Wound Care and Hyperbaric Medicine Miguel G Madariaga

Wound Care and Hyperbaric Medicine Miguel G. Madariaga, MD

What is the skin good for?

The epidermis is the tough, leathery outer surface of the skin It has five layers of cells and appendages It helps us by: n n n n Providing a barrier Regulating fluids Providing light touch sensation Controlling temperature Excretes toxins Produces vitamin D Cosmetic apperance

The dermis It is a 2 -4 mm thick layer below the epidermis It helps us by: n n n Supporting and nourishing the epidermis Housing skin appendages (nails, hair, glands) Fighting against infection Controlling temperature Providing sensation

What is a wound?

How does a wound heal?

What is a chronic wound?

Chronic wounds: the burden of disease Chronic wounds represent a silent epidemic (6. 5 million in the US) The amount of money spent on wound care, the loss of productivity for afflicted individuals and the families and their diminished quality of life come at great cost to our society It is claimed that an excess of US$25 billion is spent annually on treatment of chronic wounds Sen, Wound Repair Regen, 2009

Causes of chronic wounds Diabetes Arterial insufficiency Venous disease Pressure Radiation Others

Diabetic ulcers Diabetes is the sixth leading cause of death in the United States 7% of the American population have diabetes and several millions (6) are undiagnosed Over 85% of all diabetic related lower extremity amputations are preceded by an ulceration Risk factors for diabetic ulcers include: neuropathy, deformity/limited joint mobility, vascular disease and pivotal trauma

Why do diabetic ulcers occur? Neuropathy n n n Motor: weakness, muscle atrophy (deformity) Sensory: diminished sensation, pain Autonomic: dry, fissured skin Vascular disease

Complications of diabetic ulcers

Venous ulcers These are the most common cause of ulcers 1 -2% of the population has venous insufficiency 14% of people with venous insufficiency develop ulcers Women are three times more likely than men to have venous ulcers The risk of ulceration is 7. 5 times greater in people older than 65

Why do venous ulcers occur?

Venous ulcers: characteristics

Pressure ulcers are localized areas of dead tissue that develop when soft tissues is compressed between a firm surface and a bony prominence The overall prevalence among hospitalized patients is 15% Patients at risk: hospitalized patients, individuals in long term care and patients with spinal cord injury Pressure ulcer complications may be life-threatening The cost of caring for each ulcer can be up to 70, 000 per ulcer

Pressure ulcer stages

What is done at the Wound Center? Adequate perfusion Presence of nonviable tissue Signs of infection or inflammation Presence of edema Conduciveness of wound healing environment Optimization of tissue growth Appropriateness of pressure offloading Controllability of pain Optimization of host factors

Confirm adequate perfusion

Eliminate non-viable tissue

Different types of debridement

Control infection/inflammation

A word about MRSA

Resolve edema

Optimize wound bed

Enhance tissue growth Graft

Enhance tissue growth: hyperbaric oxygen

Provide appropriate offloading

Control pain

Optimize host factors Diabetes mellitus Renal dysfunction Ischemic heart diseaseSmoking COPD Malnutrition Mobility impairment Addiction

What to expect when going to the wound care clinic? A long initial visit with many questions A physical exam Most likely sharp debridement of the ulcer Initial tests including blood tests and maybe an ultrasound Dressing recommendations Follow up on a weekly basis Reevaluation of plan at specific time points

Hyperbaric Medicine

What is hyperbaric oxygen therapy? …the use of 100% oxygen breathed at increased atmospheric pressure It requires that… The patient be enclosed in a pressure vessel Subjected to an atmospheric pressure at least 1. 5 x sea level or ambient pressure And be breathing 100% oxygen

The “bends”

HBO: Boyle’s law

HBO and carbon monoxide poisoning

HBO mechanism of action in wound care

A randomized clinical trial Faglia, Diabetes Care, 1996

Faglia’s clinical trial 70 DFU patients consecutively admitted 2 subjects withdrew, 35 received HBO, 33 received conventional care All patients received initial radical debridement Standardized wound care protocol for all patients Infections were treated based on culture results Optimized metabolic control for all patients All patients with ABI <. 9 or Tc. PO 2 <50 mm. Hg received arteriography If possible, intervention by angioplasty or bypass graft HBO treatment protocol was 2. 5 ATA 90 minutes initially then 2. 4 ATA following Major amputation decision carried out be consultant surgeon unaware of HBO status Faglia, Diabetes Care, 1996

Faglia’s trial results HBO group: 3/35 (8. 6%) had major amputation (2 BKA, 1 AKA) Conventional group: 11/33 (33%) had major amputation (7 BKA, 4 AKA) Tc. PO 2 on dorsum of the foot significantly increased in HBO treated subjects compared to conventional group Negative prognostic determinants were poor cruclation and advanced Wagner grade Faglia, Diabetes Care, 1996

