Grand Rounds: Segment # 2 Participant Questions

Please review the questions below and answer in the comment section.

Q1. What CPGs are you considering at this point in the case?
Q2. What is your interpretation of the AP and Lateral X-Rays on Slide?
Q3. What laboratory, other radiographic and special studies would you order at this point in the case?
Q4. What consultants would you order?
Q5. What is your initial differential diagnosis?
Q6. Does this patient need hospital admission?
Q7. Is this patient a candidate for HBO?

Grand Rounds: Patient Arteriograms

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Grand Rounds: History Of Present Illness, Segment #2

History of Present Illness

Physical Examination:
1. Partial thickness necrosis and infection of R Achilles tendon
2. No palpable DP, PT pulses B/L
3. No signs of fascial or osseous tracking of infection
4. Passive ROM of ankle was painful during examination. Unable to bear weight on R foot

Progressive Plan of Care

These are the first four of the Essentials as they appear in the flow sheet in CPG W01.01

1. Adequate perfusion and/or oxygenation
2. Removal of all non-viable tissue present
3. Infection and/or inflammation controlled
4. Edema controlled, venous reflux treated

These are the last five of the Essentials as they appear in the flow sheet in CPG W01.01
5. Wound microenvironment optimized to support healing
6. Tissue growth optimized
7. Offloading and/or pressure relief appropriate
8. Pain controlled
9. Host factors optimized 

When the NHC Wound Healing Clinical Assessment Pathway is reviewed with reference to the Nine Essentials, the concordance is obvious.

W05.01 Essential 1: Essential Step 1A/B Perfusion and Oxygenation.

The design of each Clinical Practice Guideline addressing the Nine Essentials includes the appropriate section of the decision tree or flow sheet, Critical Principles, and a detailed section describing appropriate steps in Assessment and appropriate steps in Treatment, decision trees or flow sheets, and other important supplemental information and references are then provided.

In the HealSource™ document, for the sake of brevity and greater utility of this condensed pocket version, only the decision tree or flow sheet segment, Critical Principles, and additional decision tree are included as in this example.

Note the Critical Principles with the guiding principle being that (1) all patients with a lower extremity wound need additional arterial vascular assessment beyond a vascular history, pulse examination, and ABI because of the importance of malperfusion and hypoxia in this subset of the population at large, and (2) all patients suspected of having a VLU should receive a properly performed venous duplex ultrasound.

Grand Rounds: Traumatic Achilles Tendon, Segment #1

Objective

At the conclusion of this blog case, participants should be able to discuss the diagnosis and treatment of the ischemic lower extremity with a limb-threatening wound; in this case, a necrotic, infected, and ischemic Achilles Tendon and contiguous soft tissues.

Introduction

• This 92 yo female was an active, independent ambulator (without assistive device) until sustaining a traumatic wound to her R Achilles tendon in her SNF.  
• The wound was cleansed by the nursing staff and the patient was immediately transferred to an emergency room and then to the affiliated wound center of that hospital.  
• Both in the ER and in the wound center the patient, and her family were told that a BKA was the only option due to LE ischemia with no vascular surgical consideration being presented to the patient and her family. Only portable doppler studies were done at that time.

History of Present Illness

Chief Complaint:

• 92 yo, well-oriented (X3) female active ambulator with painful wound of R Achilles Tendon with a complaint of mild-moderate pain since the injury

History of the Chief Complaint:  

• Trauma to R Achilles tendon in SNF while ambulating 
• Told BKA was only option due to LE ischemia with no vascular surgical consideration presented to patient and family 

Medical History:

• PVD, A-Fib, HTN, Dementia, COPD, Depression - 

Meds: 

• Spiriva, Metoprolol, Lasix, Lisinopril, Spironolactone, Cymbalta, Warfarin, Namenda 

Surgical History:

• Cataracts - Appendectomy - No previous surgical treatment of this new wound 

Family History:

• Breast CA (daughter), Lung CA (daughter) 

Social History: 

• Alcohol - None, Tobacco - 9 Pack years (Quit in 1974) 

Allergies:

• Ativan, Haldol 

Review of Systems: 

• Memory loss, Depression, Muscle weakness and pain, Stiffness, Swelling in joints, Bruises easily 

Case Segment #1

Participants’ Questions, Comments, Suggestions, Literature References and CPG Discussion

• What would you want to know from the History and Physical Examination? 
• What CPGs are you considering at this point in the case? 
• Does this patient need hospital admission? Is this patient a potential candidate for HBO?