-2 wks

• had small ‘scab’ on foot x several weeks, suddenly got worse

73 yo NA w/DM presents to ED 11/27/18

• ED ->HRFC same day; admit for sepsis

• VASC biphasic DP and PT, slow cap refill

• LABS: CRP 10.5, ESR not obtained

• HgA1C 13.4.

• C&S

1st step of wound care; debridement and C&S after assessing vascular

12 hrs later (11/28/18 am)

• 11/28/18; Arterial study

• patent flow through popliteal arteries bilaterally,

• tibial artery occlusive disease

• probable pedal occlusive disease causing severe digital ischemia on the left”

• 12/3/18: confirmed by angio.

CASE #3 RED (HOT) SWOLLEN FOOT # ISCHEMIA

WAITING=

ISCHEMIA

• 73 yo NA w/DM presents to ED 11/27/18 w/fever/chills/weak, progressive x 1-2 wks

12/3/18

TCOM Transcutaneous O2 Monitoring

PREDICTIVE VALUES FOR HEALING

Sheffield PhD, International ATMO, 2005

TCOM 11/27/18

• ABI/TBI REFERENCE VALUES

• RIGHT ABI 0.63 LEFT ABI NA NORMAL ABI 0.91-1.40

• RIGHT TBI 0.39 LEFT TBI 0.06 NORMAL TBI >0.7

• TCOM LOCATION BASELINE/O2 CHALLENGE

•

• PURPLE LEAD L foot/medial 1st MTP 13/7.6

• ORANGE LEAD L foot/lateral 1.3/1.2

• GRAY LEAD L talocrural joint 1.1/15

• BLACK LEAD R foot/lateral 12/42

Angiogram

• Tibioperoneal Trunk- Tandem severe stenoses

• Anterior tibial- Patent only proximally, then occluded for entire length.

• Posterior tibial- Patent at origin, but then occluded, with reconstitution of a patent distal posterior tibial artery above he medial malleolus, branching into both the medial and lateral plantar arties, with the former more robust.

• Peroneal- Essentially occluded for entire length

TTA (BKA) 12/6/18

CASE #4 RED HOT SWOLLEN FOOT # TRAUMA

• Trauma in pt w/DM

WAITING=

TRAUMA

RED HOT SWOLLEN FOOT # INfection

WOUND INFECTION CELLULITIS OSTEOMYELITIS

WAITING =

INfection

Diabetic Foot Infections

Diabetic Foot Ulcers >50% s/s clinical infection on presentation

Most common organisms

*First timers • Staph aureus, Group B Beta-hemolytic

• Coag neg staph

*Chronic, recurrent, fail to respond • Polymicrobial, gram neg (enterobacter, pseudo)

*Necrotic, gangrene, ischemic • Anaerobic

WOUND HEALING * CURRENT STATE OF THE ART CONCEPTS

BIOBURDEN-INFECTION CONTINUUM

Contamination

Colonization

Increased Bioburden

Wound Bed Infection

Periwound ST Inf

Localized Cellulitis

Osteomyelitis

Limb Threatening Inf

Sepsis

0

1

2

3

4

5

6

7

8

9

10

B

A

C

T

E

R

I

A

HOST IMMUNE RESPONSE

BIOFILM

DFO diabetic foot osteomyelitis

PRESENTATION

• local ulceration

• Long duration (>8wks)

• Overlying bone

*osteo; chronic

EXAM

•Ulcer depth > 3mm

•PTB = Probe to bone

• 38-94% sensitivity

• 85-98% specificity

DIAGNOSTICS

Inflammatory Markers

CRP, ESR >70

XRAY/MRI

*Newman JAMA 1991 **Ertugul Eur J Clin Microbiol Infect Disease 2012

CASE #5 RED HOT SWOLLEN FOOT 12/13/18 83 year old MALE presents with 3 days general fatigue and malaise and a new right lower extremity erythema • yesterday significant redness in his right foot and right lower shin.

• Small wound present R gt toe approximately 4 weeks

• he will periodically bumped this and notes the scab will fall off but now with significant increased redness of his foot.

