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Wound Care for the Primary Care Provider
Jeffrey C Wienke Jr, DPM, CWSP
Director, Amputation Prevention Center at
Capital Foot and Ankle Clinic
Disclosure
• Clinical Speaker: MiMedx, Marietta, GA
Podiatrist
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Objectives:
• Review appropriate ulceration work up
• Become familiar with the IDSA guidelines for diagnosis/treatment of diabetic foot infections
• Understand treatment approaches for open ulcerations
Wound Evaluation
• Location– Bony prominence, proximal vs distal
• Size– Dimensions, depth, shape
• Tunneling/Undermining– Sinus tracts
• Bed– Granular/fibrotic/necrotic– Exposed tendon or bone
• Edges– Definition
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Etiology of Ulcerations
• P‐ Pressure
• I‐ Infection (SSSI vs osteomyelitis)
• C‐ Circulation (vascular disease)
• S‐ Swelling
Rogers, LC. Diabetic Foot Ulcers: A Clinical Practice Pathway. 2016
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Infection
• 5 cardinal signs of infection– Rubor‐ redness
– Calor‐ heat
– Dolor‐ pain
– Tumor‐ swelling
– Functio laesa‐ loss of function
– Also consider in cases of abscess:• Fluctuance
• Crepitus
• Radiographic signs of gas/fluid/air
Lipinski BA., et al. 2012 Infections Disease Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases: 54(12); 132‐173. 2102
Infection
• Other findings not indicative of wound infection:
– Drainage
– Smell
• Osteomyelitis
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Initial Evaluation
Infection
• Decide whether or not
infection is present
– Manage infection if
present
Lipinski BA., et al. 2012 Infections Disease Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases: 54(12); 132‐173. 2102
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IDSA Guidelines
• In which diabetic patients with a foot wound should I suspect infection, and how should I classify it?
1: Consider possibility in any DFU
‐ looking for redness, warmth, swelling, pain
2: Be aware of factors that increase risk
‐ + PTB, >30 days, recurrent wounds, traumatic wounds, PVD, Renal disease, or barefoot walking
IDSA Guidelines
• How should I assess a diabetic patient presenting with a foot infection
4: 3 levels‐ whole, foot/limb, wound
5: Diagnose based on at least 2 classic symptoms
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IDSA Guidelines
• When and how should I obtain specimen for culture from a patient with a diabetic foot infection?
16: For uninfected wounds, DO NOT CULTURE
17: Send specimen prior to starting ABX
18: Send specimen, not swab
‐ After irrigation/debridement
IDSA Guidelines
• How should I select ABX?
19: Uninfected wound should NOT be treated with ABX
20: Infected wounds should be started on ABX, need to be in conjunction with appropriate wound care
21: Empiric therapy based on severity
22: Definitive therapy based on cultures
23‐24: Length based on severity
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IDSA Guidelines
• When should I consider imaging studies, and which should I select?
