39/40: Ulcerations - Bennett Flashcards
define skin ulcer
A wound with complete loss of the epidermal layer of skin with extension into the dermis and possibly the subcutaneous tissues
most common single precursor to lower extremity amputations among persons with diabetes
foot ulcerations
big three complications of diabetes
- blindness
- kidney failure
- foot and leg amputation
“intrinsic minus foot”
foot deformity in diabetes due to motor neuropathy
- hammertoes
- bunions
- prominent met heads
- ankle equinus
- instability
- charcot
why is diabetic skin dehydrated?
- autonomic neuropathy
- put at greater risk for skin breakdown
describe diabetic demopathy
- xerotic, non-supple dkin
- fissuring, calluses
- more susceptible to infections
describe diabetic nails
- nails thickened, brittle
- ingrown nails (can be initial event to toe amputation)
Recommended visits for Diabetic patients based on neuropathy level
none = annual (0)
neuropathy = semi-annual (1)
neuropahty, PVD and/or deformity = quarterly (2)
previous ulcer or amputation (3) = monthly to quarterly
why no lotion b/w toes?
- if excess, can cause breakdown of the skin
- can use if rub in properly
what do you need to tell your patient about topical nail medication?
- file nail weekly and apply daily
- take off weekly with nail polish remover
- works on new nail growth
- may take 9 month to see effect
what should you not use for corns/calluses
- sharp blade removal (use pumice stone)
- medicated corn pads (acid)
what time of the day should you get shoes?
evening
- swell throughout the day
what do you need to describe about an ulcer?
- location
- size and depth *
- margins
- base
- undermining (skin is healing over top, but not attached, ‘lip’)
- sinus tracts
- probing to bone
- erythema, edema, malodor, purulence, ascending lymphangitis
fibrotic base, crusting around wound, maceration, erythema around wound
venous stasis wound
Wagner ulcer classification **
Grade 0: pre-ulcerative lesion
Grade 1: superficial without subcutaneous involvement
Grade 2: penetration through subcutaneous tissue (may expose bone, tendon, ligament, joint capsule) *** may probe to bone but no infection
Grade 3: Osteitis, abscess, or osteomyelitis *** underlying infection
Grade 4: Gangrene of forefoot
Grade 5: Gangrene of entire foot
University of Texas Wound Classification
Grade 0- III
Stage A-D
grade first, then stage
0 = pre- or postulcerative lesion completely epitheliazed I = superficial wound, not involving tendon, capsule or bone II = wound penetrating to tendon or capsule III = wound penetrating to bone or jointn
A = no infection or ischemia B = infected C = ischemic D = infected and ischemic
NPUAP staging
Suspected Deep Tissue Injury = Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Stage 1 = Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area
Stage 2 = Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Stage 3 = Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling
stage 4 = Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling
Unstageable = Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
what are the principles of ulcer management? ***
- infection
- vascular supply
- debridement
- off-loading
- wound management
- wound closure
- management of medical comorbidities
systemic symptoms of infections
- Fever, chills, nausea, vomiting
- Leukocytosis (may not be present)
- Blood glucose levels out of control
localized symptoms of infections
Erythema, edema, calor, pain, purulence, lymphangitis, malodor
what imaging will let you see an abscess?
MRI not x-ray
how do you culture a possible foot infection?
- deep swab
- collection of purulence
- deep tissue culture is best
if you suspect a bone infection ..
bone biopsy is best
general treatment of foot infection
- incision and drainage debridement to eradicate bacterial load done wet (to find the good/bad tissue based on bleeding)
- empirical antibiotics then focus
when do you use antibiotic beads?
- infected bone that can’t be removed
- limits a lot of systemic toxicity vs. oral or IV antibiotics
how often does surgical debridement need to occur?
every 48 hrs until necrotic tissue is eradicated (based on what you see - could be more or less)
4 types of wound debridement
- autolytic (use own fluids to debride, “wet to dry”)
- enzymatic (chemicals debride necrotic tissue, faster than autolytic)
- biotherapy (medicinal maggots, only necrotic
- mechanical (surgical)
moist or dry wound management?
“if its dry, wet it; if it’s wet, dry it”
The literature overwhelming supports the use of moist wound healing, and severely criticizes any attempts to desiccate a wound, especially with topical antibiotics such as betadine
reconstructive ladder of wound closure
- Secondary Intention
- skin equivalents - Primary Closure (3:1 length width ratio)
- Split thickness (better) or full thickness skin graft
- Rotation or advancement local random flap
- Transfer pedicled flap
- Transfer autogenous microvascular free flap
what is the goal ejection fraction for perfusion?
55% and above
describe ischemic ulcers
- Signs of diminished circulation
- Usually painful
- Well circumscribed
- Avascular bed
- Any location on extremity, often where trauma has occurred
tx ischemic ulcers
- Revascularization is imperative to restore blood supply to allow for healing
- Not all patients are viable candidates
- Protection of ulcers and surrounding skin
- ** Debridement of ulcer not performed (Can make the ulcer worse) (Only debride if acutely infected) (enzymatic debriding agents)
tx wet vs. dry gangrene
Dry – can be considered stable
Wet – infected and unstable (Should be debrided)
describe venous stasis ulcer
- Ulcers due to incompetent lower extremity venous system
- Usually painful
- Typically found around the medial and lateral malleoli
- difficult to manage
key tx for venosus stasis ulcers
- compression therapy and elevation
(unna boot, layered compression, pneumatic compression pumps) - can also do any type of debridement, consider pain