FDA approved usage of HBO based on UHMS Report, 2008 • • • • Decompression illness, gas embolism Carbon monoxide, cyanide poisoning Blood loss anemia Clostridial myonecrosis Other necrotizing soft tissue infections Refractory osteomyelitis Prep and preservation of compromised skin grafts and flaps Crush injury, compartment syndrome Other acute traumatic ischemias Central retinal artery and vein occlusion Other wounds with demonstrated periwound hypoxia Acute thermal burns Osteoradionecrosis Soft tissue radionecrosis Bubble compression, toxin displacement, temporary Increase in oxygen deliver Enhanced host immune response, resolution of infection Reversal of hypoxia, wound regeneration effects, tissue growth Wound regeneration effects, tissue growth, reversal of fibrosis

HBO technique Single occupancy chambers are most appropriate for the treatment of chronic medical conditions in stable patients Acute therapy may require only one or two treatments, while chronic medical conditions may warrant up to 30 or more sessions Treatment is given 3 -5 times a week, usually once a day for stable patients Chamber pressure is usually maintained between 2. 0 and 2. 5 ATM, with treatment lasting 90 to 120 minutes depending upon the indication Air breaks are given every 30 mins to prevent complications

Most common complication: barotrauma Observe TM movement during valsalva If unable to demonstrate auto inflation refer to ENT for myringotomy

Other complications of HBO Reversible myopia due to direct toxicity to the lens; recovers in weeks to months Pulmonary barotrauma is unusual Pulmonary oxygen toxicity (chest tightness, cough, reversible decline of pulmonary function), occurs in patients receiving multiple treatments or previously exposed to high oxygen levels Seizures are a rare but dramatic consequence of HBO treatment; estimates of incidence range from 1 in 11, 000 to 2. 4 per 100, 000 treatments Decompression sickness may occur in patients breathing compressed air that contains nitrogen

Scleroderma comprises a heterogeneous group of conditions linked by the presence of thickened, sclerotic skin lesions Classification: n Localized scleroderma Linear scleroderma Localized and generalized morphea n Systemic sclerosis Limited cutaneous SSc — skin sclerosis restricted to hands (and face and neck). They may suffer from the CREST syndrome (Calcinosis cutis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia) Diffuse cutaneous SSc — extensive skin sclerosis and greater risk for the development of significant renal, lung, and cardiac disease Others including overlap syndromes The classification of SSc may ultimately be based upon genetic and immunologic markers associated with an increased risk of specific complication

Scleroderma pictures Linear scleroderma Morphea

Skin involvement in Scleroderma Skin involvement is a nearly universal feature of SSc. It is characterized by variable extent and severity of skin thickening and hardening. The fingers, hands, and face are generally the earliest areas of the body involved. Edematous swelling and erythema may precede skin induration. Other prominent skin manifestations include: n n n n Itching in the early stages Edema in the early stages Sclerodactyly Digital ulcers Pitting at the fingertips Telangiectasia Calcinosis cutis

Scleroderma skin involvement Ulcers Telangiectasias Sclerodactily Calcinosis

Treatment of sclerotic skin Localized disease: n n The lesions of localized scleroderma, including morphea, appear to soften with ultraviolet-A (UVA) light therapy Other options include highly potent topical glucocorticoids, calcipotriol (a vitamin D analog), and methotrexate. Widespread disease: Immunomodulatory and antifibrotic approaches have yet to be shown to be more beneficial than harmful

Treatment of other symptoms Pruritus: n n n Antihistamines may help, but can cause drowsiness Maintaining adequate lubrication of the skin is essential Low-dose oral glucocorticoids are sometimes effective, topical steroids are rarely helpful Telangiectasia: n n Green foundation make-up Laser or other light therapy may be useful for large lesions Calcinosis: n n Medications are unhelpful Suitably located lesions can be removed surgically, sometimes by using a dental drill; this technique causes less tissue damage than conventional methods Raynaud phenomenon: n n n Avoidance of cold, stress, nicotine, caffeine, and decongestants Medications help for symptomatic relief: diltiazem, ACE inhibitors, ketanserin, fluoxetine Different forms of sympathectomy (surgery) have been tried in an attempt to treat severe Raynaud phenomenon.

Adequate perfusion: n Ultrasound and referral to vascular surgery if larger vessels are affected Presence of nonviable tissue: n Debridement is important, but it may be contraindicated if there is vascular disease Signs of infection or inflammation n A biopsy needs to be considered to rule out vasculitis Presence of edema n n Venous insufficiency is a common but unrelated problem Compression therapy is indicated Conduciveness of wound healing environment n Dressings depending on the wound environment

Optimization of tissue growth n n Hyperbaric oxygen therapy is not indicated for scleroderma, but it may be considered if there is a coexistent disease or evidence of poor oxygenation in the wound Byosinthetic substitutes may be of use Appropriateness of pressure offloading n Usually not an issue Controllability of pain Optimization of host factors

The most important message: prevention Wash skin daily using warm water and a mild soap Use a moisturizer daily (lactic acid, urea, dimethicone). Avoid perfumed moisturizers Wear wide comfortable shoes Prevent triggering Raynaud’s syndrome Consult a podiatrist for nail care and callus removal Do not attempt to remove calcinosis by yourself. Consider wearing orthotics Seek prompt attention for skin openings