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Woundhealingsa.co.zaCase Study : The WHASA Wheel THE WHASA WHEEL – Integrating multiple
specialities in patient management with wound healing
as the common basis
Widgerow AD, MBBCh, MMed(Surg), FCS(Plast), FACS
Private plastic surgeon, Linksfield Hospital, Johannesburg Correspondence to: Prof Alan Widgerow, e-mail: firstname.lastname@example.org
There is not a speciality in Medicine that I can think of today where Wound Healing does not impact. The surgical specialities by their very
nature involve the healing of wounds in one form or another, but it is not always appreciated that almost every chronic medical condition
also has associated wound problems. This reality results in an unprecedented amalgamation of medical minds and basic scientists all
contributing to a surge in knowledge related to this relatively new field.
The WHASA (Wound Healing Association of Southern Africa) WHEEL is a concept that has been developed to demonstrate the impact of interspeciality co-operation for the ultimate benefit of the patient. This article, by means of a hypothetical case, attempts to demonstrate this co-operation and to highlight esoteric situations that arise when considering wound healing among the different fields. It is by no means exhaustive of surgical scenarios but merely representative of fairly common situations that any of us could encounter on a daily basis.
The article takes the form of a case report which is interspersed with ‘wound healing' discussions that I have added under the heading ‘WHASA background comments'. In addition invited comments from our esteemed col eagues that make up the components of the WHASA WHEEL are included within the text.
Wound Healing Southern Africa 2008;1(1):07-14
bleeding, debridement of the necrotic mesentery, fascia, A 57 year old male patient was seen in Trauma Casualty following peritoneum and muscle and a motor vehicle accident. Initial examination revealed polytrauma thorough washout of the including a head injury, blunt abdominal trauma and a compound abdomen, total closure of fracture of the left tibia. His medical history included that of a type 2 the abdominal wall was not diabetic on oral medication in an otherwise healthy male. possible and the abdomen The patient responded to pain and withdrew in response to pain with was packed and closed incomprehensible verbal responses. He was assessed as a 10/15 with a broad polyurethane Glasgow Coma Scale score head injury but pupils were equal and temporary ‘sandwich' dressing responsive to light. Examination of the abdomen revealed ecchymotic with the intention of returning areas with an underlying tense distended abdomen. Palpation the patient to theatre in 72 hours once compartment confirmed fullness of the abdomen with percussion tenderness. A pressure had reduced and diagnostic peritoneal lavage showed the presence of more 200 000 the patient considered stable RBC/mm3 constituting a positive result for an intra-abdominal bleed. for further surgery. Examination of the left leg revealed an obvious compound fracture Figure 1: Tibial plateau fracture with severed of the upper third of the tibia and a weak pulse in the posterior tibial Comments from WHASA
artery region of the left lower limb. The ankle-brachial pressure index Wheel partner – Trauma
was assessed to be 0.6. Sensation to the foot was intact. surgeon: Prof Ken Boffard
Fol owing initial resuscitation and external reduction and splinting This patient's blood pressure is not recorded. If the patient is stable, of the tibial fracture, the patient was transferred to the operating he would probably get a CT scan of his head, abdomen, and a CT theatre under the care of the trauma surgeon, orthopaedic surgeon angiogram of his leg. If unstable, either the DPL or a FAST ultrasound and a vascular surgeon. A straight X-ray and on-table single-shot would be appropriate. The priorities would be to minimise secondary femoral angiogram revealed a tibial plateau fracture and a suspected brain damage through hypotension, and if there are signs of shock, transected popliteal artery with associated thrombosis (Figure 1). the abdomen takes priority.
Exploration of the abdomen revealed injury to the smal bowel The leg has a tibial fracture, in its upper third. This is generally below the trifurcation, and sensation is intact. This implies that since there mesentery with significant bleeding and pressure necrosis of the are three vessels at this point, and the mechanism of injury is not peritoneal fascia and abdominal wal muscle. Fol owing control of the Wound Healing Southern Africa 2008 Volume 1 No 1
Case Study : The WHASA Wheel compatible with transection of al three, that the most likely cause of the pulseless leg is positional, possibly with compartment syndrome. In the emergency department the fracture should be reduced and back-slabbed, or traction applied.
The X-ray (Figure 1) shows an upper tibial fracture, with popliteal transection, but reasonable col aterals. In this patient, on-table angiography is appropriate in the absence of CT angio.
