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Clin Med - II (Surgery) > Wounds > Flashcards

Wounds Flashcards

(72 cards)

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1
Q

T/F

Wounds are more common and more complex, but receive less reimbursement.

A

True

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2
Q

Why are wounds more common?

A

Rise in the aging population
Increase in diabetes population
- PAD
- Neuropathy - LOPS

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3
Q

Wounds tx challenges

A

Multiple co-morbidities
Drug resistant infections
Incorrect perception of ability to tx
Focusing on tx instead of pt

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4
Q

Wounds - Declining payment

A

Non-payment for readmission 30 days even if care was exemplary
Non-payment for readmission EVER if the wound is hospital acquired

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5
Q

Goal of Wound Care

A

Heal it quickly
Heal it cheaply
Prevent recurrence
Prevent it in the first place

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6
Q

Stages of normal wound healing

A

Hemostasis
Inflammation
Proliferation
Maturation

These are complex and overlapping

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7
Q

Hemostasis

A 
Vasconstriction and retraction of damaged vessels
Formation of platelet plug
Histamine mediated vasodilation
Increased capillary permeability
Key players - platelets and mast cells
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8
Q

Inflammation

A 
Leukocyte demargination form endothelial walls
Integrin facilitates diapedesis
Onset of phagocytosis
- Oxygen independent
- Oxygen dependent
- Oxidative burst
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9
Q

Proliferation

A

Granulation tissue formation (fibroblasts)
Angiogenesis (endothelial cells)
Epithelialization - will only migrate over granulation tissue
All of the above process is oxygen tension dependent - minimum of 30mmg TcPO2

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10
Q

Maturation

A

Immature type 3 collagen is replaced by stronger type 1 dermal collagen - continues for up to 2 year
Collagen cross-linking
Orients along lines of stress
“closed” is not the same as “healed”

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11
Q

T/F

A closed wound and a healed wound are the same thing.

A

False

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12
Q

Critical components in wound healing

A

Growth factors
Matrix receptors / integrins
Matrix metalloproteases

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13
Q

Growth Factors

A

Complex proteins (released by cells) that stimulate

  • Chemotaxis
  • Mitosis
  • Angiogenesis
  • Growth factor production by other cells
  • Production and degradation of extracellular matrix
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14
Q

Key growth factors

A

Platelet derived growth factor - PDGF
Vascular endothelial growth factor (VGEF)
Fibroblast growth factors
Transforming Growth factor - Beta

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15
Q

Platelet derived growth factor - PDGF

A

Platelets, macrophages, fibroblasts

Chemotactic for fibroblasts, smooth muscle cells, monocytes and neutrofils

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16
Q

Vascular endothelial growth factor (VGEF)

A

Modulated angiogenesis

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17
Q

Transforming Growth factor - Beta

A

Potent stimulant for collagen deposition

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18
Q

Matrix receptors / integrins

A

Cell surface receptors
Enables cells to detect and interact with components of ECM
- Platelet - collagen (hemostasis)
- Leukocyte extravasation during inflammation
- Endothelial cell budding/migration during angiogenesis
- Epithelial cell migration

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19
Q

MMPs

A

Matrix Metalloproteases

Protein degrading enzymes
Secreted in respone to biochemical marker (TNF, IL-1, IL-6)
Results in balance between GF/MMP
- Imbalance cause wound healing impairment
TIMPs - Tissue inhibitors of MMPs

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20
Q

Chronic wounds

A

Wounds that do not heal in an expected time frame
Generally underlying pathophysiologic insult to tissues
Generally procedures stagnation in one or more phases (inflammation) of wound healing)
Chronic wounds do not heal - only acute wounds do

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21
Q

Bioburden

A

Related to biofilm
Necrotic tissue, senescent cells, eschar, proteinacious secretions, bacteria (toxins, enzymes, MMPs
Physical barrier
Metabolic / oxidative stress
Not responsive to systemic or topical antimicrobials

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22
Q

Healing wound

A 
Low inflammatory cytokines
Low proteases, ROS
Intact functional matrix
High mitogenic activity
Mitotically competent cells
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23
Q

Evaluation of wounds

A 
Arterial
Venous
Infection
Pressure
M (Meds, malnutrition, metabolic, malignancy, malizia sociale)
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24
Q

Arterial Wounds

A

Ischemia/hypoxia from failure to provide adequate oxygenated blood flow to tissue/cells

