The Diagnosis and Management of

Common Wounds in Older Patients Louise Aronson, MD MFA University of California, San Francisco Division of Geriatrics

Objectives z z z z

Why Internists Should Care z

Common, costly, distressing to patients

z

Most wound management is non-surgical

z

Much wound surgery doesn’t need a surgeon

z

Chronic wounds; we provide chronic care

z

Palliative care issues – also our domain

Common Ulcers in Older Patients z

Venous Stasis

z

Neuropathic / Diabetic Foot

z

Arterial / Ischemic

z

Malignant / Fungating

z

Pressure / Decubitus

Recognize the 5 most common ulcers in older patients Describe the “wound bed preparation” paradigm for the care of chronic wounds List the essential steps in wound treatment Identify when to use adjunctive wound products and technologies

Why Internists Should Care z z

Wounds are a leading cause of law suits Average settlement = 6 figures

z

Opportunity to have a huge impact on patient morbidity and quality of life

Acute vs. Chronic Wounds z

Acute wounds – – –

z

Surgical, traumatic Orderly sequential healing Coagulation→inflammation →connective tissue proliferation →remodeling and maturation

Chronic wounds – – – –

Inflammatory stage prolonged Inflammatory products break down new matrix Defective granulation Phenotypically altered keratinocytes

1

Venous Stasis Ulcers z

Location – –

z

“Gaiter ulcers”: 95% around malleoli , medial > lateral Edema, stasis dermatitis, hyperpigmentation

Characteristics – – – –

z

Single or multiple Often large w/ significant exudate Irregular, flat borders Shallow bed with granulation and debris

Pain: +/-; worse w/ dependency

Neuropathic (Diabetic) Ulcers z

Location

z

Characteristics

–

– – – – –

z

‘Critical triad’: neuropathy, deformity, trauma Also: ischemia, callus, edema Lesions often (appear) small High risk infection Deep with ‘cliff’ / callus edge

Pain: none

–

Toes, heels, low on leg Pale cool limb; ↓ or absent pulse; hair loss; thin, shiny skin; dependent rubor

Characteristics – – –

z

Arterial Ulcers

Location –

z

Diabetic Foot Ulcers

Almost always below ankle

Arterial Ulcers z

Venous Ulcers

Deep, often small ulcer(s) Sharp borders, “punched out” appearance Base: necrotic or pale and non-granulating

Pain –

+++; worse with elevation, walking

2

Malignant Ulcers z

5-10% pts w/ met dz, usually in last 6 mos of life

z

Most common primaries:

z

Characteristics

–

– –

z

Breast, skin, head and neck, lung, colorectal, sarcoma Friable, prone to bleeding, foul odor, local tissue destruction No healing/worsening with optimal care

Pain: +++

Pressure Ulcers z

Sacrum > heels > trochanter > ischium > back, head

Characteristics – – –

Over bony prominences Pt: immobile, incontinent, undernourished, 70% elderly Appearance is stage dependent –

z

Now 6 stages, not 4

Pain: variable

New Pressure Ulcer Staging System z

DTI: Deep Tissue Injury – – –

z

Purple/maroon intact skin or blood blister Often look like deep bruise Often evolves rapidly to stage III/IV even w/good care

New Pressure Ulcer Staging System z

–

Persistent discoloration of intact skin &/or altered temperature, sensation, consistency

– –

z

– –

Loss of epidermis, dermis or both Presents as abrasion, blister, shallow crater Wound bed pink w/o slough or bruising From National Pressure Ulcer Advisory Panel, February 2007

–

z

Full thickness tissue loss Damage/necrosis of subq tissue; to not thru fascia Deep crater +/- undermining

Four –

Two –

Three –

One –

z

Pressure Ulcers

Location –

z

Malignant Ulcers

Extensive destruction of muscle/ bone/ tendon +/- Undermining and sinus tracks

Unstageable (aka UTD) –

Full thickness but too much slough or eschar to dx From National Pressure Ulcer Advisory Panel, February 2007

3

Wound Bed Preparation Model

Step 1: Address the Cause z

Diagnose wound type and status

z

Identify and manage precipitants/contributors

z

Assess likely outcome

Chronic Wound Address cause

Local wound care

Moisture balance

Control infection/ inflammation

Patient/system issues Debridement

Edge Effect Modified from Sibbald, Adv Skin Wound Care 2006

Diagnose Wound Type/Status z

Location – – –

Over bony prominence LE ddx: edema, pulse, deformities Unusual sites: consider CA; rare etiologies

z

Size and depth Ulcer edges

z

Surrounding skin

z

–

–

Diagnose Wound Type/Status z

Exudate – –

z

Wound bed –

Sloped, cliff-like, thick/rolled, inverted, epithelializing Erythema/warmth, maceration, dryness, callus, dermatitis

