Geriatric Quick Consult      Pressure Ulcers      Do #4

Order appropriate wound care.

  
Knowledge Action

General principles of care include:

  1. Remove necrotic tissue
  2. Keep the wound bed moist
  3. Eliminate excessive exudate
  4. Fill cavities
  5. Protect ulcer from contamination and further trauma.
  • Follow these basic steps in all cases.
DEBRIDEMENT: there are no randomized trials on the various methods available.

Moist devitalized tissue supports bacterial growth; removal improves the healing environment.
  • Remove devitalized tissue.
  1. Sharp - use scalpel or scissors.

    Remove thick eschar and large amounts of necrotic tissue.

    Most rapid method; necessary when signs of sepsis or cellulitis present.

    Caution advised if impaired circulation.

    Don't debride ischemic wounds unless you are certain of collateral circulation.
  • Perform sharp debridement if large eschar or infection is present.
  1. Mechanical - wet-to-dry dressings, hydrotherapy, wound irrigation.

    Wet-to-dry gauze can be removed in 4-6 hours, when dry.

    This tears out healthy tissue with necrotic tissue, so is nonselective.

    Also it is painful.

    Moistening gauze makes removing it less painful but this defeats the purpose.

    To debride wound by irrigation, adequate force can be obtained using a 35 ml syringe and 19 g angiocath.
  • Use mechanical debridement for smaller wounds.


  • Irrigate wound under pressure using syringe.
  1. Enzymatic - topical debriding agents (for example collagenase) can be used alone or in combination with sharp debridement.

    Enzymatic agents can damage newly formed tissues and should be used by experienced providers.

    They are especially useful to soften eschar.
  • Use enzymatic agents selectively.
  1. Autolytic - synthetic dressings used to cover wound allow devitalized tisse to self digest from enzymes present in wound fluid.

    Slowest method.

    Should not be used if signs of infection present. See note.

    Autolytic debridement is less traumatic than mechanical and requires fewer dressing changes.
  • Use autolytic debridement for non-infected wounds with less necrotic tissue.
CLEANING: healing is improved and infection reduced if wound bed is cleaned.

Use NORMAL SALINE for most wounds.

Safe irrigation pressures are 4-15 psi.

This can be achieved with a 35 ml syringe and a 19 g angiocath.

DO NOT clean ulcers with antiseptic agents (povidone-iodine, hydrogen peroxide, acetic acid, sodium hypochlorite [Dakin's] solution).

These are toxic to human fibroblasts.

Whirlpool should be used only for wounds with thick exudate, slough, or necrotic tissue, and should be discontinued when ulcer is clean. See note.		 Clean with:
  • NORMAL SALINE


  • 4-15 psi.


  • 35 ml syringe


  • 19 g angiocath


  • Only use whirlpool initially for problem wounds.

DRESSINGS/WOUND CARE PRODUCTS: goal is to keep ulcer bed moist and surrounding tissue dry. See Note.

Remember to eliminate dead space by loosely filling all cavities with gauze material. Avoid overpacking to prevent further tissue damage.

Protect ulcer from fecal contamination; use clean gloves for each patient; use sterile instruments for debridement.

Several categories of wound care products (with examples) include2:

See Note.
  • Fill cavities with gauze


  • Clean gloves


  • Sterile instruments
TISSUE GROWTH FACTORS: a number of growth factors have been isolated. Platelet-derived growth factors have been studied most, but there are currently no recommendations for their use in pressure ulcers1.
  • Limit use of tissue growth factors to selected cases.


  • Get a consult first.
SURGICAL REPAIR: this may be the treatment of choice for deep pressure ulcers in patients able to tolerate the surgery and comply with a meticulous rehab program.

Excision of the ulcer must include complete removal of surrounding tissue, scar, underlying bursa and bone.

Musculocutaneous flaps are usually the best choice when loss of muscle function does not contribute to morbidity, e.g., paraplegic or nonambulatory patients.

Careful rehabilitation after pressure ulcer repair is essential, so patient should be carefully assessed for ability to follow rehab plan.

Adequate social support is also necessary2, 3.
  • Consider surgical repair only in selected cases.


  • Assess patient's ability to follow rehab.


  • Make sure there is adequate social support.

References:

  1. Spoelhof GD. Management of pressure ulcers in the nursing home. Annals of Long-Term Care. 2000; 8(8):69-77.
  2. Bergstrom N, Bennett A, Carlson CE, et al. Clinical Practice Guideline Number 15: Treatment of pressure ulcers.
  3. Reuben DB, Yoshikawa TT, Besdine RW, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 3rd ed. Dubuque. Iowa: Kendall/Hunt Publishing Company for the American Geriatrics Society: 1996.
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