CASE #5 RED HOT SWOLLEN FOOT

ED VISIT * DIAGNOSTICS

• 12/14/18

• ESR not obtained

• CRP 28.4

• Uric 10.4

• WBC 14.5

CASE #5 RED HOT SWOLLEN FOOT

CASE #5 RED HOT SWOLLEN FOOT GOUT (+cellulitis)

WAITING =

GOUT

GOUT

DFU right great toe due to gout flare and complicated by acute cellulitis

• Wagner IV DFU right great toe with cellulitis, likely deep space abcess and septic arthritis of the DIP

• T2DM 12/2017 HgA1c 6.5H

• PAVE 3: high risk

• diabetic peripheral neuropathy with LOPS

• BLE edema due to chronic venous stasis and complicated by CHF and obesity

• bilateral hammer toe deformity

RISK PROFILE FOR AMPUTATION

• Antibiotic regimen:

• Vancomycin 12/14/18-12/16/18

• Zosyn 12/15/18-12/19/18

• Cephelexin 12/19/18-1/2/19

• VASCULAR: bilateral DP/PT 2+ palpable, monophasic on doppler intermetatarsals.

CLINIC FOLLOW UP

12/20/18 1/11/19

RED HOT SWOLLEN FOOT SCOPE OF THE PROBLEM

DM Foot problems

25% persons w/DM suffer ‘foot problems’

Most Common = DFU (15-20%)

Most Common cause for hospitalization

Diabetic Foot Complications

• 17 SECONDS Diabetes is diagnosed once every 17 seconds in the world

• 70% The number of lower extremity amputations in the world are associated with diabetes

• 20 seconds somewhere in the world, a lower extremity is amputated in a patient with diabetes

• EVERY 20 SECONDS!!

• Increased Mortality rate • 1 yr 15%

• 5 yrs 50%

• 10 yrs 70%

International Working Group on the Diabetic Foot

International Diabetic Foot Conference

March 2014

Los Angeles, CA

VHA

WHICH OF THE FOLLOWING STATEMENTS IS TRUE

ABOUT RATES OF NLEA in USA FROM 2000-2015

1) there has been a steady decrease

2) there has been a steady increase

3) there was a decrease for 10 yrs then increase

TOTAL NLEA

MINOR NLEA

MAJOR NLEA

Discharges/

1000/yr NON TRAUMATIC LOWER

EXTREMITY AMPUTATIONS

2000 - 2015

DIABETES CARE january 2019

Resurgence of Diabetes-Related Nontraumatic Lower-Extremity Amputation in the Young and Middle-Aged Adult U.S. Population Linda S. Geiss, Yanfeng Li, Israel Hora, Ann Albright, Deborah Rolka and Edward W. Gregg⇑

• OBJECTIVE To determine whether declining trends in lower-extremity amputations have continued into the current decade.

• RESEARCH DESIGN AND METHODS • Utilized Nationwide Inpatient Sample (NIS) on NLEA procedures and from

the National Health Interview Survey for estimates of the populations with and without diabetes.

• CONCLUSIONS After a two-decade decline in lower-extremity amputations, the U.S. may now be experiencing a reversal in the progress, particularly in young and middle-aged adults.

RESULTS

• 2000-2009 NLEA rates/1,000 adults with DM decreased 43% (P < 0.001)

• 2009-2015 Rebounded by 50% (P < 0.001).

• MINOR/MAJOR AMPUTATION RATE

• 62% increase in minor amputations

• 29% increase in major amputations

• The increases in rates of total, major, and minor amputations were most pronounced in young (age 18–44 years) and middle-aged (age 45–64 years) adults

• men > women.

DIABETES CARE January 2019

Resurgence of Diabetes-Related Nontraumatic Lower-Extremity Amputation in the Young and Middle-Aged Adult U.S. Population

Linda S. Geiss, Yanfeng Li, Israel Hora, Ann Albright, Deborah Rolka and Edward W. Gregg⇑

THEORIES

• Low hanging fruit; maximizing medical management in older adults

• Disparity of income equality, race/ethnicity, geographic location

• 2008 lingering impact

• Increase minor amputation represents change in clinical decision making?

