PRESSURE ULCERS: MEDICAL MANAGEMENT/SURGICAL
Pressure ulcer prevention and treatment following spinal cord injury for the 2000 guidelines of the Consortium for Spinal Cord Medicine.
Remove Pressure: Although removing pressure is the single most important
component of both prophylaxis and treatment in both the hospital and the
home, the principal way of treating pressure sores at home is - no sitting.
Debride: After pressure is removed, debride the wound, either surgically
(the simplest, quickest, and most effective method) or with wet-to-dry saline
dressings (if surgery is not indicated or if necrotic tissue remains). Saline
is recommended over other preparations for its efficacy and lack of adverse
reactions. Povidone-iodine, hydrogen peroxide, and Dakin's solution should
not be applied. Surgery is not recommended for patients with:
Acute illness, whose wounds heal by contraction and epithelialization
Myelomeningocele, who may not be able to prevent pressure sores
Chronic illness, who may not be candidates for a 2-3 hour operation in the
prone position, with blood loss of 250 - 1,500 mL and complete bed rest for
Steroid-dependent disease, who may fail to heal following reconstruction
Diarrhea, serum albumin less than 3.0 mg/dL, thromboembolic disease, or who
are receiving anticoagulants
Frequent and/or self-imposed pressure sores
Contractures or spasticity not yet released by physical therapy or surgery
Wound Healing: After debridement:
Manage the wound in a moist environment to promote the growth of healthy
tissue. Dakin's solution should be used until there is no more dead tissue,
followed by normal saline solution. Occlusive and non-adherent dressings,
such as DuoDERM, create a hypoxic, non-abrasive, bacteria-free environment
optimal for angiogenesis.
Supplement with zinc, vitamin C, and a multivitamin with minerals for wound
healing, but guard against high zinc levels which may interfere with wound
- FES may further promote wound healing by increasing
blood flow to the wound (Mawson,
et al 1993). Non-thermal pulsed electromagnetic
energy is recommended to speed up wound healing to as
little as one week for Stage II pressure ulcers (Salzberg,
et al 1995). However, this is no evidence of a
benefit of using electromagnetic therapy to treat pressure
sores (Fleming & Cullum,
Tension, such as range of motion exercises, may stimulate wound healing
in non-healing portions of complex wounds that require a myocutaneous flap
(Goldstein, et al 1996).
Hypoproteinemia and anemia should be properly evaluated and treated.
Ultrasound/ultraviolet-C and laser therapy may reduce healing time of pressure
ulcers (Nussbaum, et al 1994). There is no evidence of benefits of ultrasound therapy in the treatment of pressure ulcers. However, the possibility of beneficial or harmful effect cannot be ruled out due to the small number of trials, some with methodological limitations and small numbers of participants (Baba-Akbari, et al 2005).
- If infection occurs, culturing deep tissue specimens sampled from the surgically cleaned and unbridled ulcers allows for the isolation of the bacterial species that are really involved in the ulcer infection. As the identification of these bacteria and their antibiotic susceptibility are available, when the culture results of the day 1 postsurgical drainage liquid is also available, it is easier to choose targeted antibiotic treatment (Heym, et al 2004).
- MRI: Magnetic resonance imaging of soft tissues
and bones underlying pressure ulcers is recommended to determine
any deep changes in these tissues and bones, such as osteomyelitis,
heterotopic bone formation, and bone marrow edema. By diagnosing
deep changes adjacent to pressure sores, MRI can facilitate
proper clinical management and prevent contraindicated surgery
(Hencey, et al 1996).
However, the majority of severe pressure ulcers are treated
surgically by skin grafts, flaps, or primary closures (Schryvers,
et al 2000).
The Pressure Ulcers site of the PoinTIS
Spinal Cord Medicine site of the SCI Manual for Providers is based on information
in Spinal Cord Injury; Medical Management and Rehabilitation, G.M. Yarkony,
ed., Gaithersburg, MD., Aspen Publishers, 1994, except for information where
other papers are cited.