Pressure Ulcers

Question 1

What is a pressure ulcer?

Answer 1

Localized soft-tissue injury resulting from unrelieved pressure over a bony
prominence

Question 2

Why does a pressure ulcer form?

Answer 2

Perfusion
Pressure
Time

Question 3

Perfusion

Answer 3

Blood supply to soft tissue – Capillary Network

Question 4

Pressure

Answer 4

Venous 12mmHg & Arterial 32mmHg
• Anything higher – ischemia
• (Blowing into 10ml syringe = 40mmHg)

Question 5

Time

Answer 5

Inverse relationship between pressure and time
• Clinical studies (Dinsdale)
• Pressure of 70mmHg over 2 hours = Ischemia
• Same model : If relived for 5 minutes no ischemia even at pressures of
450mmHg

Question 6

Where is the injury?

Answer 6

Pressure of 600mmHg applied to skin takes 11 hours to cause skin
necrosis
• Initial ischemia : muscle -> superficial soft tissue -> skin (late sign)
• Once visible : tip of the iceberg!

Question 7

Extrinsic Factors

Answer 7

Ø Pressure - ischemia
Ø Shear - mechanical stress parallel to plane
Ø Friction - outermost layer of skin lost
Ø Moisture - local tissue maceration and breakdown

Question 8

Intrinsic Factors

Answer 8

Sepsis
Ø Decreased autonomic control
Ø Increased age
Ø Sensory loss
Ø Vascular disease
Ø Anemia
Ø Malnutrition
Ø Altered level of consciousness

Question 9

Prevalence

Answer 9

General acute setting 10-18%
• Long-term care facilities 2.3-28%
• Home care setting 0-29%
• Elderly patients with neck of femur fracture (66%)
• Quadriplegic patients (60%)
• Neurologically impaired young (spinal cord injuries)
• Chronic hospitalized & palliative care
• Mortality?
• Pressure sores do not directly cause death
• Succumb to overall disease burden

Question 10

Stages of pressure ulcer

Question 11

Prevention

Answer 11

1. Proper skin care
2. Care during transfers
3. Address spasticity
4. Pressure dispersion
   • Pressure point care – Ripple mattress, padding of assistive devices
   • Seated patients: Lifted for 10 seconds every 10 minutes
   • Supine patients: Turned every 2 hours
5. Incontinence
6. Nutrition
7. Optimize medical comorbidities

Question 12

Management – Multidisciplinary team

Answer 12

Know when not to operate…
- Rehabilitation -> Medical -> Surgical -> Rehabilitation
- Only a minority of patients with pressure ulcers are candidates for reconstruction

Question 13

MEDICAL

Answer 13

Already mentioned : intrinsic &
extrinsic factors
ü Already mentioned : pressure
care
ü Treat spasms
ü Dressings
ü Negative pressure wound therap

Question 14

Surgical

Answer 14

Bedside – wound debridement
ü Diverting colostomy
ü Debridement
ü Reconstruction

Question 15

Rehabilitation

Answer 15

What caused the pressure ulcer
ü Home environment
ü Lack of support
ü Depression
ü Poorly rehabilitated
ü Psychologically ready
ü Adequate support

Question 16

Management – Multidisciplinary team

Answer 16

Post-operative management
- Kept in bed for 6 weeks
- Active & passive mobilization in bed
- Antispasmodics
- Splints
- Ostomy care
- Sitting protocol
- Education
- Psychology

Question 17

Conclusion

Answer 17

Ø High disease burden
Ø Patients with multiple problems
Ø Often impossible to solve “pressure ulcers”
Ø Multidisciplinary team
Ø Operating is only 50% of solution
Ø Rehabilitation & education