Pressure ulcer

Background

Decubitus ulcer stages I to IV.

Common pressure ulcer points. Red: in supine position. Blue: in lateral-lying position.

• Classified into stages based on thickness
• External compression of skin causes ischemic tissue damage, necrosis which is common in
• Bedridden patients
• Nursing home patients

Clinical Features

Stage IV decubitus ulcer.

• Stage 1 - Skin intact, nonblanchable erythema
• Stage 2 - Erosion into epidermis only (dermis is intact)
  • Adipose tissue is not visible
• Stage 3 - Deep necrosis/ulceration with full-thickness skin loss
  • Adipose tissue is visible
  • Fascia, muscles, ligaments/tendons, cartilage/bone not visible
• Stage 4 - Full thickness ulceration revealing muscle and bone
• Unstageable - Full-thickness skin involvement with devitalized tissue/eschar obscuring view

Differential Diagnosis

Skin breakdown

• Cellulitis
• Diabetic ulcer
• Pressure ulcer
• Pyoderma gangrenosum
• Osteomyelitis
• Venous ulcer

Evaluation

• The most important piece of the evaluation is early identification and classification especially for patients being admitted.
• For deep wounds and in patients with signs of sepsis, evaluate for hematogenous spread (blood cultures) or osteomyelitis (imaging or deep culture)

Management

• Stage 1 and 2 ulcers
  • Wound care and dressing changes in addition to padding to relief pressure
• Stage 2 and 3 ulcers
  • Surgical debridement and ongoing intensive wound care and pressure relief

Disposition

• Disposition is not dependent on the degree of ulcer but rather depends on the patient's clincal condition

See Also

• General Approach to EM Geriatrics