Chronic Wounds: Palliative Management for the Frail Population—PART II
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The underlying pathology of ischemic ulcers that causes the clinical symptoms observed includes plaque deposits that become calcified, damage to the vessel from chronic hypertension,36,37 and increased platelet aggregation causing formation of microthrombi.
These sequelae of peripheral arterial disease result in the narrowing of the vessel lumen leading to the reduction of blood flow, loss of vessel elasticity, and a loss of vessel ability to self regulate blood flow in response to metabolic needs.
Assessment. Trauma is the precipitating event for arterial ulcers. Ischemia and infarction of local tissue occur with tissue loss and gangrene. As with all patients suspected of having arterial disease as the etiologic basis for a chronic wound, a complete clinical history and examination must be completed to confirm and then determine severity of the contributing disease.
Evaluation should accomplish the following objectives: objective confirmation of the diagnosis; assessment of hemodynamic requirements for successful intervention (revascularization); assessment of patient operative risk; assessment of atherosclerotic risk factors; and assessment of atherosclerosis in other body systems.
The examination will assess both the coronary and cerebral circulation, basic hematological and biochemical tests, resting ECG, ankle or toe pressure measurement, or other objective measures of severity of the ischemia. Additionally, the exam should include imaging of lower-limb arteries in patients if vascular surgery is assessed to be a realistic option. Duplex scan of the carotid arteries should be done in selected patients at high risk as well as a more detailed coronary assessment in selected patients.
Although the above clinical examinations would provide the ideal diagnostic information necessary to assess the severity of arterial damage, not all the listed tests are feasible for the frail elderly. Alternatively, a simple test at the bedside can confirm whether the patient has dependent rubor, which is indicative of severe ischemia. Arterial to brachial index (ABI) is the standard noninvasive examination used to assess the lower-extremity macrovascular status.38 Noninvasive studies, such as ABI, using ultrasonic Doppler will identify claudication if it is less 0.7mmHg and severe ischemia if it is less than 0.4mmHg. Also, measuring segmental pressure or pulse volumes at different levels can determine where the arterial occlusion is located. Noninvasive vascular testing, including segmental pressures, toe pressures, Doppler waveform analysis, and duplex scanning, can be helpful and should be done in patients for whom surgery is a viable option.39–42
Transcutaneous oxygen measurement (TcpO2) is used to determine the degree of microvascular perfusion. TcpO2 measures the diffusion of oxygen into the periwound tissue and is indirectly measured via transcutaneous oxygen monitoring.43 A TcpO2 greater than 30mmHg suggests the patient has adequate perfusion to heal. This measurement is valuable if the ABI is low and can aid in the decision to perform surgical revascularization, which should be avoided if possible.44,45 However, the practical application of this technology may be limited because the instrumentation is costly and requires temperature control. Additionally, the testing process is lengthy, limiting its usefulness among a frail patient population.
Physical appearance. Arterial ulcers are located on the distal lower extremity because of inadequate perfusion of the skin and subcutaneous tissue at rest.46,47 This type of ulcer has a “punched out” appearance that follows some form of trauma to the leg. The wound bed is dull pink, indicating poor perfusion, and the base will be granular. The patient will display dependent rubor and have minimal or absent pulses.
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