Single layer elastic wrap – long-stretch (ACE Wrap, Sure Press (ConvaTec))
Pressure: 20 mmHg
Indications:
Initial treatment of moderate venous insufficiency
Reusable
Note: If the patient is placing the wrap they need to be able to accurately wrap the dressing without gaps.

Single layer elastic wrap – short-stretch  (Comprilan (BSN Jobst)
Pressure:  19-29 mmHg
Indications:
Initial treatment of moderate venous insufficiency
Reusable
Note: If the patient is placing the wrap they need to be able to accurately wrap the dressing without gaps.

Compression stockings (Jobst, Mediven, Juzo, Sig-Varis. Allegro, Medi-strumpf, Therapress Duo)
Pressure: 30-40 mmHg
Indications:
Severe edema related to venous insufficiency or lymphedema
Maintenance therapy when initial edema, wound , and drainage has resolved

Pressure: 20-30 mmHg
Indications :
Moderate edema related to venous insufficiency or lymphedema
Treatment for chronic venous insufficiency
Note: Consider custom stockings for patients with: 1. a large calf with narrow ankle  2. lipodermatosclerosis

Multi-layer compression Wraps (Dynaflex (J&J), Profore (S&N), and Dynapress (J&J)
Pressure: 30-40 mmHg
Indications:
Severe edema related to venous insufficiency or lymphedema
Initial treatment choice for edema and exudate.
Appropriate for ambulating and non-ambulating patients
Changes 1 to 2 times a week depending on underlying wound and peri-wound conditions*
Best applied by a wound specialist

Inelastic (Unna’s boot or Duke’s boot) ViscoPaste (S&N), Gelocast (BSN)
Pressure: with one wrap of coban (adherent compression wrap) 30mmHg,  with two wraps of coban 40mmHg
Indications:
Severe edema related to venous insufficiency
Appropriate for ambulating and not as effective for non-ambulating patients.
Changes 1 to 2 times a week depending on underlying conditions*
Best applied by a wound specialist

Orthosis Circ-Aid (Coloplast), inelastic  (Farrow-wrap)
Circ-Aid T-3M Pressure:  20-30, 30-40, 40-50 mmHg
Indications:
Moderate to severe edema related to venous insufficiency or lymphedema
Treatment for chronic venous insufficiency (20-30mmHg).
Appropriate when initial edema and drainage are reduced.
For Patients who have difficulty placing elastic stockings.  Both Circ-Aid and Farrow wraps have velcro closure mechanism.

Farrow-wrap Pressure: 15-30mmHg
Indications:
Mild to Moderate edema related to venous insufficiency or lymphedema
Treatment for chronic venous insufficiency

Appropriate when initial edema and drainage are reduced

For individuals who have difficulty physically placing their stockings.These  products have Velcro closure mechanisms that allows for staged placement. Making the overall effort more reasonable, however, there is a learning curve that must be considered when suggesting these products to your patients.

About Arimedica:  This site has one purpose, to post and disseminate teaching
materials on certain subjects of medical and scientific interest.  It reflects
the interests and activities of its author, Marc E. Gottlieb, MD,  Phoenix,
Arizona, and colleagues.  It is focused on Wounds, Wound Practice, and related
issues of science and clinical arts.  It was started simply as a place to post
presentations in lieu of bringing printed materials to lectures and symposia.

Wound Topics include complex wound causing disorders and unique wound topics including:

Coagulopathies – Understanding wounds and pathologies due to coagulopathic and micro-occlusive disorders.

Auto-immunopathy – Understanding wounds and pathologies due to auto-immune and inflammatory disorders.

Integra – All about Integra artificial skin, it’s biology and clinical use, especially for chronic wounds.

VT & Angiogenesis – The VT model of angiogenesis and the physics of biological network formation.

This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, charcot midfoot  and heel wounds.

