(Pressure Sores)
(Jama 2008;300:2647; 2003;289:223; 1995;273:865)
Si:Stage:
I—persistent redness
II—partial thickness abrasion, blister or ulcer
III—full thickness ulcer into subcut tissue, not fascia; w/o undermining
IV—extensive and/or invasion of fascia, joint, tendon; or undermining
But heel ulcers often bad w ecchymosis but skin still intact, so it is deep tissue injury, not stage I
Rx:
None clearly best by DBCT
Prevent w alternating pressure mattress, air mattress (Jama 1993;269:1139), egg crate foam mattress 6.5 in. thick (Lancet 1994;343:568), turning; vit C2 50 mg bid po, though little evidence (Jama 2006;296:974)
Debridement of all eschar and dead tissue (except dry stable heel eschar, as long as checked daily): use topical lidocaine gel in gauze as prepare to debride;
Electrical stimlulation therapy
of stage II and III: hydrocolloid dressing
of stage III and IV and/or extensive exudate: calcium alginate followed by hydrocolloid
Table 3.4: Commonly Used Rx of Pressure Sores
| Type | Examples |
|---|---|
| Debridement of eschar | |
| Sharp surgical | scoring or excision of eschar |
| Gauze dressings | Normal saline/disinfectant wet-to-dry gauze; not very practical; very labor intensive |
| Enzymatic products | Elase (fibrinolysin & DNAase), Santyl (collagenase), Granulex (trypsin), Panafil (papain), Accuzyme |
| Irrigation | Whirlpool, low-pressure waterpik |
| Protective dressings (autolytic) | |
| Permeable | OpCit, Tegaderm |
| Hydrocolloid | DuoDERM, Comfeel, Tegasorb, Ultec |
| Petroleum gauze | Vaseline, Xeroform |
| Collagen | Medifil Kollagen, more expensive but no better than hydrocolloid (Jags 2003;51:147) |
| Antimicrobial dressings | |
| Disinfectant solutions (dry the wound; use not more than 2 wk) | Acetic acid, hydrogen peroxide, sodium hypochlorite (Dakin's), povidone iodine (Betadine), chloramine-T (Chlorazene), Silver sulfadiazine (Silvadene) cheapest but must change q 24 hr; Acticoat absorbent sheets $14 for 6 x 6 in but last 2-7 d; also Actisorb, Aquacel, Af rope, Contreet, or SilverCel,each w differing rates of Ag release and absorptive capacities) |
| Topical antibiotics if not improving | Mupirocin (Bactroban), metronidazole (Flagyl) |
| Hypertonic antimicrobials | Hypertonic saline, sucrose (granulated sugar), NaCl gauze, (Mesalt) |
| Cavity filling | |
| Gauze dressings | Normal saline gauze, hypertonic saline gauze (Mesalt™) |
| Hydrocolloids | DuoDERM Hydroactive Gel™ |
| Alginates (rope format) | AlgiDERM™, DermaSORB™, Sorbsan™ |