• Early prevention practices may not be optimized

• Decline in mortality rates may be increasing levels of multimorbidity

High Risk Foot Clinic (HRFC) (aka Limb Salvage) PAVE (Prevention of Amputation for Veterans Everywhere)

TEAM

• Providers • HRC/Wound; PA Wayment, NP Petersen

Doucette/Byrns • Podiatry; Drs. Davis, Millward

• Physical Therapists • DPT A.Stephens, K. Spiegel, • PT M. Jones (amputee)

• Nursing • LPN Lough, Cameron, Morrow, McAlpin,

Gala, Maxwell • RN Fitzpatrick, Cosdon

• CPO/Fitter • CPO Lewis, Fitter Saunders

CONSULTANTS

• Infectious Disease • Drs. Vietri,

• PharmD McClain

• Vascular Surgery • Dr. Masser

49-85% (estimate)

amputations are preventable (Driver, 2008)

85% of amputations* are preceded by non-healing ulcer (*in people with diabetes)

Pecoraro, 2003

High Risk Foot Clinic (HRFC) PAVE (prevention of amputation for veterans everywhere)

SERVICES

• HRFC Clinic

• HRFC inpt consults (acute, CLC)

• HRF-Nursing Foot Care

• Nursing dressing change

• Podiatric surgery

• TCC/Casting

• Orthotics/Footwear

DIAGNOSTICS

• TCOM

• Pressure Mapping

PACT Clinical Foot Risk Score (FRS) Risk Score Neuropathy

As evidenced by loss

of protection

sensation via Semmes

Weinstein

monofilament

PVD As evidenced by

no palpable

pedal pulses

Specified Deformity

As evidenced by visual

inspection i.e. bunion,

hammertoe, claw toe,

mallet toe, metatarsal

head deformity, etc..

Ulcer OR

Osteomyelitis

OR

Amputation

Intermittent

claudication, Rest

pain, gangrene,

peripheral bypass

surgery or

angiography;

ESRD

0 Normal

Risk Diagnosis of qualifying

at risk condition, i.e.

diabetes

1 Low Risk (one of three)

X X X

2 Moderate

Risk (two of three)

X X X

3 Highest

Risk Prior ulcer ,

osteomyelitis or

amputation or severe

PVD OR all three risk

factors (N, PVD, D)

X X X X X X

A history of smoking, although not shown to be an independent risk factor for lower extremity amputation, clearly raises the risk level for other morbid

vascular complications such as peripheral vascular disease, stroke and MI and as such aggressive smoking cessation counseling is recommended.

RED WHERE IT SHOULDN’T BE PRESSURE INJURY

PRESSURE ULCER (injury) STATS

Lawsuits: - >17,000 lawsuits are related to pressure ulcers annually.

-2nd most common claim after wrongful death - greater than falls or emotional distress

Pain: PU +/- severe pain.

Death: approx. 60,000 patients die due to complications related to pressure

ulcers each year. AHRQ 2011

CASE STUDY. 60-something male, DM, R TTA/BKA

Veteran admitted for septic hip/THA on same side as TTA

• Hip prosthetic removed

• Packed w/antb beads

• Unable to use prosthesis

• IV antb, surgery -> D/C TO SNF

APRIL 2017

7/2017

7/11/18

• 11/2/18 POST OP RESECTION AND PRIMARY CLOSURE

• 1/2019

12/2018

SUMMARY AND COST OF CARE

• MARCH 2017 – JANUARY 2019 • SNF x2

• 2-3X/Wound care, debridement

• NPWT/VAC

• ORTHOTICS

• THERAPY SERVICES

• INFECTION/ANTB

• SURGERY; initial, Nov 2018 resection and closure

• HOSPICE January 2019

• debridement (initial) , 12/2018 surgical resection and closure

PRESSURE ULCERPRESSURE ULCERS * UNCLAIMED TERRITORY

Who owns this territory?

