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Wound Care > Differential Diagnosis of Wounds > Flashcards

Differential Diagnosis of Wounds Flashcards

1
Q

How do you diagnose a wound?

A

Tissue Involvement

  • Superficial
  • Partial thickness
  • Full thickness

By etiology

  • Arterial
  • Venous insufficiency
  • Pressure
  • Neuropathic
  • Atypical

RARELY WILL THEY FALL INTO ONE CATEGORY

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2
Q

Differential diagnosis for ARTERIAL wounds

A

Location = distal digits, toes or fingers

Tissue = Dry, necrotic, or slough, little to no granulation

Pain = YES; may have depending on leg syndrome

Skin = dry, hairless, shinny, thin

Exudate = None unless infected

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3
Q

What are the characteristics of Peripheral Arterial (Occlusive Disease)

A

Peripheral arterial occlusive disease
- PAOD/POAD/PAD

Clinically, patients range from asymptomatic to mild claudication to ulceration and/or gangrene

Pts with PAD and LE ulcer and/or gangrene
-Critical limb ischemia (CLI)

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4
Q

What is Critical limb ischemia (CLI)?

A

Reduction in distal tissue perfusion below resting metabolic requirements

Usually associated with atherosclerosis

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5
Q

What are risk factors of Arterial wounds?

A

Age

Smoking

DM

HTN

Hypercholesterolemia

Dyslipidemia

Family history

Obesity

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6
Q

What is a “Critical Phase of Ischemia?”

A

Initially, circulatory system compensates by forming collateral circulation around occlusions to maintain blood flow

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7
Q

What are the characteristics of the 1st Critical Phase?

A

Collateral circulation is insufficient for needs of extremity

Limited blood supply goes to muscles, less to skin

Wound formed in this phase may be slow to heal and is more likely to become infected

Non-healing wound may be first indication of PAD

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8
Q

What are the characteristics of the 2nd Critical Phase?

A

Activity induced ischemia

Occurs when activity causes relative ischemia and pain
-Intermittent claudication–muscle pain/cramping with exercise

Pain with exercise may be the second indication that the pt had PAD

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9
Q

What are the characteristics of the 3rd Critical Phase?

A

Severe ischemia

Maybe less pain is felt during exercise/ambulation

Resting pain

Gangrene

Non-healing wounds in extremity distal to occlusion

Dependent leg syndrome

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10
Q

What is the summary of PAD critical phases??

A

PHASE 1: insufficient collateral circulation for metabolic needs
- Delaying healing of wounds on distal extremity

PHASE 2: insufficient muscle perfusion with exercise
- Intermittent claudication with exercise

PHASE 3: severe ischemia

  • Rest pain
  • Dependent leg syndrome
  • Distal digit ischemia
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11
Q

What is the clinical presentation of Arterial wounds?

A

LOCATION

  • Distal toes
  • Distal fingers

TISSUES

  • Dry eschar
  • Little to no granulation
  • Even borders/edges
  • “Punched-out” appearance

PAIN
-Ischemic pain, variable intensity

SKIN CHARACTERISTICS

  • Thin and shiny
  • Dry
  • Hairless

EXUDATE
- None unless infected

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12
Q

What are some things to think about when looking at clinical presentation of arterial wounds?

A

May have wound caused by pressure, but don’t heal due to arterial insufficiency

Wound is painful due to ischemia

Often painful with leg elevation, relief in dependent position

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13
Q

What are non-invasive diagnostic tests?

A

Pulses

Doppler exam of pulses

Capillary refill time

Rubor of dependency

ABI

Toe pressures

(Segmental Pressures)

Transcutaneous Oxygen Perfusion (TcPO2)

(Arterial color flow duplex imaging)

(Exercise stress test)

(Computerized tomographic arteriography)

(Magnetic Resonance Angiography)

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14
Q

What are the non-invasive diagnostic tests for PAD?

A

Pulses

Doppler exam of pulses

Capillary refill time

Rubor of dependency

ABI

Toe pressures

(Segmental Pressures)

Transcutaneous Oxygen Perfusion (TcPO2)

(Arterial color flow duplex imaging)

(Exercise stress test)

(Computerized tomographic arteriography)

(Magnetic Resonance Angiography)

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15
Q

What is the invasive diagnostic test for PAD?

A

Arteriogram

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16
Q

What is the PULSE DIAGNOSTIC TEST for PAD, what are the two scales?

