I.

Management
Pharmacological
o

Pain management. Pressure ulcers can be painful. Nonsteroidal antiinflammatory drugs such as ibuprofen (Motrin IB, Advil, others) and
naproxen (Aleve, others) may reduce pain. These may be very
helpful before or after repositioning, debridement procedures and
dressing changes. Topical pain medications also may be used during
debridement and dressing changes.

Antibiotics. Infected pressure sores that aren't responding to other

interventions may be treated with topical or oral antibiotics.

A healthy diet. To promote wound healing, your doctor or dietitian

may recommend an increase in calories and fluids, a high-protein diet,
and an increase in foods rich in vitamins and minerals. You may be
advised to take dietary supplements, such as vitamin C and zinc.

Management of incontinence. Urinary or bowel incontinence may

cause excess moisture and bacteria on the skin, increasing the risk of
infection. Managing incontinence may help improve healing. Strategies
include frequently scheduled help with urinating, frequent diaper
changes, protective lotions on healthy skin, and urinary catheters or
rectal tubes.

Muscle spasm relief. Spasm-related friction or shearing can cause or

worsen bedsores. Muscle relaxants such as diazepam (Valium),
tizanidine (Zanaflex), dantrolene (Dantrium) and baclofen (Gablofen,
Lioresal) may inhibit muscle spasms and help sores heal.

Negative pressure therapy (vacuum-assisted closure, or

VAC). This therapy uses a device that applies suction to a clean
wound. It may help healing in some types of pressure sores.

SURGICAL MANAGEMENT of PRESSURE ULCERS

Surgical procedures may be used to treat pressure ulcers. They include:
direct closure, skin grafting, skin flaps, musculocutaneous flaps, and free
flaps .Though there are no clear criteria or clinical practice guideline for the
indication of surgical intervention, patients with nonhealing Stage III or IV
pressure ulcers despite optimal conservative care, and those with underlying

osteomyelitis requiring debridement of the infected bone, may be candidates

for surgery. Surgical removal of a bony prominence such as orchiectomy is
contraindicated due to poor pressure distribution and postural control
postoperatively. Risk factors that impair wound healing should be controlled
before surgery is considered, including malnutrition, anemia, spasticity,
urinary tract infection, incontinence, smoking, and psychosocial issues. It is
imperative to provide postoperative pressure relief to the surgical site with
appropriate positioning of the patients and pressure-relieving mattresses. As
the long-term outcomes of pressure ulcer surgery remain unclear, careful
selection of surgical candidates is of utmost importance.

WOUND CARE
The purpose of local wound care is to provide the wound with the most
optimal environment for healing. Specific factors that need to be taken into
consideration are:
Level of moisture: the provision of a moist healing environment has been
accepted to be the standard of care in pressure ulcer management. It is
believed that wound healing is optimized at an appropriately moist
environment, while a dry or excessively moist environment will be
detrimental to wound healing. Depending on the pre-existing level of
moisture in the wound bed, various dressings can be used to correct the
level of moisture in the wound. The different types of dressings are
discussed under GENERAL DRESSING GUIDELINES.
Debridement of necrotic tissues: the removal of necrotic tissues, eschar, and
slough is a well-accepted practice in wound bed preparation for healing.
These devitalized tissues may support the proliferation of pathogens.
Though debridement is widely practiced, there has not been any substantial
research study on this topic. There are four methods by which debridement
can be achieved. In the order of their onset of action, with the most rapid
onset being first, they are: sharp debridement with scalpel or scissors,
nonselective mechanical debridement through the use of irrigation or a wetto-dry dressing, chemical debridement through the use of an enzyme such
as collagenase without damage to the granulation tissues, and autolytic
debridement
Wound cleansing: wound cleansing facilitates the removal of necrotic materials,
exudates any metabolic wastes away from the wound, thus promoting
wound healing. It also may decrease the bacterial load in the wound tissue;
this is important because a bacterial count of greater than may be
associated with the development of wound infection