Removable Cast Walker/ Walking Boots
1. Charcot Restraint Orthotic Walker  (CROW) boot:
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, charcot midfoot,  and heel wounds.
2. DH Walker (also known as Active Offloading Walker):
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, charcot midfoot,  and heel wounds.
3. Prefabricated Walker (any premade walking boot):
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, ankle, and heel wounds.
4. Patella Tendon Bearing (PTB) brace:
This product is indicated for heel wounds.

Wedge Shoes
1. IPOS or Darco Wedge Shoe:
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, and lateral metatarsal wounds.
2. Ortho Wedge Shoe:
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal, and lateral metatarsal wounds.
3. Reverse IPOS:
This product is indicated for offloading heel wounds (no longer manufactured)

Multipodus Splint / Boot (Prafo, L’nard, Bend-a-boot, Multiboot):
This product is indicated for offloading heel and ankle wounds.

Surgical Shoes or Shoes with Pressure relief Insoles
1. Post op shoe (e.g. the Darco med-surg shoe with “peg assist”):
This product is indicated for offloading dorsal digit wounds.
2. DH Pressure Relief shoe (also the DH offloading post-op shoe):
This product is indicated for offloading planter digit, planter metatarsal, medial metatarsal,  lateral metatarsal wounds, and ankle wounds.
3. Plastizote Healing Shoe:
This product is indicated for offloading the dorsal digit, planter digit, planter metatarsal, medial metatarsal, lateral metatarsal, and heel wounds.

Dry Skin

Dry flakey skin – Moisturizer or thicker moisturizer.

Dry denuded skin – Xeroform.

Dry lightly reddened skin – A moderate strength steroid  (Topicort), change underlying padding to pure cotton cast padding.

Dry itching burning skin – Viscopaste wrap as first layer.

Moist Skin

Moist denuded skin – wound veil (Smith and nephew) covered with alginate. I recommend the wound veil cover because it will prevent the alginate from binding with the denuded tissue.

Draining wound – alginate or a beveled foam dressing. Note that foams have a tendency to dig into the skin around the edges, so it is important cut and taper around the foam edges.

What antimicrobials can I place on the wound that will last seven days?

Moderate or High draining wounds – Consider Iodosorb or Acticoat 7  flex. Remember to put lots of protective cream (EPC) around the peri-wound. Consider changing the  compression wrap twice a week.

The dressing has a foul smell after a few days

Consider a carbon dressing over the primary antimicrobial, debride, treat infection if present, change the dressing more often.

Still Edematous

Swollen moist red skin with new breakdown (even with 30-40mmHg compression) – Typical with fluid over load patients including renal disease. Treat the  etiology.

Swollen extremity with reddened skin and new onset calf pain – Rule out DVT.

Edematous knee to thigh after compression – Rule out Lymphedema and consider Edema Wear or Tubigrip from the bottom of the knee (just below the top of the initial compression device) to the top of the thigh. Consider placing a strip of foam dressing just under and over the top of the multilayer compression device if the top of the compression dressing is cutting into the skin (because of the edema).

Swollen Forefoot after Compression – Typically this is a result of the compression dressing being pushed up by mechanical means (related to poor fitting shoes or human intervention). Recommend the patient wear shoes with larger toe space such as Crocs or a surgical shoe. Consider placing an extra turn of the wrap over the  swollen area. Also place a thick barrier cream such as EPC cream over the forefoot to provide some tact in the area.

Swollen Toes after Compression – Consider gently wrapping the toes by first separating each toe with a foam dressing to prevent toe to toe pressure. Then place extra padding over the toes before you finish wrapping the toes with Coban. The elastic layer shouldn’t be placed over the toes along with the Coban,  as this my apply to much pressure.

Infection

Swollen red skin with open wound and new onset fever or pus – Rule out infection, culture wound, antibiotics.

