These are wounds caused by sustained pressure on certain parts of the body. They used to be called “bed sores” but the new name conveys the cause of these sores to everyone so that they can be prevented. Common sites are the outer side of thigh, lower end of spine (sacrum), heel, and elbow and back of head. In paraplegics on wheelchair, it may form over the ischium (the bone on which one sits). Prolonged heavy pressure for as little as 30 minutes can start a pressure sore. Since pressure = weight/unit area, it is logical that heavy patients as well as emaciated bony patients (small “bony” area of contact) can get it. It is equally true that all pressure sores are preventable.
WHAT CAN YOU DO TO PREVENT THEM?
- Identify people at risk.
- Pad all pressure points with designated foam or gel pads.
- Use appropriate mattress / cushion / wheelchair.
- Frequent turning or change of position every hour
- Identify early evidence of pressure (persistent redness in a pressure prone area).
- Keep the skin healthy by keeping it clean, well moisturized and protected.
- Avoid creases / hard areas in bed.
- Avoid skin soaking in urine / faeces.
HOW TO TREAT THEM?
A. Early sores can be treated by off-loading pressure completely and using antibacterial creams, herbal ointments such as MEBO [a herbal based healing ointment, manufactured by Julphar, RAK] or covering with films such as Tegaderm or Op-site.
When the skin is broken, consult a doctor. If a plastic surgeon or a wound care/tissue viability nurse is available he/she can be consulted.
B. For deeper pressure sores: These have dead tissues and can get infected. The non-viable tissue has to be removed by one of the following ways before healing can start –
- Removal by the body (autolysis) – helped by moist dressings with gels (Intrasite, Nugel etc.)
- Removal by enzymes (Debrisan)
- Removal by surgical methods (debridement) which in many cases can be done bedside without anesthesia.
- Special methods such as Versajet (Smith&Nephew)
Healing by the body may take several weeks and it can be a realistic option in a wound 5 cm or less across. Larger wounds are better treated by local flaps. However many of these patients are quite ill or unwell and may have multiple problems. Negative pressure wound therapy (NPWT) or Vacuum assisted closure (V.A.C.) technique is very useful as it can control the wound discharge effectively, keep the wound clean and can help to achieve closure without surgery. Special equipment, knowledge and personnel are needed to initiate and maintain this form of treatment but the skills can easily be learnt by any responsible member caring for the patient. The companies (Smith & Nephew and KCI) do provide outreach support.
Plastic Surgery for Pressure Sores
A consultation with a Plastic Surgeon is very useful and is often a turning point in the management of these frustrating wounds that overwhelm the capabilities of other medical personnel.
A plastic surgeon can advise the family on pressure relieving methods, wound care, provide VAC dressings where needed and carry out wound cleaning surgeries. In the bigger cases, skin grafting or flap surgery is required and can be successful. A flap is a segment of skin and deeper tissues that is moved in from nearby areas in order to fill the deep defect and close the wound. The surgical skin defect created by moving the flap can either be closed or can be covered with a thin skin graft. This is okay because the flap donor area is usually not a pressure prone area or it has sufficient padding still.
Several types of flaps are available for complex and deep pressure sores. These can be done even in elderly patients having other complicating diseases. Please see the Before & After photos to see some illustrative cases.
Warning: Some of these pictures are very graphic and may upset you if you are sensitive. Kindly restraint if you think you are too sensitive to view such photos.