Page 1139 - TNFlipTest

Toronto Notes 2019 Ulcers Table 14. Venous vs. Arterial vs. Diabetic Ulcers (continued)
Plastic Surgery PL17
Characteristic
Pulses Vascular Exam
Pain
Treatment
Venous (70% of vascular ulcers)
Normal distal pulses
ABI >0.9
Doppler; abnormal venous system
Moderately painful
Increased with leg dependency, decreased with elevation
No rest pain
Leg elevation, rest
Compression at 30 mmHg (stockings or elastic bandages)
Moist wound dressings
± topical, systemic antibiotics if infected
± skin grafts
Arterial
Decreased or no distal pulses
ABI <0.9
Pallor on elevation, rubor on dependency
Delayed venous filling
Extremely painful
Decreased with dependency, increased with leg elevation and exercise (claudication) Rest pain
Rest, no elevation, no compression
Moist wound dressing ± topical and/or systemic antibiotics if infected
Modify risk factors (smoking, diet, exercise, etc.)
Vascular surgical consultation (angioplasty or bypass)
Treat underlying conditions (DM, proximal arterial occlusion, etc.)
Diabetic
Decreased pulses likely (take caution in calcified vessels)
ABI is inaccurately high (due to PVD)
Usually associated
with arterial disease (microvascular/macrovascular disease)
Painless (if neuropathy)
No claudication or rest pain Associated paresthesia, anesthesia
Control DM
Careful wound care
Foot care
Orthotics, off loading
Early intervention for infections (topical and/or systemic antibiotics if infected)
Vascular surgical consultation
Pressure Ulcers
Common Sites
• overbonyprominences;95%onlowerbody
Stages of Development
1. hyperemia: disappears 1 h after pressure removed
2. ischemia: follows 2-6 h of pressure
3. necrosis: follows >6 h of pressure
4. ulcer: necrotic area breaks down – N.B. skin is like tip of an iceberg
Classification (National Pressure Ulcer Advisory Panel 2014)
• StageI:non-blanchableerythemapresent>1hafterpressurerelief,skinintact • StageII:partial-thicknessskinloss
• StageIII:full-thicknessskinlossintosubcutaneoustissue
• StageIV:full-thicknessskinlossintomuscle,bone,tendon,orjoint
■ if an eschar is present, must fully debride before staging possible • StageX:unstageableulcer
Prevention
A Nutritional Formula Enriched With Arginine, Zinc, And Antioxidants For The Healing Of Pressure Ulcers: A Randomized Trial
Ann Intern Med 2015;162(3):167-74.
Among malnourished patients with pressure ulcers, 8 weeks of supplementation with an oral nutritional formula enriched with arginine, zinc, and antioxidants improves pressure ulcer healing.
• goodnursingcare(cleandryskin,frequentrepositioning),specialbedsorpressurereliefsurface,proper nutrition, activity, early identification of individuals at risk (e.g. immobility, incontinence, paraplegia, immunocompromised, DM, etc.)
Treatment
• dependsonindividualpatientandcondition • 4mainprinciples:
■ preventative measures (pressure relief, assess for pressure points e.g. wheelchairs; manage continence issues, divert contaminants e.g. urine and feces)
■ treatment of underlying medical issues including nutrition
■ moisture reduction pressure relief
■ wound bed preparation and treatment
• systemicantibioticsforinfections • assessforpossiblereconstruction
Complications
• cellulitis, osteomyelitis, sepsis, gangrene