Inflammation

Bright reddened skin   (Inflammatory with no signs of infection) – Topicort topical, medrol dose pack

Recurrent reddened skin with an open non-healing wound  – Consider differential diagnosis including autoimmune or another micro-occlusive disorder. Micro-occlusive disorders are covered in the Scottsdale Wound Management Guide (which can be purchased at swmghandbook.com). – Topicort to the wound bed and Prednisone oral weening over 6 weeks.

Dermatology

Reddened vessels around hair follicles – Rule out  folliculitus

Smaller reddened vessels (in groups or singular) – Consider treatment as fungal infection. Anti-fungal ointment for small area fungal breakouts.

Itchy rash over the majority of lower extremity below and maybe just above the knee to the thigh  (If using latex compression  wraps) , also possible systemic effects including puffy face, etc… – Rule out latex allergy, Consider Medrol dose pack, Benadryl, and Profore LF (Latex Free)

Shriveled skin – This is a common situation which happens during the first few weeks of compression therapy. The skin typically tightens on its own.

Adherent dry or dead tissue build up – Lotions (without alcohol)  and /or mist therapy to loosen. Once loose use a pick-up to remove.

Pain

Vague recurrent pain with application of compression dressing – To much tension, consider less compression to the extremity. Including placing Tubigrip instead of Coban on the final layer. Insure that ABI indicates no arterial component.

Recurrent pain over bone with the application of compression dressing – Assess the skin for areas of bruising or open skin. Cover the area with a hydrocolloid.

Recurrent pain over small protruding bone with the application of compression dressing – Cut out foam around the prominence with the idea of offloading the small protruding bones from the pressure of the wrap.

Recurrent pain over prominent shin bone with the application of compression dressing – Build up an offloading  layer of cast padding to the shins sides, then place extra cast padding over the shin down to the anterior ankle .

Pain related to wrap cutting in to skin of fluted lower extremity.  Note that fluted refers to a thick upper calf and a narrow distal third of the lower extremity – Assess for rolled undulating skin with straight indentations or openings into the skin that match up with the wrap. Place extra cotton layers around the lower third of the dressing to build the area up. This protects the skin and helps prevent the wrap from sliding down.

Swollen extremity with reddened skin and new onset calf pain – Rule out DVT

Pain with removal of dressing – Consider using Xeroform,  Adaptic, Mepetel or Comfort 2 Wound Veil.  Saturate the dressing with saline to facilitate removal of dry drainage from viable tissue.

No Improvement in Wound Size:

Consider a vascular consultation starting with a Venous Doppler R/O incompetent perforators.

Consider if wound stalling is related to chronicity or infection. Treat with collagen and /or with seven day anti-microbal dressing.

Consider secondary etiologies such as lymphedema, hypercoagulable states, autoimmune disorders, malignancy, etc…

Unable to convert patient to stockings (without increased swelling and or reopening of wounds)

Consider a vascular consultation starting with a Venous Doppler R/O incompetent perforators.

Try different compression stocking companies including more expensive brands that may have true and appropriate compression(yes there is a difference in quality between brands).

Poor health precludes vascular intervention – Palliative care (keep the patient in multilayer compression).

Revised 7/24/2010 ml

Arterial ulcers are caused by decreased blood flow to the lower extremity. Diagnostics to confirm this diagnosis include arteriograms,color duplex angiography, magnetic resonance arteriogram, arterial doppler, and transcutaneous oxygen monitoring. Treatment typically is achieved by improving the circulation with a bypass graft or angioplasty. Typically these wounds are very painful, so a silicone dressing like Mepitel or wound veil is a good choice for the primary dressing (if the wound is not infected). If the arterial wound consists of dry gangrene then betadine can be painted or Iodosorb ointment (Smith and Nephew) placed over the gangrenous tissue ( to keep the gangrenous tissue dry). There is a high risk for amputation in patients who are unable to be revascularized or if the gangrene converts to wet or gas gangrene.

