Dr. Ehsanur reza

Pressure UlcersDefinition

• Pressure Ulcers are localized areas of tissue necrosis that tend to occur when soft tissue is compressed between a bony prominence and an external surface for a prolonged period.

• These lesions are also called bedsores, decubitus ulcers and pressure sores

Pressure UlcersEpidemiology

• 1-3 million Americans are affected• Health care expenditures: $ 5 billion/year• More than 17,000 lawsuits related to pressure

Ulcers are filed annually• 1 in 4 persons in the USA who died in 1987

had a dermal ulcer• Pressure Ulcers develop primarily in elderly

patients

Pressure UlcersEpidemiology

• Setting– Hospital 60%– Nursing homes 18%– Home 18%

• 1/3 of patients undergoing surgery for hip fracture develop a pressure ulcer

• The longer the patient stays in a nursing home, the greater the likelihood of developing a pressure ulcer

THERMODYNAMICS, METABOLISM AND PRESSURE

• Thermodynamic factors - skin/surface interface

• As temperature increases, skin becomes more metabolically active and 02 demands increase

• With increased pressure, metabolic demands not able to be met and skin becomes hypoxic

• Hypoxic skin more susceptible to breakdown• Adding friction and shear to already fragile

skin is “perfect storm”

THE 4 FORCES

1. Pressure: Force applied to soft tissue between hard surface and bony prominence. When skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, blood flow is restricted. This deprives tissue of oxygen and other nutrients -> tissue death.

2. Friction: Resistance of one body sliding or rolling over another. Making skin more susceptible to pressure sores.

PRESSURE AND FRICTION

3. Shear: This occurs when skin moves in one direction, and the underlying bone moves in another. Sliding down in a bed or chair or raising the head of bed more than 30 degrees is especially likely to cause shearing, which stretches and tears cell walls and tiny blood vessels. Especially affected are areas such as tailbone where skin is already thin and fragile.

4. Strain: Tissue deformation in response to pressure

Pathophysiology

• Prolong weight bearing and mechanical shear forces act on areas of soft tissue overlying bony prominence ―> when this pressure exceeds normal capillary perfusion pressure (32 mm Hg) ―> occlusion & tearing of small blood vessels ―> reduced tissue perfusion ―> ischaemic necrosis ―> Pressure sore.

Risk factors• Age. Older adults tend to have thinner skin,

making them more susceptible to damage from minor pressure. They have less natural cushioning over their bones. And poor nutrition, delays wound healing.

• Lack of pain perception. Spinal cord injuries and some diseases cause a loss of sensation ―> bedsore is forming.

• Natural thinness or weight loss. Muscle atrophy and wasting are common in people living with paralysis. If you lose fat and muscle there is no cushion over your bones.

• Malnutrition. Pressure sores develops if you have a poor diet, especially one deficient in protein, zinc and vitamin C.

• Urinary or fecal incontinence. Problems with bladder control can greatly increase risk of pressure sores because skin stays moist, making it more likely to break down. And bacteria from fecal matter not only can cause serious local infections but also can lead to life-threatening systemic complications such as sepsis, gangrene and, rarely, necrotizing fasciitis, a severe and rapidly spreading infection.

• Other medical conditions. diabetes and vascular disease affect circulation ―> tissue damage.

• Smoking. Smokers tend to develop more severe wounds and heal more slowly, mainly because nicotine impairs circulation and reduces the amount of oxygen in blood.

• Decreased mental awareness. People whose mental awareness is lessened by disease, trauma or medications are often less able to take the actions needed to prevent or care for pressure sores.

Risk Factors

• Spinal cord injuries• Traumatic brain injury• Neuromuscular disorders• Immobility• Malnutrition• Fecal and urinary

incontinence• Altered level of

consciousness

• Chronic systemic illness• Fractures• Aging skin – decreased epidermal

turnover– dermoepidermal

junction flattens – fewer blood vessels

• Decreased pain perception

• Pressure ulcers commonly occur over the :– Sacrum– Greater

trochanter– Ischial tuberosity– Malleolus– Heel– Fibular head– Scapula

Site

While on a wheelchair a pressure sore develop on:

- tailbone or buttocks- shoulder blades and spine- The backs of arms and legs where they

rest against the chair

Stages/ classification

Classification Stage I 1. 1. most superficial, 2. non blanchable redness, does not subside

after pressure is relieved. 3. The skin may be hotter or cooler than normal 4. have an odd texture, or 5. perhaps be painful to the patient.

STAGE I

• Stage II is damage to the epidermis extending into, but no deeper than, the dermis. In this stage, the ulcer may be referred to as a blister or abrasion.

