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Integ - PTH 703 - Unit 1 > Therapeutic Modalities and Wound Healing > Flashcards

Therapeutic Modalities and Wound Healing Flashcards

1
Q

How do cells communicate?

A

Chemically (chemotaxis) and electrically (galvanotaxis - directional migration of cells to an electric field)
*increased bioelectric activity until the wound is closed

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2
Q

What does communication rely on?

A

Moisture

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3
Q

What does Senescence refer to?

A

Old, sluggish cells that do not respond well to communication or do not do their job in a timely fashion
*LACKS increased bioelectric activity until the wound is closed

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4
Q

What does estim do?

A

Reminds wound it should be in a state of repair

Encourages galvanotaxis; wound migration

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5
Q

Indications for e-stim? What are the benefits?

A

Encourage cell micgration to enhance a given healing phase
Increase angiogenesis and microvascular blood flow
Reduce local edema
? Possible reduction of BioBurden? (does not respond well to antibiotics)
Management of hematoma
Adjunct to topical wound management

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6
Q

Contradinications for estim?

A

Placement of electrodes:

  • Tangential to the heart
  • On patient with a cardiac pacemaker
  • Along regions of the phrenic nerve
  • Over the carotid sinus
  • Over the laryngeal musculature
  • In presence of malignancy in the wound base or periwound (don’t help bad cells divide)
  • Over exposed bone with untreated osteomylitis (deal with infection first)
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7
Q

Most effective e-stim parameters?

A

High volt Pulsed Current (HVPC)
-Twin peak monophasic waveform
-High peak current which leads to deeper tissue penatration
-Unidirectional - DC
-Has not been shown to change tissue pH under electrodes or cause significant change in tissue temp as found with direct current (DC)
Mono or bipolar electrode placement

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8
Q

What should amps be for estim?

A

Amp should be 80-150V

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9
Q

What should duration be for estim?

A

30-60+ mins
3-7x week
(60 mins for 5-7x week shows big benefits)
-more feasible in home or IP setting; hard to get unit at home to rent

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10
Q

How to do monopolar technique?

A

Place saline-soaked gauze over the wound bed. Apply electrode over this and secure

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11
Q

How do you choose polarity for US? (to get fibroblasts/collagen moving)

A

Choose polarity based on evidence of studies and objective measures of wound progress (used to choose based on specific cell type desired)
Start with negative polarity and continue until it stalls, then go positive until it stalls, and so forth. Stop when there are no more gains

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12
Q

What is negative pressure wound therapy ?

A

Negative pressure or vacuum to open wound to facilitate healing
-place closed system on a dressing, then apply negative pressure
Looking for -125mmHg

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13
Q

Mechanisms of actions of NPWT?

A

Fluid balance/moist wound healing
Reduction in tissue edema
Mechanical deformation “cell Stretch” promotes cell proliferation and angiogenesis (wakes up cells, excites it, and spits out more protein)
SPEEDS WOUND CONTRACTION

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14
Q

Indications by diagnosis for NPWT?

A

Pressure ulcers (stage 3 and 4)
ORthopedic trauma wounds
Diabetic ulcers
Postoperative flaps, meshed graphs, bioengineered tissue graphs (Apligraf)
Open abdominal wounds
Surgically dehisced wounds (once closed, then opened again; likely due to infection or fluid build-up)
Partial-thickness burns

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15
Q

Indications by clinical presentation for NPWT?

A

Wounds with:

  • Significant tissue deficit
  • Exposed vital structures such as bone, tendon, or hardware

Mechanism to secure grafts and flaps as a bolus dressing

Reduce frequency of dressing change in the setting of copious drainage or pain

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16
Q

Contraindications for NPWT?

A

MALIGNANCY in the wound (address the ischemia first)
Untreated osteomyelitis!!
Exposed blood vessels, anastomotic sites, organs or nerves
Presence of more than 20% necrosis (negative pressure does not help w/ necrosis)
Non-enteric or unexplored fistula
Patients with bleeding disorders or inadequate hemostasis (or on blood thinners)
(tough to do in groin area and b/t toes due to all the moisture)

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17
Q

Wound prep before application with NPWT?

A

Perform complete wound exam
-Measure, identify structures, explore for sinus tracks, undermining, ensure periwound is appropriate for adhesives
Debride the wound
Initiate treatment for infection
Assess for adequate blood supply
Manage co-morbid/intrinsic/extrinsic factors

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18
Q

Safety w/ NPWT application?

A

Position pt and manage pain
Use NON-ADHERENT DRESSING in wound base for exposed bone, tendon, fascia, skin grafts, vascular structures
Protect the periwound skin
Avoid placement of drain or TRAC pad over bony prominence
VAC use WHITE foam in sinus tracts - esp in lower abs
DON’T USE BLACK FOAM BY EXPOSED BONES!