Venous ulcers form by a complex cascade of physiological events in the venous circulation related to venous hypertension. Diagnostics used to confirm venous hypertension include pneumoplethysmography (maximum venous outflow), venous photoplethysmography, and bi-directional color doppler.  Treatment for venous ulcers includes compression wrap bandages, intermittent pneumatic compression, and apligraf.   High compression bandaging is considered the gold standard of treatment of venous leg wounds, yet the majority of published clinical data indicate that only 65% of ulcers are likely to be healed within 24 weeks of appropriate compression therapy, with 20% of ulcers remaining unhealed after more than 50 weeks (1).

(1) Skene AI, Smith JM, Dore CJ, Charlett A, Lewis JD. Venous leg ulcers: a prognostic index to predict time to healing. BMJ 1992; 305(6862): 1119-21.

Common Terms include:

FIBRINOUS– Accumulation of fluids and fibrin (a stringy insoluble protein).

HEMOSIDERIN STAINING – Hemoglobin deposited in tissues. Appears as brownish patches. Symptomatic of venous disease.

LIPODERMATOSCLEROSIS – an induration and erythematous hyperpigmentationof the leg.

MALLEOLUS – A common location of venous wounds located at either of the two rounded protuberances on the side of the ankle, the inner formed by a projection of the tibia and outer projection of the fibula.

PERIPHERAL VASCULAR DISEASE (PVD) – Alterations in the arteries and veins of the extremities; those conditions which interfere with adequate flow of blood to or from the extremities. Peripheral vascular disease broadly describes the underlying pathology of venous stasis ulcers and arterial ulcers.

VARICOSITIES – swollen, twisted veins.

VAVULAR INCOMPETENCE – Refers to damaged valves in the perforator veins of the legs; results in poor venous return to the heart. Valvular incompetence is the underlying pathology of venous stasis ulcers.

VENOUS HYPERTENSION
Patients with varicose veins or nonfunctional venous valves after deep vein thrombosis develop ambulatory venous hypertension, that is, distal venous pressure remains elevated despite ambulation. This constant venous hypertension seems to cause white cell and fibrin buildup, which impairs capillary blood flow or traps growth factors. Macromolecules pass into the dermis and eventually cause the hemosiderin deposition and brawny induration in the distal leg (gaiter area) characteristic of chronic venous insufficiency.

VENOUS INSUFFICIENCY – Stagnation of the normal flow of blood from the lower extremities to the heart due to valvular incompetence; also called venous hypertension.

VENOUS STASIS – Stagnation of the normal flow of blood from the lower extremities to the heart due to valvular incompetence; also called venous hypertension.

Diabetic wounds are related to microvascular and neuropathic changes in the diabetic patient. Diagnosis of the diabetic ulcer includes a compatible history of diabetes, monofilament test (to assess for loss of sensation), and noninvasive vascular assessments including a transcutaneous oxygen monitoring (TCOM) study. Treatment options for diabetic ulcers include off loading, growth factors (Regranex), debridement, and skin substitutes (Apligraf and Dermagraft).

Approximately 15% of Diabetic Foot Ulcers result in lower extremity amputation (2).    Though 40% to 50% of all diabetes-related amputations are preventable (1) .   Foot-care programs for diabetics (including teaching self foot assessments)  have been shown to reduce the rate of ulcers and amputations by 45% to 85% (1).

1. Garcia – Diaz, J., Pankey, G., & Gentry, Layne., 2006. The contemporary Diagnosis and Management of Diabetic Foot Infections. Health Care Co., Newtown, Pennsylvania. pg.16

2. Snyder, R., Kirsner, R., Warriner, R., Lavery, L., Hanft, J. and Sheehan, P., April 2010. Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. Supplement to April 2010 OWM, S4.

Diabetic Wound Related  Terms:

Diabetic (Neuropathic) Ulcer – Sensory neuropathy involving the feet may lead to unrecognized episodes of trauma caused by ill-fitting shoes or walking barefoot. This is compounded by motor neuropathy causing intrinsic muscle weakness and spaying of the foot on weight bearing. The result is a convex foot with a rocker-bottom appearance. Multiple fractures go unnoticed, until bone and joint deformities become marked. This is termed a Charcot foot (ie, neuropathic osteoarthropathy) and is observed most commonly in people with diabetes mellitus, affecting approximately 2% of persons with diabetes.

