Clinical Pathways for the 5 Wound Types
Choose a wound type to view the associated clinical pathways and guidelines.
Diabetic Ulcer Pathway
- Goal of HgA1c < 8% to improve healing outcomes
- Evaluate for claudication, leg edema, and palpable foot pulses
- For non-palpable foot pulses, obtain vascular studies, refer to vascular surgery
- If this goes to bone, obtain x-rays of foot and refer to orthopaedic foot & ankle surgeon
- Start empiric broad-spectrum antibiotic (Augmentin, Clindamycin, Ciprofloxacin)
- Start wound care with saline moist gauze up to 2x/day depending on draining until infection resolves; then advanced dressing may be used to promote healing
- Refer to wound center
- Sharp debridement by specialists is usually the best approach
- Debridement can be done by primary care with the following therapies:
- Mechanical (cleansing, dressings)
- Enzymatic, (collagenase ointment)
- Autolytic (moisture retention dressings)
- Most wounds require all of the above to promote healing
- Referral to wound specialists can provide advanced dressing recommendations.
Glycemic control and post-operative healing. Journal of Foot and Ankle Research; Lower Extremity Review. Naohiro Shibuya, DPM, MS, FACFAS, Jon M. Humphers, DPM, and Daniel C. Jupiter, PhD. July 2013>
Guidelines for the treatment of diabetic ulcers; Wound Repair and Regeneration (2006). Wound Healing Society. Steed, David
Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot. Diabetic foot infection: Antibiotic guidelines. Johns Hopkins. Eric Nuermberger. 6/16/2009
Lipsky BA, Berendt AR, Deery HG, et al.; Diagnosis and treatment of diabetic foot infections.; Clin Infect Dis; 2004; Vol. 39; pp 885-910; ISSN: 1537-6591; PUBMED 15472838
Debridement: A Vital Component of Wound Bed Preparation. Kirshen C, Ayello E, Sibbald, R. Advances in Skin Wound Care 2006; 19:506-17; Lippincott Williams & Wilkins.
Diabetic Ulcer Guidelines
Patients with diabetic ulcers require a multidisciplinary approach with primary care coordination of a variety of specialists to promote healing and prevent limb loss.
For patients with prior diabetic foot or leg wounds, poor diabetic control, peripheral vascular disease, renal disease or other illnesses that compromise healing, we strongly recommend referral to a wound clinic for evaluation and management.
- This includes patients with ulcers that expose subcutaneous structures when probed to tendon or bone, if wound is >30 days old or debridement of necrotic tissues/callous is needed.
- For patients with poor or limited self-care who are homebound due to illness, referral to home care wound nurse specialist is highly recommended.
- Optimizing glucose control improves wound healing.
- High HgA1c (>8%) is associated with poor outcomes.
- Clinically significant vascular disease should be assessed by checking for palpable pulses.
- Due to frequent calcification of arteries in diabetics, basic vascular studies with toe-brachial indexes (TBI) are more reliable indicators of adequate perfusion.
- TBI should be >7.0.
- Initial course of antibiotics is 1-2 weeks for mild infections and >3-6 weeks for moderate to severe infections.
- May need Infectious Disease consult.
- If wound is severely infected and patient is acutely ill, recommend hospitalization for IV antibiotics.
Wound bed preparation with debridement of necrotic, non-viable tissues is necessary to reduce infection, stimulate new tissue growth, and promote healing.