1 / 60

Introduction to Problem Wound Healing

Family Medicine Review April 14, 2011. Introduction to Problem Wound Healing. H. Sprague Taveau IV, DO, MBA, FACOFP Medical Director Center for Wound Care and Hyperbaric Medicine. Faculty Disclosure H. Sprague Taveau IV, DO, MBA, FACOFP.

trista
Télécharger la présentation

Introduction to Problem Wound Healing

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Family Medicine Review April 14, 2011 Introduction to Problem Wound Healing H. Sprague Taveau IV, DO, MBA, FACOFP Medical Director Center for Wound Care and Hyperbaric Medicine

  2. Faculty DisclosureH. Sprague Taveau IV, DO, MBA, FACOFP It is the policy of Diversified Clinical Services and Metroplex Adventist Hospital to ensure balance, independence, objectivity, and scientific rigor in all of its individually sponsored or jointly sponsored educational programs. Dr. Taveau is the Medical Director for Metroplex Adventist Hospital’s Center for Wound Care and Hyperbaric Medicine in Killeen, TX, and is a Regional Medical Director for Diversified Clinical Services. He has no other affiliations nor does he own stock in any company that produces equipment or products discussed in this presentation. REGRETABLY!!

  3. Objectives • Become familiar with the fundamental aspects of wound healing and its interrelationship with oxygen • Become familiar with the process of evaluating patients for and instituting hyperbaric oxygen therapy • Recognize the physiologic and pharmacologic benefits of hyperbaric oxygen therapy

  4. The Nine Essentials of Wound Healing • Adequate Perfusion • Elimination of Non-Viable Tissue • Control Inflammation or Infection • Control Edema • Optimize Wound Microenvironment • Optimize Tissue Growth • Ensure Proper Off-Loading • Control Pain • Optimize Host Factors

  5. The Nine Essentials of Wound Healing • Adequate Perfusion • Non-Viable Tissue • Inflammation or Infection • Edema • Wound Microenvironment • Tissue Growth Optimized • Off-Loading • Pain Control • Host Factors

  6. The Nine Essentials of Wound Healing If you can’t get water to the garden……the garden won’t grow!!!!

  7. The Nine Essentials of Wound Healing • Adequate Perfusion • Non-Viable Tissue • Inflammation or Infection • Edema • Wound Microenvironment • Tissue Growth Optimized • Off-Loading • Pain Control • Host Factors

  8. The Nine Essentials of Wound Healing Wounds Won’t Heal in a SEWER!!

  9. The Nine Essentials of Wound Healing • Adequate Perfusion • Non-Viable Tissue • Inflammation or Infection • Edema • Wound Microenvironment • Tissue Growth Optimized • Off-Loading • Pain Control • Host Factors

  10. The Nine Essentials of Wound Healing Wounds With BUGS Don’t Heal!!

  11. The Nine Essentials of Wound Healing • Adequate Perfusion • Non-Viable Tissue • Inflammation or Infection • Edema • Wound Microenvironment • Tissue Growth Optimized • Off-Loading • Pain Control • Host Factors

  12. The Nine Essentials of Wound Healing Wounds Don’t Heal in a Swamp!!

  13. The Nine Essentials of Wound Healing • Adequate Perfusion • Non-Viable Tissue • Inflammation or Infection • Edema • Wound Microenvironment • Tissue Growth Optimized • Off-Loading • Pain Control • Host Factors

  14. The Nine Essentials of Wound Healing Wounds Don’t Heal Unless The Environment Supports Healing

  15. The Nine Essentials of Wound Healing • Adequate Perfusion • Non-Viable Tissue • Inflammation or Infection • Edema • Wound Microenvironment • Tissue Growth Optimized • Off-Loading • Pain Control • Host Factors

  16. The Nine Essentials of Wound Healing Tissue Growth is OUR Business

  17. The Nine Essentials of Wound Healing • Adequate Perfusion • Non-Viable Tissue • Inflammation or Infection • Edema • Wound Microenvironment • Tissue Growth Optimized • Off-Loading • Pain Control • Host Factors

  18. The Nine Essentials of Wound Healing Wounds Don’t Heal Under Pressure!!

  19. The Nine Essentials of Wound Healing • Adequate Perfusion • Non-Viable Tissue • Inflammation or Infection • Edema • Wound Microenvironment • Tissue Growth Optimized • Off-Loading • Pain Control • Host Factors

  20. The Nine Essentials of Wound Healing Controlled Pain = Better Compliance

  21. The Nine Essentials of Wound Healing • Adequate Perfusion • Non-Viable Tissue • Inflammation or Infection • Edema • Wound Microenvironment • Tissue Growth Optimized • Off-Loading • Pain Control • Host Factors

