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Clin Med - II (Surgery) > Wounds > Flashcards

Wounds Flashcards

1
Q

T/F

Wounds are more common and more complex, but receive less reimbursement.

A

True

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2
Q

Why are wounds more common?

A

Rise in the aging population
Increase in diabetes population
- PAD
- Neuropathy - LOPS

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3
Q

Wounds tx challenges

A

Multiple co-morbidities
Drug resistant infections
Incorrect perception of ability to tx
Focusing on tx instead of pt

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4
Q

Wounds - Declining payment

A

Non-payment for readmission 30 days even if care was exemplary
Non-payment for readmission EVER if the wound is hospital acquired

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5
Q

Goal of Wound Care

A

Heal it quickly
Heal it cheaply
Prevent recurrence
Prevent it in the first place

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6
Q

Stages of normal wound healing

A

Hemostasis
Inflammation
Proliferation
Maturation

These are complex and overlapping

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7
Q

Hemostasis

A 
Vasconstriction and retraction of damaged vessels
Formation of platelet plug
Histamine mediated vasodilation
Increased capillary permeability
Key players - platelets and mast cells
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8
Q

Inflammation

A 
Leukocyte demargination form endothelial walls
Integrin facilitates diapedesis
Onset of phagocytosis
- Oxygen independent
- Oxygen dependent
- Oxidative burst
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9
Q

Proliferation

A

Granulation tissue formation (fibroblasts)
Angiogenesis (endothelial cells)
Epithelialization - will only migrate over granulation tissue
All of the above process is oxygen tension dependent - minimum of 30mmg TcPO2

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10
Q

Maturation

A

Immature type 3 collagen is replaced by stronger type 1 dermal collagen - continues for up to 2 year
Collagen cross-linking
Orients along lines of stress
“closed” is not the same as “healed”

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11
Q

T/F

A closed wound and a healed wound are the same thing.

A

False

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12
Q

Critical components in wound healing

A

Growth factors
Matrix receptors / integrins
Matrix metalloproteases

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13
Q

Growth Factors

A

Complex proteins (released by cells) that stimulate

  • Chemotaxis
  • Mitosis
  • Angiogenesis
  • Growth factor production by other cells
  • Production and degradation of extracellular matrix
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14
Q

Key growth factors

A

Platelet derived growth factor - PDGF
Vascular endothelial growth factor (VGEF)
Fibroblast growth factors
Transforming Growth factor - Beta

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15
Q

Platelet derived growth factor - PDGF

A

Platelets, macrophages, fibroblasts

Chemotactic for fibroblasts, smooth muscle cells, monocytes and neutrofils

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16
Q

Vascular endothelial growth factor (VGEF)

A

Modulated angiogenesis

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17
Q

Transforming Growth factor - Beta

A

Potent stimulant for collagen deposition

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18
Q

Matrix receptors / integrins

A

Cell surface receptors
Enables cells to detect and interact with components of ECM
- Platelet - collagen (hemostasis)
- Leukocyte extravasation during inflammation
- Endothelial cell budding/migration during angiogenesis
- Epithelial cell migration

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19
Q

MMPs

A

Matrix Metalloproteases

Protein degrading enzymes
Secreted in respone to biochemical marker (TNF, IL-1, IL-6)
Results in balance between GF/MMP
- Imbalance cause wound healing impairment
TIMPs - Tissue inhibitors of MMPs

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20
Q

Chronic wounds

A

Wounds that do not heal in an expected time frame
Generally underlying pathophysiologic insult to tissues
Generally procedures stagnation in one or more phases (inflammation) of wound healing)
Chronic wounds do not heal - only acute wounds do

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21
Q

Bioburden

A

Related to biofilm
Necrotic tissue, senescent cells, eschar, proteinacious secretions, bacteria (toxins, enzymes, MMPs
Physical barrier
Metabolic / oxidative stress
Not responsive to systemic or topical antimicrobials

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22
Q

Healing wound

A 
Low inflammatory cytokines
Low proteases, ROS
Intact functional matrix
High mitogenic activity
Mitotically competent cells
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23
Q