There is injury to smal bowel mesentery, bleeding and necrosis of fascia and abdominal wal muscle. (Presumably due to a crush injury). There is no mention of the general condition of the patient, specifical y lactic acidosis. However, this patient fits the criteria for damage control, which implies haemostasis and any contamination control. This patient should have any mesenteric and other bleeders tied off, and then the operation should be terminated. No attempt should be made, in the presence of other injuries, to resect dead muscle. The abdomen should be thoroughly washed out. Any oozing should be judiciously packed.
NO attempt should be made to close the abdomen at this stage, and specifically the fascia should not be primarily repaired, grafted, or sutured. This case is ideal for an "Opsite Sandwich negative pressure dressing." Use of the proprietary VAC dressing at this stage is not indicated due to the risk of abdominal compartment syndrome. Equally, now is not the time to waste time on the abdomen.
Figure 2B: Opsite Sandwich dressing technique. The skin is dried and shaved – pubic hair shaved as necessary. A surgical drape is placed on Opsite, Steridrape, or Ioban, covering one side only Figure 2A: Temporary Opsite® negative pressure sandwich dressing The sheet is placed on the intestines and spread between the gut and abdominal wall laterally with the plastic in contact with the bowel.
This allows the bowel to bulge out if pressures are high (Figure 3).
Figure 3: Bowel bulging under ‘sandwich dressing' Two large suction drains are secured to the outside of the covered compartment fasciotomy through bilateral open incisions was done. surgical drape to control fluids. A large Ioban® or Opsite® is placed Fol owing debridement and soft tissue closure, an external fixator from the nipples to the groins.
was applied to reduce and align the fractured tibia. Negative pressure VAC dressing was then applied to the open wound anteriorly (See Case report continued
Figure 4). Thus the vascular repair was isolated to an area apart from Thus the abdominal injury was addressed by the trauma surgeon. open wound and negative pressure dressing. Simultaneously the vascular surgeon repaired the injured popliteal artery by a femoro-popliteal bypass using autologous saphenous vein WHASA background comments
harvested from the contra-lateral limb. Complete heparinisation was This case report highlights an interesting dilemma – negative not used due to the increased risk of haemorrhagic complications pressure therapy and anti-coagulation. Complications of bleeding in intra- and post-operatively. The patient was put on low molecular patients on oral anti-coagulants have been reported particularly in weight heparin on the day after surgery. infected leg ulcers.7 Most articles in fact would list anti-coagulation In order to preserve the closure and reduce compartment tension as a relative contra-indication to negative pressure therapy. Logic in the leg and in the area of the repaired artery, it was elected dictates that preference should be given to ensuring successful not to close the anterior wound on the leg – in addition a ful four outcome of the vascular repair – an alternative wound dressing Wound Healing Southern Africa 2008 Volume 1 No 1 Case Study : The WHASA Wheel to repair the arterial supply to the distal extremity. Exposure of the distal superficial femoral artery and the second part of the popliteal artery would be required. Autologous saphenous vein is the conduit of choice in bypass surgery distal to the knee joint. The use of the saphenous vein from the contra-lateral limb reduces the risk of venous insufficiency of the ipsilateral limb, especially in the setting of a concomitant venous injury (popliteal vein).
In an effort to conserve time and reduce ischaemia, the vascular surgeon could opt for the use of a temporary vascular shunt between the proximal and distal arteries. This would al ow time for the orthopedic surgeon to complete either internal or external fixation of the fracture. While this is being done, the vascular surgeon could harvest and prepare the saphenous vein from the controlateral limb. The bypass can then be performed on a stabilised limb. In extreme cases (damage control), the shunt could remain in position until the Figure 4: Negative pressure dressing leg patient has been adequately resuscitated.
