• Skip to main content
  • Skip to secondary menu
  • Skip to primary sidebar
  • Skip to footer

Life in the Fast Lane • LITFL • Medical Blog

Emergency medicine and critical care medical education blog

  • MENU
  • ECG
  • CCC
  • Top 100
  • PODCASTS
  • JOBS
  • TOX
  • PART ONE
  • INTENSIVE
Home | CCC | Pressure Areas and Pressure Ulcers

Pressure Areas and Pressure Ulcers

by Dr Chris Nickson, last update April 23, 2019

OVERVIEW

International NPUAP-EPUAP Pressure Ulcer Definition

  • A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear
  • A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated

Pressure ulcers are preventable!

PATHOPHYSIOLOGY

Predisposing factors (4Ps)

  • pressure +/- shear
  • poor perfusion
  • poor healing
  • poor ‘padding’ / prominence’s

Development of pressure ulcers

  • can develop within 2-6 hours
  • most vulnerable areas are the heels, coccyx, sacrum, femoral trochanter (bony prominences)
  • skin and subcutaneous tissues compressed or subjected to shear forces
    -> decreased perfusion
    -> tissue necrosis

RISK FACTORS

Patient and care characteristics

  • advanced age
  • male
  • white race
  • smoker
  • low BMI
  • impaired mobility
  • urinary and faecal incontinence
  • history of pressure ulcers
  • altered mental state
  • fever
  • hypotension
  • requiring physical restraints
  • inadequate care

Comorbidities

  • malignancy
  • diabetes mellitus
  • stroke
  • pneumonia
  • heart failure
  • sepsis
  • malnutrition
  • renal failure

Laboratory

  • anaemia
  • lymphopenia
  • hypoalbuminaemia

ASSESSMENT

Assess risk score (various risk scales are in use — none are validated in critical care settings)

  • Braden score
  • Norton score
  • Waterlow score

Assess ulcer features and possible causes

  • ulcer location, area, depth, drainage, tissue type present and presence of cellulitis
  • ulcer staging
  • underlying risk factors and reversible conditions

International NPUAP-EPUAP pressure ulcer staging (detailed description here and images here)

  • Stage I: Non-blanching erythema
  • Stage II: Partial thickness
  • Stage III: Full thickness skin loss — involving subcutaneous tissue (underlying fascia is intact)
  • Stage IV: Full thickness tissue loss — involving underlying bone, tendon, muscle or cartilage

Various other staging systems exist

MANAGEMENT

Overview

  • aim to provide the ulcer the optimal environment for healing
  • evidence base is lacking

Prevention

  • risk assessment and monitoring
  • treat underlying critical illness and reversible factors
  • mobilize
  • manage urinary incontinence and diarrhoea
  • avoid pressure and friction e.g. 2 hourly repositioning, appropriate padding and mattresses
  • ensure adequate nutrition
  • skin care e.g. keep clean and dry
  • minimise sedation
  • promote wound healing e.g. stop medications that impair wound healing, control diabetes, optimise local and systemic perfusion
  • staff education

Specific therapy

  • Debridement
    – mechanical (wet to dry gauze)
    — autolytic (dressings that promote breakdown of necrotic tissue by body’s own enzymes)
    — enzymatic (proteolytic enzymes)
    — scalpel or laser debridement
    — maggot therapy
  • Managing bacterial burden
    – silver impregnated dressing or silver sulfadiazine
  • Exudate management
    – avoid excessive moisture
    — > 300 dressings available!
  • Monitor healing
  • Surgery rarely required
    — direct closure, skin grafting, skin flaps, musculocutaneous flaps, free flaps, stents and revascularisation
  • Adjunctive therapies
    — electrical stimulation, topical growth factors, skin equivalents, hyperbaric oxygen

Supportive care and monitoring


References and Links

Journal articles

  • Agrawal K, Chauhan N. Pressure ulcers: Back to the basics. Indian J Plast Surg. 2012 May;45(2):244-54. PMC3495374.
  • Health Quality Ontario. Pressure ulcer prevention: an evidence-based analysis. Ont Health Technol Assess Ser. 2009;9(2):1-104. PMC3377566.

FOAM and web resources

  • National Pressure Ulcer Advisory Panel (NPUAP)
  • Australian Wound Management Association — Publications (includes pressure ulcer guidelines)

CCC 700 6

Critical Care

Compendium

…more CCC

Share this:

  • Facebook
  • Twitter
  • LinkedIn
  • Print

Related

About Dr Chris Nickson

An oslerphile emergency physician and intensivist suffering from a bad case of knowledge dipsosis. Key areas of interest include: the ED-ICU interface, toxicology, simulation and the free open-access meducation (FOAM) revolution. @Twitter | INTENSIVE| SMACC

Reader Interactions

Leave a Reply Cancel reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Primary Sidebar

  • Twitter
  • Facebook
  • Vimeo
  • LinkedIn
  • Twitter
  • Twitter
  • RSS Feed
ECG Mastery

Recent Posts

Adult CXR Cases 002

Is climate crisis a medical emergency?

Pain scale

Pediatric CXR Cases 007

Name that murmur

Footer

RSS FEED  LITFL posts by EMAIL or RSS

RSS FEED  LITFL Review by EMAIL or RSS

RSS FEED  FFFF by EMAIL or RSS

#FOAMed Medical Education Resources by LITFL is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Based on a work at https://litfl.com

  • Twitter
  • Vimeo
  • Facebook
  • LinkedIn
  • Twitter
  • Twitter

Authors • Blog • Contact • Disclaimer

2018 Launch

  • 22,372,687 visitors

Copyright © 2019 · Powered by vocortex and iSimulate