Makindo Medical Notes

Pressure ulcers (also known as bedsores or decubitus ulcers) can develop in as little as 1–2 hours. It's crucial to avoid leaving patients on hard surfaces such as A&E trolleys or X-ray tables for extended periods. Early detection and preventive measures are essential to reduce the risk of pressure sores.

About

• Development of a pressure sore increases mortality risk fourfold.

Common Sites

• Heels, lateral malleoli (outer ankle bones), sacrum, and ischia (lower pelvis).
• Greater trochanters (hip bones) and other bony prominences.

Causes (often multifactorial)

• Immobility (e.g., prolonged bed rest).
• Dementia or cognitive impairment.
• Neurological disease (e.g., stroke, multiple sclerosis).
• Mental health issues affecting self-care.
• Spinal cord injury or cauda equina syndrome.
• Shear forces and moisture (predisposing factors for skin breakdown).
• Incontinence of bladder and/or bowels.
• Underlying medical conditions (e.g., diabetes, anaemia, malnutrition).
• Peripheral neuropathy (reduced sensation increases the risk of unnoticed pressure).
• Medications (e.g., steroids, analgesics, sedatives) that can affect skin integrity or mobility.
• Cauda equina or spinal cord compression, limiting movement and sensation.

Clinical Assessment

• Assess the patient’s mental state and comorbidities.
• Evaluate nutritional status, including body weight and hydration.
• Perform a detailed neurological examination (motor and sensory function).
• Conduct an abdominal exam, paying particular attention to bladder and bowel function (important in cases of incontinence).

Grading of Pressure Ulcers

Grade	Description
Grade 1	Intact skin with non-blanchable redness, usually over a bony prominence. The area may feel harder or warmer than surrounding skin. On darker skin, redness may not be as visible.
Grade 2	Partial-thickness loss of dermis, presenting as a shallow open ulcer with a red-pink wound bed, without slough. May present as an intact or open/ruptured blister.
Grade 3	Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss.
Grade 4	Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often involves undermining and tunnelling into deeper layers.
Unstageable	Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, making it impossible to determine the true depth of the wound.

Investigations

• Full Blood Count (FBC): May show anaemia or raised white cell count (WCC) indicating infection.
• U&E (Urea and Electrolytes): Low albumin suggests malnutrition, which can delay healing.
• Blood glucose: To exclude or assess diabetes, which increases risk of pressure ulcers.
• C-Reactive Protein (CRP): Elevated in infection or chronic inflammation.
• Wound swabs: For culture and sensitivity to identify causative organisms if infection is suspected.
• Blood cultures: If there is concern about sepsis from systemic infection originating from the ulcer.
• X-ray of underlying bone: To rule out osteomyelitis, especially in long-standing or deep ulcers over bony prominences.

Complications

• Osteomyelitis: Infection of underlying bone, particularly in deeper ulcers.
• Sepsis: A life-threatening systemic infection that can develop from untreated or infected pressure ulcers.

Management

• General Care: Includes debridement of necrotic tissue, regular repositioning, use of air mattresses, and diligent wound care. Regular turning of immobile patients is essential.
• Risk Assessment: Use tools such as the Braden or Norton scale to identify at-risk patients. Optimize underlying conditions like diabetes, hypertension, malnutrition, and anaemia.
• Pressure Relief: Regular repositioning, use of specialized mattresses or heel protectors, and careful wound offloading by nursing staff. Use of bed sheet cradles and removal of extrinsic pressure sources.
• Debridement: Essential for removing necrotic tissue, promoting granulation, and accurate staging. Necrotic tissue promotes infection and delays healing.
• Infection Management: Address infections aggressively. Common organisms include Proteus mirabilis, Group D Streptococci, E. coli, Staphylococcus, and Pseudomonas. Systemic signs of infection (e.g., fever, tachycardia, hypotension) require immediate intervention.
• Good Nutrition: Adequate nutrition, including calories, hydration, vitamins, and minerals, is critical for wound healing.
• Local Wound Care: Involves cleansing, antimicrobial ointments, debriding agents (e.g., proteolytic enzymes), and appropriate dressings to facilitate healing.
• Surgical Intervention: Stage III and IV ulcers may require surgical treatments, including grafts and plastic surgery. Early involvement of plastic surgeons is often beneficial in severe cases.

References

• Comprehensive Management of Pressure Ulcers in Spinal Cord Injury: Current Concepts and Future Trends
• Pressure Ulcers: Pathogenesis, Epidemiology, and Management
• The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper