Pressure Areas and Pressure Ulcers


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!


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


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


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


  • anaemia
  • lymphopenia
  • hypoalbuminaemia


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



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


  • 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

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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