Wound Bed

–

z

amount, color, odor (after cleansing) serous, serosanguinous, sanguinous, purulent “red, yellow, black system” z granulation - beefy red new tissue z slough - yellow, brown, or gray fibrinous debris z eschar - hard, brown-black, scab-like, adherent give % of each type

Pain

Manage Precipitants/Contributors z

Compression for edema control

z

Pressure offloading

z

Assess/correct vascular insufficiency

z

Nutrition

z

Palliative XRT, chemo, hormones

–

–

–

–

Venous, neurotrophic/diabetic Pressure, diabetic Arterial, diabetic > pressure, venous Pressure, diabetic, venous

4

Assess Likely Outcome

Assess Likely Outcome z

Healability Healable

Maintenance

Adequate vascular supply Reversable precipitants Manageable patient/system issues

Non-healable

Enough blood but pt/system issues Needs revascularization/infection rx

Wound Bed Preparation Model

Toe pressure

≥ 40-50 mmHg

TCO2

> 30 mmHg

ABI

> 0.5 (0.7)

Palpable pulse

+ = 80 mmHg

Step 2: Local Wound Care z

Local wound care

Moisture balance –

Chronic Wound Address cause

LE wounds: determine adequacy of vascular supply

–

Patient/system issues

z

Control infection/inflammation – –

Moisture balance

Control infection/ inflammation

–

Debridement

z

Edge Effect

Keep surface moist Absorb excess exudate Cleanse before each treatment Obliterate dead space Identify and eliminate infection

Debride if necrotic –

Except: toe dry gangrene; heel eschar?

Modified from Sibbald, Adv Skin Wound Care 2006

Keep Surface Moist z

Faster healing – –

z z z z

Prevents dessication Promotes epidermal migration

↓ pain, infection New tissue stronger No trauma on dressing removal Dressings for clean wounds – – –

Gels Hydrocolloids Transparent films (only if shallow, no exudate)

Reducing Excess Moisture z z z

Use less gel/ointment Change dressing more frequently Use more absorbent dressing z z z

z

Alginates Foam Wound fillers (paste, beads)

Other z z

Moisture barrier cream to surrounding skin Air flow bed

5

Wound Cleansing z

At each dressing change –

NS/water best cleanser; avoid antiseptics

z

Shallow: gentle swabbing Deep: irrigate with – –

Colonization – – –

z

z

–

z

–

Revascularization (more) Debridement

If clean, rx critical colonization – –

z

z

Wet wounds

–

– – –

Topical abx x 2 weeks (silver, cadexomer iodine) R/o osteo

Vaseline-, aquaphor- or hydrogel-impregnated gauze Alginates or foam Cotton gauze: open and fluff Wound fillers: copolymer starch powder, dextranomer beads, or hydrocolloid paste

Eliminating Infection z

Topical tx for “critical colonization” –

Silver-based dressings

–

Cadexomer iodine

–

Avoid agents used systemically Neomycin/bacitracin cause allergic sensitivity Treat for 2 – 4 weeks

z z

– –

z

Kill in 3 ways; gets MRSA; high conc for Pseudomonas Slow release iodine; absorptive, forms gel

Infection –

Warmth, pain, erythema > 2cm, ↑odor/exudate, probe to bone Dx clinical; swabs to i.d. resistance only

Change dressing type Consider –

z

Dry wounds

Unhealthy granulation, delayed healing, hard, ↑odor/exudate

Non-progressing Wounds

Exudate control Prevent superficial before deep healing

z

Replicating microorganisms adherent to the wound w/o tissue damage Present in all chronic wounds Wound < 4wks Gram-pos; >4wks Gram-pos/neg, anaerobes

