Text Atlas of Wound Management PDF

Introduction

It has been almost 12 years since the fi rst edition of Text Atlas of Wound Management came out, which focused mainly on chronic wounds. The need for this title Text Atlas remains, and is perhaps even more important in view of new diagnostic and therapeutic challenges. In constructing this largely new second edition, we have maintained the philosophy that led us to publish its fi rst edition in the year 2000. Text Atlas remains a pictorial guide to wound management, and we have revised it with a broad audience in mind without sacrifi cing details. Therefore, the guide should remain useful to clinicians (physicians, nurses, health care students, other health care professionals, etc.) who are interested in knowing about wounds and how to approach them. Their interest may be in understanding wound healing and impaired healing, or in specifi c diagnostic approaches, or in procedures meant to diagnose and treat certain conditions.

We would like to think that, regardless of the professional background of the reader, our work will provide a fundamental framework for understanding the challenges presented by cutaneous wounds. In that respect, we remain aware that surgeons and physicians with a more internal medicine background often think differently about wounds. Still, they should gain confi rmation and new perspectives from this informative pictorial guide and its informative text. The nursing profession has adopted an essential and increasingly important role in the management of wounds. We trust that this work will guide them in feeling even more comfortable about patient management and the details of therapy that, after all, are so critical to a successful management plan. We think that medical and nursing students are becoming increasingly aware of the medical and fi nancial importance of chronic wounds; this Text Atlas should be an important primer for them as well, we hope. Regulatory agencies, including FDA offi cials, should benefi t from this Text Atlas by gaining greater understanding of the therapies and pitfalls they are asked to evaluate. We would like to think that even professionals involved in the fi nancial aspect of chronic wounds would draw from this work useful lessons that would enhance their knowledge of diseases that are becoming extremely expensive to treat. Last, but no less important, we sincerely hope that wound healing clinics and their personnel (physicians and surgeons, nurses, medical assistants, etc.) will feel more comfortable and confi dent after reading this Text Atlas.

Our intent in revising this Text Atlas has remained unchanged. We have strived to keep and project an open mind about wound management. As we had predicted in the fi rst edition, we have now seen new and more thorough guidelines for wound management, particularly for venous, diabetic, and pressure (decubitus) ulcers. However, we have realized that infl ammatory ulcers continue to present a tremendous challenge for many clinicians. Such ulcers still do not fall in welldefi ned categories, although this pictorial guide has made substantial advances in that regard. For example, the linear streaks of microlivedo should immediately raise the possibility of microthrombotic disease, such as cryofi brinogenemia, the antiphospholipid syndrome, livedoid vasculitis, etc. Undermining of the skin (other than in pressure ulcers) immediately raises suspicions about the diagnosis of pyoderma gangrenosum. These examples, like other situations regarding vascular ulcers, are presented as "clinical vignettes," which can stand on their own and are meant to deliver a teaching point or a point for discussion; we do not claim to have the answer in each and every case. Indeed, the conditions we present project the reality of wound management, from factitial disease, to poor compliance, to attempts in improving compression and dressing strategies, etc. In general, these "clinical vignettes" of the Text Atlas do not require the reader to refer back and forth to different portions of this guide. We do not claim that our work will take the place of other larger textbooks about etiology, pathogenesis, guidelines, treatment approaches and so on. However, we do feel strongly that this unique pictorial guide, which is supplemented with what we hope are thoughtful and informative comments (both in each legend and in the introduction to each of the eight sections) will be very desirable and worthwhile. In many cases, we have provided our own unique perspectives on the cases being shown and on the disease process. The rich bibliography can be used for more extensive reading, if so desired.