Protection of wounds: this can be achieved by the use of an appropriate dressing

to protect the wound from external factors such as further trauma, and
bacterial or chemical exposure.
Adjuvant Therapeutic Modalities
There are many therapeutic modalities used in the treatment of pressure
ulcers, including electrical stimulation (ES), hyperbaric oxygen, infrared,
ultraviolet, low-energy laser irradiation, and ultrasound. The AHCPR
Guidelines supported only the use of hydrotherapy for the cleansing of the
ulcers and ES for nonhealing Stage III and IV pressure ulcers. This section will
examine these recommended modalities, and some newer, but commonly
used therapeutic modalities.
HydrotherapyWhirlpool and Pulsatile Lavage
Therapy
Hydrotherapy is particularly helpful for cleansing and mechanical
debridement of Stage III and IV wounds. Conventionally, hydrotherapy for
pressure ulcer management has been carried out through the use of a
whirlpool. Despite its clinical efficacy, whirlpool therapy has been found to
have some clinical and practical limitations, including cross-contamination
between patients, pseudomonas infections, and potential skin infections for
caregivers who are in contact with the contaminated water.
Pulsatile lavage therapy is a different form of hydrotherapy that encompasses
all of the advantages of whirlpool therapy, but without the potential adverse
effects. A portable device is used that delivers pulsed jet streams of water at
a known, preset pressure, which is compliant with the pressure range (415
psi) recommended for wound cleansing. The potential for cross-contamination
between patients is eliminated because the device is for single-patient use,
and is carried out by a caregiver in the patients room. Furthermore, pulsatile
lavage therapy is less labor intensive than whirlpool hydrotherapy because it
does not involve any patient transfer and there is no decontamination of
equipment afterwards. Pulsatile lavage appears to be a preferred alternative
to whirlpool therapy in the management of pressure ulcers. The clinical
efficacy of pulsatile lavage in the treatment of pressure ulcers is under
investigation
Electrical Stimulation
ES has been used for the treatment of chronic wounds for many years and
has been specifically recommended for the treatment of severe (Grade III or
IV) pressure ulcers by the AHCPR Clinical Practice Guidelines. There have
been many clinical reports of the technique. Three separate Meta analyses
have attempted to consolidate the many varying clinical reports on the

success of this technique. All these reports considered ES to be an effective

modality; however, the specific treatment and stimulation paradigms
employed were found to be highly variable. The mechanisms by which ES
promotes wound healing are not fully understood, leading to a need to
optimize delivery of treatment.
Negative Pressure Wound Therapy
Negative pressure wound therapy (NPWT) is based on the theory that the
negative pressure facilitates drainage of wound exudates and enhances
wound healing through a number of mechanisms. More specifically, NPWT is
proposed to decrease the bacterial load and edema while concurrently
promoting an improved local circulation and increasing granulation. NPWT
devices consist of a suction pump with foam and occlusive dressing to create
negative pressure on the wound being treated. Despite the lack of official
guidelines on the use of NPWT, it has been widely used in clinical practice
and there have been consensus reports (136,137). The primary
recommendations are that NPWT is indicated when the following clinical
criteria are met:
Anatomical surfaces that allow a tight seal
Adequately prepared wounds, for example, debrided, free of eschar, and
necrotic materials
Wound drainage
Patient compliance
NPWT is contraindicated when wounds are dry, there is uncontrolled pain,
untreated infection, malnutrition, or poor hemostasis. Effective NPWT will
produce a response within 2 to
4 weeks. Discontinuation is recommended if there is less than
30% wound size reduction after 4 weeks.
Despite its popularity, none of the major clinical reviews and guidelines have
found sufficient scientific evidence to support the use of NPWT for wound
healing (138141). There were too few randomized controlled trials. Small
sample size and poor study design limit the validity of existing studies.
Further research is needed to determine the utility of NPWT as a treatment
modality for appropriate nonhealing pressure ulcers.
Therapeutic Ultrasound
Therapeutic ultrasound is a deep heating modality that is commonly used for
pressure ulcer healing. Its deep heating property is theorized to improve the
vascularity of the wound tissues, thus improving healing. However, there is
only limited evidence from clinical trials.

Electromagnetic Therapy
There is growing interest in the use of electromagnetic therapy for the
treatment of pressure ulcers. This modality has been shown to increase the
blood flow, collagen formation, and also granulocyte infiltration in both in
vitro and animal models to induce healing. However, clinical trial evidence is
again lacking.
I.MANAGEMENT
A. PHARMACOLOGICAL MANAGEMENT
1. Pain management
- Interventions that may reduce pain include the use of nonsteroidal antiinflammatory drugs such as ibuprofen (Motrin, Advil, others) and naproxen
(Aleve, others) particularly before and after repositioning, debridement
procedures and dressing changes.
- Topical pain medications, such as a combination of lidocaine and prilocaine, also
may be used during debridement and dressing changes.
2. Antibiotics
- Pressure sores that are infected and don't respond to other interventions may be
treated with topical or oral antibiotics.
3. Healthy diet with Vitamins
- Appropriate nutrition and hydration promote wound healing.
- Increase in calories and fluids, a high protein diet, and an increase in foods rich
in vitamins and minerals.
- Dietary supplements, such as vitamin C and zinc.
4. Muscle spasm relief
- Muscle relaxants such as diazepam (Valium), tizanidine (Zanaflex), dantrolene
(Dantrium) and baclofen may inhibit muscle spasms and enable the healing of
sores that may have been caused or worsened by spasm-related friction or
shearing.
B. SURGICAL MANAGEMENT
INDICATIONS FOR SURGERY

Reduces protein loss from the wound.

