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COAST TO COAST WOUND CARE Wound Care Training Program & MDS 3.0

COAST TO COAST WOUND CARE Wound Care Training Program & MDS 3.0. SPERO THEODOROU, MD Surgical Director. Manhattan Eye, Ear Nose and Throat Hospital New York University Plastic and Reconstructive Surgery. WOUND HEALING. Smith Papyrus 1700 BC Ambroise Pare 1500 AC Joseph Lister

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COAST TO COAST WOUND CARE Wound Care Training Program & MDS 3.0

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  1. COAST TO COAST WOUND CARE Wound Care Training Program & MDS 3.0

  2. SPERO THEODOROU, MDSurgical Director Manhattan Eye, Ear Nose and Throat Hospital New York University Plastic and Reconstructive Surgery

  3. WOUNDHEALING • Smith Papyrus 1700 BC • Ambroise Pare 1500 AC • Joseph Lister • Alexis Carrrel

  4. WOUNDHEALING • Inflammatory phase Vasoconstriction Vasodilation Histamine Fibronectin 24-48 hrs

  5. WOUNDHEALING • Fibroblastic Phase (proliferative phase) 2ndday (2-4 weeks) fibrous scaffolding Hyaluronic acid collagen deposition Increase tensile strength

  6. WOUNDHEALING • Maturation Phase (remodeling phase) week #3 collagen organization increase in tensile strength 80% Type I collagen : Type III collagen 4:1 scar maturation

  7. WOUNDHEALINGFACTORS • Oxygen Fibroblast proliferation 30-40 mmHg delivery system faults (DM, atherosclerosis…..) Hyperbaric oxygen

  8. WOUNDHEALING • SKIN High tolerance for ischemia Does not operate @ 37 C Great blood supply thermoregulation

  9. WOUNDHEALINGFACTORS • Hematocrit Quality of oxygen delivery Anemia

  10. WOUNDHEALINGFACTORS • Steroids Inhibition of wound macrophages Interference with : fibrogenesis angiogenesis wound contraction

  11. WOUNDHEALINGFACTORS • Vitamin A 25.000 IU 200.000 IU topical ointment Fights steroids collagen deposition stimulation increase breaking strength

  12. WOUNDHEALINGFACTORS • Vitamin C deficiency defective cappilaries local hemorrhages immature fibroblast proliferation no supra normal healing with excess!

  13. WOUNDHEALINGFACTORS • Vitamin E membrane stabilizing properties inhibition of wound healing in large doses antioxidant increase in tensile strength pre radiation therapy

  14. WOUNDHEALINGFACTORS • NSAIDS ASA, Ibuprofen….45% decrease in wound healing at therapeutic doses dose dependant

  15. WOUNDHEALINGFACTORS • Smoking Nicotine……vasoconstriction cappillary flow decrease carboxyhemoglobin hypoxia

  16. WOUNDHEALINGFACTORS • AGE FINALLY! tensile strength wound closure rates phases last longer qualitative changes decrease ischemia tolerance

  17. WOUNDHEALING • NUTRITION serum protein levels 2% prolonged inflammatory phase impaired fibroplasia methionine amino acid

  18. WOUNDHEALINGFACTORS • Hydration • Temperature • Denervation • Chemotherapy • Radiation • Diabetes Mellitus

  19. Diabetes + Wounds • Highest amputation rate • 20% of hospitalizations foot infections • 50% of all non-traumatic amputations • 25% of diabetics severe foot problems during lifetime

  20. Diabetesclinicalpresentation • Small punctuate wound plantar surface beneath a deformed metatarsal head • Neuropathy • Clawing • Microvascular disease • microemboli

  21. Diabetes • Invasion inside the foot along fascial planes • Transmetatarsal amputation • BKA • AKA

  22. Diabetesfactors • Atherosclerosis microvascular macrovascular palpable pulse due to calcification

  23. Diabetesfactors • Uremia • Neuropathy • Sensory deficit • Motor deficit loss of foot arch…2nd metatarsal head MC • Loss of sympathetic activity…no foot sweating….cracking of skin….infection

  24. Diabetesfactors • Hyperglycemia….bacterial nutrients • ? Loss of growth factors • Impaired immune system

  25. Diabetestreatment • Predictors (Margolis et al) • small ulcer size • Shorter duration of time present • Non-caucasian

  26. Diabetestreatment • Control hyperglycemia • Preventive foot maintenance • Care with toenail cutting • Good-fitting footware • Vascular examination (AB index) • doppler

  27. Diabetestreatment • Pressure elimination “off loading” total contact casts 89% removable cast walker 65% half shoes 58.3% Armstrong et al

  28. DiabetesTreatment • Debridment of devitalized tissue • Clindamycin + ciprofloxacin 95% 95% response rate 55% cured 21% improved 21% failure rate

  29. Diabetestreatment • Limit antibiotic ointments • discourage routine Cx • Infection vs colonization • odor

  30. DiabetesTreatment • Hyperbaric Oxygen? • Growth factors Regranex Human Platelet derived GF Frequent debridment

  31. VENOUSSTASISULCERS PATIENT ASSESMENT WEEKS 1-2 H&P Wound evaluation Vascular assessment Infection assessment

  32. VENOUSSTASISULCER • WEEKS 3-8 Ongoing treatment Venous arterial insufficiency Wound care treatment wound excision weekly surgical debridment compression Rx, Elevation

  33. VENOUSSTASISULCER • WEEKS 8 and OVER Skin Coverage grafts flaps Successful healing

  34. PRESSURESORES • Egyptian Mummies 1961 • Decumbre “to lie down” Decubitus sacrum, trochanter,heel,occiput,back • All types of tissue loss from pressure • Ischial tuberosities

  35. PRESSURESORES • EPIDEMIOLOGY General acute care setting 10-18% Long term care facilities 2,3%-28% Home Care setting 0-29%

  36. PRESSURESORES • Incidence Elderly with femoral neck fractures 66% Quadriplegic patients 60%

  37. PRESSURESORES • Pressures sores on admission to LTF 25-33% of residents • After admission 35% • first year 13.2% • second year 21.6%

  38. PRESSURESORES • Residents already in LTF with no PS first year 9.5% second year 20.4%

  39. PRESSURESORES • Mortality Hospital 1yr mortality after PS 59.5% (Thomas et al) LTF 55.7% death within 6weeks (Kennedy et al)

  40. PRESSURESORES • WHAT DOES THIS MEAN? PS not independent risk factor for mortality Indirect marker for coexisting illness, malnutrition,associated comorbidities

  41. PRESSURESORES • Spinal cord injury patients 7-8% direct cause of death Osteomyelitis, sepsis SUPERMAN

  42. PRESSURESORES • COSTS 2004-2005 National Pressure Advisory Panel

  43. PRESSURESORES • COSTS $15,229 per year per patient length of stay increased by 8.2 days

  44. PRESSURESORES • Anatomic distribution Ischial tuberosity 28% Sacrum 36% Heel 30%

  45. PRESSURESORES • Pathophysiology • Neuropathic theory • cappillary pressure 30mmHg • shear

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