Pressure sores (DERM) Flashcards
Define pressure sores.
Localised damage to the skin and underlying soft tissue usually over a bony prominence, or related to a medical/other device
Why do pressure sores happen?
Constant pressure limits blood flow to the skin leading to tissue damage
How do pressure sores occur on lying?
- mean capillary pressure normally 25mmHg
- when lying down, pressure increases due to compression, especially on contact points (heel, sacrum, greater trochanters) to 100mmHg
- –> sores form on prolonged lying >4h with mean capillary pressure >100mmHg
- occlusion of capillaries –> hypoxia of neighbouring tissues –> necrosis of surrounding skin, muscle, vessels –> ulcers
What are some risk factors for pressure sores? (6)
- immobility
- recent surgery/intensive care stay
- diabetes
- malnutrition
- sensory impairment
- older age
Who/where are pressure sores most common in?
Hospitals and elderly population
How do we screen for patients at risk of pressure sores?
Waterlow score - takes BMI, nutritional status, skin type, mobility and continence into account
What are the majority of pressure sores?
- majority are superficial ulcers
- deep ulcers form with prolonged occlusion –> extensive necrosis of wedge-shaped tissue which can separate from bony prominences
What are the clinical features of pressure sores? (6)
- location - over bony prominences, typically sacrum or heel
- focal area of non-blanching erythema or purple/maroon localised area of discoloured skin
- evidence of decreased skin perfusion (increased CRT)
- painful (unlike neuropathic ulcers = painless), firm, mushy, boggy –> early stage of tissue damage
- signs of infection - purulent drainage, foul smell, localised tenderness and warmth
- use of non-pressure-relieving support surface
What can occur in advanced stages of pressure sores?
There may be full-thickness skin loss, in which adipose (fat) is visible in the ulcer
What are the 4 stages of pressure sores?
- stage 1: non-blanchable erythema of intact skin
- stage 2: loss of dermis +/- epidermis; superficial ulcer
- stage 3: loss of all skin layers (full thickness)
- stage 4: extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures
How are pressure sores diagnosed?
Clinical diagnosis
What predisposing factors can we evaluate for pressure sores? (3)
- blood glucose (DM if elevated)
- HbA1c
- serum albumin (malnutrition)
How do we check for infection in pressure sores?
Raised WCC and CRP
If ESR/WCC elevated –> osteomyelitis
What are some differential diagnoses for pressure sores? (6)
- moisture-associated dermatitis
- venous ulcers (near ankles + skin staining)
- arterial ulcers (feet, heels or toes, painful at night, skin white and shiny)
- diabetic neuropathy
- pyoderma gangrenosum (edge of ulcer purple and undermined, associated with other conditions)
- osteomyelitis (bone pain, tenderness, swelling, PMH)
What is the first-line management of pressure sores? (4)
- pressure relief over affected areas
- repositioning - frequent position changes (every 2h) for immobile patients, depends on level of activity/mobility
- moist wound environment - encourages ulcer healing
- ensure good nutrition
What do we give for pain in pressure sores?
Analgesia - paracetamol, ibuprofen, topical lidocaine (5% ointment)
What promotes healing of pressure sores?
Hydrocolloid dressings promote healing, regularly cleanse and dry and apply protective creams
How do we manage infected pressure sores?
Antimicrobial therapy
How do we manage stage 3/4 pressure sores (full thickness loss, necrosis etc) if suitable vs not suitable for surgery?
- suitable - surgical debridement and reconstruction with flap formation
- not suitable - debridement of necrotic tissue
What are some complications of pressure sores? (4)
- sepsis (infection spreads, systemic Abx for all)
- cellulitis
- osteomyelitis
- mortality
Describe the prognosis of pressure sores.
Good, as long as appropriate treatment and wound care is provided promptly