Evaluation of wounds

A 
Arterial
Venous
Infection
Pressure
M (Meds, malnutrition, metabolic, malignancy, malizia sociale)
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24
Q

Arterial Wounds

A

Ischemia/hypoxia from failure to provide adequate oxygenated blood flow to tissue/cells

PAD, vasoconstriction and edema are most common

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25
Q

PAD - RF

A 
Smoking
DM
Hyperlipidemia
HTN
Prior radiation therapy exposure
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26
Q

Vasoconstriction - RF

A 
Nicotine
Caffine
Pressors
Raynaud's / Berger's
BB
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27
Q

Arterial Occlusive Disease - PE

A 
Palpate pulse
Listen for pulse (doppler)
Capillary refill
Hair growth
Mottling
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28
Q

Arterial Occlusive Disease - Eval

A

Ankle-Brachial Index (ABI)
Trans-Cutaneous Oxygen Measurement (TCOM)
Laser Doppler flow
Angiography

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29
Q

Peripheral Venous Insufficiency - Causes

A 
Valvular Dz
- Hereditary
- Venous Thrombosis
- Chronic venous HTN
Saphenous-femoral vein junction incompetence
Perforators
30
Q

Peripheral Venous Insufficiency - Eval

A

US and Venography

31
Q

Peripheral Venous Insufficiency - which US to order

A

Venous Duplex exam with varicose veins studies

32
Q

Peripheral Venous Insufficiency - PE

A

Varicose veins
Abnormal skin pigmentation - hemosiderin staining
Edema
Dermal hypertrophy

33
Q

Edema

A

Increased distance from capillary wall to cell

  • Oxygen delivery
  • Nutrients
  • Leukocytes
  • Metabolic wast products
  • Meds
34
Q

Infection - in general

A

Microbial progression in wounds

Soft tissue vs. deep tissue

35
Q

Soft Tissue Infection

A

Acute wound infections are typically Gram positive bacteria

Chronic wounds transition to Gram negatives

Anaerobes are found in deep and poorly oxygenated wounds

36
Q

Acute wound bacteria

A

Gram positive

Increasing frequency of MRSA and cMRSA

37
Q

Chronic wound bacteria

A

Transition to Gram negative

E. coli, Pseudomonas, Proteus, and Klebsiella

38
Q

Bacteria found in deep wounds with poor oxygenation

A

Anaerobes

39
Q

Microbial progression - main steps

A

Contamination
Colonization
Infection

40
Q

Microbial progression - Contamination

A

Host control
Local tx
- Physically remove/reduce microbes (irrigation)
- Dressings, topical anti-infectives of secondary importance

41
Q

Microbial progression - Colonization

A

Bacteria and host at “equilibrium”
Associated with biofilm (bioburden)
Requires removal of biofilm and any necrotic tissue
Requires topical (and possibly systemic anti-infectives

42
Q

Microbial progression - Infection

A

Microbial control, host damaged
Debridement
Topical anti-infectives
Systemic abx necessary

43
Q

Wound culture

A

Swab cultures are typically unreliable (infection vs. colonization?)

Tissue cultures are superior, if feasible

44
Q

Pressure - in general

A

If the wound is caused / prolonged by pressure, why would it heal if the pressure is not removed?

45
Q

M is for miscellaneous - in general

A 
Meds
Malnutrition
Metabolic
Malignancy
Malizia sociale
46
Q

Medications that could cause a wound

A

Anti-neoplastics
Anti-rheumatologics
Corticosteroids

47
Q

Malnutrition as a cause of a wound

A

Macro / micro nutrient needs

48
Q

Metabolic d/o as a cause of a wound

A

DM

Thyroid d/o

49
Q

Wound care products

A

Cost-effectiveness
Outcome based - studies vs. case reports
Normal wound healing is a moist, sterile/clean process
Choice of product(s) should help accomplish this w/o inhibiting cell/tissue growth

50
Q

Cost-effectiveness - how to eval

A

Not always the cheapest per unit
Need to track cost to closure/prevention
Must be effective to be cost-effective

