Wound Care and Diabetic Neuropathic Ulcer Cordell Corky
Wound Care and Diabetic Neuropathic Ulcer Cordell “Corky” Atkins PT, DPT, CWS, CDE, CPed Intermountain Medical Center Salt Lake City, Utah
Objectives v. Review the anatomy and physiology of the skin. v. Understand the cascade of wound healing. v. Present interventions for the care of the diabetic foot wound. v. Review the research associated with wound healing and the diabetic foot.
Glabrous skin Hairy skin Epidermis Meissner's corpuscles Hair shaft Epidermis Dermis Merkel's discs End-bulb of Krause Free nerve endings Ruffini end organ Dermis Pacinian corpuscle Hypodermis Vein Bone Artery Adipose tissue Connective tissue Erector pili muscle Muscle Hair folicle Sweat gland Sebaceous gland
Epidermal layers Glabrous skin Hairy skin Stratum corneum Stratum lucidum Stratum granulosum Stratum corneum Stratum spinosum Stratum granulosum Stratum spinosum Stratum basal
Epidermis v. Prevents dehydration of other tissues v. Protects from organism, toxins, mechanical injury and light. v. Keep the nutrients in the skin v. Responds to various stimuli
Dermis v. Provides Strength and elasticity to skin v. Regulation of body temperature v. Provides nourishment to the epidermis
Subcutaneous Fatty Layer v. Insulates v. Provides support and cushion v. Stores energy
Anatomy v. Hair Follicles-produce hair v. Sweat Glands-produce sweat (cooling) v. Apocrine-stress v. Eccrine-thermoregulatory v. Sebaceous Glands-produce sebum to keep hair and skin supple. Nerve endings-pain, heat, cold, touch v. Arteries and Veins-nutrients, O 2, & waste v. Lymph Vessels-remove excess fluid
Phases of Wound Healing v. Hemostasis v. Inflammatory Phase v. Proliferative Phase v. Maturation Phase
Hemostatis (5 - 10 minutes) v. Vasoconstriction v. Vasodilation v Fibrin clot formation v Coagulation
Inflammatory Phase (3 -4 days) v. Clinical Activities v. Cellular Activities v. Erythema Rubor v. Warmth Calor v. Edema Tumor v. Pain Dolor v. Leukocyte migration v. Neutrophils v. Monocyte conversion v. Macrophagesv. PDGF--TGF-ß
Proliferative Phase (21 days) v. Clinical Activities v. Cellular Activities v. Beefy red granulation v. Macrophagesproduce chemotactic and growth promoting substances for granulation and epithelialization
Proliferative Phase (21 days) v. Clinical Activities v. Cellular Activities v. Beefy red granulation v. Thin epithelial tissue around the red granulation tissue v. Wound Shrinkage v. Collagen synthesis. Tensile strength v. Angiogenesis- Endothelial cell buds v. Epithelializaton – Keratinocyte migration v. Contraction- Fibroblasts change to Myofibroblasts
Maturation Phase (12 -18 months) v. Clinical Activities v. Cellular Activities v. Shrinking, v. Collagen (Type III to Type I) remodeling and thinning, paling capillary regressionof scar fibroblasts leave wound, fibronectin eliminated, tensile strength increases
Wound Healing v. Moist v. Warm v. Clean
Wound Not Healing v. Dehydration v. Reinjury v. Hypergranulation v. Maceration v. Cooling
Wound Needs v. Proper Hydration v. Thermal protection v. Relief of necrotic tissue v. Bacterial Control v. Optimal p. H
Topical Management v. Compression v. Stockings v. Wraps v. Other
Diabetes Mellitus v. Diabetes mellitus consists of a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.
Classification Type 1 v Develops at any age but most before age 30 v Develop weight loss, polyuria, polydipsia with signs of marked hyperglycemia and strong propensity for ketoacidosis Type 2 v 90% of individuals with diabetes v Usually after age 40 v Frequently asymptomaticv Not prone to ketosis v Approximately 80% obese @diagnosis
Complications v. Retinopathy v DCCT N Engl J Med vol 329 v. Nephropathy v Follow- up v. Neuropathy Diabetes Care 2010 May; 33(5) v. Vascular changes v. UKPDS v. Atherosclerosis v. Angiogenesis Lancet vol 352
Diabetic Neuropathy v. A demonstrable disorder, either clinically evident or subclinical, that occurs in the setting of diabetes mellitus without other causes for peripheral nervous system. Diabetes Care. 1988; 11: 592 -597
Neuropathy v. Affects sensory, motor, autonomic nervous system v. Underdiagnosed v. Total costs - $37 billion v. Type 1 and Type 2 DM pts at equal risk v. Increases with time
Peripheral Neuropathy v. Tingling, burning, or prickling v. Sharp pains or cramps v. Extreme sensitivity to touch, even light touch v. Numbness or insensitivity to pain or temperature v. Loss of balance and coordination v. Stocking Glove
Motor Neuropathy v. Intrinsic muscle weakness v. Increase pull of long flexors
Autonomic neuropathy v. Autonomic sympathetic neuropathy causes vasodilation and decreased sweating resulting in warm overly dry feet → cracks and fissures → infection.
