PRESSURE SORES

PRESSURE SORES

Bed sores or decubitus ulcer

• results over a bony prominence – following ischemic loss of tissue – due to extrinsic pressure

Etiology

• lack of mobility
• lack of protective sensations – as in paralyzed individuals
• absence of vasomotor reflex – poor muscle bulk and tone
• metabolic abnormalities
• poor nutrition – anemia – hypoproteinemia – delayed wound healing
• skin atrophy

Pathology

• pressure over a bony prominence over 2 hours continuously can initiate the insult
• skin becomes emphysematous – reversible if correct action taken
• persistence of pressure – tissue is compressed between bony prominence and external force – ischemia results
• required pressure – as low as two times the capillary filling pressure – 2x35 – 70mmHg
• ischemia further progress – necrosis – tissue gets infected – liquefaction
• muscle, s/c tissue, bone, skin : varies in resistance to external pressure
  • muscle least resistant – necrosis earlier
  • bone changes are : infection of underlying bone – reactionary bursa etc.
• Anatomical distribution
  • Hip and buttocks : 70% (ischeal tuberosity – trochanter – sacral )
  • Rest of lower limb : 20% (malleoli – heel – patellar – pretibial - popliteal)
  • Rest of body : 10% ( occiput – forehead – nose,chin, ear – scapular – elbow – back )

Staging : National Pressure Ulcer Advisory Panel Classification

• Stage I : Intact skin – impending ulceration – reversible
  • blanchable erythema to non blanching erythema
• Stage II : partial thickness loss of skin – abrasion – blister – superficial ulcer
• Stage III : full thickness loss of skin and s/c tissue
• Stage IV : skin and s/c tissue + muscle, bone, tendon, joint capsule – osteomyelitis – sinus tracts – severe undermining ulcers

Complications

• osteomyelitis
• septicemia
• internal organ injury by eroding into rectum or urethra

Management

• Prophylaxis
  • good nursing care – frequent position changing – avoid skin rubbing or shearing while changing position
  • air / water bed
  • skin care : ethyl alcohol – talcum powder – gentle massage to improve circulation – eliminate moisture
  • nutrition : high protein – high calorie – high vitamin diet
  • catheterisation or condom drainage to avoid soiling with urine
  • avoid fecal contamination
  • early fixation of fractures – aids mobilization – reduces pain
• Treatment
  • Acute phase
    • control infection
    • contain the area
    • debride all necrotic tissue surgically and with H2O2
    • local wound care with saline / providone iodine
    • systemic antibiotics have NO proven role
    • all dead tissue has to be removed – no fresh slough appear – the undermining has stopped
  • Definitive
    • replace tissue loss with similar tissue
    • should be done when ulcer starts to contract
    • only dermis and epidermis loss : SSG
    • Deep ulcers (floor is formed by bone) : flap
      • flaps
        • can be : skin + s/c tissue - skin + s/c tissue+muscle – muscle+SSG
        • must have good blood supply
        • enough bulk to cover the tissue loss
        • flap donor site should be such that primarily closed or by SSG
        • Sacra bed sore
          • local bilateral
            
            
            V-Y flaps
          • rotation flaps
          • both based on gluteus maximus
        • Trochanteric bed sore
          • TFL flap – can cover areas up to 15x40cm
          • based on terminal br of lateral circumflex femoral artery

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