INTRODUCTION

Overview

This case illustrates how a seemingly innocent decision in the life of a person at risk for pressure ulcer/injury (PI/PI) can lead to a new episode of PU/PI. For a list of guidelines and quality measures related to PU/PI, see topic "Pressure Ulcers/Injuries - Overview". For an introduction and assessment of PU/PI including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding, see "Pressure Ulcers/Injuries - Introduction and Assessment". For management of PU/PI, see topic "Pressure Ulcers/Injuries - Treatment". For a systematic approach to identifying patients at risk for PU/PI and developing specific care plans, see topic " Pressure Ulcers/Injuries - Prevention". For best practices in care coordination, see "Pressure Ulcers/Injuries -Coordination of Care".

CASE

Background

A 36 year old white male architect, paraplegic from an all-terrain vehicle accident 16 years ago presented to a wound center with a new sacral pressure injury. 

Due to his paraplegia, he routinely used a manual wheelchair with a properly fitted seating cushion. The patient reported that a week prior to his visit to the clinic, he had gone to a local pumpkin patch to pick up pumpkins in the fields with his kids. At the pumpkin patch, he did not resist the temptation to ride out to the fields on a hay wagon with his kids.  He hoisted himself out of the wheelchair and up onto the edge of the hay wagon where he sat on a hard wooden surface without any cushion for about 20 minutes as the hay wagon made its way out to the fields and back to the central barn. Back home, that evening he noted some redness and dusky skin changes to his sacral area.  

The patient was otherwise healthy, with a well developed upper body that showed his dedication to his side job as a fitness instructor. 

Physical examination and workup

Vital signs showed a blood pressure of 125/77 mm Hg, a heart rate of 67 beats/minute, and a temperature of 97.6°F (36.4°C). Physical examination of the sacral area revealed intact skin with localized area of persistent non-blanchable deep red/maroon discoloration, measuring approximately 10 cm in diameter. Skin temperature felt lower upon touch compared to non-affected areas. Patient reported no sensation or pain in the affected area. There were no signs of incontinence-associated dermatitis. 

Laboratory tests below were ordered to help establish a baseline and monitor any chronic underlying medical conditions. 

• White blood cells and differential white blood count (WBC)
• C-reactive protein or erythrocyte sedimentation rate (ESR)
• Complete metabolic panel
• Coagulation panel
• Urinalysis and culture/sensitivity

Diagnosis and differential diagnoses

Patient was diagnosed with a deep tissue injury (DTI). With this history and physical exam, differential diagnoses are limited but would include a spider (or any insect) bite, contusion/abrasion due to trauma, tissue maceration from friction or moisture not related to pressure.   

Treatment and follow-up

The DTI was cleansed and no debridement was performed at the initial visit. Patient was instructed to: 

• Offload the sacral area: 
• Continue to use his high specification foam mattresses when in bed (See definition and types of support surfaces in section 'Pressure Redistribution' in "Pressure Ulcers/Injuries - Treatment")
• When lying down, reposition to 30° tilted side-lying position (alternate right side, ventral decubitus, left side) at least every 2 hours
• Limit sitting time on the wheelchair to time needed for meals, bathing, bowel routine, and office visits
• Perform local care: 
• Dressings are of limited use at this stage so patient was instructed to protect skin with moisture barrier products and skin protectants. 

The unstageable lesion was observed every 7 days at the wound healing center. A firm eschar developed and ultimately the eschar showed separation from the adjacent viable tissue. The eschar and necrotic tissue were then sharply debrided at the wound center leaving a 5 x 7 x 1.5 cm Stage 3 pressure ulcer/injury (PU/PI). After debridement, silver alginate dressings were applied by his caregiver every 2-3 days depending on exudate level for 2 weeks. When the  wound bed was free of necrotic debris, Negative Pressure Wound Therapy (NPWT) was initiated. The NPWT was applied at 125mm Hg negative pressure using NPWT dressing kits with foam dressings and standard techniques for 4 weeks. After 4 weeks, the ulcer bed showed signs of improvement and a stable granulation bed developed, so the NPWT was discontinued and standard wound care with foam dressings was resumed. The patient adhered to all care instructions, and PU/PI achieved complete closure in 8 weeks. After 3 months of therapy, the ulcer was completely healed and patient could resume his normal daily routine, including use of his wheelchair and fitness classes. 

DISCUSSION

Pressure ulcers/injuries (PUs/PIs) are among the most common complications for people with paraplegia secondary to traumatic spine injury.[1] Between 32-40% of spinal cord injured individuals develop PUs/PIs in their lifetime.[2]

Individuals with limited mobility (i.e., paraplegia, quadriplegia) dwelling in the community are usually instructed by healthcare personnel to perform daily skin assessments in order to detect skin changes (e.g. red patches) or other injuries. However, most PUs/PIs occur internally first and are difficult to detect early.[3] Therefore it is imperative that individuals with mobility limitations think through carefully before venturing out in changes of their daily routine.[4] In this patient’s case, a 20 minute detour from his routine resulted in a 4-month long disruption in his life. 

Key takeaways