(anything from simple hydrogel to foam cavity dressing) could There should be a low threshold to perform four compartment lower easily have been chosen if bleeding was deemed to be a real risk. limb fasciotomies through medial and lateral incisions in this patient, Fortunately most surgeons now do not routinely use systemic due to the patient's increased risk of developing compartment heparinisation fol owing vascular repair, so the negative pressure syndrome of his left leg. Post-operative wound care within this dressing should not be too much of a problem.
setting is of great importance. Various types of dressing, including negative pressure dressings, could be considered. A debridement The timing of arterial repair and exposure of the site are also of the fasciotomies is required within 24 to 48 hours. As soon as important. Obviously one would like to carry out the arterial repair the fasciotomy wounds can be closed, either primary closure of the as rapidly as possible to diminish ischaemic time, but one has to wound or skin grafting can be utilised. consider the amount of manipulation and soft tissue exposure that the orthopaedic surgeon would need to fix the fracture. The surgeons Due to the fact that fasciotomies compromise the normal muscle would work together on that decision making process, and external pump function of the lower extremities, the limb should be elevated fixation of the fracture considerably simplifies the problem.
in the post-operative period. As soon as the wounds al ow, low grade graduated compression bandages and eventual y compression For both procedures the avoidance of sepsis is paramount to success hosiery can be applied to prevent venous insufficiency. – thus the dressing chosen would be aimed at promoting granulation tissue and preparing the wound bed for closure (likely skin graft) as Comments WHASA Wheel partner –
soon as possible. In this case this would coincide with the secondary Orthopaedic surgeon: Dr Chris McCready
abdominal closure envisaged within the following week. Ideally The patient, in this case study, has suffered severe trauma, with discussion and planning between surgeons, and possibly the wound multiple injuries. The main role of the orthopaedic surgeon in therapist involved with the negative pressure dressing, should take this case is damage control, regarding the left leg injury. He has place so that the needs of the patient can be orchestrated.
sustained a Gustil o-Anderson type I Ic injury to the left tibia. The Comments WHASA Wheel partner –
critical issue that needs to be addressed is the injury to the popliteal Vascular surgeon: Dr Gregory Weir
artery. The ischaemic time plays a role in deciding if the artery should be repaired first, or if the fracture should be stabilised first. Most published articles on the topic of vascular injury stress the If the fracture is stabilised, the arterial repair is easier, however, importance of reducing the ischaemic time. This wil reduce the the viability of the limb should not be compromised. Another, more morbidity and risk of amputation in these patients. In this specific commonly used means of fixation is that of an external fixator. This case, the absent/diminished pedal pulses and reduced ankle- is quickly applied, gives stable fixation, and can be converted to rigid brachial pressure index, could have been due to a displaced fracture, internal fixation once the patient is more stable. which might have caused pressure on the artery. The presence of a thrombosed vessel on the arteriogram confirmed an arterial injury Another consideration, is the open wound. There is a 42% incidence requiring urgent intervention.
of sepsis with these fractures. A complete surgical debridement should be performed, preferably within 6 hrs of the injury. Due to the Life threatening injuries always require higher priority than limb- high energy transfer involved, the extent of the soft tissue injury is threatening injuries. The trauma surgeon and vascular surgeon would difficult to evaluate. Therefore, it is preferable to leave these wounds probably have explored the abdomen as a team. Only after the life- open, and should the patients condition al ow, perform a second threatening injury had been control ed, would the limb-threatening debridement in 72 hrs to remove any remaining necrotic tissue. With injury be addressed. exposed bone, or metalwork, an occlusive dressing is preferred. A Due to the fact that the patient was in a supine position for the negative pressure dressing wil assist in stimulating granulation explorative laparotomy, direct access to the popliteal artery behind tissue, which wil provide an excel ent bed for a split skin graft at the knee joint (usually done through a posterior incision), would have been impractical. A short femoro-popliteal bypass could be used Wound Healing Southern Africa 2008 Volume 1 No 1
Case Study : The WHASA Wheel Comments from WHASA Wheel partner –
Basic principles involved are the following:
Trauma surgeon: Prof Ken Boffard
1. Creating and preserving the peritoneal space between the Vascular surgeon is correct and timing is appropriate. Orthopaedic abdominal viscera and the abdominal wal preventing adhesions repair should, NEVER in this case be internal fixation, as there would and fistulae.
be too much additional disruption of the blood supply and muscle 2. The space is usual y created with either a temporary prosthetic attachments. This case should be external y fixed as described. The sheet for early closure, absorbable meshes of varying types or vascular repair takes priority over the orthopaedic fixation, but if a non-absorbable bioprosthetic material that is non adherent to necessary, a shunt can be used. External fixation is very rapid (10 underlying bowel where it is felt that fascial advancement and closure wil not occur. Progressive closure of the peritoneal fascia It is mandatory in this case to do a ful four compartment fasciotomy should be attempted in all cases.
