A  24-year-old   male   mountain  bike   rider  crashes   into   a   tree,  resulting  in   a   severe hyperextension neck injury, and  fractured lower left ribs. He now presents to hospital  with shock and a painful distending  abdomen.

After another 24 hours it is apparent that he has a complete spinal cord lesion at C4.

d) Despite regular pressure area care, he develops a deep, 5cm by 5cm sacral ulcer. How should this be managed  and how may it have been prevented?

[Click here to toggle visibility of the answers]

College Answer

Initial management involved complete evaluation and staging, close monitoring, and providing adequate pain relief.   Further treatment involves correcting any precipitating factors, review preventative measures, correct nutritional status (deficiencies diagnosed and corrected), manage tissue pressure (eg. specialised beds) remove necrotic tissue, manage wound infections and maintain a moist environment.

Preventative techniques require identification of patients at risk, daily skin inspections, patient positioning (two hour turning, pressure reducing mattresses, special beds), encouraging mobility (physical therapy, reduce sedatives), and provision of adequate nutrition.

Discussion

LITFl have a nice section on pressure areas. A structured approach would resemble the following:

Risk factors for pressure ulcers in ICU

A good article from 2000 has an exhaustingly long table (Table 1).

Highlights from this article include the following:

  • Prolonged immobility
  • Use of neuromuscular junction blockers
  • Age over 60
  • Severe illness (APACHE II score over 13)
  • Hemodynamic instability preventing pressure area care
  • Diabetes
  • Incontinence
  • Low albumin
  • Poor nutrition
  • Oedema
  • Peripheral vascular disease
  • Steroid use

Prevention of pressure ulcers in ICU

  • Risk assessment and monitoring
  • Mobility (may be unreasonable in this context)
  • Minimise sedation and restraints to allow for self-repositioning (may not be relevan in this context)
  • Management of incontinence
  • 2 hourly repositioning
  • Air mattress or specialised foam (evidence is not strong)
  • Adequate skin care

Management of pressure ulcers in the ICU

  • Engagement of a multidisciplinary wound care team
  • Debridement
  • Antibacterial (silver sulfadiazine) dressings
  • Frequent dressing changes
  • Exudate-absorbing dressings
  • Promote wound healing:
    • Adequate nutritional supplementation, particularly of protein (2g/kg/day)
    • Control of diabetes
    • Avoidance of corticosteroids
    • Optimisation of tissue perfusion
    • Avoidance of oedema

References

References

Keller, Paul B., et al. "Pressure ulcers in intensive care patients: a review of risks and prevention." Intensive care medicine 28.10 (2002): 1379-1388.

 

Cullum, N., et al. "Beds, mattresses and cushions for pressure sore prevention and treatment." The Cochrane Library (2000).

 

REULER, JAMES B., and THOMAS G. COONEY. "The pressure sore: pathophysiology and principles of management." Annals of Internal Medicine94.5 (1981): 661-666.

 

Health Quality Ontario. "Pressure Ulcer Prevention: An Evidence-Based Analysis." Ontario health technology assessment series 9.2 (2009): 1.

 

Stratton, Rebecca J., et al. "Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis." Ageing research reviews 4.3 (2005): 422-450.

 

Henzel, M. Kristi, et al. "Pressure ulcer management and research priorities for patients with spinal cord injury: consensus opinion from SCI QUERI Expert Panel on Pressure Ulcer Research Implementation." J Rehabil Res Dev 48.3 (2011): xi-xxxii.

 

Theaker, C., et al. "Risk factors for pressure sores in the critically ill."Anaesthesia 55.3 (2000): 221-224.