4. Epidemology
• General acute care, long-term care, and home care
• International Pressure Ulcer Prevalence Survey (IPUPS)- prevalence
rate was 14.8%;
• Nursing homes- 2-28%
• SCI- 33–60%
• Hip fractures- 8.8% to 55%
• 8.8% incidence of hospital-acquired pressure sores in a study
involving multiple centers in the US – 36.1 % in elderly
5. • John Staige Davis was the first to suggest replacing the unstable scar
of a healed pressure sore with flap tissue in 1938.
• General Assembly had made the disinterment of a dead body a
felony. Like many other medical professors of the day, Davis turned to
grave robbing to meet the needs of his students, who numbered
more than twenty-five per year by 1860
• On January 9, 1883, Davis wrote to Dr. S. G. Pedigo, of Martinsville,
that “we were never so much in need of subjects as now. Is any body
to be hung in Henry [County], whose corpse I might procure?”
6. • Supine- Points of highest pressure were the sacrum, buttocks, heel,
and occiput, all of which were subject to pressures of roughly 50–60
mmHg.
• Sitting, pressures up to 100 mmHg were recorded over the ischial
tuberosities
7. • Dinsdale found that pressure roughly double capillary closing
pressure, applied for 2 hours, resulted in irreversible ischemic
damage to tissue.
• Pressure dissipating to connective tissue, Autoregulation
8. • Friction- Abrasion, blisters, Tear
• Moisture- Increases coefficient
of friction
• Shear- underlying blood vessels
are then stretched, angulated,
and may be injured
• Subcutaneous, elevated head,
reduce level of pressure needed
for sore
10. Patient evaluation
• History, noting the onset, duration, prior treatments and procedures,
and wound care regimen
• Exudate amount
• Sources of friction, shear, and pressure
• NPUAP system – stages 4(stage 1 ,2 nonoperative) , unstageable
• Osteomyelitis- CRP, ESR, Biopsy, Xray, MRI
• Biopsy + 6 weeks of antibiotics then flap
• 37.5 % SCI- depression
11. Prevention
• Documentary elements is the risk assessment of developing pressure
injuries.
• Braden Scale,
• The Norton Scale(general physical condition, mental status, activity,
mobility, and incontinence and ranges from 5 to 20, with lower scores
associated with greater risk. )
• , and the Waterlow Scale
12. Braden Scale
• The most widely used in the US, consists of six items:
• Scores range from 6 to 23, 16 being threshold- Original study
• Sensory perception,
• Moisture,
• Activity,
• Mobility,
• Nutrition, and
• Friction and shearing
13. General skin care principles
• Assess the patient’s skin daily
• Cleanse skin when indicated using a pH-balanced cleanser
• Avoid soap and hot water
• Avoid friction and scrubbing
• Minimize exposure to moisture (e.g., incontinence, wound leakage)
• Use skin barrier product to protect vulnerable skin
• Use emollients to maintain skin hydration
15. Spasticity
• May not only reduce the risk of pressure sores, but may also improve
patient reports of pain and ability to perform activities of daily living
• To relieve tension on the suture line
• Diazepam, baclofen, clonidine, tizanidine, gabapentin, and dantrolene
• Intrathecal Baclofen
• Injection- chemodenervation- ethanol, botulinum
• Tenotomy, Myelotomy
16. Nutrition
• Most studies have failed to find reduction in pressure sore rates for
specific BW, Serum nutritional markers, caloric, intake
• Meta-analysis- 19.25 patients would need to be given enteral
nutritional support to prevent 1 pressure sore
17. Pressure relief
• Fluidized bed,
• Low air loss
• Constant low pressure bed
• Alternating pressure
• Decrease time of repositioning 4-2 hrs
19. Non- surgical Management
• Pressure relief- Low air loss, fluidized air
• Spasticity- weight distribution, and hygiene, prevent tension on the
healing wound
• Malnutrition
• Infection- OM- biopsy-directed antibiotic therapy
• Wound care- sharp, enzymatic, Biologic(maggot therapy)
• Negative pressure therapy- Deva et al.215 noted positive results in
treated grade III ulcers
20.
21.
22. Surgical treatment
• Excision of the ulcer, surrounding scar, underlying bursa, and soft-
tissue calcifications, if any
• Radical removal of underlying bone and any heterotopic ossification
• Padding of bone stumps and filling dead space
• Resurfacing with large regional pedicled flaps
• Grafting the donor site of the flap, if necessary
24. Options
• Random skin flap,
• Myoplasty plus skin graft,
• Pedicled muscle,
• Myocutaneous, fascial, or fasciocutaneous flap, Free flaps, and tissue
expansion
25. Muscle flaps
• Dead space obliteration
• Skin necrosis decreases when muscle is interposed
• Innoculation pigs with E.coli and staph- better resistance than only
skin flaps
28. Tissue expansion
• Sensate flap for pressure awareness and future prevention
• pre-expansion of tensor fasciae latae and lumbosacral
fasciocutaneous flaps Increased vascularity
• Cons- Foreign expandor
• Currently- cover shallow ulcers with no dead space to fill, particularly
if sensate skin can be used to resurface a previously insensate area