Diabetes: The long-term effects of diabetes impair wound healing by diminishing sensation and arterial inflow. In addition, even acute loss of diabetic control can affect wound healing by causing diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis.

DIABETIC ULCER – An ulcer that develops due to diabetic risk factors. Diabetes affects circulation as well as the nerve endings in the feet. As a result, many diabetics suffer reduced circulation and loss of sensation in their feet. The loss of sensation is dangerous, because diabetics are unable to feel rubbing, pinching or other pain that could cause a wound to develop on the foot. Lack of circulation to the feet makes it very difficult for a wound to heal. Risk factors for developing a diabetic foot ulcer include loss of sensation or peripheral neuropathy, structural foot deformity, infection, and decreased circulation.

Charcot Foot (Arthropathy) –Acute- Foot deformity with sudden onset of swelling,
increased local skin temperature, erythema, rapid joint changes, looseness of ligaments,
dislocation and fractures without apparent cause.

Charcot Foot (Arthropathy -Chronic -progressive degeneration of the stress-bearing
portion of a joint, with hypertrophic changes at the periphery. It is manifested by rapid
joint changes, looseness of ligaments, dislocation and fractures.

HgbA1c – Glycated hemoglobin, also known as glycohemoglobin, glycosylated hemoglobin, HbA1c or HbA1, refers to a series of stable hemoglobin components formed by the combination of glucose and hemoglobin. Individuals with higher levels of blood glucose will have higher levels of glycated hemoglobin. Because the hemoglobin
components are stable, the level provides an average indication of the overall blood glucose levels over the prior two to three month period. The most commonly used version of the glycated hemoglobin test is the HbA1c.

Hyperkeratotic – Hypertrophy of the horny layer of skin and often appears as a callus ring around a diabetic wound.

Monofilament Test or Semmes Weinstein Monofilament Test  – Is a sensory exam of the foot to detect sensory neuropathy – a 10 gram monofilament
which is pressed to several sights on the feet for 1.5 seconds on each sight and the patient is asked to say “yes” when the monofilament is felt.

Orthotics – a full contact semi rigid, soft insert designed to redistribute pressure, reduce impact, shear and stabilize involved joints. A suitable prescription should include a
complete diagnosis, reflecting the risk category of the patient. Orthotics must be casted and fitted appropriately by an experienced professionally trained clinician.

Osteomyelitis – Inflammation of bone and marrow, usually caused by infection.

A Biofilm is a surface-associated community that is composed of various types of microbes, which encases itself in a 3-dimensional matrix of extracellular polymeric substances (EPS) (e.g. polysaccharides, nucleic acids and proteins) and demonstrates increased resistance to cellular and chemical attack.

Microorganisms may exist in at least two distinct phenotypes – planktonic (free floating) and sessile (attached). A biofilm refers to a group or community of planktonic bacteria that may be incased in part of the extracellular matrix. The fragments have the ability to attach to another suitable surface and reform a biofilm community in the new area.

AAWC, (2008). Advancing your practice: Understanding wound infection and the role of biofilms. UKCT-A0021

Consider biofilm if the wound signs and symptoms includes:

Thick tenacious slough non-responsive (in the form of fast returning slough) to sharps debridement

Bright pink hypergranular tissue that bleeds easily

Wound bed has a slimy appearance

A biofilm may explain the delayed healing seen in some chronic wounds

Tx:

Serial Debridement

Alternate Silver (Acticoat) with Iodine based (Iodosorb)

Dakin’s solution 0.025 BID (for uncomplicated wounds)

Antibiotics

For more information connect to the center for biofilm engineering at Montana State University www.erc.montana.edu/