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This patient has an unstageable pressure ulcer to hip with hard, adherent eschar. What is the best treatment recommendation for the patient?
Sep 23, 2021 by Erika Martin,
1 replies
Elaine Horibe Song
MD, PhD, MBA
Hi Erika,

Thank you for sharing this case. Here are some initial thoughts on cases like these: a comprehensive assessment would be important for an adequate care plan. This algorithm can help perform a comprehensive patient assessment (see PU/PI assessment algorithm https://woundreference.com/files/1857.pdf).' target='_blank'>https://woundreference.com/files/1857.pdf). Briefly, assessment includes: history focused on identification of risk factors for development of PU/PI and infection, Nutritional Assessment, Functional, Equipment, and Seating Evaluation, Staging. Work up including labs (see algorithm); for trochanteric ulcers, plain X rays of the pelvis in the AP position, and bilateral hip X-ray in the lateral position. X-rays may help detect ectopic bone or bone changes that may lead to PU/PI, and air within the PU/PI, which helps assess extent of the lesion beyond physical examination.

This PU/PI management algorithm and accompanying tables walk us through details on how to manage PU/PIs, including unstageable trochanteric PU/PIs (https://woundreference.com/files/1871.pdf). It can also be accessed on the PU/PI - Treatment topic, in the right column. In a nutshell, main steps of the framework include: 
- Treat the cause and co-factors impeding healing: For all patients, ensure adequate pressure redistribution on bed and seating surfaces, reposition patient and encourage mobility, mitigate/ eliminate any factors impeding healing, correct nutritional deficiencies, manage excessive moisture and shear. Refer to tables on the algorithm for more details and specific situations (see details on the algorithm)
- Address patient's concerns and educate patient (see details on the algorithm)
- Local Wound Care for Unstageable PU/PI: perform conservative sharp wound debridement to determine Stage. Stage of a PU/PI can only be determined when enough slough and/or eschar is removed to expose the anatomic depth of soft tissue damage involved. After staging, determine if the ulcer is healable, that is, if there is enough blood supply to heal, and if the cause can be corrected/mitigated so that ulcer can heal. (see PU/PI assessment algorithm https://woundreference.com/files/1857.pdf).' target='_blank'>https://woundreference.com/files/1857.pdf). Care plan (e.g. pressure redistribution strategy, local wound care, need for surgical consult, etc) depends on staging.
- Order referrals/ consults as needed (see details on the algorithm)

Here are some other references that might be useful:
- PU/PI Classification and Staging: https://woundreference.com/app/topic?id=pressure-ulcersinjuries-classificationstaging
- PU/PI Treatment:  https://woundreference.com/app/topic?id=pressure_ulcer_injury_treatment
- Conservative sharp wound debridement: https://woundreference.com/app/topic?id=how-to-perform-conservative-sharp-wound-debridement

Hope this helps, let us know if you have further questions.
Sep 24, 2021
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