Wound Etiology

What population most commonly gets skin tears?

Old peeps

Describe a category I skin tear

Skin tear with no tissue loss where the skin flap can be approximated so that no more than 1 mm of the dermis is exposed

Describe a category II skin tear

• 2 kinds

  • Little bit of skin loss where ya got partial thickness depth with 25% or less epidermal flap loss and ya got at least 75%+ of the dermis covered by the skin flap

  • Bit of tissue loss that’s partial thickness in depth where 25%+ of the epidermis flap is lost and more than 25% of the dermis is exposed

Describe a category III skin tear

Epidermal flap be gone

What should you use to flush out a skin tear?

Saline

What are some signs that a would is infected?

• Yellow/green discharge

• Change in ordor

• Change in the size of the incision

• Redness/hardening of the surrounding area

• Increase in temp

• Fever

• Unusual pain or increase in pain

• Excessive bleeding

How does pressure on the skin lead to necrosis of the tissue?

Pressure → ischemia → acidosis → inflammation → increased capillary permeability & edema → local tissue anoxia → necrosis

How long does it take for hyperemia to appear?

30 minutes of sustained pressure

How much time of sustained pressure will cause tissue ischemia?

2-6 hrs

How much time of sustained pressure will cause tissue necrosis?

6+ hours

What factors determine the extent of pressure damage?

• magnitude of mechanical load

• Duration of mechanical load

How might someone in the ICU get a pressure wound?

• Endotrachreal tube

• Nasogastric tube

Where might someone with a CPAP get a pressure injury?

Bridge of nose

Where might someone with oxygen tubing get a pressure injury?

Neck or ears

what do the edges of a pressure injury often look like?

Round, crater-like shapes with regular edges

Where do pressure injuries normally develop?

Over bony prominences (sacral/coccyx, greater trochanter, ischial tuberosity, heel, lateral malleolus)

Describe a stage 1 pressure injury

• Non-blanchable erythema of intact skin

• Color changes are NOT purpose or maroon

Describe a stage 2 pressure injury

• Partial thickness skin loss that involves the epidermis and/or the dermis

• Wound bed be viable, pink/red, mouse

• Adipose is NOT visible

• Granulation (red bubbly stuff), slough (yellow necrotic tissue), and eschar are NOT present

Describe a stage 3 pressure injury

• Full thickness skin loss of involving damage or necrosis of subcutaneous tissue that may go to fascia

• Slough and/or eschar may be present

• Fascia, muscle, tendon, ligament, cartilage, and/or bone are NOT exposed

Describe a stage 4 pressure injury

• Full thickness skin loss with extensive destruction

• Tissue necrosis

• Slough and/or eschar visible

• Epiboly (rolled edges)

Describe an unstageable pressure injury

• Eschar covers at LEAST a stage 3 wound

If someone has an unstageable wound and has stable eschar, you should remove it. True or false?

False!

Describe a deep tissue injury injury

• Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purpose discoloration or epidermal separation that reveals a dark wound bed or blood filled blister

• Pain and temp changes precede skin change

What are the primary treatment approaches for pressure wounds? What treatment approaches could you use if those don’t work?

• Primary

  • Pressure relief

  • Wound clean

  • Negative pressure wound therapy (NPWT)

  • Debridement

• Other options

  • HBO2

  • E-stim

  • Muscle flaps

  • Pulsed lavage

  • Low frequency ultrasound

  • Ultraviolet

  • Low level laser therapy

What is the point of a muscle flap?

Reduces dead space and gives some vascularization to the area

How long after a surgery for a muscle flaps does someone have a JP drain?

1 week

How long after a surgery for a muscle flaps does someone use a low air loss or air-fluidized mattress?

2 wks at minimum

The first ___ to ___ days are critical after a muscle flaps Pulsed lavage surgery because it relies on the vascular pedicle for blood supply

5-7 days

What are the 3 layers of a vein?

• Intima

• Media

• Adventitia

What is the primary cause of primary venous insufficiency?

Venous HTN

What are the factors that can lead to venous insufficiency?

• Venous HTN

• Varicose veins

• Dysfunction of the gastric/soleus

• Genetic predisposition

• DVT

What are some risk factors for the development of a venous insufficiency ulcer?

• Obesity

• DVT

• Pregnancy

• Incompetent valves

• HF

• Muscle weakness

• Decreased activity

• 40+ yrs old

• Fam history

• Female sex

• Work in a sitting or standing position for a long time

What does CEAP stand for? What kind of ulcers is the abbreviation for?

