Skin Ulcers (11/4) Flashcards Preview

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Flashcards in Skin Ulcers (11/4) Deck (21)
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1

Types of Ulcers

Pressure
Venous
Arterial
Neurotrophic (diabetic, loss of sensation)
Special cases - pyoderma gangrenosum, cancer

2

Pressure Ulcer Staging

Stage 1 - Intact skin w/ non-blanching redness
St. 2 - Shallow, open ulcer with red-pink would bed (unroofed blister, dermis exposed)
St. 3 - Exposed subdermal tissues, undermined edges (full thickness, see fat)
St. 4 - Exposed tendon or bone, full thickness
Unstageable - cannot see base

3

3 steps wound healing (surgical)

Inflammation, Epithelialization, Remodeling

4

Granulation Tissue

Richly vascular fibroblast stroma, provides supportive base for advancing epithelial tissue -- good in ulcer healing (no fibrin clot on top)
May exude serous fluid

5

Pressure Ulcer Treatment

Take pressure off, manage infection (colonized, may not need treatment - topical abx, worry about bone/systemic), nutritional support (protein), local wound care/dressings

need to know underlying cause

6

Stage 1 PU Care

Epidermis intact --> No debridement/dressing needed, clean with soap/water, pressure relief, maybe protective film

7

Stage 2 PU Care

Blister-like --> No debridement, saline cleanse, dressing polyurethane film/hydrocolloid wafer, provide moist wound bed/surrounding area dry

8

Stage 3 PU care

Debridement: If eschar/slough present - autolytic, wet-to-dry, enzymatic, sharp
Cleansing: Saline
Dressing: Hydrocolloid, alginate, hydrogel (may need packing/foam if undermined)
Debride necrotic tissue, protect granulation tissue

9

Stage 4 PU care

Same as Stage 3
Debridement: If eschar/slough present - autolytic, wet-to-dry, enzymatic, sharp
Cleansing: Saline
Dressing: Hydrocolloid, alginate, hydrogel (may need packing/foam if undermined)
Debride necrotic tissue, protect granulation tissue

Odor - metronidazole gel, activated charcoal

10

Venous Leg Ulcers (overview)

Medial malleolus typical (most common LE ulcer)
Chronic edema, varicose veins often
2 systems of veins in LE - superficial and deep with deep having more pressure
Valve system between - overloaded by CHF, obesity, obstruction, inactivity (muscle pumps)

11

Venous Leg Ulcers Treatment

Same as Pressure Ulcers
Control of Edema essential (like 30-40mmHG at ankle)

12

Arterial Ulcers

Circumscribed "punched-out" ulcers, often multiple
Areas least well perfused (lateral malleolus, tibial, feet/toes), shiny/hairless skin, absent pulses, claudication (Cramping w/ exercise)

13

Ankle-Brachial Index

Normal is 1 or above
ABI below 0.8 - claudication
ABI below 0.4 - rest pain
worry about ulcers at 0.8 - also coronary/cerebral arterial disease

Not usually just stenosis in one place...

14

Buerger's Disease

Thombangiitis obliterans
Occurs in (young) smokers
Hands and feet
Sensitivity to vasoactive effects of nicotine
Impaired endothelium relaxation
Both venous and arterial involvement
Allen test

15

Allen Test

Test patency of ulnar artery (smaller - first to be occluded)
Occlude radial and ulnar arteries after making a fist to empty blood from hand
Open hand and release pressure over ulnar artery - should refill with blood from ulnar artery - pink

16

Treatment of Arterial Ulcers

Same cleansing, debridement and dressing as pressure ulcers
NO external compression
Smoking cessation
Revascularization
skin graft
amputation

17

Neurotrophic Ulcers

Plantar aspect of foot/toes typical
Prominent callus formation
Caused by peripheral neuropathy, usually diabetic (d/t lack of sensation --> repetitive trauma)
Diabetes also have arterial ischemia
Bone/joint may also be destroyed

18

Charcot foot

Collapse of ankle/foot d/t neuropathy, rocker-bottom appearance, ulcers over lateral plantar, osteomyelitis common

19

Neurotrophic ulcer treatment

Same cleansing, debridement, dressing as PU
Protection: footwear, total contact cast
Recombinant platelet-derived growth factor (becaplermin)
DM management
Watch arteries/infection

20

How to know not a normal ulcer

Unusual location/atypical appearance
Doesn't heal
--> skin cancer, pyoderma gangrenosum

21

Pyoderma gangrenosum

May start as pimple/pustule --> edges blue/purple hue
Associated with autoimmune (RA, leukemia, irritable bowel)
Tx according to underlying disease