51
Q

Characteristics of the ideal dressing

A

Maintain wound moisture while absorbing excess fluid
Free of particles and toxic wound contaminants
Non-toxic and non-allergenic
Capable of protecting the wound from further trauma
Can be removed w/o causing trauma to the wound
Impermeable to bacteria
Thermally insulting
Will allow gaseous exchange
Comfortable and conformable
Require only infrequent changes
Cost effective
Long shelf life

52
Q

Foam as a dressing

A

Low adherent
Small amount of exudate
Provide comfort
Duration depends on amount of drainage

53
Q

Semi-permeable film

A 
Promote moist environment
Adhere to healthy skin, but not to wound
Allow visual checks
May be left in place several days
Useful as secondary dressing
Not for infected or heavily exuding wounds
54
Q

Hydrocolloid

A

Cavity or flat shallow wounds with low to medium exudate; absorbent; conformable; good in “difficult” areas
May be left in place for several days
Useful debriding agent
May cause maceration

55
Q

Difficult wound areas to dress

A

Heel
Elbow
Sacrum

56
Q

Hydrofiber

A 
Useful in flat wounds, cavities, sinuses, undermining wounds
Medium to high exudate wounds
Highly absorbent
Non-adherent
May be left in place for several days
Needs secondary dressing
57
Q

Alginates

A 
Useful in cavities and sinuses and for undermining wounds
For all wound types with high exudates
Highly absorbent
Need secondary dressing
Need to be changed daily
58
Q

T/F

Understanding why wounds do not heal is necessary to achieve healing

A

True

59
Q

What part of a treatment plan must be secondary to patient evaluation?

A

product selection

60
Q

What is essential for an effective plan of wound care?

A

Systematic wound evaluation

61
Q

Hyperbaric Oxygen Therapy (HBOT)

A

Inhalation of 100% oxygen in a chamber at pressures greater than atmospheric pressure
Typically 2.0 - 3.0 ATA, but may be up to 6 ATA
Topical oxygen is NOT HBOT

62
Q

Monoplace Hyperbaric Chamber - Advantages

A

Cheaper
Fewer staff needed
Safer for staff
“Mobile”

63
Q

Monoplace Hyperbaric Chamber - Disadvantages

A

Do not allow direct interaction with pt
No fire suppression system
Limited depth

64
Q

Multiplace Hyperbaric Chamber - Advantages

A

Able to tx multiple pts at once
Able to directly interact with pt
Suitable for research
Able to compress to 6 ATA

65
Q

Multiplace Hyperbaric Chamber - Disadvantages

A

Cost
Risk to tenders
Profile to lowest common denominator
Immobile

66
Q

HBOT as a drug - Definable dose

A 
Concentration (Fio2 = 1.0)
Pressure (2.0-6.0 ATA)
Time exposure (minutes, UPTD)
67
Q

HBOT as a drug - Therapeutic index

A

Minimum effective concentration (MEC)

Maximum dose toxic concentration (MDTC)

68
Q

Primary therapy

A

HBOT is the effective therapy
No other therapy will be as effective
Healing/recovery not expected w/o HBOT

69
Q

Adjunctive therapy

A

HBOT is added to the therapeutic regimen to effect a better outcome
Healing/recovery may/may not occur w/o HBOT
No other therapy alone is thought to be as effective as HBOT

70
Q

HBOT - Physiologic Effects

A

Increases TpO2 independent of Hgb

With a common tx profile, there is almost a 20x increase in the amount of oxygen delivery to the tissue

71
Q

Approved indications for HBOT

A 
DCI / Age
CO poisoning
Failed flaps/grafts
Acute arterial ischemia
Central retinal A. occlusion
Exceptional anemia
Brain abscess
DM extremity wounds
Chronic osteomyelitits
Necrotizing fascitis
Gas gangrene
Delayed radiation injury
Idiopathic sensori-neural hearing loss
Crush injury
72
Q

Important aspects of HBOT

A 
Compresses bubbles
Supports ischemic tissue
Enhances angiogenesis
Alters metabolic/physiologic functions
Adjunctive to abx in tx infection (gas gangrene)
Negates CO

Clin Med - II (Surgery) (10 decks)

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