Prevents progressive osteomyelitis and sepsis.

Improves patient hygiene and appearance.

Reduces rehabilitation costs.

Averts future Marjolins ulcer and amyloidosis

SOFT TISSUE RECONSTRUCTION

Musculocutaneous flaps are usually the best choice for stage 4 pressure ulcers
of the buttocks4 in spinal cord-injured patients, or when the concomitant loss of
muscle function does not contribute to comorbidity. Tissue expanders might
optimize.

SKIN GRAFT

A skin graft is a patch of skin that is removed by surgery from one area of the
body and transplanted, or attached, to another area.

Healthy skin is taken from a place on your body called the donor site. Most
people who are having a skin graft have a split-thickness skin graft. This takes
the two top layers of skin from the donor site (the epidermis) and the layer under
the epidermis (the dermis).

Risks for this surgery are:

Bleeding
Chronic pain (rarely)

Infection

Loss of grafted skin (the graft not healing, or the graft healing slowly)

Reduced or lost skin sensation, or increased sensitivity

Scarring

Skin discoloration

Uneven skin surface

BONE REPAIR AND RECONSTRUCTION

The diabetic foot has deformities that predispose to ulceration. If the ulcer heals
and then recurs several times, the orthopedic or podiatric surgeon should
evaluate the patient for foot reconstruction, osteotomies, or tendon recessions.

REVASCULARIZATION

Strides have been made in bypass of infrapopliteal stenoses via femoral-distal

bypass.2o Revascularization is the standard of care for patients with ischemic or
gangrenous wounds, understanding that the most appropriate intervention might

occasionally be non-surgical, because many high-risk patients are not candidates

for arterial bypass. A less invasive option is angioplasty.
AMPUTATION

Dysvascular amputation can be done at the digital, transmetatarsal, Symes,

transtibial, or transfemoral level for rapidly expanding gangrene and/or
overwhelming infection

C. PHYSICAL THERAPY MANAGEMENT

WOUND CARE

The purpose of local wound care is to provide the wound with the most optimal
environment for healing. Specific factors that need to be taken into consideration
are:

a. Level of moisture:

the provision of a moist healing environment has been accepted to be

the standard of care in pressure ulcer management. It is believed that
wound healing is optimized at an appropriately moist environment, while a
dry or excessively moist environment will be detrimental to wound
healing.

b. Debridement of necrotic tissues:

the removal of necrotic tissues, eschar, and slough is a well-accepted

practice in wound bed preparation for healing. These devitalized tissues
may support the proliferation of pathogens. Though debridement is widely
practiced, there has not been any substantial research study on this topic.

Purposes of Debridement

It improves the local vascular supply to the wound

It allows healthy granulation tissue to form
It reduces wound contamination and further tissue destruction
It reduces dead spaces that harbor bacterial growth
It allows for determining quality and depth of wound bed

When to debride depends on:

Presence of necrotic tissue

Epiboly at wound edges
Signs of an unstable wound
Discoloration under a callus
Callus formation on a neuropathic foot of a diabetic patient

Methods of Debridement
a. Autolytic Debridement
Use of endogenous enzymes of the body to debride necrotic
tissue
Use of moisture retentive or moisture donating dressing
Safe, non-invasive, does not disrupt healthy tissue
Indications: necrotic tissue, dry eschar
Contraindications: dry gangrene, ischemic wound, poor
circulation
Dressings that promote autolysis: thin films, hydrocolloids,
hydrogels, alginates, semi-permeable foams
b. Enzymatic Debridement
The use of topical applied chemical agents to stimulate the
breakdown of necrotic tissue
Common topical agents: collagenase, fibrogen, papain/ urea
c. Sharp Debridement
It is the most effective and most rapid type of debridement
It is the use of scalpel, forceps, scissors or lasers to remove
dead tissue
It is used for large amount of necrotic tissue
Indications: extensive devitalized tissue, advancing cellulitis,
thick and adherent eschar
Contraindications: arterial insufficiency, excessive bleeding,
immunocompromised
d. Mechanical Debridement
It is used for moderate amount of necrotic tissue
It is the use of dressings like gauge
e. Biological Debridement
Maggot Therapy
Indications:
All types of wound problems
Surgical or other types of debridement are difficult, risky o not
available
Other conditions like osteomyelitis, burns, abscesses,
nerotising fasciitis
Preparation for grafting
Contraindications:
Absolute: fistula, wound connected to body cavity, rapid
advancing tissue necrosis
Relative: exposed vessel, bleeding tendency, difficult
dissolving tissue
Advantages:
Effective
Selective
Simple
Rapid
Universally usable