through bilateral open incisions which are of adequate length. Almost 3. Wherever possible early closure (within approximately 9 days of certainly, the medial one wil be in continuity with the vascular the initial procedure) should be attempted to encourage success incision. In this case, since there is a col ateral blood supply, it is and prevent adhesions of abdominal wall and mesh.
reasonable to do the vascular repair first. However, in the absence of pulses with absence of sensation, the fasciotomies should be done 4. Negative pressure dressings are used in al the above scenarios before the repair. The popliteal vein should be checked since it is as this wound therapy has lead to the egression of bowel oedema, often damaged as wel . It is critical therefore to preserve the great slow advancement of the fascial edges and early closure of the saphenous vein, as this may be the only viable venous return, and open abdomen.
if vein grafting is required, the vein should be harvested from the Various prostheses are available opposite leg.
for temporary abdominal closure, The use of the VAC on the open fasciotomies is fine, but may be including polytetrafluoroethylene ineffective in the presence of an external fixator.
patch, polypropylene mesh, and polyglactin mesh. They al ow for I don't believe anticoagulation is an issue here. One does not routinely sequential closure when possible, anticoagulate a vascular repair (especial y with the mesenteric provide protection to the underlying ooze, etc). Additional y, we would routinely put this patient on low bowel as well as a method for molecular weight heparin on the day after surgery.
fluid egress, and it al ows for Case report continued
easy abdominal re-entry when necessary.1-4 The patient was returned to theatre at 72 hours fol owing the The prostheses and negative initial procedure. Abdominal compartment pressure had decreased pressure dressing also address considerably but not sufficiently for full abdominal closure. It was the problems of fascial retraction uncertain whether sufficient tissue would be available for full and adherence of the viscera to fascial/muscular closure. As a further interim measure VAC negative the overlying abdominal wall, Figure 5: VAC Dressing to the abdomen pressure dressing was applied (Figure 5). The plan was to return the al owing for continuing attempts at patient to theatre in a further 72 hours – if tissue was deficient for abdominal closure several weeks closure additional materials such as vicryl mesh or acel ular dermis after laparotomy. would be considered for interposition closure. Temporary abdominal wal closure WHASA background comments
techniques in the past have been Negative pressure therapy is intended to create an environment that associated with enterocutaneous promotes wound healing by secondary intention by preparing the fistula produced by erosion of wound bed for closure, reducing oedema, promoting granulation the bowel by overlying dressings. tissue formation and perfusion, and by removing exudate and The major barrier has been lack infectious materials. The concept of leaving the abdomen open of a prosthetic material that can intentional y after laparotomy is an accepted method of management be put directly on bowel without in certain circumstances (such as decompressive laparotomy as eroding and can be inserted into a depicted above). One needs to protect the viscera and al ow for contaminated field. Authors have Figure 6: Skin grafting directly on a simple return to the abdomen at the time of reoperation. In the reported success with aggressive past simple skin grafting of the open area was undertaken with the early closure of the open abdomen resultant herniation needing secondary repair later (Figure 6). using a nonabsorbable biological prosthesis made up of with human acellular dermal matrix (Alloderm, Utilising negative pressure dressings, current data demonstrate Lifecell Corporation, Branchburg, NJ).1 a fascial closure rate of 88%,1 with almost half of these closures In these authors experience most of even the largest defects can occurring at 9 to 21 days after initial operation. Thus the technique easily be closed with just a few sheets because the dermal matrix al ows for the large majority of abdomens to be closed with fewer expands up to 40% of its original size once well hydrated. Successful hernia repairs required. In addition, the technique allows for incorporation of tissue into this prosthesis has been demonstrated.1 successful closure at a significant interval after laparotomy.
Wound Healing Southern Africa 2008 Volume 1 No 1
Case Study : The WHASA Wheel Comments from WHASA Wheel partner –
Trauma surgeon: Prof Ken Boffard
With regard to the WHASA principles elaborated above: I. I absolutely agree. The ideal is that the plastic is in contact with bowel, while the swab or drape is in contact with the anterior abdominal wall. This stops it sliding about.
