NOSM VASCULAR RESOURCE

vascular medicine , surgery and wound care


Table of contents


Wound care overview

Wound quiz

Pressure sores

Necrotizing fasciitis

Wound Care Overview

How to approach a wound

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How to prepare the wound

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It is important how we dress

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Types of dressing

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How do we choose?

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A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.


Stage 1 Pressure Injury: Non-blanchable erythema of intact skin


Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis


Stage 3 Pressure Injury: Full-thickness skin loss


Stage 4 Pressure Injury: Full-thickness skin and tissue loss


Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss


Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration
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Was the patient below predictable?

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The answer is yes…therefore try to prevent

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If it is predictable , it may be preventable

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How to document healing in a pressure wound :The PUSH Tool

Directions:
Observe and measure the pressure ulcer. Categorize the ulcer with respect to surface area, exudate, and type of wound tissue. Record a sub-score for each of these ulcer characteristics. Add the sub-scores to obtain the total score. A comparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing.

Length x Width:
Measure the greatest length (head to toe) and the greatest width (side to side) using a centimeter ruler. Multiply these two measurements (length x width) to obtain an estimate of surface area in square centimeters (cm2). Caveat: Do not guess! Always use a centimeter ruler and always use the same method each time the ulcer is measured.
Exudate Amount:
Estimate the amount of exudate (drainage) present after removal of the dressing and before applying any topical agent to the ulcer. Estimate the exudate (drainage) as none, light, moderate, or heavy.
Tissue Type:
This refers to the types of tissue that are present in the wound (ulcer) bed. Score as a “4” if there is any necrotic tissue present. Score as a “3” if there is any amount of slough present and necrotic tissue is absent. Score as a “2” if the wound is clean and contains granulation tissue. A superficial wound that is reepithelializing is scored as a “1”. When the wound is closed, score as a “0”.
4 – Necrotic Tissue (Eschar):black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin.
3 – Slough:yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous.
2 – Granulation Tissue:pink or beefy red tissue with a shiny, moist, granular appearance.
1 – Epithelial Tissue:for superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface.
0 – Closed/Resurfaced:the wound is completely covered with epithelium (new skin).
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For an up to date overview of hospital approach to skin injury see Skin Integrity Injury Prevention 2017(Angelic & Arruda)
Necrotizing Fasciitis (back to top)

A progressive, rapidly spreading inflammatory infection involving the superficial/deep fascia with secondary necrosis of the subcutaneous tissue/ skin and occasionally underlying muscle(associated myonecrosis ).

The initial usual presentation is fever, severe pain and a severe rapidly spreading red swelling +/- dishwater discharge.


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Types



Type 1………..most common…mixed aerobic and anaerobic bacteria

Type 2……….group A strept +/- staph aureus. This form may develop into a streptococcal myonecrosis and toxic shock syndrome

Type 3……….Clostridial myonecrosis( Clostridial gas gang
rene C. perfringes or septicum)




Type 1 NF including Fournier's gangrene
Type 2 NF (GAS) leg alpha hemolytic strep
Type 2 NF ( GAS ) arm alpha hemolytic strept
Type 3 NF from Clostridium septicum myonecrosis
Background

Presentation will vary from otherwise healthy patient to immune compromised ,diabetic patient +/- history of trauma or foreign body.Bacteria are usually both aerobic and anaerobic.

Staph aureus
Bacteroides
Clostridium
Group A hemolytic streptococcus
E.coli
Proteus
Pseudomonas
Klebsiella
Peptostreptococcus
Enterobacter

Remember the oxygengen requirements of bacteria

Aerobes

Obligatory aerobes

Facultative anaerobes

Obligatory anaerobes

Micro-aerophiles


Historically, most attention has been to (GAS) , group A hemolytic streptococcus.For complete overview see
Necrotizing fasciitis in my powerpoint presentation section.




Virulence from pyrogenic exotoxins which stimulate Tumor Necrosis factor and interleukin plus impede phagocytosis and promote”superantigen” response

Streptococcus is a gram+ bacteria found in chains It is a fermentative (anaerobic) organism which is oxygen tolerant.It is classified by its cell wall carbohydrate.
Strept A ….enzymes that break down tissue host
Streptokinases which dissolve clot
Cytolysins which kill leukocytes
Hyaluronic capsule and M proteins which resist phagocytosis

20% asymptomatic carriers in pharynx especially in winter Also found on the skin.Worst scenario usually “strept throat” or impetigo
Clearly a problem arises when the immune system unable to keep in check
THE ORGANISM enters the host through mucous membranes or open wound
Virulence dependent on M-protein, hyaluronic acid capsule and C-5 peptidase
Common theory held that bacteria makes proteins that causes the immune system to destroy both the bacteria and body as well as destroying the tissue directly




In the above situation , leukocytes show decreased function in a hypoxic state with a decrease vin oxidative / reduction potential stimulating growth of facultative anaerobic and aerobic growth.



What to look for:


Look for fever, malaise ,flu-like symptoms, tissue necrosis/discharge, vesicles/bullae +/_severe pain
There may be early gas formation or burrowing through fascial planes
Note there may also be lack of classical signs of inflammation
If left untreated may advance to myositis/ myonecrosis


There may be no antecedent history or a recent trauma or surgery
Pain/ swelling are primary features particularly pain out of proportion to clinical findings.
Within hours the are may become totally anaesthetic
Presentation may be very subtle or a florid toxic shock syndrome

Fournier's is a variant of type 1 NF and involves:

Pain , erythema, swelling of scrotal skin
Necrosis of scrotal fascia / enlarged scrotal size
Crepitus in 50%
May be indolent(2-7 days)
If advanced beyond scrotum , behaves like all other necrotizing fasciitis
Female variant is classical necrotizing variant because of thicker/denser tissue involvement


Diagnosis

Clinical: must distinguish from cellulitis, often not straight forward .Significant because treatment my be radically different.


Cellulitis: affects dermis/subcutaneous tissue, not fascia.May be associated with red , swollen , tender, warm borders not usually raised.Organisms usually s.aureus or hemolytic strept. Infection may be blood borne, associated with medical disorder or skin disruption.

NF: affects dermis, subcutaneous tissue AND fascia and associated with vasculitis, thrombosis and tissue necrosis Often involves the extremities ,abdomen and perineum. This can affect both compromised/normal population.

If not treated early, reported75% mortality
Early on may mimic a cellulitis



Workup

Complete blood work and blood cultures

Imaging such as a flat plate, ultrasound,CT or MRI

Finger test and biopsy(
see Medscape April 2017)

Deep excisional skin biopsy

Aspiration and gram stain


Treatment

Radical surgical debridement+/- amputation

Antibiotic coverage: PEN G(Eagle effect), Aminoglycoside and Clindamycin

:Vancomycin plus Peptaz

:
Flagyl plus newer Cephalosporins

:Merem/Primaxin


Hyberbaric Oxygen: If you have it use it but it is not a substitute for surgery

Imune globulin:

Nutrition




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