. Petrone K, Mathis L. Pressure ulcer litigation: what is the wound center’s liability? Today’s Wound Clinic. 2017;11(9). https://www.todayswoundclinic.com/articles/pressure-ulcer-litigation-wha... [16]. Accessed onjan 8, 2019

• 29% in home care

• 28% in long-term care

• 15% in acute care.1

RATES

LAWSUITS

• 2009 University of Michigan retrospective study on pressure ulcer litigation.

• FINDINGS; 67% of lawsuits regarding pressure injuries/ulcers did not involve a medical error or omission, and yet nursing homes are being fined, and criminal charges are being filed against nurses, physicians, and even nursing home operators.3

PRESSURE ULCER (PU) decubitus * bedsore * dermal ulcers * deep tissue injury

localized area of tissue necrosis that tends to develop when soft tissue is compressed between bony prominence and external surface for prolonged time

PRESSURE ULCER STAGING 6 Options

PU Stages I-IV

Describes level of tissue injury

Unstageable

Deep Tissue Injury (DTI)

PRESSURE ULCER STAGING 6 Options

PU Stages I-IV Describes level of tissue injury

Stage 1 = Non-blanchable erythema

Stage 2 = Partial thickness

Stage 3 = Full thickness (into subq tissue)

Stage 4 = Deep to muscle/tendon/bone

Unstageable

Deep Tissue Injury (DTI)

1)STAGE I

2)STAGE II

3)STAGE III

4)STAGE IV

5)US (unstageable)

6)DTI (Deep Tissue Inj)

6) DTI (Deep

Tissue Inj)

4) STAGE IV

Deep to m/t/b

3) STAGE III

Full thickness

1) STAGE I

2) STAGE II

Partial thickness

5) US (unstageable)

Stage 1 PU -non-blanchable erythema

Not used to describe skin tears,

tape burns, moisture dermatitis,

maceration or excoriation

STAGE 2 Pressure Injury

Partial thickness

Stage 2 (vs friction)

Get the history!

MOST IMPORTANT FACT ABOUT STAGES 1 & 2?

• NURSES can manage it

• Pressure Ulcer order sets

• Offload

• MEPILEX ISLAND DRESSING for prevention, Stage 1, 2

PROTECTION

UNSTAGEABLE

You can’t stage what you can’t see!

suspected Deep Tissue Injury *sDTI

NPUAP definition of Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue from pressure

Tissue may be firm or boggy, warmer or cooler when compared to adjacent tissue

Evolution may be rapid, exposing additional layers of tissue even with optimal treatment

Suspected DEEP TISSUE INJURY

Who should be turning the pts?

Helme (1994); Survey (324 CNA, RN, RN-s)

40 LTC (midwest USA)

68% placed responsibility on someone else

EXCEPT DR BYRNS

What’s next?

TREATMENT WOUND CARE OPTIONS

FOCUS

ON

PRINCIPLES NOT

PRODUCTs

PRINCIPLES OF WOUND TREATMENT

• If it’s wet dry* it!

• If it’s dry wet* it!

• If it’s dead remove it (or have someone else do so)

• If you are treating infection systemically, • treat it topically

Principle #1 Clean the Wound

DEBRIDEMENT

• Enzymatic

• Surgical (sharp)

• Mechanical (dressings, forceps, gauze)

• Autolytic (dressings)

Principle #2

*Moist Wound Healing

TOPICAL TREATMENT

Moist Wound Healing YES; Bacitracin, silver mesh, wound gels, *bactroban

NO: soaks, H2O2, chloraprep, betadine, *neosporin

Cover dressing YES: foam, telfa (non-adherent), ABD pad, sanitary pads

NO: gauze,* adaptic/petrolatum

MOIST WOUND HEALING

Frequency of dressing changes?

-based on drainage, caregiver, infection

-based on product

MOIST WOUND HEALING

Wound Care Product Favorites

Cover Dressings based on drainage or need to

protect

Dry-small drainage---------topical antb + non-stick/Polymem (Ag)

Mepilex

Small-mod drainage---Polymem/Polymem Ag/Mepilex/Triac Ag+ cover

Mod-Heavy drainage------Foam, ABD, sanitary pads

Questions?