CAUSAL PATHWAYS FOR FOOT ULCERS Neuropathy Deformity Minor Trauma Mechanical (shoes) Thermal Chemical Ulcer % Causal Pathways Neuropathy: 78% Minor trauma: 79% Deformity: 63% Poor self foot Care Diabetes Care 1999; 22: 157
Treatment Interventions v. Off-loading v. Debridement v. Dressings v. Management of Infection v. Vascular reconstruction v. Amputation Diabetes Care. 1999; 8: 1354 -1360
Benefits of Off-loading v Hyperkeratosis at wound edges v Hypertrophic dermis v Less inflammatory cellular components v Newly formed small vessels orienting from wound edges v Replication of keratinocytes with migration to center of the wound Piaggesi A. et al, Diabetes Care. 2003 Nov; 26(11): 3123 -8
Repetitive Stress Brand, 1982 used with permission of J Birke GWLHDC
Control 7 days / 10, 000 steps 2 days / 10, 000 steps Weekends off / 7, 000 steps used with permission of J Birke GWLHDC
Off-loading Pressure v. Total Contact Casting v. Surgical Shoes v. Half Shoes v. Sandals v. Felted Foam
Pressure It's not what you put on, but what you take off… Armstrong, Lavery, CID, 2004: 39 (Supp 2) The Total Contact Cast is the Gold Standard But is not commonly used because of concerns about secondary injuries, inadequate skill/training and time constraints Armstrong, Lavery. Diabetes Care 2001: 24: 1019 -1022
Debridement v. Removal of devitalized, nonviable tissue to help the diabetic ulcer heal more rapidly v. Surgical v. Sharp Steed. J Am Coll Surg 1996; 183: 61– 4.
Dressings v. Minimize further trauma v. Minimized infection risk v. Optimize environment v 9 Topical trials v. Collagen, Gels, Foam, ORC Collagen, Cadexomer Iodine, Alginate, Sodium CMC
Dressing Benefits v. Absorption v. Hydration v. Moisture Retention v. Conforms to Depth and contours v. Thermal Insulation v. Bacterial Barriers v. Active Bacterial Control v. Odor Control v. Adherence
Infection Management v. Clinical uninfected < 105 org/gm v. Non-limb-threatening -superficial v. Limb-treatening -involving tendon, bone, capsule plus ischemia v. Osteomyelitis –infected bone
Infection v. Increased bacterial count v 105 organism/gm of sample v. Erythema (Rubor) v. Warmth (Calor) Fever/Chills v. Edema (Tumor) v. Pain (Dolor) v. Uncontrollable Blood Glucose v. Drainage v. Odor
Vascular Reconstruction v. Favorable results v. Improved healing v. Reduced pain v. Improved function/mobility Hirsch AT, et al. /J Vasc Interv Radiol. 2006 Sep; 17(9): 1383 -97
Amputation v. After extensive discussion v. Treatment options v. Level of choice v. Contralateral limb
Multidisciplinary Care v. Patient and family v. Physicians and surgeons v. Nurse/Educators v. Therapists v. Social worker v. Orthotists, prosthetists, pedorthitists v. Others
Modifications v. Personal care v. Activity limitations v. Assistive devices v. Gait v. Irritations v. Wound
Repetitive walking stress is the most common mechanism of injury and faulty healing in the neuropathic foot. - Brand, 1982 Brand 1982
Cost Analysis of Ulcer Care • Medicare costs for patients with foot ulcers were 3 times higher than for diabetes patients in general. • Inpatient care accounted for 74% of diabetic ulcer-related Medicare costs. • Any wound care intervention that reduces the need for hospitalization should reduce costs. - Harrington, 2000
Ulcer Management Wound Care Off-Loading Remodeling Protective Footwear
“The treatment of neuropathic foot ulcerations is (a matter of) mechanics not medicine” Dr. Paul W. Brand 1915 -2003
Insanity Is Continually Doing the Same Thing Expecting Different Results
Thank you Cordell “Corky” Atkins PT, DPT, CWS, CDE, CPed Cordell. Atkins@imail. org Intermountain Medical Center Salt Lake City, Utah
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