Infection –

z

–

“Critical colonization” –

Why? –

35ml syringe with 19 gauge needle Water Pik on lowest setting; Irrijet

The Spectrum of Infection z

z

Removes debris and decreases colonization

z

z

Filling Dead Space

–

Broad spectrum coverage Rx osteo 6 – 12 weeks

Debridement z

Removes necrotic tissue, harmful waste

z

Reduces bacterial burden, pathological cells

z

Facilitates accurate assessment

z

Goal: turn chronic wound into acute one

z

In DFUs ↑ healing rate

If “edge effect”: adjuctive therapies

6

Types of Debridement z z

Cochrane Review: no one method superior Surgical/sharp – – – –

z

Fast and selective Essential if cellulitis, sepsis Scalpel, scissors, anesthesia Avoid if malignant, severe ischemia, bleeding issues

– – – –

Slower, pain-free, spare viable tissue Cost-effective QD or BID Inactivated by silver Papain urea (eschar; non-selective), collagenase (slough; selective)

Choosing a Dressing

– –

z z z

Autolytic – – –

z

Biologic – – –

z

Self-digestion beneath dressing: hydrocolloid, alginate, gel, foam Time/cost effective; pain free Requires thorough cleansing between treatments Sterile maggots: Lucilia sericata Up to 3 applications q 2-3d; ↓ bacterial spread, amputations “ick factor”

Mechanical – – –

Wet to dry: costly, painful, harms good tissue Hydrotherapy: ↑ circulation; trauma and maceration; ++labor/time Ultrasound: new, promising; uses low-freq sound waves

Wound Bed Preparation Model

Wound –

z

z

Enzymatic –

z

Types of Debridement

Red, yellow, black base? Amount of exudate? S/sx infection?

Cost and availability Burden on patient/caregiver Change based on response Think in categories not by specific products

Chronic Wound Address cause

Local wound care

Patient/system issues

Moisture balance

Control infection/ inflammation

Debridement

Edge Effect Modified from Sibbald, Adv Skin Wound Care 2006

Step 3: Patient/system issues z

Goals of care –

z z

Access to products, interventions Quality of life issues – –

z

Cure v. maintenance v. palliation

–

z z

Inadequate vascular supply Personal/system issues – –

Pain control Impact of wound/tx on patient and caregiver

Ability of patient/caregiver to follow tx plan –

Non-healable wounds

–

z

Can’t afford offloading shoes Won’t use compressive dressing Inadequate turning surfaces

Malignant ulcer

Address concerns Education

7

Non-healable wounds z z

Avoid moisture balance and debridement Use antiseptics to control bacterial load – –

z

z

Green color, sweet odor Acetic acid 0.5% or metronidazole gel

z

z

Use hemostatic dressings

z

Cautery – – –

z

Malignant Ulcers: Pruritis z

Systemic antihistamines often not helpful

z

Topical doxepin 5% cream –

In the room Kitty litter Activated charcoal Vanilla

Premedication 30-60 min before dsg Δ Nonadherent dsgs – –

z

Moisten edges or apply lotion to cg hands Silicone and polymer dressings less adherent

Topical opioids (controversial) –

Sucralfate paste, Ag nitrate sticks, pressure Hemostatic surgical sponges ($) XRT, emoblization, antifibrinolytics

EOL: dark towels for clean up

Cheaper than gel, silver products

Malignant Ulcers: Pain

Warm NS to dressing before removal

z

Charcoal or silver impregnated dressings

–

z

alginates, collagen, gelfoams, sucralfate paste, nonadherent gauze

–

–

z

–

Topical antiseptics and antibiotics Metronidazole tablets crushed and sprinkled

–

Odor, pruritis, bleeding, pain

Malignant Ulcers: Bleeding

–

z

Special considerations in malignant wounds –

On the wound –

Chlorhexidine, povidone-iodine least toxic Pseudomonas z

z

Malignant Ulcers: Odor

–

1mg MSO4 to 1gram hydrogel/metrogel qd EMLA cream (lido/prilo) z z z

z

Apply 45-60 min prior to debridement Occ causes burning May interfere with wound healing

Adjuvant tx: XRT, surg, chemo, HT, CAM

Wound Bed Preparation Model

Chronic Wound

Data from burns only

z

Cool hydrogel sheets prior to application

z

Topical menthol to closed wound or surround

z

TENS and other distractions

Address cause

Local wound care

Patient/system issues

Moisture balance

Control infection/ inflammation

Debridement

Edge Effect Modified from Sibbald, Adv Skin Wound Care 2006

8

The Edge Effect z z z z z

When epithelium fails to migrate across a healthy granulation base Non-progressing healable wound Edge: often cliff-like, discolored, cicatrix Phenotypically altered dysfunctional cells ↓ growth factors