2 & 3. Most times, early closure is critical to avoid sepsis, so I would suggest that 72 hours is optimum. 4. I absolutely agree with VAC as a secondary closure. It should not be used initially, since it can exacerbate an Abdominal Figure 8: Grade 2 heel pressure sore Figure 9: Desquamating areas on the Compartment Syndrome due to its rigidity under vacuum.
back – Stevens Johnson Syndrome Case report continued
Successful resolution of this difficult condition transpired fol owing a treatment regimen that included: oral carbamazepine for epilepsy Seven days later the patient was returned to theatre, the abdomen control, intravenous methylprednisolone initially and decreasing was successful y closed and the left leg wound was skin grafted. The doses over the following 2 weeks, and oral pheniramine maleate. patient was returned to ICU for ongoing monitoring. Topical wound care with hydrocortisone acetate cream and On the eighth day nurses observed an area of redness and inflammation polyurethane sheet dressings. in the sacral region and on the undersurface of the right heel. The Comments WHASA Wheel partner –
sacral pressure sore progressed rapidly to significant skin breakdown. Wound healing specialist: Prof Magda Mulder
Simultaneously the patient developed a rash on his back. The symptomatic treatment in these patients are almost the same The sacral pressure sore was diagnosed as a Grade 4 pressure as for burns.
sore (full thickness damage involving underlying muscle ) (Figure 7). The nursing objectives are to:
Hydrocol oid dressings were initial y used then hydrogel dressings were introduced to stimulate granulation tissue in preparation • Maintain fluid and electrolyte balance for surgery. • Prevent wound infection and sepsis• Promote wound healing Fortunately the heel pressure was diagnosed as Stage 2 (damage to • Control environmental temperature (30 – 32ºC reduces caloric the epidermis and part of the dermis presenting as a blister) (Figure loss through the skin) 8). The heel blister was evacuated, hydrocol oid dressings applied • Give psychosocial support and a pressure relieving system was utilised. Due to the patient's background diabetic condition, the resident podiatrist was consulted Because skin and mucosa are the body's first line of defence, to manage the patients feet and to educate him on long term care infection is almost an unavoidable consequence. Scrupulous aseptic of his feet. technique is essential when any procedure is carried out on the patient. Prophylactic systemic antibiotics are not recommended.
Several approaches in wound management are used:
• Extensive debridement of nonviable epidermis fol owed by immediate cover with biological dressings or non-adherent dressings that can either absorb excess exudate, add moisture to a dry wound bed or retain moisture to ensure moist wound healing.
• Leaving the involved epidermis that has not yet peeled off in place and cover it with dressings only to protect and absorb and using biological dressings on raw dermis.
Comments WHASA Wheel partner –
Figure 7: Sacral pressure ulcer Dermatology specialist: Dr Gary Levy
The rash that presented on the patients back was initially a mystery. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis The rash then progressed rapidly to involve the patient's eyelids (TEN) are severe life-threatening forms of skin disease. In about half and lips. The rash consisted of atypical blistered targets and the cases the cause is not known while in 50 % of cases the use erythematous macules encompassing bullous lesions of irregular of a drug can usually be identified. The more severe the reaction, size and shape dispersed over his body progressing to desquamating the more likely that it was drug-induced. Anticonvulsants, non- skin lesions (Figure 9). The dermatologist consulted carried out a steroidal anti-inflammatories and antibiotics especially penicillin and detailed analysis and discovered that following on the head injury the sulpha drugs are the most commonly reported drugs, but more than patient was being treated with an anti-epileptic drug (lamotrigine) as 100 other medications have been implicated.
preventative therapy. Stevens Johnson Syndrome was diagnosed. Wound Healing Southern Africa 2008 Volume 1 No 1 Case Study : The WHASA Wheel SJS and TEN are probably the same condition, the name SJS being oedema makes footwear difficult and is a major cause of foot applied when less than 10% of the skin surface is involved, TEN ulceration. Wearing roomy shoes, with fastenings that can improve when more than 30% of the skin surface is involved, and SJS-TEN width fitting (such as laces or Velcro fastenings) may be required overlap when the involvement is 10-30 %. Skin involvement is until the peripheral oedema is resolved. Post surgical compression usually preceded by malaise, fever, cough and a sore throat.
hose may be required based on the input of the vascular surgeon. Custom footwear may need to be considered in col aboration with Skin lesions usually begin on the face and trunk and spread rapidly the orthotist.
to involve other areas of the body. The initial lesions are macular, and may remain so, fol owed by desquamation, or may transform The fracture and reconstruction of the left leg is bound to alter lower into target lesions with purpuric centres, and may even form bullae, limb mechanical function, placing uneven forces on one or both which will later slough. Mucosal surfaces are almost always involved: feet which may increase the risk of foot ulceration. This needs to the oral mucosa and the conjunctiva being the most frequently be assessed; and measures taken to normalise foot function with affected. The genitalia, oesophagus and respiratory epithelium can the use of an in-shoe device, such as foot orthoses, and/or shoe also be involved. Consequently, eating, drinking and urinating can be extremely painful.
