Chronic Wound Care 4th Edition Excerpts
Chapter 43
Technologies for Assessment of Wound Microcirculation
William J. Ennis, DO, MBA, FACOS; Douglas Smith, BS; Patricio Meneses, PhD
The search to understand the form and function of various organ systems has led to an explosion of invasive and noninvasive diagnostic techniques and imaging devices. Until recently, however, the same could not be said for developments in skin assessment. The fact that the clinician could simply “look” at a patient and arrive at a preliminary dermatological working diagnosis significantly delayed the field. Techniques, such as biopsy, photography (eg, ultraviolet [UV] light, polarized light), and digital image analysis, have been developed to analyze dermal form and structure. Recently, high frequency ultrasound techniques with axial resolution to 50–80 microns have been developed that hold promise for providing structural and physiological information.
Section 6: Leg Ulcers—Venous, Arterial, and Others
Chapter 44
Venous Leg Ulcers
R. Gary Sibbald, BSc, MD, FRCPC (Med Derm), ABIM DABD, MEd; Diane Williamson, MBChB, MRCP (UK); Jose Contreras-Ruiz, MD; Cathy Burrows, RN, BScN; Marc Despatis, MD, FRCSC; Vincent Falanga, MD, FACP; George W. Cherry, DPhil (Oxon)
The treatment of venous disease has progressed tremendously over the past 15 years. Noninvasive diagnostic procedures can now localize thrombosis and reflux to the superficial, perforatoring, and deep venous systems. Handheld Dopplers and a full duplex Doppler examination in the vascular laboratory are the gold standards to accurately diagnose co-existing arterial and venous disease. A meta-analysis has clearly demonstrated the effectiveness of high compression systems for treatment in the absence of significant arterial disease. Healthcare delivery and improved patient outcomes have been facilitated by the emergence of interprofessional wound care teams and community clinics. Surgical procedures, intermittent pneumatic compression, complementary therapies (ultrasound), medical treatments (pentoxifylline, horse chestnut extract), new silver dressings, and biological agents can all potentially improve healing.
Chapter 45
Arterial Ulcers: Assessment, Classification, and Management
G. Allen Holloway, Jr, MD
[A]rterial ulcers occur due to ischemia, and the only effective way to heal these ulcers is to provide an increase in blood supply. In the presence of arterial ulcers, the patient must be referred to the vascular surgeon or interventionalist for revascularization, as other approaches are virtually never effective. Given this overall approach, this chapter addresses how to evaluate these ulcers and what adjunctive management techniques may be applicable.
Chapter 46
Uncommon Ulcers
Siobhan M. Ryan MD, FRCPC; Robert J. Sargeant, MD, PhD, FRCPC
A wide variety of medical conditions and environmental factors can lead to the development of chronic skin ulcers or wounds. The less common causes of skin ulcers can be classified into 2 main categories: uncommon conditions that usually present as ulcers and common conditions that rarely present as ulcers. In either case, the clinical presentation may be complicated by the presence of more common causes of skin ulceration, such as venous insufficiency, peripheral arterial disease, and/or diabetes mellitus; thereby, making the diagnosis of the uncommon ulcer difficult. A systematic approach to the patient who may have one of the less common types of chronic wounds is necessary to direct appropriate management of the wound and to address the underlying disorder that is contributing to ulcer formation or delayed wound healing.
Chapter 47
Measurement: Lower Leg Ulcer Vascular and Wound Assessment
Marco Romanelli, MD, PhD; Valentina Dini, MD; Diane Williamson, MBChB, MRC (UK); Danielle M. Paterson, RVT; Marc Pope, MD, FRCSC; R. Gary Sibbald, BSc, MD, FRCPC (Med Derm), ABIM DABD, MEd
The assessment of vasculature requires a holistic approach: considering symptoms, signs, or investigations in isolation can be misleading. The presence of venous disease, for example, does not imply that an ulcer is of purely venous etiology. The patient may have co-existing arterial disease or the presence of another etiological factor that is responsible for the ulcer. In a similar analogy, the presence of a dorsalis pedis pulse does not rule out significant co-existing arterial disease. Findings from the history, physical examination, and laboratory investigations must be taken as a whole before disease etiology and severity can be adequately assessed.
