Pressure/decubitus sore (ulcers): obstructed blood flow and skin shear

the ischium (28%), the sacrum (17-27%), the trochanter (12-19%), and the heel (9-18%)
Proteus mirabilis, group D streptococci, Escherichia coli, Staphylococcus species, Pseudomonas species, and Corynebacterium
organisms.
60,000 people die each year from complications.

Risk factors
factors that influence the tolerance of skin for pressure and shear
Wheelchairs or confinement to bed
protein-calorie malnutrition,
microclimate (skin wetness caused by sweating or incontinence),
diseases that reduce blood flow to the skin,
o arteriosclerosis,
diseases that reduce the sensation in the skin
o paralysis or neuropathy.
??
The healing slowed by the
o age
o medical conditions (such as arteriosclerosis, diabetes or infection),
o smoking or
o medications such as antiinflammatory drugs.

Braden Scale for Predicting Pressure Ulcer Risk. The scale contains 6 areas of risk: cognitive-perceptual, immobility, inactivity,
moisture, nutrition, friction/shear.
Evaluation
4 Stages
1. Erythema
2. Partial dermis loss
3. Full dermis loss, SQ fat visible, no underlying structures visible
4. Underlying structures exposed: bone, muscle, nerves

Treatment
Primary prevention: turning every 2 hours, eating a balanced diet with adequate protein and keeping the skin free from
exposure to urine and stool, Pressure-redistributive mattresses, antidecubitus mattresses, Vit C,
Biofilm occurs rapidly in wounds and stalls healing by keeping the wound inflamed. Frequent debridement and antimicrobial
dressings are needed to control the biofilm.
Dressings with cadexomer iodine, silver or honey have been shown to penetrate biofilms. Systemic antibiotics are not
recommended in treating local infection in a pressure ulcer, as it can lead to bacterial resistance. Hydrogen peroxide (a near-
universal toxin) is not recommended for this task as it increases inflammation and impedes healing.
Debridement
1. Autolytic debridement is the use of moist dressings to promote autolysis with the body's own enzymes and
white blood cells. It is a slow process, but mostly painless, and is most effective in patients with good immune
systems.
2. Biological debridement, or maggot debridement therapy, is the use of medical maggots to feed on necrotic
tissue and therefore clean the wound of excess bacteria. Although this fell out of favour for many years, in
January 2004, the FDA approved maggots as a live medical device.
[17]

3. Chemical debridement, or enzymatic debridement, is the use of prescribed enzymes that promote the removal
of necrotic tissue.
4. Mechanical debridement, is the use of debriding dressings, whirlpool or ultrasound for slough in a stable
wound
5. Surgical debridement, or sharp debridement, is the fastest method, as it allows a surgeon to quickly remove
dead tissue.

The following are general indications for negative pressure wound therapy
[103]
:
Chronic wounds
Acute wounds
Traumatic wounds
Partial-thickness wounds
Dehisced wounds
Diabetic ulcers
Pressure ulcers
Flaps
Grafts
The following are general contraindications for negative pressure wound therapy
[103]
:
Malignancy of the wound
Untreated osteomyelitis
Nonenteric or unexplored fistulas
Known allergies or sensitivity to acrylic adhesives
Placement of negative pressure dressings directly in contact with exposed blood vessels, organs, or nerves
Silver sulfadiazine has an excellent antimicrobial spectrum of activity, low toxicity, ease of application, and minimal pain. Silver
sulfadiazine inhibits DNA replication and modification of the cell membrane of Staphylococcus aureus; Escherichia coli; Candida
albicans; Klebsiella, Pseudomonas, and Proteus species; and Enterobacteriaceae.

Three debridement procedures are commonly used: enzymatic debridement, mechanical nonselective debridement, and sharp
debridement.
Enzymatic debridement uses various chemical agents (proteolytic enzymes) that act by attacking collagen and liquefying
necrotic wound debris without damaging granulation tissue.

Proteolytic enzymes are used to chemically debride wounds. The
action of these enzymes is aimed specifically at necrotic tissue.
Mechanical nonselective debridement, in which necrotic tissue is loosened and removed, is generally accomplished
by whirlpool treatments, forceful irrigation, or use of wet-to-dry dressings. Wet-to-dry dressings involve placing wet
gauze into the lesion and allowing it to dry. A few hours later, when the dressing is removed, the necrotic debris that
has adhered to the dressing is also removed. Solutions commonly used for wet-to-dry dressings include normal saline
and 0.25% acetic acid solution.
Povidone-iodine solution can be used to debride infected ulcers. Although the effervescent action of hydrogen
peroxide results in wound debridement, it is not recommended for frequent use in pressure ulcers, because it
indiscriminately removes necrotic material and fragile granulation tissue.
The widespread practice of using hydrogen peroxide continues, but it is not recommended for long-term use because
it and other cleansing agents have been found to be toxic to fibroblasts.
Once debridement has been completed and clean granulation tissue has been established, the use of debridement
agents should be discontinued and the site should be kept clean and moist.
Sharp debridement is surgical removal of the eschar and any devitalized tissue within it. Although sharp
debridement is the most effective method of removing necrotic tissue, it is contraindicated in certain patients,
particularly those who cannot withstand the loss of blood that may occur during the procedure. Moist devitalized
tissue supports the proliferation and growth of pathogens. The removal of this devitalized tissue is a prerequisite to
new tissue growth.
Sharp debridement is indiscriminate in the removal of vital and devitalized tissue. A great deal of clinical skill and
judgment are needed in surgically debriding a wound.
Elderly patients and those with diabetes often have pressure ulcers of the heel that look black and have eschar.
Conventional wisdom encourages physicians to debride the eschar, but it is usually protective and should be left to
autodebride unless an active infection dictates more aggressive measures.
Surgical debridement is well established as an approach to pressure ulcer care, but more research is needed.



Transparent adhesive dressings are semipermeable and occlusive. They allow gaseous exchange and transfer of water
vapor from the skin, and they prevent maceration of the healthy skin around the wound. In addition, these dressings
are not absorptive, they reduce the incidence of secondary infection, and they eliminate the risk of traumatic removal.
However, transparent adhesive dressings do not function well on patients who are diaphoretic or on patients with
wounds that have significant exudate.
[35]

Hydrocolloid wafer dressings contain hydroactive particles that interact with wound exudate to form a gel. These
dressings provide absorption of minimal to moderate amounts of exudate and keep the wound surface moist. This gel
can have fibrillolytic properties that enhance wound healing, protect against secondary infection, and insulate the
wound from contaminants.
[35, 91]

Gel dressings are available in sheet form, in granules, and as liquid gel. All forms of gel dressings keep the wound
surface moist as long as they are not allowed to dehydrate. Some gel dressings provide limited to moderate
absorption, some provide insulation, and some provide protection against bacterial invasion. All gel dressings provide
atraumatic removal(see Table 2, below).
[25, 35, 92]

Calcium alginate dressings (eg, Sorbsan) are semiocclusive, highly absorbent, and easy to use.
[93, 94]
They are natural,
sterile, nonwoven dressings derived from brown seaweed. Calcium alginate dressings are extremely effective in
treating wet (exudative) wounds and can be used on wounds that are contaminated or infected.
[93]