Case report continued
The pathogeneses of SJS and TEN have not been fully elucidated. Histology in both conditions shows extensive keratinocyte apoptosis. Following 10 days of aggressive treatment for the dermatologic It is now hypothesised that the apoptosis is caused by the suicidal condition and dressings of the sacral pressure sore and heel sore, interaction of Fas which is expressed by keratinocytes and increased the sacral area was clean enough for definitive closure and the amounts of soluble Fas ligand (sFasL) secreted by peripheral blood heel sore had resolved. Ongoing cleaning and maintenance of the mononuclear cells (PBMC's).
sacral area was extremely difficult due to the proximity to the anal area. Surgeons thus decided to perform a defunctioning colostomy Management of these patients is similar to those with an extensive (cognisant of the previous abdominal reconstruction performed). burn. Most patients are hospitalised and suspected drugs are immediately stopped. Fluid and electrolyte balance must be Once the patient had once again stabilised, he was returned to theatre maintained via intravenous fluids. Bacteraemia and septicaemia and the plastic surgeon performed a bilateral V-Y advancement flap are common complications and can result in death. Appropriate for closure of the sacral pressure sore (Figure 10). antibiotics are usually given intravenously. The use of intravenous The patient stil suffered from residual skin hypersensitivity and steroids is controversial: in theory the use of immunosuppressives was treated by the stoma therapist for stomal dermatitis. The cause is to prevent further "immune" damage to the skin. Whether there appeared to be an inadequate seal and leakage of effluent. Once this is any benefit remains controversial and certainly once most of the was corrected overall healing occurred uneventfully. skin is lost, steroids only add to the morbidity and perhaps mortality of the patients.
More recently, reports of high doses of intravenous immunoglobulin (IVIG), administered within the first 4 days of onset of SJS/TEN have shown promising results. It is felt the IVIG blocks the Fas- sFasL interaction and thereby reduces/stops apoptosis. Renal function, which may already be impaired, must be carefully monitored, as there are reports, especial y in adults, of deterioration of renal function following IVIG administration. In patients who survive, re-epithelialisation takes 3-4 weeks. Complications include scarring, loss of vision and blindness. Mortality averages 5% for SJS patients Figure 10: Grade 4 sacral pressure sore closed with V-Y advancement flap and 30% for those with TEN. A rule of thumb is that the mortality rate parallels that of skin involvement i.e. 50% skin involvement will Comments WHASA Wheel partner –
result in a 50 % mortality rate.
Wound care specialist: Prof Magda Mulder
Comments WHASA Wheel partner –
It is essential to try and prevent pressure sores in all bedfast Podiatric specialist: Joanne Crawford
patients. (Prevention is better than cure.) An important aspect of the This patient appears to have intact sensation; however a thorough prevention of bedsores is the identification of those who run the risk medical history and comprehensive clinical examination may reveal of developing them. If it appears that a patient does run that risk, subtle signs and symptoms of early peripheral neuropathy. This adequate precautions in terms of a scientifically based nursing care patient needs education on the foot complications of diabetes and plan must be implemented from the time of admission. the importance of good metabolic control to prevent or reduce future A number of pressure sore risk assessment instruments are available, foot complications.
e.g. the Norton, Douglas, Waterlow, Gosnell and Braden scales.
The immediate podiatric concerns in this situation are the right heel Pressure sore risk assessment scales attempt to identify the and peripheral oedema. The resolved pressure ulcer of the right presence of extrinsic and intrinsic factors that are known to increase heel may require in-shoe cushioning/accommodation now that an individual's susceptibility to pressure damage, and to quantify the the patient is ambulatory, to protect the recently healed area from risk with a numerical scale.
breakdown. Post surgery any peripheral oedema must be assessed, Wound Healing Southern Africa 2008 Volume 1 No 1 Case Study : The WHASA Wheel Since most patients' conditions do not remain static, pressure sore Case report continued
risk assessment should be seen as a dynamic process. Patients should be reassessed when their conditions alter.