• The ulcer is superficial and manifest clinically as an abrasion, blister or shallow crater

STAGE II

STAGE II

• Stage III involves the full thickness of the skin and may extend into the subcutaneous tissue layer. This layer has a relatively poor blood supply and can be difficult to heal.

The ulcer manifests clinically as a deep craterwith or without undermining of adjacent

tissue

STAGE III

STAGE III

• Stage IV is the deepest, extending into the muscle, tendon or even bone.

• “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/or tunneling”

• Depth varies according to anatomic location• Exposed bone/tendon usually directly visible

and/or palpable

STAGE IV

B

A

Stage 4

STAGE IV

Complications

• Cellulitis. This causes pain, redness and swelling, all of which can be severe. Cellulitis can also lead to life-threatening complications, including sepsis and meningitis.

• Bone and joint infections. These develop when the infection from a bedsore burrows deep into joints and bones. Joint infections (septic or infectious arthritis) can damage cartilage and tissue, whereas bone infections (osteomyelitis) may reduce the function of joints and limbs.

• Sepsis. It occurs when bacteria enters bloodstream through the broken skin and spreads throughout the body — a rapidly progressing, life-threatening condition that can cause shock and organ failure.

• Cancer. This is usually an aggressive carcinoma affecting the skin's squamous cells.

Tests and diagnosis

• Bedsores are usually unmistakable, even in the initial stages, but doctor is likely to order blood tests to check nutritional status and overall health. Depending on the circumstances, there may have other tests.

• Wound swab – C/S• Incision biopsy – if malignancy is suspected.

Treatments and drugs

• Treating bedsores is challenging. Open wounds are slow to heal, and because skin and other tissues have already been damaged or destroyed, healing is never perfect.

• Requires a multidisciplinary approach – nurses, physician, social worker, physical therapist, urologist or gastroenterologist, a neurosurgeon, orthopedic surgeon and plastic surgeon.

TREATMENT OBJECTIVES• Identification of problem• Debridement of necrotic tissue• Moist wound care without maceration• Control of infection/bioburden• Management of pain• Pressure redistribution/Offloading

• Choice of wound care products is individual preference as long as above objectives met.

• A) Conservative treatmentAlthough it may take some time, most stage I and stage II sores will heal within weeks with conservative measures. But stage III and stage IV wounds, which are less likely to resolve on their own, may require surgery.

• 1. Changing positions often. Carefully follow the schedule for turning and repositioning — approximately every 15 minutes if in a wheelchair and at least once every two hours when in bed. If unable to change position on own, a family member or other caregiver must be able to help.

• 2. Using support surfaces. These are special cushions, pads, mattresses and beds that relieve pressure on an existing sore and help protect vulnerable areas from further breakdown.

PRESSURE REDISTRIBUTION

• 3. Cleaning. It's essential to keep wounds clean to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores should be cleaned with a saltwater (saline) solution each time the dressing is changed. Avoid antiseptics such as hydrogen peroxide and iodine, which can damage sensitive tissue and delay healing.

• 4. Controlling incontinence as far as possible is crucial to helping sores

• 5. Removal of damaged tissue (debridement). To heal properly, wounds need to be free of damaged, dead or infected tissue. This can be accomplished in several ways -

• a. Autolytic debridement is autolysis with the body's own enzymes.

• b. Biological debridement, or maggot debridement therapy,

• c. Chemical debridement, or enzymatic debridement• d. Mechanical debridement • e. Sharp debridement is the removal of necrotic tissue

with a scalpel or similar instrument.• f. Surgical debridement • g. Ultrasound-assisted wound therapy

• 6. Dressings. • 7. Oral antibiotics. • 8. Healthy diet. • 9. Muscle spasm relief • 10. Educating the caregiver

• B) Surgical repair by - tissue flap, free flap, Negative Pressure Wound Therapy

• C) Other treatment optionsResearchers are searching for more effective bedsore treatments. Under investigation are hyperbaric oxygen, electrotherapy and the topical use of human growth factors.

Prevention

• Bedsores are easier to prevent than to treat, but that doesn't mean the process is easy or uncomplicated. Although wounds can develop in spite of the most scrupulous care, it's possible to prevent them in many cases.

• Position changesChanging position frequently and consistently is crucial to preventing bedsores. Experts advise shifting position about every 15 minutes that you're in a wheelchair and at least once every two hours, even during the night, if you spend most of your time in bed.

• Skin inspectionDaily skin inspections for pressure sores are an integral part of prevention.

• NutritionA healthy diet is important in preventing skin breakdown and in aiding wound healing

• Lifestyle changes – -Quitting smoking, - Exercise - Daily exercise improves

circulation