Chapter 115 - Wound care

Question 1

Phases of wound healing

Answer 1

1) inflammatory 2) proliferation 3) remodeling

Question 2

Inflammatory phase key points

Answer 2

1) mast cells, neutrophil and macrophages 2) 24 hrs to 2 weeks 3) cytokine: TNF alpha, TFN delta and ILs 4) fibroblast and epithelial cell recruitment 5) MMPs from neutrophil –> break down collagen, gelatin and elastin

Question 3

MMPs corresponding to the breaking down of collagen, gelatin and elastin

Answer 3

Collagen: MMP-1 and 8 Gelatin: MMP-2 and 9 Elastin: elastase

Question 4

MMP activity controlled by

Answer 4

Tissue inhibitor of MMP (TIMPs) produced by macrophages

Question 5

Proliferative phase key points

Answer 5

1) macrophages make PDGF, TGF beta and VEGF 2) fibroblast recruitment and synthesize collagen and proteoglycan –> granulation 3) VEGF, TGF beta and HIF1 (hypoxia-inducible factor) –> capillary growth and network 4) MMP –> breakdown old capillary

Question 6

Remodeling/epithelialization phase key points

Answer 6

1) epithelial GF and keratinocyte GF –> epithelialization 2) epithelial cell migrate into wound by secreting MMP to degrade non-viable tissue (controlled by TIMPs) 3) type III collagen replaced by mature type I collagen

Question 7

Chronic disorders that cause unchecked proinflammatory state and reduce healing

Answer 7

1) venous HTN 2) chronic pressure 3) bacterial colonization 4) inadequate tissue perfusion 5) cellular senescence

Question 8

Prolonged inflammation results in

Answer 8

1) upregulation of proinflammatory cytokines and MMPs (2 and 9) low levels of TIMPs 2) inhibit DNA synthesis and mitotic activity of normal cells 3) upregulation of TNF alpha, IL1, IL6

Question 9

MMP levels after compression therapy in venous disease

Answer 9

decrease wounds with high MMPs show better response to compression therapy

Question 10

Cell senescence key points

Answer 10

1) reduced activity of cells from chronic ulcers 2) worse with higher CEAP class

Question 11

Etiology of wounds various possible causes

Answer 11

1) infection 2) malignancy 3) macrovascular arterial insufficiency 4) vasculitis/vasculopathy (microvascular) 5) venous insufficiency 6) lymphatic obstruction 7) hematologic abnormalities 8) collagen vascular disorders 9) excessive pressure

Question 12

Distribution of venous refluex in deep, superficial and perforator or combination

Answer 12

TABLE 115.2

Question 13

Marjolin’s ulcer

Answer 13

squamous cell malignancy = Squamous transformation from preexisting benign chronic wound

Question 14

Wagner grading system and associated 1 year amputation risk

Answer 14

For diabetic foot ulcers TABLE 115.3

Question 15

ways to debride a wound

Answer 15

1) surgical debridement 2) chemical debridement: collagenase) not effective against thick tissue 3) larval therapy: faster debridement; higher pain score; no difference in healing or QOL 4) ultrasound/hydro: better wound healing but lack clear evidence

Question 16

Dressing type: Gauze pro/con/example uses

Answer 16

Pro: mechanical debridement permeable to gas fills dead space Con: damage granulation on removal dehydrate wound frequent changes Kling, sof-wick use in infected or draining wounds

Question 17

Dressing type: film pro/con/example uses

Answer 17

Pro: semipermeable, waterproof, retain moisture, visualization con: cannot use in infection tegaderm post-op wounds, partial thickness wounds

Question 18

Dressing type: hydrogel pro/con/example uses

Answer 18

Pro: rehydrate wound, extended time between dressing change Con: maceration possible, minimal absorption NU-GEL, curasol, hypergel use on dry wounds, DFU

Question 19

Dressing type: hydrocolloid pro/con/example uses

Answer 19

pro: impermeable to bacteria, autolytic debridement, water resistant, self adhesive con: cannot use on infected wound with heavy exudate Restore use on partial thickness low exudate pressure sore