PAD, vasoconstriction and edema are most common

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25
PAD - RF
``` Smoking DM Hyperlipidemia HTN Prior radiation therapy exposure ```
26
Vasoconstriction - RF
``` Nicotine Caffine Pressors Raynaud's / Berger's BB ```
27
Arterial Occlusive Disease - PE
``` Palpate pulse Listen for pulse (doppler) Capillary refill Hair growth Mottling ```
28
Arterial Occlusive Disease - Eval
Ankle-Brachial Index (ABI) Trans-Cutaneous Oxygen Measurement (TCOM) Laser Doppler flow Angiography
29
Peripheral Venous Insufficiency - Causes
``` Valvular Dz - Hereditary - Venous Thrombosis - Chronic venous HTN Saphenous-femoral vein junction incompetence Perforators ```
30
Peripheral Venous Insufficiency - Eval
US and Venography
31
Peripheral Venous Insufficiency - which US to order
Venous Duplex exam with varicose veins studies
32
Peripheral Venous Insufficiency - PE
Varicose veins Abnormal skin pigmentation - hemosiderin staining Edema Dermal hypertrophy
33
Edema
Increased distance from capillary wall to cell - Oxygen delivery - Nutrients - Leukocytes - Metabolic wast products - Meds
34
Infection - in general
Microbial progression in wounds Soft tissue vs. deep tissue
35
Soft Tissue Infection
Acute wound infections are typically Gram positive bacteria Chronic wounds transition to Gram negatives Anaerobes are found in deep and poorly oxygenated wounds
36
Acute wound bacteria
Gram positive Increasing frequency of MRSA and cMRSA
37
Chronic wound bacteria
Transition to Gram negative E. coli, Pseudomonas, Proteus, and Klebsiella
38
Bacteria found in deep wounds with poor oxygenation
Anaerobes
39
Microbial progression - main steps
Contamination Colonization Infection
40
Microbial progression - Contamination
Host control Local tx - Physically remove/reduce microbes (irrigation) - Dressings, topical anti-infectives of secondary importance
41
Microbial progression - Colonization
Bacteria and host at "equilibrium" Associated with biofilm (bioburden) Requires removal of biofilm and any necrotic tissue Requires topical (and possibly systemic anti-infectives
42
Microbial progression - Infection
Microbial control, host damaged Debridement Topical anti-infectives Systemic abx necessary
43
Wound culture
Swab cultures are typically unreliable (infection vs. colonization?) Tissue cultures are superior, if feasible
44
Pressure - in general
If the wound is caused / prolonged by pressure, why would it heal if the pressure is not removed?
45
M is for miscellaneous - in general
``` Meds Malnutrition Metabolic Malignancy Malizia sociale ```
46
Medications that could cause a wound
Anti-neoplastics Anti-rheumatologics Corticosteroids
47
Malnutrition as a cause of a wound
Macro / micro nutrient needs
48
Metabolic d/o as a cause of a wound
DM | Thyroid d/o
49
Wound care products
Cost-effectiveness Outcome based - studies vs. case reports Normal wound healing is a moist, sterile/clean process Choice of product(s) should help accomplish this w/o inhibiting cell/tissue growth
50
Cost-effectiveness - how to eval
Not always the cheapest per unit Need to track cost to closure/prevention Must be effective to be cost-effective
51
Characteristics of the ideal dressing
Maintain wound moisture while absorbing excess fluid Free of particles and toxic wound contaminants Non-toxic and non-allergenic Capable of protecting the wound from further trauma Can be removed w/o causing trauma to the wound Impermeable to bacteria Thermally insulting Will allow gaseous exchange Comfortable and conformable Require only infrequent changes Cost effective Long shelf life
52
Foam as a dressing
Low adherent Small amount of exudate Provide comfort Duration depends on amount of drainage
53
Semi-permeable film
``` Promote moist environment Adhere to healthy skin, but not to wound Allow visual checks May be left in place several days Useful as secondary dressing Not for infected or heavily exuding wounds ```
54
Hydrocolloid
Cavity or flat shallow wounds with low to medium exudate; absorbent; conformable; good in "difficult" areas May be left in place for several days Useful debriding agent May cause maceration
55
Difficult wound areas to dress
Heel Elbow Sacrum
56
Hydrofiber
``` Useful in flat wounds, cavities, sinuses, undermining wounds Medium to high exudate wounds Highly absorbent Non-adherent May be left in place for several days Needs secondary dressing ```
57
Alginates
``` Useful in cavities and sinuses and for undermining wounds For all wound types with high exudates Highly absorbent Need secondary dressing Need to be changed daily ```
58
T/F | Understanding why wounds do not heal is necessary to achieve healing
True
59
What part of a treatment plan must be secondary to patient evaluation?
product selection
60
What is essential for an effective plan of wound care?
Systematic wound evaluation
61
Hyperbaric Oxygen Therapy (HBOT)
Inhalation of 100% oxygen in a chamber at pressures greater than atmospheric pressure Typically 2.0 - 3.0 ATA, but may be up to 6 ATA Topical oxygen is NOT HBOT
62
Monoplace Hyperbaric Chamber - Advantages
Cheaper Fewer staff needed Safer for staff "Mobile"
63
Monoplace Hyperbaric Chamber - Disadvantages
Do not allow direct interaction with pt No fire suppression system Limited depth
64
Multiplace Hyperbaric Chamber - Advantages
Able to tx multiple pts at once Able to directly interact with pt Suitable for research Able to compress to 6 ATA
65
Multiplace Hyperbaric Chamber - Disadvantages
Cost Risk to tenders Profile to lowest common denominator Immobile
66
HBOT as a drug - Definable dose
``` Concentration (Fio2 = 1.0) Pressure (2.0-6.0 ATA) Time exposure (minutes, UPTD) ```
67
HBOT as a drug - Therapeutic index
Minimum effective concentration (MEC) Maximum dose toxic concentration (MDTC)
68
Primary therapy
HBOT is the effective therapy No other therapy will be as effective Healing/recovery not expected w/o HBOT
69
Adjunctive therapy
HBOT is added to the therapeutic regimen to effect a better outcome Healing/recovery may/may not occur w/o HBOT No other therapy alone is thought to be as effective as HBOT
70
HBOT - Physiologic Effects
Increases TpO2 independent of Hgb | With a common tx profile, there is almost a 20x increase in the amount of oxygen delivery to the tissue
71
Approved indications for HBOT
``` DCI / Age CO poisoning Failed flaps/grafts Acute arterial ischemia Central retinal A. occlusion Exceptional anemia Brain abscess DM extremity wounds Chronic osteomyelitits Necrotizing fascitis Gas gangrene Delayed radiation injury Idiopathic sensori-neural hearing loss Crush injury ```
72
Important aspects of HBOT
``` Compresses bubbles Supports ischemic tissue Enhances angiogenesis Alters metabolic/physiologic functions Adjunctive to abx in tx infection (gas gangrene) Negates CO ```

Clin Med - II (Surgery) (10 decks)

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