#141 Wound Care Pearls

February 25, 2019 | By Carolyn Chan

Demystify wound care with tips from expert Dr Foy White-Chu

Demystify chronic wound care management with high yield pearls from wound care expert Dr. Elizabeth (Foy) White-Chu. She takes us through a simple yet thorough approach to manage complex chronic wounds. We discuss everything from selecting a dressing, to pain management, and what kind of water should you really use when cleansing a wound. Answers to all of these burning questions and more await you, so don’t waste anymore time! Press play and let Dr. White-Chu take you on a journey through evidence based practices for the management of chronic wounds. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST).

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Credits

Written by: Carolyn Chan MD

CME questions by: Justin Berk MD

Produced by: Matthew Watto MD

Hosts: Matthew Watto MD, Paul Williams MD, Carolyn Chan MD

Guest: Dr. Elizabeth (Foy) White-Chu

Sponsor

Time Stamps

• 00:00 Sponsor – ACPs MKSAP 18
• 00:25 Disclaimer, intro, guest bio
• 03:58 Guest one-liner, movie recommendation, favorite failure, career advice
• 11:40 Picks of the week
• 15:58 Sponsor – ACPs Medical Knowledge Self Assessment 18
• 17:50 Clinical case of lower extremity ulcer; describing a wound
• 21:04 Taking a wound focused history
• 26:28 Differentiating wound types
• 29:04 Edema and compression therapy; Should diuretics be used?
• 36:43 Description of the multi-component wrap
• 38:10 Counseling a patient about wound care and setting expectations for healing
• 41:29 High value options for each wound type
• 44:35 Gardening and wound bed preparation
• 51:32 A bit on silver therapy
• 53:40 Back to the case; Red flags in wound care
• 55:40 Culturing a wound
• 58:17 Instructions on how to write wound care orders
• 62:00 Rundown of topical therapies for wound care
• 65:04 Negative pressure wound therapy aka “wound vac”
• 66:14 How often are dressing changes needed?
• 68:27 Take home points
• 70:20 Outro
• 71:30 Carolyn gives a wound care PUN!

Wound Care Pearls from Dr White-Chu

Assess a wound by describing its features from the outside in by noting the location, periwound, edge, wound bed, and drainage.

History Taking – Start with standard HPI questions, followed by assessment of the patient’s daily activities to devise a plan to decrease pressure on the wound. Next, focus a ROS on signs and of systemic infection. Finally, screen for OSA, depression, and anxiety. Oh yeah…and ask about PETS!

A general approach to the management of chronic wounds is to address the following: the potential to heal, off-loading, edema management, nutrition/diabetes, arterial flow, infection and local wound care.

The “trifecta” for lower extremity edema management: compression wrapping, a walking program and leg elevation. Remember the calf muscle pump is the “peripheral heart”. Encourage your patients to keep moving.  (White-Chu, et al, 2014)

Edema management is important for healing chronic wounds. Avoid diuretics unless they have a separate medical indication ie congestive heart failure.

Venous leg ulcers will require compression wrapping to help them heal. Make sure to palpate dorsalis pedis pulses before starting compression therapy. Many patients have mixed arterial and venous disease! –Dr. White-Chu’s expert opinion. Guidelines recommend palpating pulses AND/OR performing an ABI prior to initiating compression wrapping (Wound Heal Guidelines – venous ulcers).

Remember three key principles in healing chronic wounds: moisture balance, bacterial balance and debridement. These three factors must be balanced for wounds to heal.

To help manage pain during dressing changes, pre-soak a gauze in 4% lidocaine, then place it on the wound for 5 to 10 minutes!

Writing wound care orders. Remember to provide instructions on how to cleanse, what dressings to apply, cover, and how to secure them.

Wound Care Show Notes

Describe the wound

Describe a wound from the outside in with the following checklist: location, periwound, edge, wound bed, and drainage.  

1. Location: Where is the wound? In particular, note if it’s over a bony prominence such as the coccyx, ischium, or sacrum.
2. Periwound: Assess pain, moisture, and irritation of the area surrounding the wound bed.
3. Edge: Describe any erythema present, maceration, and if the edges are well demarcated. Don’t forget to describe if the edge has a cliff, or if it’s more like a hill.
4. Wound bed: Is the tissue viable (pink granulation tissue) or non-viable?
5. Drainage: Note the amount (small, medium, or large) and color.

History Taking

Obtain your standard HPI and try to play detective to assert how the wound first started. Next, ask the patient to describe their day so you can help them develop a plan to keep pressure off the wound. Don’t forget to ask what side they sleep on. This can be an overlooked source of pressure.

ROS

Ask about systemic signs and symptoms of infection. Fevers, chills, and increasing pain in the wound are worrisome.