One week fol owing the sacral surgery the patient was transferred to a general ward and began his process toward recovery. He was Consequently the precautions must be continuously adapted now ambulatory, metabolical y stable and recovery transpired uneventfully from here. Two months following this severe injury, Comments WHASA Wheel partner –
multiple surgeries and concomitant complications the patient was Stoma therapy specialist: Sr Jane Hoole
discharged from hospital. His holistic management involved 11 different specialists working in tandem. Trauma: There are many injuries involving the colon, anus, rectum and perineal area that may require temporary diversion of the faecal Two years fol owing this episode, the patient presented to the wound stream. The most common of the diversions is the colostomy. The care clinic with a non-healing ulcer of the left leg (Fig 15). Armed with patient wil have the stoma until continuity of the distal tract can a history of significant trauma to the leg, an ankle -brachial index be restored.
of greater than 0.8 and the typical appearance of the wound, the wound care sister diagnosed a venous ulcer. The vascular surgeon Obstetric injuries, skin grafting of extensive sacral pressure was informed and treatment was instituted with hydrogels, foams ulceration, extensive anal fistulae are but a few of the indications for and most importantly compression bandages to the area. Healing diversion of the faecal stream, thus preventing wound contamination was accomplished over the fol owing six weeks and the patient in the perineal area.
received training in long term maintenance (stockings, diet, hygiene, exercise, etc) of this condition. Figure 11: Loop Colostomy Figure 12: Loop colostomy 1 day following surgery Peristomal dermatoses are a significant problem, affecting more than one third of patients with colostomies and more than two thirds of patients with urostomies and ileostomies. The most common cause of peristomal dermatitis is the leakage of effluent due to ill fitting/incorrect use of the various pouching systems and accounts for approximately 22% of al skin problems. Al ergy accounts for only 0.6% of skin problems. Figure 15: Venous Ulcer There are however, many and varied reasons for the development of peristomal dermatoses besides leakage, example: psoriasis, Comments WHASA Wheel partner –
eczema, allergens and disease. Wound healing specialist: Prof Magda Mulder
As the patient is diabetic, infection due to abnormal cellular and/or inflammatory responses is always a great risk. In view of this, a bone scan must always be taken first to exclude osteomyelitis before compression bandages are applied.
Secondly, ankle-brachial pressure index values are not very reliable in diabetics. An ABPI of 0.8 can therefore be misleading due to arteriosclerosis because the hardened arterial walls are not effectively occluded by the cuff. Transcutaneous oximetry (TcPO2) Figure 13: Second degree burn ileal Figure 14: Persistent irritation would therefore be a better option. A TcPO2 of less than 40 mmHg colostomy effluent at a temperature of 44ºC on the dorsum of the foot indicates tissue vulnerability, while a value of 10 mmHg indicates critical limb Comments WHASA Wheel partner –
Plastic surgery specialist: Prof Widgerow
Should it appear that the arterial supply is adequate and that the The V-Y advancement flap is not the workhorse for closure of sacral application of compression would be safe, the patient must be pressure sores. Closure utilising this technique results in an incision careful y assessed beforehand for peripheral neuropathy. The line directly in the area of pressure. This is only acceptable in the application of compression bandages in the presence of peripheral above case as the patient is ambulant (at this stage) and the area is neuropathy can be risky as the patient wil be unaware of symptoms sensate. Other choices (such as rotation flaps, gluteal island flaps) such as a local burning pain that could indicate possible underlying would be better in paraplegic patients. Wound Healing Southern Africa 2008 Volume 1 No 1 Case Study : The WHASA Wheel If compression bandages are applied, the patient should preferably also wear a sandal with Velcro straps on the foot of the affected leg. 1. Rodriguez, Eduardo D. D.D.S., M.D.; Bluebond-Langner, Rachel M.D.; Silverman, Ronald P. M.D.; A half-stocking must be pul ed over the toes to protect them against Bochicchio, Grant M.D.; Yao, Alice B.A.; Manson, Paul N. M.D.; Scalea, Thomas M.D. Abdominal Wall Reconstruction following Severe Loss of Domain: The R Adams Cowley Shock Trauma Center Algorithm. trauma and to prevent smal particles such as pebbles from landing Plastic & Reconstructive Surgery. 120(3):669-680, September 1, 2007.
between the sole of the foot and the bandages.