  22. The Nine Essentials of Wound Healing Wounds Don’t Heal Without Building Blocks!!

  23. Selecting Patients for HBO • By ability to reverse specific pathophysiology …of wound healing failure • By diagnosis

  24. Benefits of Hyperbaric Oxygen • Physiologic Effects: • Improved leukocyte function and bacterial killing • Antibiotic potentiation • Enhanced collagen synthesis and cross-linking • Pharmacological Effects: • Direct antimicrobial effects, toxin synthesis • suppression • Blunting of systemic inflammatory responses • Prevention of leukocyte activation and adhesion • PDGF-BB receptor stimulation (multiple effects) • VEGF release and angiogenesis • Detoxification (CO, CN, H2S)

  25. Selecting Patients for HBO • By ability to reverse specific pathophysiology …of wound healing failure • By diagnosis

  26. Emergency/Acute Indications • Cerebral Arterial Air or Gas Embolism • Carbon Monoxide Poisoning • Cyanide Poisoning • Hydrogen Sulfide Poisoning • Clostridial Myositis & Myonecrosis • Acute Traumatic Ischemia • Crush Injury • Compartment Syndrome • Replantation Limb/Digits Etc.

  27. Emergency/Acute Indications • Decompression Sickness • Exceptional Blood Loss (Anemia) • Intracranial Abscess • Necrotizing Soft Tissue Infections • Thermal Burns (Not CMS Approved) • Combined Synergistic Necrotizing STI • Compromised Skin Grafts/Flaps

  28. Acute Traumatic Ischemia • 4 year old slipped and fell into a riding lawn mower, sustaining a mid-calf amputation of his leg. Leg was successfully replanted. • Ischemic time: 10 hours • Tx’d aggressively with HBO

  29. Acute Traumatic Ischemia • Appearance of muscle three days after replantation shows 100% viability as HBO counteracted reperfusion injury.

  30. Acute Traumatic Ischemia • Three Months after Injury • HBO @ 2.4 ATA x 90 minutes q8h x 6 • Then q12h x 4

  31. Acute Traumatic Ischemia • The result was excellent function of the leg. The patient regenerated his nerves and ended up with a sensate foot. He was able to walk and run with the aid of a brace.

  32. Non-approved Emergent Indications • Retinal Artery Insufficiency • Actinomycosis

  33. Chronic/Elective Indications • Problem Wounds • Diabetic Foot Ulcers (Chronic; Wagner III) • Arteriolar Insufficiency • Etc. • Chronic Refractory Osteomyelitis • Delayed Radiation Injury • Soft Tissue • Bony • Meleny Ulcer (Invasive Group A Strep)

  34. Age associated differences in cellular Proliferation (in vitro)… New born Young adult Old adult (Buras and Buras, Harvard Medical School, MGH, Boston)

  35. Decreased cellular proliferation with diabetes… (Buras and Buras, Harvard Medical School, MGH, Boston)

  36. HBO Dramatically Increases Old Adult Fibroblast Proliferation… (Buras and Buras, Harvard Medical School, MGH, Boston)

  37. HBO Dramatically Increases Diabetic Fibroblast Proliferation… (Buras and Buras, Harvard Medical School, MGH, Boston)

  38. PtcO2 < 30 mmHg indicated 39 fold increased risk of early healing failure. PtcO2 As A Predictor of Wound Healing in Diabetic Foot Wounds… = Initial healing success = Initial healing failure Pecoraro, et al. Diabetes 40:1305-1313, 1991

  39. Post Smoking Pre Smoking Baseline 2 hours pre…………………………2 hours post What About Smoking?

  40. Wagner Classification Diabetic Foot Ulcers • Grade 0: Intact skin • Grade I: Superficial without penetration deeper layers • Grade II: Deeper reaching tendon, bone, or joint capsule • Grade III: Deeper with abscess, osteomyelitis, or tendonitis extending to those structures • Grade IV: Gangrene of some portion of the toe, toes, and/or forefoot • Grade V: Gangrene involving the whole foot or enough of the foot that no local procedures are possible Grade I or II w/Infection = Grade III Wagner FW. Foot & Ankle 1981, 64-122

  41. DFU 10/16/09

  42. DFU 11/20/09

  43. DFU 12/30/09

  44. Soft Tissue Radionecrosis • Malignant Fibro-Histiocytoma • Wide excision • Radiation therapy • 2 months post-op • Dehiscence • Radionecrosis • Purulent drainage

  45. Soft Tissue Radionecrosis • Close-up view • 9 x 6.5 cm • Stage III/IV Ulceration

  46. Soft Tissue Radionecrosis • 1 week post-HBO • 2 ATA • 90 minutes each • Q24h • 20 treatments • 5 days/week • Routine wound care • Oral antibiotics

  47. Soft Tissue Radionecrosis • 10 days post-STSG • Ambulating without difficulty • No further procedures required

  48. Absolute Contraindications • Untreated Pneumothorax • Pregnancy (Almost)

  49. Relative Contraindications • Upper Respiratory Infections • Chronic Sinusitis • Emphysema w/CO2Retention • High Fevers • History of Seizure Disorder • Pregnancy

  50. Relative Contraindications (Continued) • History of Surgery for Otosclerosis • PE tubes • Viral Infections • Get worse • Congenital Spherocytosis • Hemolysis in presence of increased PaO2 • History of Optic Neuritis • May be associated with blindness

More Related