25: Plain film x‐rays for all DFU
26: MRI only I abscess questionable or to R/O OM
27: IF no MRI, consider bone scan
Rogers, LC. Diabetic Foot Ulcers: A Clinical Practice Pathway. 2016
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Circulation/Vascular
• Palpate pedal pulses
• CFT
• Doppler
• Consider NIVS even in the presence of palpable pedal pulses if the wound is not progressing as expected
• Referral for revascularization
Hingorani A., et al. The Management of Diabetic Foot: A Clinical Practice Guideline by the Society for Vascular Surgery in Collaboration with the American Podiatric Medical Association and Society for Vascular Medicine. J Vasc Surg: 63(2); 3s‐21s. 2016
Circulation/Vascular
– Pulses
• Popiteal
• posterior tibial
• dorsalis pedis
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Circulation/Vascular
– Capillary Refill
– Digital Hair Growth
Rogers, LC. Diabetic Foot Ulcers: A Clinical Practice Pathway. 2016
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Pressure‐ offloading
• Difficult and individualized
• Most effective is Total Contact Cast or Other Non‐removeable device
• Numerous other options exist– NWB
– AFO
– Custom shoes/orthotics
– Diabetic shoes
* Hingorani A., et al. J Vasc Surg: 63(2); 3s‐21s. 2016*Snyder RJ., et al. JAPMA: 104(6); 555‐567. 2014
Pressure‐ offloading
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Rogers, LC. Diabetic Foot Ulcers: A Clinical Practice Pathway. 2016
Treatment of DFU‐ Debridement
• Sharp debridement of open ulcerations removes fibrotic tissue and bacteria, stimulates angiogenesis, and turns a chronic wound into an acute wound
Myers, BA. The Wound Care Practitioner: Guidelines for Clinical Practice. Taken from: Wound Management: Principals and Practice, Third edition. Pearson 2012
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Dressings
• Moist wounds heal 3‐5 times faster than dry wounds
• Divided into two basic types:– Primary dressing
• Dressing that comes into contact with the wound, sometimes called the contact layer
– Secondary dressing• Placed over the primary
dressing• Provides increased protection,
cushioning, absorption, or occlusion
• Functions of dressings:– Create moist wound
environment• Absorb excess exudate• Donate moisture to the wound
– Provide thermal insulation (37‐38 degrees C)
– Provide barrier to microorganisms
– Protect exposed nerve endings
– Hemostasis– Edema control– Elimination of dead space
Myers, BA. The Wound Care Practitioner: Guidelines for Clinical Practice. Taken from: Wound Management: Principals and Practice, Third edition. Pearson 2012
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Dressings
• Continuum of dressings
– Gauze
– Impregnated Gauze
– Semipermeable Film
– Hydrogel
– Semipermeable Foam
– Hydrocolloid
– Alginate
Dressings
• Gauze:
– Example: Kerlix, Kling, Nu‐Gauze
– Benefits: Cheap, readily available
– Limitations: Adhere to wound bed, non‐selective debridement, higher infection rate
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Dressings
• Impregnated Gauze:
– Example: Xeroform, adaptic
– Benefits: Decrease trauma, decrease pain
– Limitations: more costly, require secondary dressing
Dressings
• Semipermeable Film:
– Example: Tegaderm
– Benefits: Moisture retentive, allow visualization, encourage autolytic debridement
– Limitations: Adhesive, limited on amount of drainage, can not be used on infected wounds
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Dressings
• Hydrogel:
– Example: SAF‐GEL, Solosite, AQUASORB
– Benefits: Moisture retentive, encourage autolytic debridement, reduce pain, inexpensive
– Limitations: may dehydrate, can not be used on highly exudative wounds, require secondary dressing
Dressings
• Semipermeable Foam:
– Example: Mepilex
– Benefits: Moisture retentive, encourage autolytic debridement, thermal insulation, protection
– Limitations: Adhesive, may roll, expensive
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Dressings
• Hydrocolloid:
– Example: Aqua‐cell, Duo‐derm
– Benefits: Absorb drainage, able to be packed into tunneling wounds
– Limitations: Leave residue in wound, may cause hypergranulation, expensive
Dressings
• Alginate:
– Example: CURASORB
– Benefits: Absorbent, used on infected wounds
– Limitations: Requires secondary dressing, care must be taken on exposed tendon/bone
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Rogers, LC. Diabetic Foot Ulcers: A Clinical Practice Pathway. 2016
Common Mistakes
• Soaking
• Inappropriate offloading
• Petroleum based dressings
• Hydrogen peroxide
• Antibiotics
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Advanced Healing Modalities
• Split thickness skin grafts• Dermal substitutes
– Dermagraft– Apligraft– Oasis– Graft Jacket– Integra– Etc
• Whirlpool• Negative Pressure Wound
Therapy• HBO• Mist Therapy
Rogers, LC. Diabetic Foot Ulcers: A Clinical Practice Pathway. 2016
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Case Studies
Case #1
• 67 y/o male
• Poorly controlled Type II DM (HgA1c: 8.3%), HTN, Hyperglycemia, obesity
• Denies tobacco, every day alcohol, employed part time, very active
• Presents today complaining of a draining lesion on the plantar aspect of his foot, present for the past couple of weeks. Notes occasional drainage. Treating daily with soaks, TAO, band‐aid, leaving open to air at night
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Case #1
What would be the first step in the focused physical exam?