Question 20

dressing type: foam pro/con/example use

Answer 20

Pro: absorptive, nonadherent, protect from trauma con: mascerate, cannot use on dry exchar Allevyn, hydrofera blue use in exudative wound, venous ulcer under comperssion

Question 21

Dressing type: alginate pro/con/example use

Answer 21

Pro: moist gel in wound, absorptive, control exudate Con: cannot use in dry wound, dehydrates bed Kaltostat, algisite use in heavy exudative deep wound, venous ulcer under compression, tunnelling wounds

Question 22

Benefit of including silver in dressing care for wounds

Answer 22

no clear evidence by Cochrane analysis

Question 23

Adjunctive strategies to treat venous ulcers besides surgery

Answer 23

1) compresion 2) pharmacologic agents: pentoxifylline, flavonoids, anticoagulants 3) skin graft 4) human skin equivalents

Question 24

Pentoxifylline in venous ulcer

Answer 24

higher healing rate in venous ulcer than placebo

Question 25

Flavonoid what is it and does it help venous ulcer

Answer 25

plant-derived compound with antiinflammatory and antioxidant properties benefit in venous ulcer healing

Question 26

Anticoagulation in venous ulcer

Answer 26

LMWH 1 year accelerated venous wound healing 83.8% vs 60.6% without cost and complication not suitable for all patients but select patients yes

Question 27

Venous strippling for venous ulcer

Answer 27

1) when there’s superficial reflux 30-50% of the time 2) reduces ulcer recurrence 31% vs 56% at 4 years

Question 28

Rate of healing venous ulcer with just compression alone

Answer 28

60-70% after 4-6 months

Question 29

STSG and free flap in venous leg ulcer

Answer 29

may help to reduce wound burden but Cochrane no clear evidence

Question 30

Apligraf what is it

Answer 30

Cultured bilayer cellular construct (BLCC) from neonatal foreskin bovine collagen lattice at base Cytokines released include FGF, VEGF, PDGF, TGF-beta, ILs

Question 31

When can human skin equivalents be used

Answer 31

1) well-grandulated 2) no exudative and bacteria

Question 32

Types of synthetic skin

Answer 32

1) Apligraf 2) porcine small intestine submucosa

Question 33

Evidence of synthetic skin

Answer 33

not clear and not cost effective maybe in chronic wounds

Question 34

Adjunctive therapy in DFU healing

Answer 34

1) vitamin D 2) PDGF (Becaplermin) topical 3) Apligraf 4) Dermagraft (neonatal foreskin) 5) integra

Question 35

Black box warning of becaplermin

Answer 35

increase death from cancer

Question 36

Integra what is it

Answer 36

Acellular dermal matrix product Integra dermal regeneration template 1) acellular bilayer matrix 2) bottom: 3D matrix collagen and chondroitin-6-sulfate (glycosaminoglycan 3) top layer = silicone (temporary)

Question 37

Benefit of integra in DFU

Answer 37

complete healing 51% vs 32% without Improved pain and physical function

Question 38

Prostaglandin in ischemic ulcers

Answer 38

1) not FDA approved 2) needs IV infusion 3) side effect headache and dizziness

Question 39

Pentoxifylline and cilostazol in ischemic ulcers

Answer 39

no clear evidence for either

Question 40

IPC in ischemic ulcer key points

Answer 40

1) improves circulation 2) increases vasodilator activity 3) improves wound healing 4) long lasting effect even after termination of therapy 5) synchronized vs not synchronized no clear difference

Question 41

Managing ischemic wounds after arterial intervention

Answer 41

IPC may decrease swelling eschar can be taken or left alone

Question 42

Hyperbaric oxygen therapy key points

Answer 42

1) treat patient with 100% 2) higher atmospheric pressure 3) 1-2 treatments/day for 20-40 treatments 4) oxygen stimulate angiogenesis, enhance fibroblast and leukocyte function and normalize cutaneous microvascular reflexes

Question 43

Side effect of hyperbaric oxygen chamber

Answer 43

1) barotraumatic otitis 2) hyperoxic seizure 3) pneumothorax all rare

Question 44

Grafix what is it

Answer 44

cryopreserved living cells from placental membrane seeded into 3D cell matrix then apply to wound