Help with Sarcoma Wound - Warning, graphic description!

[Wildbriar]

I'm am running out of ideas and could use some new inspriation... I have a client with radiation induced spindle cell sarcoma from a previous mastectomy and breast cancer treatment. The sarcoma has caused a nasty wound and is eroding the skin and muscle on the left side of the chest, beneath the axilla and is moving deeper and deeper into her chest wall. It is so deep I can now visualize fascia and her collarbone. We've been controlling small bleeds with silver nitrate. This client is absolutely petrified of bleeding to death but i think that is where this is headed as the erosion continues toward her brachial artery. The area is so tender and difficult to dress that it is generally left open to air, with any eschar formed left in place to prevent large scale bleeds. Does anyone have any ideas of what I can do with this wound, or where it might be going? I've never seen anything like it before and feel at a bit of a loss.

Thanks, Erin

[augigi, CNS]

Tried a vac dressing?

[leslie :-D]

this requires a medical consult.

perhaps your med'l dir...

only a doctor can state the implications of the festering wound, i.e., whether she is bleeding out or if it will even penetrate any artery.

i'm hoping the doctor does understand the direction the course is taking and all of its' implications.

once wounds are this aggressive, they can't be stopped.

normally it is not 'blood' that is a wound's demise, since blood is filled w/nutrients.

that's why i'm saying the doctor/np should understand the underlying etiologies, and make recommendations based on this knowledge.

leslie

[leslie :-D]

ok, depending on various factors, there are certain considerations to keep in mind.

- if an infection is contributing to bleeding, give broad spectrum abx.

- alginate dsgs will aid in controlling surface bleeding.

- if your pt is on coumadin, dc? vit k?

add- please remember to take pts off of coumadin during terminal phase.

nothing worse than family watching the pt literally bleed out with blood trickling out of all orifices.

doctor may consider palliative radiotherapy.

again, it depends if it's cap bleeding or deeper.

and in the event it looks like your pt will bleed out, then preparatory sedation is indicated.

our pharmacy used mso4, scopalamine and thorazine in a prefilled syringe.

a red blanket also aids in disguising the effects of mass bleeds.

if in the event she is bleeding, i would refer her to an inpt hospice until the plan of care can be modified to reflect her deteriorating status.

leslie

[Wildbriar]

Leslie, thanks for the suggestions. This pt does not want to do any palliative raidiation and wishes to remain home so we are doing what we can. I think my frustration is that this is not a typical wet, draining wound. She had some significant bleeding when the erosion really started to go below the skin but since then things have slowed down to what looks like cappillary bleeding only. Someone else mentioned a vac, but this is not a wound that a vac would help, only create more pain and tissue damage. I've never seen anything quite like this but obviously this wound has no chance of healing. No signs of infection present either. In fact, with the exception of this nasty hole in her chest this woman is doing remarkably well, good appetite, cheerful disposition, and still ambulatory. I have discussed this with our Med Dir and his thought was that this was likely to cause an arterial bleed if it continues so we have tried to prepare her husband as best we can. I may have to approach the idea of inpt care again with them if the idea of her bleeding out at home is too much for him.

Thanks again.

-Erin

[leslie :-D]

i didn't know the med'l dir had been consulted already.

yet, s/he really needs to look at the wound rather than cite possibilities, based on a verbal report.

i have seen wounds such as the one you describe, and watching someone bleed to death is one of the lingering horrors of hospice care.

while the bleeding may be on the capilliary level, do not trust it to remain.

if the md has already anticipated an art bleed, then preparations need to start immediately as any infiltration into the arterial bed will be spontaneous and highly combustible.

please, start your planning now.

i cannot emphasize this enough.

leslie

[caroladybelle, BSN, RN]

I've had MDs prescribe surgiseal (expensive and hard to come by) to reinforce sites that have potential to bleed out. But it will merely delay the inevitable, if a serious arterial erosian is pending.

[doodlemom]

Tried a vac dressing?

I wouldn't try this. Wound Vac's are only used for healable wounds and are not usually used in hospice patients. It would not keep the sarcoma from growing into her artery and it would be causing damage to already fragile tissue. It's an unfortunate situation and she may just bleed out. If that happens, it will be quick and should be painless.

[BeExcellent]

An "old school" hospice nurse turned me on to a product called Icthammol 20% ointment. I have never seen a wound product work better including the silver impregnated products and the granulation promoters. This is an ointment that has antimicrobial and antifungal properties. It is thick, dark and sticky and made from shale oil! But I have used it on HUGE wounds that have granulated and healed. It is also very cheap. I used 1/2 strength Dakins to decrease bacterial load, then alginate with Icthammol liberally in the wound. It is amazing stuff. It has healed wounds that others declared unhealable. It is too cheap for anyone to make any money on at about $3.00 a tube.

[RN4hospice]

Our hospice has had several similar wounds. As the disease progresses, it is a possibility that the patient could "bleed out". Placing dark towels in the home is less frightening to families when there is bleeding. We have used Monsel's solution (Ferric Subsulfate) directly on the bandages that touches the wounds (leave in place). This prevents or greatly minimizes bleeding. I feel it is much better than the silver nitrate sticks because if helps prevent the bleeding. The solution is a stypic or haemostatic agent. Your hospice pharmacist should have more information on it. Our pharmacy keeps it in stock. We were actually introduced to it by an OB/GYN physician when we had a pt. who had lady partsl bleed outs. Saturate a tampon in the solution and insert it for several hours....stops the bleeding! Works great!I think it is great that this forum is available...so we can get ideas from others to treat our patients. Good luck!

[doodlemom]

Our hospice has had several similar wounds. As the disease progresses, it is a possibility that the patient could "bleed out". Placing dark towels in the home is less frightening to families when there is bleeding. We have used Monsel's solution (Ferric Subsulfate) directly on the bandages that touches the wounds (leave in place). This prevents or greatly minimizes bleeding. I feel it is much better than the silver nitrate sticks because if helps prevent the bleeding. The solution is a stypic or haemostatic agent. Your hospice pharmacist should have more information on it. Our pharmacy keeps it in stock. We were actually introduced to it by an OB/GYN physician when we had a pt. who had lady partsl bleed outs. Saturate a tampon in the solution and insert it for several hours....stops the bleeding! Works great!I think it is great that this forum is available...so we can get ideas from others to treat our patients. Good luck!

Wow! I've not heard of this product before. I am going to file that away in my brain for the next time I come into this situation. Thanks!

[Wildbriar]

Me too, thanks everyone for the great insights!