2. Miller, Preston R. MD; Meredith, J Wayne MD; Johnson, James C. PA-C; Chang, Michael C. MD Prospective Evaluation of Vacuum-Assisted Fascial Closure After Open Abdomen: Planned Ventral Hernia Rate Is Substantially Reduced. Annals of Surgery. 239(5):608-616, May 2004.
After the ulcer has healed, compression bandages must be applied 3. Miller, Preston R. MD; Thompson, James T. MD; Faler, Byron J. BS; Meredith, J. Wayne MD; Chang, for a further two to three weeks as premature degradation of col agen Michael C. MD Late Fascial Closure in Lieu of Ventral Hernia: The Next Step in Open Abdomen Management. Journal of Trauma-Injury Infection & Critical Care. 53(5):843-849, November 2002.
may occur in diabetics.
4. Stone, Patrick A. MD; Hass, Stephen M. MD; Flaherty, Sarah K. BS; DeLuca, John A. MD; Lucente, Frank C. MD; Kusminsky, Roberto E. MD Vacuum-Assisted Fascial Closure for Patients With Abdominal Trauma. Journal of Trauma-Injury Infection & Critical Care. 57(5):1082-1086, November 2004.
5. Scott, Bradford G. MD, FACS; Welsh, Francis J. MD; Pham, Hoang Q. MD; Carrick, Matthew M. MD; Liscum, Kathleen R. MD, FACS; Granchi, Thomas S. MD, MBA, FACS; Wall, Matthew J. Jr MD, FACS; Wound healing forms the basis of medicine in al its forms. It is Mattox, Kenneth L. MD, FACS; Hirshberg, Asher MD, FACS Early Aggressive Closure of the Open noteworthy that the speciality has found its own unique position Abdomen. Journal of Trauma-Injury Infection & Critical Care. 60(1):17-22, January 2006.
6. Pretre, Rene MD; Bruschweiler, Ivan MD; Rossier, Jacques MD; Chilcott, Michael MD; Bednarkiewicz, in medicine today as the incorporation of basic science, general Marek MD; Kursteiner, Karine MD; Kalangos, Afksendiyos MD Phd; Hoffmeyer, Pierre MD; Faidutti, medicine and surgery in all its forms all contribute to furthering the Bernard MD Lower Limb Trauma with Injury to the Popliteal Vessels. Journal of Trauma-Injury Infection & Critical Care. 40(4):595-601, April 1996.
knowledge and advancement of this field. The above case il ustrates 7. Steenvoorde, Pascal M.D., M.A.; van Engeland, Anneke M.D.; Oskam, Jacques M.D.,Ph.D. Vacuum- the co-operative ideal of multi-specialist input in managing a patient assisted closure Therapy and Oral Anticoagulation therapy Plastic and Reconstructive Surgery Volume 113(7), June 2004, pp 2220-2221.
with multiple problems and one common goal – achieving wound 8. Kocak, Sedat 1; Girisgin, Sadik A 1; Gul, Mehmet 1; Cander, Basar 1; Kaya, Halil 1; Kaya, Esengul 2 healing efficiently and effectively. Herein lies the WHASA wheel of Stevens-Johnson Syndrome Due to Concomitant Use of Lamotrigine and Valproic Acid. American Journal of Clinical Dermatology. 8(2):107-111, 2007 Figure 16: WHASA Wheel Wound Healing Southern Africa 2008 Volume 1 No 1
The EMBO Journal (2006) 25, 868–879 & 2006 European Molecular Biology Organization All Rights Reserved 0261-4189/06 Y-family DNA polymerases respond to DNAdamage-independent inhibition of replication forkprogression Veronica G Godoy1,3, Daniel F Jarosz2, properly restored. Mutations in components of such check- Fabianne L Walker1,4, Lyle A Simmons1
Using the NADA Protocol to Improve Wellbeing for Prostate Cancer Survivors: Five Case Studies Beverley de Valois and Tarsem Degun cardiovascular disease, and cardiac events. Distress, anxiety, This paper presents case studies of five men diagnosed and irritability, depression, and loss of confidence are emotional and