• Clinical signs, Etiology, Anatomy involved, Pathophysiology

• For venous insufficiency ulcers

What is telangiectasia?

Dilated intradermal venues < 1 mm in diameter, small spider veins, reticular varicose veins

What is brawny edema?

Firm discolored skin with non-pitting edema that is a result of the underlying fibrosis of the subcutaneous tissue

What is lipodermatosclerosis?

Inflammation of the layer of fat under the skin

What are the S/S of lipodermatosclerosis?

• Pain

• hardening of skin

• Change in skin color

• Swelling

• Tapering of the legs above the ankles (champagne bottles leg)

What does fibrotic/hypertrophic skin look like? What is a risk of it?

• Epidermis gets thick and scaly

• Run the risk of the skin under the epidermis ulcerating or bacteria getting there and causing cellulitis

Where are venous insufficiency ulcers commonly found?

Between the medial and lateral malleoli in the distal third of the lower leg (gaiter area)

Describe the wound appearance of a venous insufficiency ulcer

• Uneven edges

• Shallow depth

• Fibrotic or granular wound base

• Chronic rolled edges

• Little to no eschar

Are venous insufficiency ulcers normally painful?

Nah

Is there typically drainage with a venous insufficiency ulcer?

Ya, usually serious

An ABI below what would indicate that a pt should go to a vascular specialist?

Below 0.8

What are the primary treatments for venous insufficiency ulcers? What are some other approaches you can try?

• Primary

  • Compression

  • Exercises

  • Infection tx

  • Debridement

• Secondary

  • US (low frequency/non-contact)

  • Electrical stimulation

  • Negative pressure wound therapy

Describe a spiral wrap for the LE. What kind of ulcer often gets this?

• 50%-66% overlap (gives 2-3 layers of compression respectively) at a 30-45° angle

• For venous insufficiency ulcers

How much pressure at the ankle does a support compression stocking have?

15-20 mmHg

How much pressure at the ankle does a class I compression stocking have?

20-30 mmHg

How much pressure at the ankle does a class II compression stocking have?

30-40

How much pressure at the ankle does a class III compression stocking have?

40-50 mmHg

How much pressure at the ankle does a class IV compression stocking have?

60+ mmHg

Why might someone use a support class compression stocking?

• Early signs of CVI without ulceration

• Prophylaxis for high risk factors

Why might someone use a class I compression stocking?

• Signs of CVI without ulceration

• Post-sclerotherapy

• Prophylaxis for high risk actors

• Post-healing with inability to don/doff or tolerate higher compression

• Mild lymphedema

Why might someone use a class II compression stocking?

• Post-ulceration

• Pronounced varicose disease

• Moderate lymphedema

• Post-traumatic edema

• Burn scar management

Why might someone use a class III compression stocking?

• severe lymphedema

• Severe CVI

• Venous wounds with no arterial disease

Why might someone use a class IV compression stocking?

• Severe lymphedema

• Elephantiasis

• Severe post-thrombotic disease

What are some exercises that you should do for a pt with venous wounds?

• Gastroc/soleus stretches to optimize ankle ROM

• Ankle pumps and circumduction

• Heel/toe raises in sitting and standing

• Ankle rocker board exercises

• Step overs with 3-4 inch obstacles with a heel strike in front, toe push-off in back

• Exaggerated heel/toe sequence during ambulation

• walking or bicycling for fun

What condition greatly increases the risk and accelerates the course of PAD?

DM

What are some risk factors for the development of an arterial ulcer?

• Atherosclerosis

• PVD

• Diabetes

• Smoking

• HTN

• Older

• Obese

• CVD

What are the critical phases of ischemia? Describe them

• Phase 1

  • Collateral circulation is insufficient

  • Limited blood supply is shunted and flow to resistance is low

  • Wound caused by trauma will heal, just more slowly than usual

• phase 2

  • Intermittent claudication

• Phase 3

  • Resting pain, gangrene, and non-healing wounds

  • Dependent leg syndrome

  • Rest pain during the night

What is typically the first indication that a pt has PAD?

Non-healing wound

Where are arterial ulcers most commonly located?

