Pressure Sores

Question 1

Define pressure sores

Answer 1

Localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or of pressure in combination with shear

Question 2

Aetiology of pressure sores

Answer 2

Interplay between pressure, shear, friction and moisture

Shear forces, typically generated when patients slide down in bed, may cause stretching and tearing of small blood vessels and contribute to pressure-induced damage
Role of circulation and tissue perfusion as inadequate blood flow (sepsis, hypotension, heart failure, PVD) contributes to tissue ischaemia and pressure ulceration

Question 3

Risk factors for pressure sores

Answer 3

Increased age
Reduced mobility
Neurological impairment resulting in loss of sensation or paralysis
Surgery
Intensive care stay
Malnourishment
History of previous pressure ulcers
Faecal or urinary incontinence, diabetes, peripheral vascular disease

Question 4

Symptoms and sign of pressure sores

Answer 4

Ulcer: usually over bony prominences, covered with necrotic tissue

Grade 1: non-blanchable erythema, discolouration on INTACT skin
Grade 2: Shallow open wound or tissue (epidermis/dermis or both)
Grade 3: full thickness skin loss
Grade 4: extensive destruction, tissue necrosis and damage to muscle/bone

Question 5

Investigations for pressure sores

Answer 5

Clinical diagnosis
Assess risk via Waterlow score

Wound swab: ?infection
CRP/ESR: ?osteomyelitis
FBC: ?osteomyelitis
Serum glucose: ?diabetes

MRI: ?OM
Deep tissue biopsy: ?OM

Question 6

Management for pressure sores

Answer 6

Photograph of wound
Pressure relief: patients are repositioned every 2 hours
Dietary optimisation: ensure adequate total calorie and total protein intake
Pain management:
- PO analgesia (NSAID, codeine, oxycodone) 30-60 minutes before any procedures
- Ibuprofen-releasing foam dressings or topical morphine
- ± topical lidocaine
Good hygiene practice
Skin care

Deep ulcers
- Sharp debridement
- Autolytic debridement (using products such as hydrogels to facilitate autolysis)
- Application of enzymatic agents, maggots, or high-pressure water jet
- Surgical debridement + ulcer excision/skin grafting/flap formation

Question 7

Complications of pressure sores

Answer 7

Infection: S. Aureus, Proteus mirabilis, pseudomonas aeruginosa
Sepsis
Cellulitis
Osteomyelitis