 Kills bacteria
May increase healing
Disadvantages:
The ethical aspect
Requires some skill
Maybe expensive
Can cause pain
Not available in all place
c. Wound cleansing:

wound cleansing facilitates the removal of necrotic materials, exudates

any metabolic wastes away from the wound, thus promoting wound
healing . It also may decrease the bacterial load in the wound tissue; this
is important because a bacterial count of greater than 105 may be
associated with the development of wound infection

d. Protection of wounds:

this can be achieved by the use of an appropriate dressing to protect the

wound from external factors such as further trauma, and bacterial or
chemical exposure.

GENERAL DRESSING GUIDELINES

Dressings provide a physical barrier that protect the wounds, help

optimize the moisture level in the local wound microenvironment, assist in
autolytic debridement, and can also be used as a medium to deliver
topical medication to the wound. The following factors need to be
considered when selecting a dressing:
o

Does the dressing provide sufficient physical barrier for protection

from the environment?

Is there necrotic material in the wound? If so, is autolytic,

enzymatic, or mechanical debridement most appropriate?

What is the moisture level in the wound? Is drainage control or

moisture retention the goal?

Is there a suspicion of bacterial overload in the wound bed, for

example, strong odor, excessive drainage? All pressure ulcers will
have some degree of colonization but this does not necessarily
mean that the wound is infected. Is an antimicrobial topical agent
necessary?

The frequency of change and ease of application of the dressing.

The availability and cost of the dressing to the patient.

CLASSES OF AVAILABLE DRESSING

CLASS
DRESSING

OF PRESSURE
ULCCER
INDICATION
GAUZE Dry
Scabbed
over
dressing
wounds
WetStage
III,
IV
to-dry
pressure
ulcers
with
necrotic
materials
Wet-toStage
III,
IV
moist
pressure sore
OCCLUSIVE
Stage I, II pressure
transparent film ulcers
with
no
dressings
that drainage
are
semipermeable
GEL hydrophilic Stage II, III, IV
polymer
that pressure
ulcers
comes in a sheet, with little to no
granules
or drainage
liquid gel forms
HYDROCOLLOID Stage
II
(III)
pressure
ulcers
dressings
containing
gel- with little to great
forming
agents drainage
(e.g.
sodium
carboxymethylce
llulose
and
gelatin),
often
combined
with
elastomers
and
adhesives
applied
to
a
carrier
FOAM

polyurethane
dressing
that
comes in sheets
or fillers
ALGINATES
highly
absorbent,
biodegradable

MECHANISM
ACTION

OF POTENTIAL
ADVERSE EFFECT

Physical barrier
Mechanical
debridement,
absorbent
Provide
moist
healing
environment

Nonselective, may
remove granulation
tissue
May dry out and
turn into wet-to-dry
dressing

Physical
barrier, Excessive moisture
moisture retention, retention of wound
promote autolytic drains excessively
debridement
Provide
moist
healing
environment,
promote autolytic
debridement
Occlusive
and
adhesive
wafer
dressing that forms
a
gel-like
substance
with
wound
exudate,
promoting
moist
healing
and
autolytic
debridement

Too much exudate

from wounds may
cause
excessive
moisture

Provide
moist
healing
environment,
promote autolytice
debridement
Stage
III,
IV Absorb
excessive
pressure
ulcers exudates, promote
with moderate-to- autolytic
great drainage
debridement

Too much exudate

from wounds may
cause
excessive
moisture

Stage II, III, IV

pressure
ulcers
with little to great
drainage

Too much exudate

from wounds may
cause
excessive
moisture;
may
crease and roll up
and
create
pressure to wounds

May cause foreign

body reaction

dressings
derived
from
seaweed
MATRIX
Stage
III,
collagen matrix pressure ulcers
that
provides
threedimensional
scaffolding
attracts
host
cells and tissue
remodeling