Other

Ask about nutrition, weight loss, and appetite. Screen for obstructive sleep apnea, especially in patients with unexplained lower extremity swelling (Dr White-Chu’s expert opinion). Screen for depression and anxiety and provide referrals as needed. In the social history: ask about functional status and pets. Some animals can lick wounds! Gross. Hygiene, cleanliness, and ability to maintain a wound care regimen are important aspects of healing.

How important is it to differentiate between the different types of ulcers?

Do your best to figure out the type of ulcer based on the history and exam, but regardless gather information about a patient’s activities and day to help create a plan to “off-load” pressure. The general principles of wound care apply to all types of wounds.

Generalized approach to tackle chronic wound care

All wound care plans must address the following: assess whether wound has potential to heal (viable vs non-viable wound bed), off-loading, edema management, nutrition/diabetes, arterial flow, burden of infection, and local wound care.

Edema Management

Venous leg ulcers require compression wrapping to heal. Remember the “trifecta” = compression wrapping, walking program and leg elevation. Simple heel pumps (dorsiflexion and plantarflexion) have been associated with improved wound function as well. Think of the calf muscle as the “peripheral heart” promoting venous return (White-Chu, et al, 2014).  Avoid diuretics unless the patient has a separate medical indication (ie heart failure) because it could worsen the wound.

Feel for Pulses before Starting Compression Wrapping

Many patients have mixed arterial and venous disease. Hold on compression wrapping for those patients with severe arterial disease. Guidelines recommend performing an ankle brachial index (ABI) AND/OR palpating a pulse before starting compression wraps (Wound heal guidelines – venous ulcers, 2015) . Dr White-Chu’s expert opinion: if you can feel a pulse start out with a simple two-layer compression with a rolled gauze then bandage and escalate as tolerated.

Ways to Wrap

The goal is to get a patient to a four layer multi-component wrap. But there are other options…such as Unna’s boot and a Duke’s modified Unna boot. See O’Meara, et al Cochrane review on compression for venous ulcer for more details.

Multi-component wrap

Four layers from inside to outside including: 1) cotton, 2) crepe long elastic (long stretch), 3) ace bandage (shorter stretch), 4) stiffer self-adhesive bandage.  The multi-stretch component provides more compression at rest than an Duke’s modified Unna boot. Additionally, it does not elevate leg pressures as much when walking.

Counseling patient for venous ulcer

Have a discussion to set realistic expectations. Comment on healability of the wound (eg good, fair, guarded, or poor). Educate the patient to keep their legs elevated as high as they can tolerate. Ideally, elevate legs above the heart, but this can be challenging in patients with underlying MSK diseases.  Venous leg ulcers should be about 40% healed within 4 weeks. Ask the patient to trial your recommendations for two weeks. Then, reassess. Consider referral for venous ablation studies in patients with recalcitrant wounds. –Dr White-Chu’s expert opinion.

High Value Wound Care

1. Recurrent venous leg ulcers: Try conservative management before referring for ablation studies and therapy.
2. Arterial wounds: Send for a vascular surgery evaluation for angiogram and consideration of bypass.
3. Neuropathic/Diabetic foot ulcers: Apply a total contact cast. Note: This approach is logistically challenging. A clinic must have the resources needed to replace the cast weekly. The casts are often fit by podiatrists.

Chronic wound care treatment

Remember these three principles for healing chronic wounds: moisture balance, bacterial balance and debridement. One must address all three in order for a wound to heal.

A wound is like a GARDEN, and other musings.

A wound is like a garden, if you pull out all the weeds you pull out the good soil with it.  One also does not want to pour weed killer all over the garden either – so avoid antiseptics. We need to take out some of the weeds – with conservative sharp debridement. Or, add a product that will foster debridement such as a hydrogel or hydrocolloid. An enzymatic debrider called collagenase can also be used. But, it must be applied every day and is expensive. Your garden (wound bed) should not be too wet or too dry. Excess moisture fosters bacterial growth, infection. Excess dryness impairs the growth of healthy cells. Choose a topical therapy and type of dressing based on a wounds moisture balance (eg too wet or too dry). When choosing a product, target the factor (eg infection, moisture, need for debridement) that is the most predominant. See more in Schultz article on wound bed preparation.

Is this wound infected?

The Rational Clinical Exam – Chronic Wound Infection, JAMA, 2003. Studies have looked at different symptoms and their association with infection in chronic wounds. Pain in chronic wounds is associated with a positive likelihood ratio of 11 to 20 of having an infection (JAMA’s 2012, Does this patient have an infection of a chronic wound?). Obtain a deep tissue culture when possible to tailor treatment. Utilize the “Levine technique” to obtain a superficial swab if a deep wound culture is unfeasible. First, clean the wound. Then, take a swab to the deepest, cleanest part of the wound. Lastly, rotate the swab over a 1×1 cm area with pressure to express fluid.