Chapter 48
Compression Therapies
R. Gary Sibbald, BSc, MD, FRCPC (Med Derm), ABIM DABD, MEd; A. Alavi, MD; L. Norton, OT; A.C. Browne, MB, MICGP; P. Coutts, RN
As the population ages, the proportion of pure venous ulcers is decreasing with more patients presenting with mixed venous and arterial disease. Compression therapy, in the form of bandaging, is the cornerstone of management in the absence of any significant arterial disease.
Chapter 49
Understanding Peripheral Edema and Managing the Edematous Lower Legs
Evonne Fowler, RN, CNS, CWOCN; Stanley N. Carson, MD, FACS (Deceased)
Peripheral edema of the lower legs is a frequently encountered problem in clinical practice. Persistent lower limb edema is an underestimated problem in the elderly population. The prevalence of chronic edema increases with age, and in the United States, the fastest growing segment of the population is the octogenarian. Edema in older people is often multifactorial, and gravitational forces on dependent limbs are a significant factor in its development. Among the complications of lower leg edema are cellulitis, open wounds, and the development of lymphedema. Chronic edema is a frustrating problem for healthcare professionals as well as the patient, as it creates a chronic condition that is costly in terms of dollars as well as human emotion. Without appropriate and timely intervention, edema can lead to further tissue damage and functional impairment. Determination of the underlying cause of edema is needed to specifically guide treatment.
Chapter 50
Skin Substitutes
Kevin Woo, RN, MSc, PhD(c), ACNP, GNC(C); R. Gary Sibbald, BSc, MD, FRCPC (Med Derm), ABIM DABD, MEd
Improved wound healing can be facilitated by the local addition of deficient components using cellular therapies that include autologous epidermis, allografts, and living skin equivalents. In general, skin substitutes represent a diversity of products ranging from derivatives of naturally occurring tissues, synthetic bilaminates, and collagen-based dermal analogs to culture-derived tissue. Exogenous skin substitutes may function as a temporary or permanent wound covering.
Chapter 51
Surgical Management of Vascular Insufficiency of the Lower Extremity
David P. Coll, MD, FACS; Dale Buchbinder, MD, FACS
The surgical management of vascular disease has exploded with the new technological and patient-driven demands of less invasive solutions to age-old diseases. Clearly, standard open vascular reconstruction is often the only durable intervention in a number of vascular beds. It continues to be the gold standard to which all nuances must be compared. Catheter-based interventions, however, do have an expanding and definite role in the surgical management of vascular insufficiency. This chapter will review the 3 “I”s of vascular management: indications, imaging techniques, and interventions employed in the different segments of the lower-extremity arterial system. However, if no other message is communicated to the reader, it is imperative that one realizes that vascular occlusive disease is a systemic malady and portends to its sufferers an extremely high incidence of associated coronary artery disease and shortened longevity.
Chapter 52
Oxygen, Oxygen-Free Radicals, and Reperfusion Injury
P.D. Coleridge Smith, DM, FRCS
Free radicals are chemically reactive and may cause severe damage to many chemical compounds of which cells are made, especially the lipids, which comprise the cell membranes. A number of enzymes are present in cells that catalyze the safe breakdown of oxygen-free radicals, affording protection from these compounds. These include superoxide dismutase, glutathione peroxidase, and catalase. In addition, tocopherol (a vitamin E component) in the lipid membranes and ascorbic acid (vitamin C) are also able to break down free radicals safely, acting as free radical scavengers.
Section 7: Foot Ulcers and Wound Care for People with Diabetes
Chapter 53
Wounds in People with Diabetes: Assessment, Classification, and Management
David L. Steed, MD
Foot ulcers in persons with diabetes are a significant healthcare problem affecting more than 1 million patients at some point in their lives. Inadequate or improper diagnosis and treatment lead to limb loss. People with diabetes require careful attention to their feet, starting with preventive strategies. If a wound develops, people with diabetes require aggressive treatment, including proper footwear, nonweight bearing, appropriate antibiotics, debridement, aggressive revascularization, and careful monitoring. New active advanced therapies are being developed that might have significant benefits in lower amputation rates for refractory ulcers.