New/Adjunctive Treatments z z

Use only when optimal usual care fails Categories –

z

– –

Growth factors Matrix-based (promising but more study needed)

Cellular therapies Complementary therapies

Cellular Therapies Autologous skin grafting – – – –

z

Growth Factors z

Acellular therapies z

z

Edge Effect

z

z

– – –

Vacuum suction –

Requires clean wound ↓Pain Recurrence common (PU > VSU) Time delay with in vitro culture and expansion methods Living full-thickness allogeneic skin Protects, ↓pain, provide growth factors, doesn’t persist FDA approved for VU and DFU VU: increases chance healing over compression

GM-CSF – VSU: + RCT of perilesional injn – DFU: accelerated resolution of infn; ↓ amputation rate – PU: accelerates healing

Complementary Treatments

–

Provides continuous subatmospheric pressure Benefit multiple wound types z

– –

“Skin equivalents” –

Platelet-derived GF (becaplermin) – Only FDA approved GF; used for DFU, PU – Small but signif ↓ healing time in RCTs – $$, cost-benefit ratio not great – Only works w/wound bed preparation/debridement

–

z

pre-graft; post amputation/debridement; failed other tx

CI if osteo, exposed organs or vessels, eschar Drains xs fluid from chronic wounds, ? incr. blood supply Very popular but little data

Electric stimulation – – –

Positive trials, esp in PU Contraindicated in CA, pacemaker, osteo Markedly increases exudate

9

Complementary Treatments z

Cochrane: no evidence benefit but trials small Recent trials showed faster healing DFU, VU

– –

z

Electromagnetic Therapy Electrodes produce EM field across wound No evidence of bene PU or VU but no really good studies

– –

z

End

Therapeutic U/S

Questions?

Hyperbaric O2 ↓ major amputation risk in DFU NNT=4; no diff minor ampu Signif chance healing at 1 year but not sooner VU: reduction in ulcer area at 6 weeks Issues: cost; inconvenience; potential damage to other tissues

– – – –

Transparent Films

Hydrogels

z

Adhesive polyurethane membrane

z

z

Uses

z

– – –

z z z

PT wounds: clean, shallow, min exudate Stage I or II PU (avoid w/ blisters; tears skin) Secondary dressing

Occlusive, waterproof, impermeable Non-absorbent, risk maceration See-thru, Δ q 3-7 days

Hydrocolloids

z

Glycerin or water based gel, sheets, gauze Cool, sooth, facilitate autolytic debridement Uses – – –

z z z

Partial thickness w/ slough, min or no exudate To soften eschar for sharp debridement Clean, dry full thickness wounds

Needs secondary dsg, Δ qd or BID Non-adherent, semi-occlusive, rehydrating Risk of maceration

Alginates

z

Gelatin/pectin/cellulose wafers, sheets, paste

z

Seaweed derivatives, pads or ropes

z

Uses

z

Uses

– – – –

z

Clean wounds Partial thickness wounds w/ min-mod necrosis, slough Secondary dressing over wound fillers Preventing recurrence

Occlusive, waterproof, mod absorbent –

Avoid if infection, heavy exudate

z

Impermeable to bacteria, contamination

z

Promotes autolysis (caution: odor, debris)

– – –

Full thickness wound mod to heavy exudate Packing of tunnels, undermining Autolytic debridement +: stage III, IV PUs

z

Non-adherent; needs secondary dsg, Δ qd

z

OK w/ infection

z

Autolytic, non-adherent, highly absorbent

10

Foam

Gauze

z

Polyurethane wafers, sheets, pillows

z

Inexpensive, non-adherent, mod absorbent

z

Uses

z

Use = controversial

z

Disadvantages

– – –

Heavy exudate FT wound; VSU ulcer Deep cavity (OK even w/ infn) Intermediate dressing over packing material

z

Need waterproof secondary dressing

z

Freq of change depends on exudate (qs → q3d)

z

Comfortable, conformable, non-adhesive, reduces maceration, thermal insulation

– – – –

Indiscriminate debridement If dries hard Æ pressure injury Ineffective if not opened; woven variety abrasive Even when used correctly, less good than other debriding methods

z

Not necessarily cheaper

z

Best as a secondary dressing

Wound Fillers z

Copolymer starch powder, dextranomer beads or hydrocolloid paste

z

Uses – –

z

Fill dead space, mod to heavy exudate FT Packing of tunnels, undermining

Non-adherent, need secondary dressing

11