Wound Interventions; Adjunct Treatment Options

Question 1

E Stim - a number of RCTs support the use of estim for what wounds

Answer 1

pressure, neuropathic and venous insufficiency

Question 2

E stim - Medicare coverage for estim only if

Answer 2

Stage 3 or 4 pressure, arterial, diabetic, and venous ulcers that is being used as adjunctive tx AND there has to have not been any measurable signs of healing for at least 30 days of tx with standard wound care!

Question 3

E stim contraindications

Answer 3

Malignancy
Osteomyelitis (untreated)
Use of metal ion therapies
Electronic implant effects
Not over reflex centers
Pregnant uterus

Question 4

Effects of E stim

Answer 4

Dec pain and edema
Inc blood flow and O2 supply (inc cutenaous PP of oxygen)
Antibacterial effects
Increase ATP
Promotes collagen matrix organization

Question 5

High voltage pulsed current - how is it applied

Answer 5

Can be applied directly to the wound, to peri wound area, or via immersion

Question 6

High voltage pulsed current - polarity

Answer 6

Neg until progress is made, then switch to positive
If infected, start positive
45-60 min, 3-5 days/week
(time consuming - have home units now)

Question 7

High voltage pulsed current - negative polarity effects

Answer 7

1 Epidermal proliferation
2 Inc blood flow
3 Fibroblast proliferation
4 Enhanced collagen synthesis
5 Attract neutrophils
6 Lyse necrotic tissue
7 Edema reduction
8 Stimulate granulation
9 Capillary growth
10 Bacteriocidal effect

Question 8

High voltage pulsed current - positive polarity effects

Answer 8

1 Attract macrophages to area
2 Epithelial growth
3 Stimulate formation of new capillaries
4 Bacteriocidal effect

Question 9

Ultrasound - what are its effects

Answer 9

It increases angiogenesis
Accelerates mast cells and macrophages
Inc cellular Ca uptake
Inc fibroplastic activity
Stimulates NO synthesis which inc vascular perfusion

Question 10

Ultrasound - application

Answer 10

Cleanse the wound
Apply gel to the peri wound area
Sheet hydrogel applied over the wound area

Question 11

Ultrasound - parameters

Answer 11

1 or 3 MHz depedning on depth needed
20% duty cycle
0.3 with acute
0.5 with reparative stage
up to 1.0 with early remodeling stage 
Overall lower duty and intensity to minimize thermal effects)

Question 12

Low frequency ultrasound - frequencies

Answer 12

22.5, 25, 35 kHz are for selective debridement

40 kHz for long wave mist US (non debriding)

Question 13

Low frequency US - properties

Answer 13

Antibacterial
Contact or non contact transport of US through an atomized vapor mist
40Hz is non contact and non debriding

Question 14

Disadvantage to low frequency US

Answer 14

Can only be used on smaller wounds

Question 15

Ultraviolet is what

Answer 15

Form of radiant energy

Follows physical laws of radiant energy - reflection, refraction, absorption, inverse square, cosine law

Question 16

Ultraviolet - wavelengths

Answer 16

UVA 400-320
UVB 320-280
UVC 280-200

Question 17

Ultraviolet - Which wavelength has peak bacteriocidal effects

Answer 17

UVC!

So use this for infection

Question 18

Ultraviolet - depth of penetration with A, B, C

Answer 18

C = stays very superficial on epidermis (melanocytes)
B = basale layer of epidermis 
A = deeper into papillary layer of dermis

Question 19

Sources of UV rays

Answer 19

Sun - UVC is filtered by ozone
UVA and UVB reach earth though
Mercury/Quartz lamps can be used

Question 20

Effects of UV rays

Answer 20

Inflammatory response
Stratum corneum thickening
Inc vit D production
Bactericidal effects

