Chronic Wound

Aka: Chronic Wound, Chronic Wound Care, Non-Healing Wound, TIME Principle of Chronic Wound Care

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II. Definitions

  1. Chronic Wound
    1. Failure of Wound Healing to result in anatomic and structural restoration after 3 months

III. Epidemiology

  1. Chronic Wound Incidence: 2.21 per 1000 population
    1. Martinengo (2019) Ann Epidemiol 29:8-15 +PMID:30497932 [PubMed]

IV. Pathophysiology

  1. Persistent inflammation (inflammatory Cytokines, proteases)
  2. Biofilms affect 60% of Chronic Wounds
    1. Bacteria colonize sites and form a cohesive matrix and develop into organized mass (known as biofilm)
    2. Infectious factors provoke persistent inflammation
    3. Excessive White Blood Cell activity

V. Types: Chronic Wounds

  1. Arterial Ulcer (Peripheral Vascular Disease)
  2. Venous Ulcer (Venous Insufficiency, most common Chronic Wound type)
  3. Pressure Ulcer (Decubitus Ulcer)
  4. Diabetic Foot Ulcer (Neuropathic Foot Ulcer)
  5. Lymphedema-related wound

VI. Exam

  1. Wound measurement (length x width x depth)
  2. Use the clock system (12:00, 3:00, 6:00, 9:00) to describe wound
    1. Wound site, orientation, underming
  3. Photograph wound (with ruler)
  4. Probe wound with sterile cotton swab
    1. Evaluate for tunnels and undermining
  5. Define composition
    1. Percent slough
    2. Percent granular
  6. Exposed structure
    1. Bone
    2. Muscle, tendon or fascia
    3. Fat
    4. Viscera
    5. Vessels and nerves
    6. Hardware
  7. Drainage
    1. Amount (minimal, moderate, maximal)
    2. Characteristics
      1. Serosanguinous
      2. Serous
      3. Purulent (thin, oily, thick)
    3. Color
      1. Tan or brown
      2. Yellow
      3. Green
    4. Odor
      1. Minimal, moderate or maximal
      2. Provoked by dressing removal or wound stimulation
      3. Foul odor, anaerobic or ammonia-like
  8. Vascular evaluation
    1. Peripheral pulses (femoral pulse, posterior tibial pulse, dorsalis pedis pulse)
    2. Venous Stasis changes
  9. Neurologic evaluation
    1. Distal Sensation (consider monofilament testing)

VII. Labs

  1. Hemoglobin A1C
    1. Diabetes Mellitus (or suspected, but undiagnosed)
  2. Serum Albumin and Prealbumin
    1. Suspected Malnutrition
  3. Wound culture
    1. Indicated in suspected Wound Infection, or poor healing despite active management
    2. Press a sterile cotton swab against the wound to extract fluid from the wound for culture
    3. Obtain both aerobic and anaerobic cultures (Pressure Ulcers are infected with Anaerobic Bacteria in 60% of cases)

VIII. Imaging

  1. Ankle brachial index (ABI)
    1. Suspected Arterial Insufficiency
  2. Osteomyelitis Imaging
    1. Suspected extension into bone (confirmed if bone exposed or probe to bone positive)

IX. Management

  1. See Wound Dressing
  2. TIME Principle of Chronic Wound Care
    1. Tissue Debridement of non-viable tissue
    2. Infection Control
    3. Moisture Balance restoration
    4. Edge of the wound (promote epithelial advancement)
    5. Fletcher (2005) Nurs Stand 20(12):57-65 [PubMed]
  3. Wound Debridement
    1. Debride necrotic tissue and Hematomas
    2. Do not debride wounds that are poorly vascularized
      1. Evaluate first with ABI if suspect significant Peripheral Arterial Disease
  4. Reduce edema
    1. Swelling significantly delays healing
    2. Identify and treat underlying causes
      1. Lymphedema
      2. Venous Stasis
      3. Third spacing (Congestive Heart Failure, Chronic Kidney Disease)
    3. Compression is key (contraindicated in significant Peripheral Arterial Disease)
      1. Allows for redistribution of fluid
      2. Use elastic, tubular or paste bandages
      3. Use stretch compression garments
      4. Consider pneumatic devices
      5. Keep leg elevated at least 6 inches above the level of the heart
  5. Evaluate for biofilm and active infections (wound culture and treat)
    1. See Chronic Wound Infection
    2. Most wounds are colonized and do not require Antibiotics
    3. Treat critical colonization
    4. Treat infection (e.g. Cellulitis, abscess)
  6. Control wound moisture
    1. Wounds should not be too wet or too dry
    2. Moist Wound Healing speeds healing by as much as 50%
    3. However, macerated wounds (too moist) heal poorly
  7. Treat underlying vascular disease
    1. Revascularization and conservative measures for peripheral Arterial Insufficiency
    2. Compression for Lymphedema, Venous Insufficiency
  8. Offload wounds
    1. Pressure Sores
    2. Neuropathic wounds (e.g. Diabetic Foot Wounds)
  9. Ensure adequate nutrition
    1. Calorie Needs: 30 kcal/kg Ideal Body Weight per day (35-40 kcal/kg/day for underweight patients)
    2. Protein Needs: 1.25 to 1.5 g/kg Ideal Body Weight/day (use 2-2.5 g/kg IBW/day for morbidly obese patients)
      1. Requires increased fluid intake taken with the increased Protein intake
    3. Fluid needs: 30-40 ml/kg/day (add 10-15 ml/kg for those on air-fluidized beds)
    4. Vitamin Supplementations
      1. Daily Multivitamin chewable
      2. Zinc supplement 50 g orally daily for no more than 2 weeks
        1. Indicated for Zinc Deficiency or suspected (Dysgeusia, skin slouging)
    5. References
      1. Meyer (2017) Wound Care Update, Park Nicollet Conference, St Louis Park, MN (attended 9/15/2017)
  10. Evaluate atypical wounds with biopsy and possible referral
    1. Wounds in atypical locations, appearance or refractory to standard wound care after 3-6 months
    2. Atypical wounds may represent malignancy, Vasculitis or other Autoimmune Conditions, Calciphylaxis

X. References

  1. Cole (2017) Wound Care Update, Park Nicollet Conference, St Louis Park, MN (attended 9/15/2017)
  2. Bowers (2020) Am Fam Physician 101(3):159-66 [PubMed]

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