Makindo Medical Notes.com

Pressure ulcers can develop in 1–2 h. Beware of leaving patients on hard A&E trolleys or X-ray tables for too long.

About

• Development of a pressure sore increases mortality fourfold

Sites

• Heels, lateral malleoli, sacrum, ischia
• Greater trochanters

Causes often many

• Immobility, dementia
• Neurological disease e.g. stroke
• Mental health issues
• Spinal cord injury, cauda equina injury
• Shear forces and moisture are predisposing factors
• Incontinence of bladder and bowels
• Diabetes, anaemia, malnutrition
• Peripheral neuropathy
• Steroids, Analgesics, Sedation
• Cord or cauda equina compression

Clinical Assessment

• Assess mental state, comorbidities
• Nutritional state, including body weight
• Assess neurological examination
• Abdominal examination, especially bladder and bowel.

Grading

• Grade 1 is defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The skin may also appear a little harder than usual and than the surrounding areas. It may also be warmer than usual.
• Grade 2: partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. The skin now starts to look like a blister, with whitening of the skin whereas before it was red. It will now look like an abrasion or a blister. The skin can also appear cracked and broken.
• Grade 3: full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. May include undermining and tunnelling. The skin beneath is more visible and red. There may be a smell emanating from the ulcer. It now looks unpleasant.
• Grade 4 is defined as full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunnelling. There is now a deep ulcer with broken skin and you can see down through the layers of skin often including damage into the muscle, bone or supporting structures. Grade 4 ulcers can be life threatening.
• Unstageable is defined as full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Investigations

• FBC: anaemia, raised WCC
• U&E: low albumin due to malnutrition
• Blood sugar: exclude diabetes
• CRP: Elevated with infection often chronically
• Wound swabs: for culture and sensitivity
• Blood cultures: if concern about septicaemia
• X-ray of the underlying bone: to rule out osteomyelitis if the wound is deep, overlies a bony prominence and has been present for some time

Complications

• Osteomyelitis and sepsis.

Management

• General: Depending on the severity of the ulcer treatment can include debridement of the area, removing as much of the infection as possible, dressings, sleeping on an air mattress and regular turning of an immobile patient
• Risk assessment tools to identify those at risk. Optimise diabetes mellitus, hypertension, malnutrition, anaemia.
• Pressure relief : Regular turns. Aggressive wound care and off-loading by nursing staff. Speciality beds and mattresses, complying with turning orders, use of heel protectors, bed sheet cradles, or removal of any extrinsic pressure sources
• Debridement: removal of devitalized tissue is essential to allow for granulation and accurate staging of the wound. Necrotic tissue will serve as a nidus for colonization and infection that will hinder and prolong the healing process.
• Infection and osteomyelitis: most common organisms isolated from pressure ulcers are Proteus mirabilis, group D Streptococci, Escherichia coli, Staphylococcus species, Pseudomonas species, and Corynebacterium organism. Signs of systemic infection (leukocytosis, fever, hypotension, tachycardia, and altered mental status) should be treated aggressively.
• Good nutrition: Nutrition is a critical component of normal wound healing, a relationship that has been known since antiquity. Provide calories, hydration and adequate vitamins and mineral.
• Local wound care: Local wound care utilizes cleansing solutions, antimicrobial ointments and creams, debriding agents (e.g. proteolytic enzymes), and dressings (with passive or active wound effects).
• Surgical: Stage III and IV ulcers may require surgical treatments. Involve plastic surgery.

References

• Comprehensive management of pressure ulcers in spinal cord injury: Current concepts and future trends