• Between toes or tips of toes

• Phalangeal heads

• Lateral malleolus

• Areas subjected to trauma/rubbing foot wear

Describe an arterial ulcers

• Even wound margins

• Punched out appearance

• Pale, deep wound bed

• Blanched peri-wound tissue

• Extreme pain

• Cellulitis

• Minimal exudate

• Gangrene/necrosis

What are the 5 P’s of critical limb ischemia?

• Absence of pulses

• Resting pain during

• Pallor

• Paresthesias

• Paralysis

What are the two types of gangrene? Describe them

• Dry

  • Distal part of the limb gets it and it spreads slowly

  • Be dry, shrunken, and dark black

• Wet

  • Will occur naturally in moist tissues and organs

  • Big risk for active infections and so, gotta be urgently debrided

  • Necrotic tissue will start to drain, have detached edges, and have wet peri-wound skin

What are the primary treatment approaches for an arterial ulcers? What are some other options?

• Primary

  • Re-vascularization

  • Prevention

• Secondary approaches

  • Clean

  • E-stim

  • Enzymatic debridement

  • MIST/US

What is one intervention that you CANNOT do with an aretrial ulcer? Why?

No sharp debridement because it will actually make the wound larger cuz it won’t give it adequate perfusion

What are some risk factors for the development of a neuropathic foot ulcer?

• DM

• Peripheral neuropathy

• PAD

• Infection

• pressure

Where are neuropathic ulcers most commonly found?

• Pressure points

• Under the metatarsal heads

• Tips of toes

• The heel

• IF you can’t tell, most common at the feet

What are some characteristics of neuropathic ulcers?

• Form around a callus/callused edges

• On plantar ascent of the foot

• Can be deep but have a good blood supply so they got a pink/red base

• Small and round

What are the treatment approaches for a neuropathic ulcer?

• Total contact casting

• Pressure redistribution

• Blood glucose control

• US/anodyne

• Pulsed lavage

• E-stim

• Debridement

How often is a total contact cast changed?

Weekly

How does a total contact cast help with a neuropathic ulcer?

• Allows weight bearing forces to be more dispersed

• Rigidity helps with edema control

• Immobilizes the foot and ankle

• Encloses insensate foot

• Can help increase pt adherence

What are some contraindications to total contact casting?

• Gangrene

• Osteomyelitis

• Fluctuating edema

• Active infections

• Pt can’t care for hte cast

• ABI less than 0.45

What toes can get a hammertoe deformity?

2-4

Describe a hammertoe deformity

Flexed PIP that is rigid with a flexible MP and DIP joint

What are some interventions that can be done for a hammertoe deformity?

• Soft roomy toe box in shoes

• Shoes that are ½ inch longer than the longest toe

• Avoidance of tight, narrow, high-heeled shoes

• Sandals as long as they don’t pinch or rub

• Gentle manual toe stretched

• Using toes to pick things up off the floor

• Towel flat under feet and use toes to crumple it up

What is a bunion?

Enlarged medial prominence of the first MTP joint

What shoe changes would be appropriate for someone with a bunion?

• Widened toe box

• Arch with heel support

• NO bunion pads

What gait deviations does someone with DM present with compared to a healthy adult?

• Slower gait speed

• Greater step variability

• Higher plantar pressure

When treating a pt with peripheral neuropathy, what exercises warrant precaution? Which ones are recommended?

• Precaution

  • Treadmill

  • Prolonged walking

  • Jogging

  • Step exercises

• Rec

  • Swimming

  • Bicycling

  • Rowing

  • Chair exercise

  • Arm exercise

  • NWB exercise

What 3 things need to be present for a Charcot foot to develop?

• Peripheral neuropathy

• Intact peripheral vasculature

• Presence of a trigger (walking, some activity)

Describe a Charcot foot

Midfoot collapse and becomes convex due to an increase in blood flow to the bones that weakens and collapses the midfoot

What are the symptoms of a Charcot foot?

• Dislocation of the darn joint

• Heat

• Insensitivity in foot

• Instability of the joint

• Redness

• Strong pulse

• Swelling of foot and ankle

How would you treat Charcot foot?

• Immobilization and reduction of stress via NWB with crutches and/or a walker

What changes in a Charcot foot indicate the stage of quiescence has started and you should move to the post-acute phase of treatment?

Reduction of skin temp and an increase in edema

What kind of brace/cast is appropriate for someone with a Charcot foot?

• Total contact cast

• Bivalves cast

• Patellar tendon-bearing brace