IV Promote
granulation
and
epithelialization
into the matrix

ADJUVANT THERAPEUTIC MODALITIES

HYDROTHERAPY
A. whirlpool therapy
has been found to have some clinical and practical limitations,
including cross-contamination between patients, pseudomonas
infections , and potential skin infections for caregivers who are in
contact with the contaminated water.
B. Pulsatile lavage therapy

is a different form of hydrotherapy that encompasses all of the

advantages of whirlpool therapy, but without the potential adverse
effects. A portable device is used that delivers pulsed jet streams of
water at a known, preset pressure, which is compliant with the
pressure range (415 psi) recommended for wound cleansing
ELECTRICAL STIMULATION

ES has been used for the treatment of chronic wounds for many years (128) and
has been specifically recommended for the treatment of severe (Grade III or IV)
pressure ulcers.
ES to be an effective modality; however, the specific treatment and stimulation
paradigms employed were found to be highly variable. The mechanisms by
which ES promotes wound healing are not fully understood, leading to a need to
optimize delivery of treatment.

NEGATIVE PRESSURE WOUND THERAPY

Negative pressure wound therapy (NPWT) is based on the theory that the
negative pressure facilitates drainage of wound exudates and enhances
wound healing through a number of mechanisms. NPWT is proposed to
decrease the bacterial load and edema while concurrently promoting an
improved local circulation and increasing granulation. NPWT devices consist

of a suction pump with foam and occlusive dressing to create negative

pressure on the wound being treated.
Indications

Utility is suggested for traumatic acute wounds especially with skin grafts
or skin flaps, open amputations, lower extremity fasciotomy, open
abdomen, etc.
Appears to increase burn wound perfusion and limit burn wound
progression

Management of diabetic foot ulcers and wounds from diabetic foot

surgery (important to establish adequate perfusion prior to use of
NWPT.)
Not indicated for venous ulcer management, contraindicated for arterial
insufficiency ulcers
Contraindications

Do not use if necrotic tissue (slough) is evident in >30% of the wound

Do not use in untreated osteomyelitis (may initiate NPWT 24 hours after
initiation of systemic antibiotic therapy) or other wound infections
Do not use if there is cancer within the wound bed or its margins
Do not use on unexplored non enteric fistulas
DO NOT place suction catheter dressing directly over exposed veins or
arteries, vital organs or vascular grafts
Do not use in wounds with inadequate perfusion
Advantages

Less frequent dressing changes

Easier to tailor and maintain in position
Significant reduction in time to wound closure in diabetic patients
Reduce complexity of subsequent reconstructive surgery with more
rapid wound closure
Precautions

Uncontrolled active bleeding

Difficult hemostasis of wound
When anticoagulants are being administered
Enteric fistula
Irradiated vessels and tissue
Bony fragments
Untreated malnutrition
Close proximity of blood vessels, organs, muscle, and fascia requiring
adequate protection
Nonadherent patient

THERAPEUTIC ULTRASOUND

Therapeutic ultrasound is a deep heating modality that is commonly used for

pressure ulcer healing. Its deep heating property is theorized to improve the
vascularity of the wound tissues, thus improving healing.

ELECTROMAGNETIC THERAPY

There is growing interest in the use of electromagnetic therapy for the

treatment of pressure ulcers. This modality has been shown to increase the
blood flow, collagen formation, and also granulocyte infiltration in both in vitro
and animal models to induce healing

POSITIONING

Turn and reposition the immobile patient every 2 hours, or more

frequently as necessary
Provide active and passive exercises every 8 hours

USE OF SUPPORT SURFACES

Use assistive devices to prevent pressure such as alternating air pressure

mattress or sheepskin padding
Apply medications or dressing to the wound as prescribed

TYPES OF SUPPORT SURFACES

>

Replacement mattresses: Mattresses with pressure-reducing features placed

on an existing bed frame in place of at the standard mattress

>

Overlays: A support surface placed on top of a standard mattress; made of foam,

water, gel, air, or a combination

>

Foam: A thick slab of foam with a textured surface placed on top of a standard
mattress to reduce pressure by surrounding the body; should be at least 34
inches thick to be effective at reducing pressure (2 inches is for comfort only)

>

Water: A vinyl mattress or overlay with sections filled with water to distribute
pressure more evenly and create a flotation effect

>

Gel: Made of a thick fluid that conforms to the contours of the body

>

Air: A vinyl mattress or overlay inflated with a blower to reduce pressure;

powered or dynamic mattresses have a pump that inflates the mattress sections
in an alternating cycle

>

Lowair loss: A mattress or overlay with controlled air-flow sections

Air-fluidized: Uses a high rate of blown air to fluidize fine particulate material (such as silicone
beads) to float the patient on the surface