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19
Q

What is Hyperbaric Oxygen Therapy used for? (use of sub-atmospheric pressure to increased dissolved oxygen in plasma)

A

Collagen synthesis
Angiogenesis
Epithelialization
Management of bioburden

Wound Senescence may be related to wound hypoxia

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20
Q

What does TCOM (Transcutaneous Oxygen Mapping) measure?

A

It measures transcutaneous oxygen pressure of the wound

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21
Q

What is normal O2 pressure

A

60 mmHg at room air
Less than 30-40 is impaired wound healing

Vascular interventions for PAD should be completed prior to start of HBOT

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22
Q

What does HBOT do?

A

Increase the amount of O2 dissolved in plasma

  • Induces neovascualrization of hypoxic tissue (O2)
  • Improves leukocytes bactericidal function
  • Increases fibroblast replication and collagen production (excites)
  • Cumulative effect
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23
Q

Indications for HBOT?

A

Diabetic foot ulcer (DFU) - Wagner 3-5 (deep ulcer w/ tendon or bone exposed)
Chronic refractory osteomyelitis (CROM)
Radionecrosis of either bone or soft tissue
Necrotizing soft tissue infections
Decompression sickness
CO poisoning**

24
Q

Contraindications for HBOT?

A

Untreated pneumothorax
In conjunction w/ certain chemo drugs
Uncontrolled seizure d/o
-Must come up slow (so if seizes during therapy, you still cannot bring them up quickly due to nitrogen imbalances that would occur)

25
Q

Precautions and side effects for HBOT?

A

Claustrophobia
Respiratory/ear infections/excessive mucous
Sinus squeeze - typically severe frontal sinus pain (like diving into botto, of the pool - ears hurt)
Pneumothorax
Visual changes from lens refraction (pressure changes shape of lens in eye)

26
Q

Clinical parameters for HBOT?

A

90-120 min dive time
2 atmospheres absolute (ATA)
20-35 treatment sessions
Typically 5 days per week
HBOT in addition advanced and standard care
Must be done long-term, big commitment; hard to find in rural areas

27
Q

What do studies show about HBOT?

A

Improved outcome with LRTI
Decreased risk of amputation
But in 2013, it was shown that HBO neither improved the likelihood that a wound would heal nor prevented amputation

The usefulness of HBO in the treatment of DFUs needs to be re-evaluated

28
Q

Difference between black and white foam for the VAC (NPWT)?

A

The black foam – V.A.C. GranuFoam Dressing –is a polyurethane (PU) , reticulated open pore foam dressing and is considered to be the most effective at stimulating granulation tissue while aiding wound contraction. It is hydrophobic (or moisture repellent), which enhances exudate removal.

The white foam – V.A.C. WhiteFoam Dressing - is a polyvinyl alcohol (PVA), dense and open pore foam dressing with a high tensile strength and less adherent properties that is ideal for use in tunnels and shallow undermining. It is hydrophilic (or moisture retaining) and is packed pre-moistened with sterile water. Its properties help to reduce the likelihood of adherence to the wound base.

29
Q

What is “the use of acoustic mechanical energy to enhance wound healing?”

A

Therapeutic ultrasound

30
Q

What is Attenuation?

A

Sound energy passes through tissue; energy is scattered and absorbed

31
Q

What is Cavitation?

A

Vibration/expansion of gas bubbles

-electric activity excites - cell stretches

32
Q

What is Acoustic Microstreaming?

A

High velocity fluid gradients along cell membranes

33
Q

What is the difference between MHz and KHz Ultrasound?

A

Continuous MHz is used when elevation in tissue temperature is desired. Pulsed MHz is used to reduce the risk of overheating (Thermal vs non-thermal)

KHz has emerged as an effective way to manage BIOBURDEN and NECROSIS while reducing pain DURING DEBRIDEMENT

34
Q

What are the settings for Pulsed MHz (to reduce the risk of overheating)

A

3Mhz, pulsed 20%, 0.5 W/cm2

*Reduces Periwound Edema!!

35
Q

What are the benefits of MHz?

A

Promotes absorption of hemorrhagic materials
Increases circulation and tcPO2 if patient is well hydrated and oxygenated
Reduces Periwound edema
Enables noninvasive non-traumatic treatment of deep or superficial tissue depending on frequency

36
Q

What is the Protocol MHz for periwound edema?

A 
Can use bacitracin as coupling medium for periwound technique or stadnard US gel
0.25-0.5W/cm2, 20% pulsed, x 2-15 min
1MHz or 3 MHz
3 TIMES PER WEEK!
Currently Not Reimbursable :(
(but you can bill for debridement)
37
Q

What are different KHz US machines (contact v noncontact)

A

SonicOne - 22.5 KHz contact low thermal device
Qoustic Wound Therapy System - 35 kHz contact/noncontact low thermal device
MIST (Celleration) Therapy System - 40 kHz noncontact

38
Q

What are indications for using kHz US?

