PRESSURE ULCERS: MEDICAL MANAGEMENT/SURGICAL IMPLICATIONS

Click on Pressure ulcer prevention and treatment following spinal cord injury for the 2000 guidelines of the Consortium for Spinal Cord Medicine.

  1. 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.

  2. 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 two weeks
    • 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

  3. 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 healing.
    • 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, 2005).
    • 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).

  4. 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.