A. Vitals
B. Palpate Pedal Pulses
C. Visual exam (R/O Infection)
D. Gait exam
Case #1
What would be the first step in the focused physical exam?
C. Visual exam (R/O Infection)
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Case #1
Case #1
What would be the most reasonable first step of his treatment?
A. Topical Mupirocin
B. Wound Culture
C. Augmentin 875mg
D. None of the above
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Rogers, LC. Diabetic Foot Ulcers: A Clinical Practice Pathway. 2016
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Case #1
What would be the most appropriate was to offload this ulceration?
A. Non‐weightbearing
B. Total Contact Cast
C. CAM Boot
D. Post‐op shoe
E. Diabetic Shoes
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Case #1
What would be the most appropriate wound cleanser?
A. Hydrogen peroxide
B. Tap water shower
C. NS
D. Epsom salt soak
Case #1
What would be the most appropriate wound cares?
A. Silvadene and telfa
B. Triple antibiotic and gauze
C. Therabond
D. Wound gel and band‐aid
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Case #1
What would be the most appropriate wound cares?
Debridement
Showering (no soaking)
Moist contact layer
Non‐stick secondary dressing
Case #2
• 71 year old male with Hxof CVA
• Patient now confined to power wheel‐chair
• Called EMS due to arm weakness and speech difficulty
• Back‐boarded by EMS, transported to hospital
• Transferred to CT scan on backboard (total of over 3 hours)
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Case #2
• Patient now has posterior heel wound
– 6 month duration
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Case #2
• What would be the most appropriate next diagnostic/treatment plan?
– A: IV Antibiotics
– B: Wound culture
– C: MRI foot
– D: Vascular Exam
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Case #2
• The patient undergoes aortogram with stenting
• What next?
– Wound cares and offloading
Case #2
• The patient undergoes aortogram with stenting
• What next?
– Wound cares and offloading
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Case #2
• The patient undergoes aortogram with stenting
• What next?
– Wound cares and offloading
Case #3
• 68 year old male with chronic bilateral ulcerations
• What is the etiology of these ulcerations?– A: Arterial
– B: Diabetic
– C: Venous
– D: Pressure
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Case #3
• Venous insufficiency ulcerations– No need for antibiotics
• Often misdiagnosed as cellulitis– Erythema is constant
– Look for warmth, fever, leukocytosis
– No topicals!
– Treatment?• Absorption
• Compression
– Ensure cardiac health prior to compression
• Lasix?
• Edema pumps
• Elevation
• Diet modification
Case #3
• Venous insufficiency ulcerations– No need for antibiotics
• Often misdiagnosed as cellulitis– Erythema is constant
– Look for warmth, fever, leukocytosis
– No topicals!
– Treatment?• Absorption
• Compression
– Ensure cardiac health prior to compression
• Lasix?
• Edema pumps
• Elevation
• Diet modification
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References
• Hingorani A., et al. The Management of Diabetic Foot: A Clinical Practice Guideline by the Society for Vascular Surgery in Collaboration with the American Podiatric Medical Association and Society for Vascular Medicine. J Vasc Surg: 63(2); 3s‐21s. 2016
• Lipinski BA., et al. 2012 Infections Disease Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases: 54(12); 132‐173. 2102
• Myers, BA. The Wound Care Practitioner: Guidelines for Clinical Practice. Taken from: Wound Management: Principals and Practice, Third edition. Pearson 2012
• Rogers, LC. Diabetic Foot Ulcers: A Clinical Practice Pathway. 2016• Sheehan P, et al. Percentage Change in Wound Area of Diabetic Foot Ulcers Over a
4‐Week Period Is a Robust Predictor of Complete Healing in a 12‐Week Prospective Trial. Diabetes Care: 26; 1879‐1882. 2003
• Snyder RJ., et al. The Management of Diabetic Foot Ulcers Through Optimal Offloading: Building Consensus Guidelines and Practical Recommendations to Improve Outcomes. JAPMA: 104(6); 555‐567. 2014