A

Locally infected wounds - planktonic infection and biofilms
Impaired circulation at the wound base
Debridement, irrigation, topical treatment
-Antiseptic solutions can b used as coupling medium
Pressure ulcers, DFUs, arterial ulcers, venous ulcers, surgical wounds

39
Q

What are precautions against using kHz US?

A

Untreated advanced celluitis with signs of systemic response
Wounds with metal components
Wounds associated with implanted electronic devices
Uncontrolled pain

40
Q

What are contraindications against using kHz US?

A 
Over pregnant uterus
Central nervous system (CNS) tissue
Joint cement
Plastic joint components
Pacemaker
Acute thrombophlebitis
Reproductive organs or eye
41
Q

How does an electromagnetic field work?

A

Use of exogenous electromagnetic fields to induce a healing electric field within tissue
Tissue repair:
-Pulsed electromagnetic field (PEMF)
-Pulsed radio frequency (PRF)
-Pulsed shortwaves diathermy (PSWD)
-Continous Shortwave Diathermy (CSWD) - not typically used in wound care

42
Q

When do you use Pulsed Electromagnetic Field/how does it work?

A

Used as a bone stimulator
Increased production of growth factors
PEMF may assist in modulating communication between cells
Improved angiogenesis

43
Q

How does Pulsed Radio Frequency work?

A

Non-thermmal exogenous electric field is applied to damaged tissue
Promote wound granulation and contraction
Stimulates growth factors
Modulates cell communication
Pain reduction

44
Q

How does Pulsed Shortwave Diathermy?

A 
Low thermal impact on tissues
Heats tissues to improve perfusion
Increases collagen production
Oxidative stress improves defense against colonization
Post-op pain reduction
45
Q

Contraindications against Electromagnetic Field?

A 
Ischemic tissue
Metallic implants
PAcemakers
Where primary or metastatic growth is expected
Immature bone
Pregnancy
Internal organs
Hx of hemorrhage
Transcerebrally
Anesthetized areas
Moist situations, perspiration, adhesives
Heat sensitivity
Inflammatory rpocesses
46
Q

What is Light Therapy?

A

Infrared Light/Lasers
UVA vs UVB vs UVC
Longer wavelength = deeper penetration of skin

47
Q

Which is deepest? UVA, UVB, or UVC?

A

UVA is deepest. UVC is most shallow

48
Q

What are the effects of UV?

A

Bactericidal effects across all 3 bands
Pure UV light (containing all 3 bands) kills pathogens but requires high doses - can cause SEVERE tissue destruction
UVC band only (in vitro) has been shown to kill pathogens with short duration, low dose (3 seconds)
Primarily indicated in wounds with heavy BIOBURDEN!!!!

49
Q

When is UV primarily indicated?

A

Primarily indicated in (stalled) wounds with heavy BIOBURDEN!!! (as seen on previous card)

50
Q

What is the use of UVC?

A

Bactericidal
-Short dose time (in vitro) 3-5 seconds
-99.9% kill rate includes MRSA and VRE
Induces inflammation
Dosing as treatment protocols are NOT well established
Indicated in stall wounds with heavy bioburden

51
Q

What are Contraindications for UV treatment?

A 
Pulmonary Tuberculosis
HYPERthyroidism
Systemic Lupus erythematous
Cardiac, renal, hepatic disease
Acute eczema or psoriasis
Herpes simplex
52
Q

Should you use Whirlpool?

-Hydrotherapy used for centuries
-Assists with removal of debris
Non-selective debridement
Assists with dressing removal

A

No, here’s why:

  • Lack of evidence for clinical use
  • Increases tissue edema
  • Questionable infection control
53
Q

Are modalities primary or adjunct treatments?

A

Adjunct; do other stuff first!

54
Q

How does modality reimbursement work?

A

Based on CMS guidelines
All modalities coded differently
US is NOT REIMBURSABLE!
Medicare PT cap poses barrier to care
-Wound care modalities tend to be used for longer periods of time
-Healing can be slow even with adjunct treatment

55
Q

What is the Wagner Grading System?

A

For DFU

  • 0 - Intact Skin
  • 1 - Superficial ulcer of skin or subcutaneous tissue
  • 2 - Ulcers extend into tendon, bone, or capsule
  • 3 - Deep ulcer with osteomyelitis, or abscess
  • 4 - Gangrene of toes or forefoot
  • 5 - Midfoot or hindfoot gangrene

Integ - PTH 703 - Unit 1 (9 decks)

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