A

Compare to contralateral side

Confirm with hand-held doppler

SCALE A: Scale of 0-3+

  • 0 = absent
  • 1+ = diminished pulse
  • 2+ = normal pulse
  • 3+ = pathologically prominent pulse (severe aortic insufficiency of aneurism)

SCALE B: Scale 0-4+

  • 0 = absent
  • 1+ = faint but detectable
  • 2+ = diminished pulse
  • 3+ = normal pulse
  • 4+ = bounding pulse
17
Q

What is the capillary refill time (CRT) diagnostic test for PAD?

A

Estimation of microvascular disease

Press end of toe or skin just proximal to wound until color disappears and then measure time for return of original color

Normal is < 3 seconds, but varies greatly

Screening test to indicate if further test might be needed

18
Q

What is the Rubor of dependency diagnostic test for PAD?

A

Screening for ischemia, not definitive for PAD

Extremity is elevated and observed for pallor

Foot is returned to dependent position

  • Normal = color returns within 15 seconds
  • Severe ischemic disease = color takes 30 seconds or more and is dark red vs healthy pink
19
Q

What is the Ankle Brachial Index diagnostic test for PAD?

A

Slide 20

20
Q

What is the Transcutaneous oxygen perfussion (TcPO2) diagnostic test for PAD?

A

Skin oxygenation

Depends on cutaneous blood flow, oxyhemoglobin dissociation, and diffusion of oxygen through tissues

Reflects the metabolic state of the target tissues

21
Q

What is normal with certain BP ranges while testing Transcutaneous Oxygen Perfusion (TcPO2)?

A

> 40 mm Hg = desired for healing of minor amputation site

> 30 mm Hg = healing can be expected, but may be delayed

> 30 mm Hg = Proximal to the toes–wound can be debrided

< 30 mm Hg = Proximal to toes–wound should NOT be debrided until revascularization is accomplished

< 20 mm Hg = Unlikely that healing will occur; pts typically have pain at rest

22
Q

What is the Color flow duplex imaging diagnostic test for PAD?

A

Combines doppler and US

Detects changes in velocity that occur with occlusion

Localizes partial or full occlusion in arteries

23
Q

What is the segmental pressures diagnostic test for PAD?

A

Give an initial indication of localization of arterial occlusive lesions

May be falsely elevated in pts with calcified arteries

24
Q

What is the toe pressures diagnostic test for PAD?

A

Used in pts with calcified vessels or abnormally high ABI

Similar procedure to ABI, but done in toe

25
Q

What is the Arteriogram INVASIVE diagnostic test for PAD?

A

Radiographs of vascular system after injection of radiopaque dye

Used to determine specific site of lesion prior to bypass surgery

26
Q

What is Buerger disease?

A

Also known as thromboangitis obliterans

Disease of macrovascular circulation

Occurs in feet and/or hands

More common in men, especially heavy smokers

Pathology entails inflammation of the peripheral arteries with thrombi and vasospasm

27
Q

What is the treatment used for PAD BEFORE revascularization?

A

Do not debriede–there is no blood flow to area

  • Leave intact eschar alone
  • Debride wet gangrene (infected tissue)

Keep area dry, protect toes with cotton or sterile gauze between toes

Use foot cradle and off-load heels

Discourage limb elevation and elevate head of bed 5-7 degrees–encourage blood flow

Keep extremities warm

Avoid excessive exercise–blood flow goes to muscles

28
Q

In terms of revascularization, what is done in open bypass surgery?

A

Take saphenous vein from ipsilateral limb and use it to bypass stenosed or occluded area

Advantage: establishes direct blood flow to area of tissue loss

Disadvantage: Length of surgery, need to harvest vein (pt may not even have one due to previous CABG surgery); lifelong monitoring

29
Q

In terms of revascularization, what is done with and without stent?

A

Threads a catheter through artery and uses balloon to open it up

A stent will be put into place by the baloon

Advantages:

  • Excellent for pts who may not be surgical candidates
  • Shorter recovery time

Disadvantages:
- Less durability, artery may close back up again (with or without stent)

30
Q

What is the treatment used for PAD AFTER Revascularization?

A

Debride wound of necrotic tissue when granulation tissue is viable at the edges

Provide moist wound environment

Protect foot with pillows under calves

Off-load wound with orthotic, special shoes, or an AD

Control post-op edema to prevent incisional dehiscence

  • Cover incision with dry, sterile gauze or thin foam
  • Apply short stretch bandage in spiral wrap

Wound Care (12 decks)

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