Differential Diagnosis of Wounds Flashcards
How do you diagnose a wound?
Tissue Involvement
- Superficial
- Partial thickness
- Full thickness
By etiology
- Arterial
- Venous insufficiency
- Pressure
- Neuropathic
- Atypical
RARELY WILL THEY FALL INTO ONE CATEGORY
Differential diagnosis for ARTERIAL wounds
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
What are the characteristics of Peripheral Arterial (Occlusive Disease)
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)
What is Critical limb ischemia (CLI)?
Reduction in distal tissue perfusion below resting metabolic requirements
Usually associated with atherosclerosis
What are risk factors of Arterial wounds?
Age
Smoking
DM
HTN
Hypercholesterolemia
Dyslipidemia
Family history
Obesity
What is a “Critical Phase of Ischemia?”
Initially, circulatory system compensates by forming collateral circulation around occlusions to maintain blood flow
What are the characteristics of the 1st Critical Phase?
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
What are the characteristics of the 2nd Critical Phase?
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
What are the characteristics of the 3rd Critical Phase?
Severe ischemia
Maybe less pain is felt during exercise/ambulation
Resting pain
Gangrene
Non-healing wounds in extremity distal to occlusion
Dependent leg syndrome
What is the summary of PAD critical phases??
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
What is the clinical presentation of Arterial wounds?
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
What are some things to think about when looking at clinical presentation of arterial wounds?
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
What are non-invasive diagnostic tests?
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)
What are the non-invasive diagnostic tests for PAD?
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)
What is the invasive diagnostic test for PAD?
Arteriogram
What is the PULSE DIAGNOSTIC TEST for PAD, what are the two scales?
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
What is the capillary refill time (CRT) diagnostic test for PAD?
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
What is the Rubor of dependency diagnostic test for PAD?
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
What is the Ankle Brachial Index diagnostic test for PAD?
Slide 20
What is the Transcutaneous oxygen perfussion (TcPO2) diagnostic test for PAD?
Skin oxygenation
Depends on cutaneous blood flow, oxyhemoglobin dissociation, and diffusion of oxygen through tissues
Reflects the metabolic state of the target tissues
What is normal with certain BP ranges while testing Transcutaneous Oxygen Perfusion (TcPO2)?
> 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
What is the Color flow duplex imaging diagnostic test for PAD?
Combines doppler and US
Detects changes in velocity that occur with occlusion
Localizes partial or full occlusion in arteries
What is the segmental pressures diagnostic test for PAD?
Give an initial indication of localization of arterial occlusive lesions
May be falsely elevated in pts with calcified arteries
What is the toe pressures diagnostic test for PAD?
Used in pts with calcified vessels or abnormally high ABI
Similar procedure to ABI, but done in toe
What is the Arteriogram INVASIVE diagnostic test for PAD?
Radiographs of vascular system after injection of radiopaque dye
Used to determine specific site of lesion prior to bypass surgery
What is Buerger disease?
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
What is the treatment used for PAD BEFORE revascularization?
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
In terms of revascularization, what is done in open bypass surgery?
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
In terms of revascularization, what is done with and without stent?
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)
What is the treatment used for PAD AFTER Revascularization?
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
