Surgery Book


Chronic Wound

Aka: Chronic Wound
  1. See Also
    1. Skin Wound
    2. Wound Infection
    3. Laceration Repair
    4. Leg Ulcer Causes
    5. Decubitus Ulcer
  2. 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
  3. 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)
  4. 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)
  5. 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)
  6. Management
    1. 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
    2. 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
    3. Evaluate for biofilm and active infections (wound culture and treat)
      1. Most wounds are colonized and do not require antibiotics
      2. Treat critical colonization
      3. Treat infection (e.g. Cellulitis, abscess)
    4. 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
    5. Treat underlying vascular disease
      1. Revascularization and conservative measures for peripheral Arterial Insufficiency
      2. Compression for Lymphedema, Venous Insufficiency
    6. Offload wounds
      1. Pressure Sores
      2. Neuropathic wounds (e.g. diabetic Foot Wounds)
    7. 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)
  7. References
    1. Cole (2017) Wound Care Update, Park Nicollet Conference, St Louis Park, MN (attended 9/15/2017)

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