By Gary M. White, MD
Pressure ulcers and sores occur in soft tissue that is compressed for prolonged periods of time between an external surface and a bony prominence. Risk factors include older age, low body weight, black or Hispanic ethnicity, cognitive impairment, malnutrition, dehydration, immobility, moisture, venous insufficiency (lesions on the legs), sensory deficit, smoking, and fecal incontinence.
Pressure ulcers over the sacrum, greater trochanter, ischial tuberosity, lateral malleolus, and the calcaneus may complicate the care of the debilitated patient. The sides of the feet may become ulcerated if patients routinely sleep on that side. Various classifications have been proposed with the spectrum beginning with nonblanching erythema to partial thickness ulceration to full thickness ulceration to extension to muscle, bone, and joint.
|II||Partial thickness, shallow open ulcer with red-pink wound bed.|
|III||Full thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed.|
|IV||Full thickness tissue loss with exposed bone tendon or muscle.|
Bacteria may merely colonize the pressure ulcer or they may cause infection. Infection may be defined as invasion of tissue and is signaled by heat, redness, swelling, drainage, and pain. Bacteremia may occur and if it does, mortality is high.
Osteomyelitis should be considered in the setting of a non-healing pressure ulcer. The diagnosis may be difficult. Various radiographic nuclear imaging techniques may be employed.
Squamous cell carcinoma (SCC) may develop in long standing ulcers.
A sinus tract may occur, even in ulcers that seem superficial.
Direct and constant pressure should be avoided by use of supports, donuts, anti-pressure mattresses, foam, and routine movement of the patient. Any infection should be treated and debridement of dead tissue performed. Any putrid smell may be combated with metronidazole gel. The patient's nutritional status and hydration should be optimized (BUN and albumin may be followed). It is well recognized that wound occlusion is the optimum environment for healing. The application of one of various synthetic dressings is indicated (e.g., hydrocolloid, hydrogel, alginates, composite).
Pulsed, low intensity direct current significantly sped healing in a double-blind sham-controlled multi-center study. The use of topical negative pressure (AKA vacuum-assisted closure) has been reported helpful [Ann Plast Surg 1997;38;563]. In that, foam is placed into the wound in a manner to allow for sub-atmospheric pressure conditions. Those ulcers which do not improve after months of adequate therapy may need grafting.
A common location is overlying the bone in the hip from sleeping on that side.
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