Literature 142 Presentation

Ariel Fox
LITERATURE
LITERATURE_142_PRESENTATION
The exact duration of time which distinguishes a chronic wound from an acute wound is not
clearly defined, although many clinicians agree that wounds which have not progressed for
over three months are considered chronic wounds.==== Common causes of chronic wounds
====
Diabetes mellitus – Wound healing impairment in the setting of diabetes is
multifactorial.Hyperglycemia, neuropathy, microvascular complications, impaired immune
and inflammatory responses, and psychological factors have all been implicated in the
formation and propagation of diabetic wounds.Feet are the most common location of
diabetic wounds, although any type of wound can be negatively impacted by diabetes.It has
been estimated that up to 25% of patients with diabetes mellitus will be affected by non-
healing wounds in their lifetime.Venous/Arterial insufficiency – Impaired blood outflow
(venous) or inflow (arterial) can both impair wound healing, thereby causing chronic
wounds.Much like diabetes, venous/arterial insufficiency most commonly result in chronic
wounds of the lower extremities.In chronic venous insufficiency, blood pooling impedes
oxygen exchange and creates a chronic pro-inflammatory environment which both promote
formation of venous ulcers.Peripheral artery disease, on the other hand, causes wounds due
to poor blood inflow and typically affects the most distal extremities (fingers,
toes).Immunologic disease – The immune system plays a critical role in the inflammatory
process; therefore, any disease of the immune system has the potential to impair the
inflammatory phase of wound healing, thereby leading to a chronic wound.Patients

suffering from diseases such as rheumatoid arthritis and lupus have been found to have
larger wounds and prolonged time to heal when compared to the general
population.Pressure ulcer – Also known as decubitus ulcers or bedsores, this type of wound
is a result of chronic pressure to the skin over a prolonged period.While most individuals
have intact sensation and motor function which allow for frequent positional change to
prevent the formation of such ulcers, older individuals are particularly susceptible to this
type of chronic injury due to impaired neurosensory responses.Pressure ulcers can occur in
as little as two hours of immobility in a bedridden patient or person who is otherwise
unconscious/sedated (surgery, syncope, etc.).In the United States, pressure ulcers are
graded using the National Pressure Injury Advisory Panel (NPIAP) system.In this system,
ulcers are graded on wound depth with stage 1 being the least severe (erythema, intact
skin) and stage 4 being full thickness damage through subcutaneous tissue down to muscle,
tendon, or bone.Any ulcer that cannot be assessed due to overlying eschar is considered
unstageable.=== Wound sterility ===
Wound sterility, or degree of contamination of a wound, is a critical consideration when
evaluating a wound.In the United States, the CDC's Surgical Wound Classification System is
most commonly used for classification of a wound's sterility, specifically within a surgical
setting.According to this classification system, four different classes of wound exist, each
with their own postoperative risk of surgical site infection:
Class 1 – clean wound: a wound that is not infected and without signs of inflammation.This
type of wound is typically closed.By definition, this type of wound excludes any wounds of
the respiratory, genital, alimentary, or urinary tract.Class 2 – clean-contaminated wound: a
wound with a low level of contamination.May involve entry into the respiratory, genital,
alimentary, or urinary tract.Class 3 – contaminated wound: an open, accidental wound

resulting from trauma outside of a sterile setting is automatically considered a
contaminated wound.Additionally, any surgical wound where there is a major break in
sterile technique or obvious contamination from the gastrointestinal tract is considered a
contaminated wound.Class 4 – dirty/infected: a wound with evidence of an existing clinical
infection.Class 4 wounds are usually found in old traumatic wounds which were not
adequately treated and will show evidence of devitalized tissue or gross purulence.==
Presentation ==
=== Workup ===
==== Physical examination ====
Wound presentation will vary greatly based on a number of factors, each of which is
important to consider in order to establish a proper diagnosis and treatment plan.In
addition to collecting a thorough history, the following factors should be considered when
evaluating any wound:
Size of wound: Should be accurately measured at time of initial presentation and regularly
remeasured until wound resolution.Wound location: Very useful consideration in many
chronic wounds, such as diabetic foot ulcers, pressure ulcers, and venous ulcers.Acute
wounds will be located in areas consistent with the mechanism of injury (e.g.diagonal chest
wall bruising from seatbelt following car accident).Wound bed: A healthy wound bed will
appear pink due to healthy granulation tissue.Presence of a dark red wound bed which
bleeds easily on contact or excess granulation tissue (i.e.hypergranulation tissue) may

indicate the presence of an infection or non-healing wound.Wound depth: The depth of a
wound is often not apparent on visual inspection alone.Proper evaluation of wound depth
includes use of a probe to measure wound depth and evaluate for undermining of wound
edges or sinus/fistula formation.Necrotic tissue, slough, eschar: Wounds may be covered
with a layer of dead tissue which may appear cream/yellow in color (slough) or as a black,
hardened tissue (eschar).Removing this tissue is critical for properly evaluating both the
depth of a wound and quality of the wound bed, and promotes wound healing.Wound
edges: May provide clues to cause of specific wounds, such as gently sloping edges of venous
ulcers or rolled edges of certain tumors.

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Ariel Fox

Diabetes mellitus – Wound healing impairment in the setting of diabetes is

multifactorial.Hyperglycemia, neuropathy, microvascular complications, impaired immune

healing wounds in their lifetime.Venous/Arterial insufficiency – Impaired blood outflow

wounds.Much like diabetes, venous/arterial insufficiency most commonly result in chronic

inflammatory phase of wound healing, thereby leading to a chronic wound.Patients

as little as two hours of immobility in a bedridden patient or person who is otherwise

unstageable.=== Wound sterility ===

Wound sterility, or degree of contamination of a wound, is a critical consideration when

with their own postoperative risk of surgical site infection:

the respiratory, genital, alimentary, or urinary tract.Class 2 – clean-contaminated wound: a

alimentary, or urinary tract.Class 3 – contaminated wound: an open, accidental wound

contaminated wound.Additionally, any surgical wound where there is a major break in

sterile technique or obvious contamination from the gastrointestinal tract is considered a

contaminated wound.Class 4 – dirty/infected: a wound with evidence of an existing clinical

=== Workup ===

==== Physical examination ====

important to consider in order to establish a proper diagnosis and treatment plan.In

evaluating any wound:

remeasured until wound resolution.Wound location: Very useful consideration in many

bleeds easily on contact or excess granulation tissue (i.e.hypergranulation tissue) may

edges or sinus/fistula formation.Necrotic tissue, slough, eschar: Wounds may be covered

ulcers or rolled edges of certain tumors.

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