At the time of writing the fi rst edition of Text Atlas, we formulated the unique concept of Wound Bed Preparation (WBP). With the advent of this useful concept, we think that the fi eld of wound healing changed dramatically. WBP provided the foundation for making wounds heal more rapidly and, most importantly, for developing the conditions that allow advanced therapeutic products (including bioengineered skin and growth factors) to be more successful. Presently, WBP drives the fi eld of chronic wounds, because it takes into account not only the overall diagnosis and defi nitive treatment, but the choice of dressings, compression bandages, elimination of biofi lms, bacterial colonization and high bacterial burden, as well as the formation of proper granulation tissue and epidermal migration. Some clinicians may fall into the error of trying to correct each abnormality in sequence. However, WBP dictates that all aspects of the wound need to be addressed at about the same time, including the following: debridement by surgery, hydrosurgery, autolytic means with dressing and slow-release antiseptics, and enzymatic approaches; the use of stimulatory autografts and bioengineered skin; attention to the removal of edema and other local impediments to healing; correction of systemic components, including congestive heart failure, hyperglycemia, etc. This ongoing revolution of WBP has benefi ted chronic wound care in these and many other ways, and is likely to further improve the outlook and prognosis for diffi cult-to-heal wounds.

In the context of developing "clinical vignettes" we sort of invited the reader to be with us at the bedside, facing the same problems and challenges we are dealing with. We have purposefully adopted a rather informal, narrative approach for that purpose. We do not stand at the podium, instructing clinicians about how to approach these challenging wounds. Rather, we invite thinking and an inner discussion about what we state in our narrative. A decade after our fi rst edition, the management of some chronic wounds and practical problems is still an uncharted territory, and there is no absolutely right answer for their optimal management. Much depends not just on the condition being treated but also on the patient's circumstances and their environment

This edition of Text Atlas of Wound Management is divided into eight sections, with each preceded by what we hope is a useful introduction and some key clinical points. The fi rst section is about more acute wounds. We do not deal here with burns and major trauma, which are better dealt with in very specialized textbooks and surgical approaches. The second and third sections address wound infection and neuropathic ulcers, respectively. These are problems that commonly affect patients with diabetes but are also applicable to other clinically diffi cult wounds. The diffi culty of distinguishing true infection from wound colonization, biofi lm development, and from an infl ammatory process is highlighted. We do not always have an answer for that, but we do discuss some helpful clues and approaches. Vascular ulcers and infl ammatory ulcers are discussed in sections 4 and 5, respectively. It might at fi rst seem easy to separate these two problems, and the challenge is made greater by frequent overlaps between the two etiologies and pathogeneses. We think we have provided a useful working approach to these challenging wounds. Indeed, we predict that the reader will develop a very good sense of how to deal with these problems, based on our experience and our

struggles. Section 6 deals with wounds complicated by or caused by neoplasms. A high degree of suspicion must be kept when wounds do not heal. Even when a biopsy does not demonstrate a neoplastic process, the burden is on the clinician to ensure that a sampling problem did not occur or that the interpretation of the histology was diffi cult or fl awed. In section 7 we devote ourselves to some practical points of wound management. This is an important section that both physicians and nurses must be quite familiar with. One may identify the etiology of the wound, but healing does not take place unless proper WBP is applied and the very practical aspects of patient care are addressed. Finally, we complete our Text Atlas with section 8, which deals with some procedures that are grouped together for the benefi t of the reader. In that section, we conclude our work with a discussion of clinical trials, which are the fountain from which new treatments spring from. Over the years, clinical trials have become more demanding and challenging, in order to better address patient safety and to overcome regulatory hurdles. The clinician needs to have a working knowledge of these matters.

We humbly apologize for any shortcoming in preparing this second edition. However, we do hope that our patients' quality of life will improve as a consequence of our addressing these problems related to chronic wounds. Our patients tend to be elderly, are often unable to express themselves properly or unable to make themselves heard when suffering. They are often at the mercy of health systems that do not pay for the considerable expenses of wound management. They have pain, discomfort, and offensive odors from their wounds, and interestingly put up with these and other tremendous challenges with patience and silence. We dedicate this Text Atlas of Wound Management to them, our true teachers.