Ulcer dressing and management Flashcards
1
Q
What are the three principles of wound management?
A
- Define aetiology
- Control factors affecting healing
- Select appropriate dressings
2
Q
What are the most common chronic wounds seen in GP?
A
- Leg ulcers (arterial, venous and mixed)
- PRessure wounds
- Skin tears
3
Q
What is the pathophysiology of venous ulcers?
A
- Breakdown of venous circulation in the legs with increased venous pressure, pitting oedema and reduced circulation to the skin.
- So when trauma occurs to the skin, insufficient supply for healing
4
Q
What are the clinical features of venous ulcers?
A
- Occurs in the lower one thirsd of the leg
- Irregular in shape
- Skin is often stained around the ulcer area due to haemosiderin deposition
- Skin changes such as eczema or atrophy blanche (white stippled scars) are typical
5
Q
What are the risk factors for venous ulcers?
A
- Obesity
- Past DVT
Poor mobility resulting in venous stasis
6
Q
What are the management principles in venous ulcers?
A
- The mainstay of treatment is application of graduated compression therapy toe-to-knee (30-40mm Hg at the ankle)
- Exclude arterial involvement by testing the ABI/ultrasonography
- Lower limb exercises and addressing occupational factors which leads to prolonged standing should be addressed
- Surgery may be needed in some cases
7
Q
What are the common causes of oedema to the legs?
A
- Venous disease(pitting oedema)
- Lymph disease
- Medications (CCB)
- Renal failure
- Hepatic failure
- Cardiac failure
- Hypothyroidism
8
Q
What is the aetiology of arterial ulcers?
A
- Atheroma is the most common cause of arterial ulcers due to ischaemia
- Poorly controlled DM and smoking are risk factors
9
Q
What are the clinical features of arterial ulcers?
A
- Located mostly over pressure sites which includes distal(toes), pretibial, supramalleolar(lateral)
- Ischaemic pain/intermittent claudication is a feature
- The edes are sharply defined and the ulcer is punched out
- The base is often covered with slough and may be deep enough to expose the tendons
- Lower ABI,reduced cap refill and weak.\/absent pulses are features
- The skin is often shiny and friable
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10
Q
What are the management principles of arterial ulcers?
A
- Surgical intervention for angioplasty, stenting, bypass grafting and/or amputation
- Pain control is an important aspect
- Compression stockings not to be applied even if concomitant venous ulcer is noted
11
Q
What are the features of mixed ulcers?
A
- 15-20% of ulcers are mixed
- Difficult to heal because of associated oedema, cellulitis and thrombophelibitis
- The most important aspect is to detemrine the predominant cause (arterial or venous) and treat it
- Purplish discolouration of the periskin is a feature of vasculitic ulcer
12
Q
What are the features of skin tears?
A
- Most common wound type in the elderly population
- If treated inappropriately, can develop into chronic wounds
- As one ages, skin becomes thinner, brittle and the blood supply is reduced, fragile and more prone to injury
13
Q
What are the management principles of skin tears?
A
- Replace the flaps with few adhesive strips with no tension and covering with a silicone foam dressing and tubular compression bandages to put mild pressure
- Redress every 5-7 days
- Moisturising lotion applied twice daily significantly reduces skin tears
14
Q
Who are at risk of pressure ulcers and how does it develop?
A
- Most preventable of all chronic wounds
- Bedridden
- Stroke, spinal injury, multiple sclerosis or dementia are risk factors.
- It develops when capillary blood flow to the skin and tissue over a bony prominence is decreased for a period of time
- Friction from ill footing footwear and shear also can cause ulcers
15
Q
How to manage pressure ulcers?
A
- Remove all pressure on the wound
- Increase nutrition
- Use of topical or cavity products
16
Q
What are the intrinsic factors that affect wound healing?
A
Factors that aids healing are
- Good arterial and venous circulation
- Normal immune function
- Balanced diet especially arginine
Factors that inhibits healing are
- Anaemia
- Diabetes, RA and reduced immune function
- Age related changes such as reduced blood supply, dryness and thinning
- Reduced nutrition
17
Q
What are the extrinsic factors that inhibit wound healing?
A
- Mechanical stress such as pressure/friction and shearing forces
- Debris including slough and necrotic tissue
- Drying of the wound surface results in death of the tissues
- Excessive moisture(maceration) retards healing
- temp <37 degrees
- Antiseptics
- Smoking
- NSAIDs and steroids
18
Q
What are the principles of wound management?
A
- It is based on wound bed preparation which address wound debridement, bacterial balance, exudate management and the local tissue in the wound environment
- TIME principle is helpful (tissue, inflammation/infection, Moisture, Edge/ epithelialisation)
- The underlying cause is the most important factor in wound healing
19
Q
What are the different wound management products?