Wound Care and Pain Management

Ask the patient to describe the type, quality, and chronicity of the pain. Consider trialing topical 4% lidocaine if the pain is only with dressing changes. First, soak the gauze in lidocaine. Next, place the gauze on the wound and allow it to sit for 5 to 10 minutes. Perform sharp debridement if indicated. Don’t forget that pain can be a marker of infection, so be careful to not dismiss new or worsening pain.

Wound Care Cleaning

Tap water or normal saline can be used to clean the wound. Wet a 4×4 gauze and wipe the wound enough to ensure any old product applied has been removed along with debris. Wound care cleansers may help decrease the biofilm on the wound. But, there have been no head to head studies comparing these cleansers. Consider a zinc paste on the edges to protect the healthy skin if edge/periwound has extensive maceration. A dilute solution of acetic acid (present in vinegar) can be used to cleanse the area if pseudomonas is present, or suspected.

Wound Care Dressing

Choose a product that will address the predominant issue (see garden reference).

Dry Wound?

Add moisture. Use a hydrogel if the wound has any depth. Use an oil emulsion gauze if wound is superficial.

Wet Wound?

Select a moisture wicking dressing (eg Calcium alginate) followed by foam topper. Some calcium alginates can have silver products added if needed to assist with bacterial burden. Cadexomer iodine is another great option and comes as a paste or cream. It has beaded technology so it slowly releases iodine. It is 7x more absorbent than regular gauze.

Dressings should be changed based on drainage. Some dressings can stay on for up to seven days if minimal drainage.

Negative Pressure Wound Therapy – “Wound vac”

Wound vacs were originally designed for post-op wounds. A two week trial can also be considered to help get the drainage under control if a non-surgical wound has a large amount of drainage. Be sure to rule out osteomyelitis and infections as etiologies of increased wound drainage. –Dr White-Chu’s expert opinion

Wound Care Take Home Points

• Always address the underlying condition(s). Etiology is important. BUT, address offloading, and edema management regardless of the wound type. Always feel for pulses before starting compression. Then, start your local wound care regimen.
• The Wound Healing Society is focused on wound healing, research and education. Free guidelines on their website at woundheal.org.

Goals and Learning Objectives

Goal

Listeners will develop an approach to the diagnosis and treatment of chronic wounds.

Learning objectives

After listening to this episode listeners will…

1. Describe an approach to the clinical assessment of wounds.
2. Obtain a history of present illness focused on pertinent information needed to develop a comprehensive wound care plan.
3. Describe general principles of wound care such as moisture management, bacterial burden and wound debridement.
4. Recall the basic principles of edema management in chronic wounds
5. Explain basic principles in selecting wound care dressing applications.

Disclosures

Dr White-Chu has no relevant financial disclosures. The Curbsiders were sponsored by the American College of Physicians MKSAP 18 for this episode.

Links from the show

1. Foy’s movie picks: Spider Verse, How to Train your Dragon -The Hidden World,  Hidden Figures, Crazy Rich Asians
2. Carolyn’s book pick: Educated by Tara Westover
3. Paul’s pick of the week: Spider-Man: Into the Spider-Verse (film)
4. Matt’s pick of the week: The Knowledge Project with guest Naval Ravikant, by Shane Parrish.
5. Treatment of venous leg ulcers: White-Chu, E. Foy, and Teresa A. Conner-Kerr. “Overview of guidelines for the prevention and treatment of venous leg ulcers: a US perspective.” Journal of multidisciplinary healthcare 7 (2014): 111.
6. Wound healing society 2015 update on guidelines for venous ulcers: Marston, William, et al. “Wound healing society 2015 update on guidelines for venous ulcers.” Wound Repair and Regeneration 24.1 (2016): 136-144.
7. Cochrane review on compression: O’Meara  S, Cullum  N, Nelson EA, Dumville  JC. Compression for venous leg ulcers. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD000265. DOI: 10.1002/14651858.CD000265.pub3.
8. Wound bed preparation: Schultz, Gregory S., et al. “Wound bed preparation: a systematic approach to wound management.” Wound repair and regeneration 11 (2003): S1-S28.
9. Biofilms and Debridement: Schultz, Gregory, et al. “Consensus guidelines for the identification and treatment of biofilms in chronic non-healing wounds.” Wound Repair and Regeneration 25.5 (2017): 744-757.
10. Pain and likelihood ratio of infection: JAMA’s The Rational Clinical Exam: Chronic Wound infections, 2003 – Book Chapter
11. Pain and likelihood ratio of infection: JAMA’s The Rational Clinical Exam, 2012  JAMA Article: L Reddy, Madhuri, et al. “Does this patient have an infection of a chronic wound?.” Jama 307.6 (2012): 605-611.
12. Dr. White-Chu’s Final Plug: National Wound Heal Guidelines

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