Comparison of proximally versus distally placed spatially ...
INTERNIST’S GUIDE TO WOUND CARE · Angiogram •Tibioperoneal Trunk- Tandem severe stenoses...
Transcript of 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?