A
Passive dressings
- these include gauze, non stick dressings and mostly used as secondary dressing
Interactive dressings
- Six classes include film, hydroactive, hydrocolloid, hydrogel, foa and alginate absorbent fibre dressings
- the choice of dressing will depend on the depth, level of exudate and the presence of bacteria
Bandages
- They help in keeping dressing in place, support an injured joint and assists venous return from the leg
20
Q
What is the A2BC2D approach incorporating TIME principle in wound management?
A1- Assessment of the wound
A2-Assessment of the patient
B-BEst dressing to choose
C1- Consider compression bandaging
C2-Concern of the patient
D-Documentation
A
A1-Assessment of the wound-
- Location size and number of wounds
- Digital photograph is highly recommended
- T-Necrotic tissue in the wound bed
- I-Infection and or inflammation
- M-Surrounding maceration
- E-presence or absence of epidermsi reconstruction
- A-Assessment of the arterial supply with clinical examination and ABI (<0.8 requires further Ix; >1.2 could be due to calcified arteries); presence of venous stasis(varicose veins, lipodermatosclerosis); presence of lymphoedema; testing for sensations great toe, first and fifth metatarsal bone for diabetic neuropathy (10g monofilament nylon) and atypical ulcers which are mostly proximal associated with palpable distal pulses
A2- Assessment of the patient
- Co-morbidities such as HTN, IHD< heart failure, PVD, asthma, COPD, IBD, cancer, anaemia, malnutrition and lack of mobility needs to be assessed
- TIME-H (Healing) concept to define prognosis of the wound by combining the local and general factors
21
Q
What is the A2BC2D approach incorporating TIME principle in wound management continued ?
A
B- Best dressing
- Moisture balance
- Control/eradicate biofilm
- Prevent adherence of the dressing to the wound bed
- Control pain
- Provide pressure relief for ulcers
- Debride wound before applying dressing
C1-Consider compression bandaging
- Most effective MX of chronic venous leg ulcers
Concern of the patient
- Pain during change of dressing
- Social isolation due to wound exudate
- Increasing pain is a reliable indicator of wound infection
- Stasis dermatitis due to venous ulcer benefits from moderate potent steroid around the ulcer
- Si;ver dressing is expensive and not justified by available evidence
Documentation
- Examination findings
- Wound scores
- Management plan for future reference
22
Q
When to consider specialist referral?
A
- Atypical leg ulcers
- Diabetic ulcers
- Arterial ulcers/features of peripheral arterial disease
- Ulcers not healing despite medical Mx or increaisng in size
- TIME-H score >6
- Suspicion of malignancy
- Venous ulcer patient not able to tolerate compression due to pain
23
Q
What is the algorithm for approach to leg ulcers in general practice?
A
- TIME-H score is crucial
24
Q
What are the features of tropical ulcers?
A
- Relatively rare in Australia
- Best managed with a Dermatologist/ID specialist
- TRansmtted by mosquitoes and flies in tropical and subtropical countries where whether is hot and humid
- Poor hygiene, low SES, poor nutrition, poverty and lack of protection are risk factors
- Increased tourism in term sof work, foreign aid, immigrants, military and recreation have increased tropical ulcers in Australia
25
Q
What are the clinical features and Mx of simple bacterial ulcer?
A
- Small papule usually on the lower leg at the site of trauma
- It then forms a blister and undergoes necrosis which is associated with pain, fever and malaise
- Ulcer then enlarges with necrotic, malodorous, purulent discharge
- Little undermining
- Sin biopsies may be needed
- Wound care, wound debridement where necessary, nutrition support and immobilisation are the key
- Penicillin for 7 days and metronidazole for 10 days
26
Q
What are the features of lupus vulgaris?
A
- Usually a solitary lesion which is a tuberculous skin lesion
- Head and neck common
- Classic plaque which then become keratotic, hypertrophic, ulcerative
- High risk of SCC
- Other forms of cutaneous TB include tuberculoid chancre, scrofuloderma and warty TB
- Diagnosis required two skin biopsies (Quantiferon Gold and culture are performed)
- Managed with anti-tubercular drugs over several months
27
Q
What is fish tank granuloma/swimming pool granuloma?
A
- It is caused by Mycobacterium.marinum
- It is mostly seen in fishermen, oyster workers, swimmers and aquarium workers
- starts as a solid papule/nodule which progresses into an ulcer
- Two biopsies for culture and PCR
- 3-6 months of tetracyclines or erythromycins
28
Q
A
