Pressure sore

Academic presentation as junior resident in orthopaedic and trauma at National Orthopaedic Hospital Dala Kano.
by Dr Kabiru SALISU
[email protected]

1. DISCUSS THE MANAGEMENT OF PRESSURE SORE By DR Kabiru Salisu NOHD

2. INTRODUCTION MANAGEMENT - Diagnosis Treatment Complication CONCLUSION REFERANCES

3. INTRODUCTION Definition - This is a representative of traumatic ulcer due to direct pressure on bony tissues or shearing forces resulting in microvascular compromise leading to tissue necrosis and ulceration - Decubitus Ulcer;- Latin decumbere means "to lie down

4. History Thompson Rowling 1861 Devis 1938

5. Epidemiology Pressure sores are common conditions among patients hospitalized in acute- and chronic-care facilities Hospitalised 3-10% Studies reported prevalence rates as high as 25-33% In SCI 57.1% FMC Gombe and NOHI

6. Management of pressure sore

7. Multidisplinary Plastic surgeon Neurosurgeon Orthopedic surgeon Nurses Social workers Physician Dietitian Physiotherapy

8. A- Diagnosis Aim at: - Determining the vulnerable individuals - Risk assessment - Skin assessment - Ulcer assessment

9. 1- People vulnerable to pressure ulcers - Post surgery - Critical care - Orthopaedic patient -Spinal injured - Diabetes - Peripheral vascular disease - Previous history of pressure ulcers -Extremes of age.

10. 2- RISK ASSESSMENT

11. RISK SCORING

12. Score ranges between 4-20, the higher the score the lower the risk <14 – Greatest risk 14-18 – Moderate risk 18-20 – Minimal risk

13. Inspect the vulnerable areas

14. Characterised the ulcer if present Look for: – persistent erythema – non-blanching hyperaemia – blisters – localised heat – localised oedema – localised induration – purplish/bluish localised areas – localised coldness - site, Size, shape, surrounding, edge , base & color Discharge Bleeding Necrotic tissue Odour

15. 4- classify the ulcer

16. Investigation FBC Wound swab M/C/S Serum protein (Albumin / transferin ) E/U X-Ray Biopsy

17. TREATMENT A- NON OPERATIVE

18. PREVENTION 1- Repositioning 2- Protect bony areas frequency- 2hrly on bed 15min wheelchair Assisted/ by self Devices eg specialise wheelchair or mattress eg trapeze bar Special cushions foam mattress pads, air-filled mattresses water-filled mattresses/ gloves Bed sheet should be smooth

19. 3- Skin care 4- Improve Nutrition Bathing Skin protecting agent eg talcum powder frequent skin inspection Managing incontinence/ UTI Good diet Dietary suppliment vit . C, A, and Zinc - Feeding Assistance

20. 5 - Early mobilization 6- Quit smoking 7- Control spasticity 8- Adequate pain control 9- psychological counseling

21. 10- pressure measurement

22. Pressure mat / map

23. Pressure mapping system

24. Superficial sores (stage 1and 2) I. Take all preventive measures 2. wound dressing using aseptic technique sing N/S, hydrocolloid dressing , antibiotic gels/gauze or adhesive dressing 3. Minimal wound debridement 4. Determine presence of infection and treat 5. Avoid urine or faecal contamination of wound 6. Keep record of wound size , shape and other changes

25. 7. Tetanus prophylaxis 8. Antibiotic/ suppliments

26. Operative treatment (stage III/IV) A- preoperative considerations Determine whether the underlying cause can be eliminated post operatively Patient / care giver EDUCATION about the treatment Nutritional Consideration ( SA – 3.5g/100ml & transferin 220g%) Sterilize the urinary tract Treat spasticity Radical wound debridement Determine presence of osteomylitis

27. Intraoperative Excision of the ulcer, surrounding scar, underlying bursa, and soft-tissue calcification, • Radical removal of underlying bone and any heterotopic ossification padding of bone stumps and filling dead space with fascia or muscle flaps Resurfacing with large regional pedicle flap Grafting the donor site of the flap with thick split skin

28. Example of flap to be raise include; - Tensor faciae latae flap Transverse lumbosecral flap Sliding gluteal flap Hamstring V-Y advancement flap Rhomboid double Z plasty Gluteal maximus island flap

29. Post operative measures Prevent pressure or shearing force Drain Sitting begin at 4-6wks Initially 10min once or twice daily Sitting period increase gradually up to 2hrs Improve nutrition

30. complications Osteomylitis Pyoarthrosis Anaemia Urethral fistula Recurrence Autonomic dysreflexia Malignant transformation Depressive illness

31. CONCLUSION Pressure ulcer management is challenging both to the patient and the managing team. Is associated with high morbidity, mortality and economic burden. ALWAYS REMEMBER THAT IT IS EASIER PREVENTED THAN TREATED.

32. References Al- fallouji M. A: post graduate surgery, 2 nd edition, Read publishing Ltd. 1998 Onche I.I, Yiltok S.J, Obiano S. K; pressure ulcer in spinal cord injury patient in gombe Nigeria, nigerian journal of orthopaedics and trauma Vol-3 ,2004 Idowu O.k , yinusa W; Risk factors of pressure ulcer in resource constrained spinal injury service, nature.com, j an. 2011 Douglas A. H ; principles of pressure management, national institute on disability and rehabilitation research, sept . 1999 Jeffrey E.J. etal ; Pressure sore, baylor university medical centre, vol 9,2003 Bed sore by Mayo foundation for medical education and research, march 2011 Bradon J. W; surgical treatment of pressure ulcer, medscape 2011 Prevention and treatment of pressure ulcer, clinical guideline 29, royal collage of nursing 2006 John L. Ziller ; pressure ulcer, JAMA patient page , the journal of American medical associationVol296, Aug. 2006