Pressure sore

By
Dr. AMHA M.
JULY 2005
 Out Line
• Definition
• Epidemiology
• Pathophysiology
• Diagnosis & Work up
• Treatment & prevention
medical therapy
surgical therapy
• complications
 Pressure sore
.Tissue ulceration mainly produced by prolonged &
uninterrupted pressure in association with contributing
factors.
result from a complex process of tissue destruction so
multi disciplinary approach to Rx is required.
In general wounds acquired from pressure over boney
prominences.
.
 Epidemiology

3-10% of hospitalized pts with acute illness will have

pressure sore at any time.
2/3rd of pressure sores that develop in hospitalized pts
occur in pts older than 70.
Most young individuals suffering from pressure ulceration
are male---traumatic spinal cord injuries.
In older popn. most pts are women b/c of survival
advantage over men.
Bimodal age 3rd decade of life & 8th decade of life.
96% will occur below level of umbilicus &up to 75%of all
pressure sores are located around pelvic girdle.
 Pathophysiology
A. External factors B. Host factors
pressure immobility
shearing forces incontinence
friction nutritional status
moisture circulatory status
neurologic dd.
other factors.
 Pathophysiology cont`d
Pressure ischemia theory
pressure sores result from constant pressure sufficient to
impair local blood flow to soft tissues for an extended
period.
The external pressure must be
>32mmHg(arterial capillary pressure)-to impair inflow.
>8-12mmHg(venous capillary closing pressure) to impede
return of flow for an extended time.
Pressure ischemia inflammation & tissue anoxia cell
death ,necrosis & ulceration.
 Pathophysiology cont`d
Point of greatest pressure
Supine sacrum ,heel &occiput at 40-60mmHg.
prone chest &knee absorbed greatest pressure at
50mmHg.
Sitting ischial tuberosities are under most pressure at
100mmHg.
Most common sites for pressure sores are
ischial,trochantric ,sacral region
In bed ridden (acute care setting) sacral(36%),heel(30%),
ischial, trochantric,malleolar(6%)
 Diagnosis & Work up
History
overall physical &mental health
prior hospitalizations ,operations ,or ulcerations.
diet &recent wt.loss.
bowel habits &continence states.
Presence of spasticity or flexion contractures.
Medications &allergies to Medications.
natural Hx of present ulcer-onset &duration.
presence of signs or symptoms related to current ulceration
-------pain ,fever ,discharge ,odor.
P/E
Describe the location of pressure sore based on underlining
bonny prominence.
 Determine the level of tissue injury (staging)
Stage 1.-skin intact but reddened for>1hr.after relief of pressure.
Stage 2.-blisters or other break in dermis with or with out infection.
Stage 3-subcutaneous destruction into muscle with or with out
infection.
Stage 4-involvement of bone or joint with or with out infection.
 Character of wound base-- verrucous heaps of white tissue with
in or around the wound  malignant transformation.
Lab studies
CBC with differentials
Electrolyte determination
Evaluations of nutritional parameters
albumin ,prealbumin ,transferrine ,serum
protein level
U/A,S/E, Blood culture ,tissue biopsy.
 Treatment & prevention
multi disciplinary approach to Rx is required
1. Medical therapy (conservative)
stage 1&2 pressure sore & stage3&4 with
coexisting medical problem
appropriate wound care
 debridement of necrotic tissue
 Optimization of nutrition
 Release of pressure turning pt at bedQ2hr,
pressure reducing mattress.
 Minimization of spasticity
diazepam ,baclofen ,dantrolene sodium
 2.Surgical treatment
In general for stage 3&4
choice of flap for reconstruction depend on location of ulcer .
Goals of pressure sore reconstruction
 Improvement of pt hygiene&appearance.
 Prevention or resolution of osteomyelitis or infecn.
 Reduction of fluid & protein loss through the wound.
 Prevention of future malignancy(marjoline ulcer) .
Follow 3 main principles
1.Excisional debridment of the ulcer, its bursa & any
hetrotopic calcification.
2.Perform partial or complete ostectomy to reduce boney
prominence.
3.Wound Closure with healthy tissue i.e. durable & can
provide adequate padding over the boney prominence.
.
 Preoperative care
Specific contributing factors must be
corrected.
Control involuntary muscle spasm.
Control infection.
Maintain adequate nutrition.
Release contracture.
Relief of pressure.
Diversion of urinary or fecal stream.
 Intraoperative details
Ischial pressure ulcers