Question 21

Effects of UV rays - inflammatory response

Answer 21

VD, inc permeability, inc cellular activity

Question 22

Effect of UV rays - Stratum corneum thickening leads to

Answer 22

exfoliation
melanocyte migration
activation of melanin

Question 23

Effect of UV rays - Inc vit D production which does what

Answer 23

improves calcium and phosphorus availability

Question 24

Effect of UV rays - bactericidal effects -wich is most effective

Answer 24

UVC

Question 25

MED is what

Answer 25

Minimal erythemal dose

Question 26

MED - how to determine

Answer 26

1 - explain to pt and clean area 2 EYE PROTECTION for PT and pt 3 Place MED cutout on area - cover surrounding area 4 Position lamp 30 in away 5 Expose each shape for 15 sec, starting with 75 shape 6 Pt should check area and track the time it takes for each shape to show up and then resolve

Question 27

MED - Dosage - MED - Time to response? Time to resolution? Skin Reaction?

Answer 27

Response: 4 to 6 hrs Resolution: within 24 hours Skin rxn: slightly red

Question 28

MED - Dosage - E4 - Time to response? Time to resolution? Skin Reaction?

Answer 28

Response: 2 hrs Resolution: several days Skin rxn: sig erythema, blistering, exfoliation, pigmentation, edema, exudate

Question 29

With UVA and UVB what can you use as way to figure out dosage? What will be the distance between the source and the body part?

Answer 29

MED Skin typing about 30 inches

Question 30

UVC - effects Treatment parameters

Answer 30

Bactericidal effects Exposure time in 3 to 5 sec increments, might need up to 30 sec for some pathogens Distance is determined by equipment Might also help reduce odor

Question 31

Negative pressure wound therapy (NPWT) AKA

Answer 31

vacuum assisted closure

Question 32

Negative pressure wound therapy (NPWT) - how does it work

Answer 32

Wound bed must be 100% granular! Has to be clean! Sterile foam placed into wound bed Lightly fill tunnels and undermined areas Collection canister is connected to pump free end of tubing placed into the wound bed Film placed over it to seal Pump turned on (125 mmHg) Intermittent or continuous Keep on for 48-72 hours

Question 33

Negative pressure wound therapy Indications (NPWT) -

Answer 33

``` Acute and traumatic wounds Subacute wounds (dehisced incision) Pressure ulcers Chronic open wounds (stasis ulcers and diabetic ulcers) Meshed grafts Flaps ```

Question 34

Negative pressure wound therapy (NPWT) - small ambulant is recommended for

Answer 34

``` Venous stasis ulcers LE diabetic ulcers Pressure ulcers Dehisced incisions Grafts LE flaps ```

Question 35

Negative pressure wound therapy (NPWT) - Contraindicated for

Answer 35

Fistulas to organs or body cavities Necrotic tissue in eschar Osteomyelitis (untreated) Malignancy in the wound

Question 36

Hyperbaric oxygen therapy - application

Answer 36

systemic or topical application

Question 37

Hyperbaric oxygen therapy - how does it work

Answer 37

Inc oxygen concentration gradient May dec bacterial growth Limited research to support efficacy

Question 38

Total contact cast - used to treat

Answer 38

Grade 1 and grade 2 neuropathic ulcers

Question 39

Total contact cast - how does it work

Answer 39

Allows weight bearing with better distribution of forces Improves circulation secondary to edema control and warmth Protects foot and leg from additional trauma

Question 40

Total contact cast - contraindicated

Answer 40

With infection or gangrene In conditions with fluctuating edema ABIs less than 0.5 (she says mayber even 0.7)`

Question 41

Total contact cast - negatives

Answer 41

Requires training to apply | If improperly applied, there is significant risk of additional skin breakdown and infection! NEUROPATHY!

Question 42

Total contact cast - steps

Answer 42

1 Apply primary dressing 2 Stockinette 3 Felt is applied in areas of body prominence 4 Cover toes with foam 5 Add thin layer of cast padding 6 Apply fiberglass casting tape 7 Mold cast tape to extremity with use of a moist elastic wrap 8 Use cast shoe if a walking heel was not incorporated into the cast