Pressure Injury

Pressure Injury

David Ray Velez, MD

Table of Contents

Definition and Staging
Pathophysiology
Management

Definition and Staging

Definition: Skin and Soft Tissue Injury Caused by Persistent Pressure

  • Older Terms No Longer Used: “Pressure Ulcer” or “Pressure Sore”

Staging

Stage Depth Presentation
I Epidermis Erythema but No Skin Loss
II Partial Thickness – Dermis Shallow Ulceration
III Full Thickness – Subcutaneous Exposed Adipose Tissue
VI Full Thickness – Deeper Structures Exposed Bone, Muscle, or Tendon
Unstageable Unknown Base Covered by Slough or Eschar
Deep Tissue Pressure Injury Deep Tissue with Intact Skin Purple/Maroon Skin Discoloration or Blood-Filled Blister

Pressure Injury Staging: (A) Stage I, (B) Stage II, (C) Stage III, (D) Stage IV, (E) Unstageable, (F) Deep Tissue 1

Pathophysiology

Inciting Factors

  • Pressure
  • Shearing Force
  • Friction
  • Moisture – More Limited Role

Pathogenesis

  • Applied Pressures Greater than the Arteriolar Pressure Cause Ischemia and Reperfusion Injury
    • Approximate Arteriolar Pressure: 32 mmHg
  • Direct Cell Membrane Damage
  • Extracellular Membrane (ECM) Proteins Further Damage
  • Reactive Oxygen Species – Increase Inflammatory Markers and Proteolytic Enzymes
  • Deeper Tissues are More Severely Affected
    • Pressure Over a Bony Prominence Produces a Cone-Shaped Distribution
    • Unseen Extent of Injury is Often Greater than the Superficial Ulcer May Show (“Tip of the Iceberg”)

Risk Factors

  • Immobility – The Most Important Patient Factor
  • Malnutrition
  • Reduced Skin Perfusion
    • Peripheral Vascular Disease
    • Hypotension
    • Vasoconstriction and Vasopressor Use
  • Sensory Loss
    • Peripheral Neuropathy
    • Spinal Cord Injury
    • Dementia
    • Delirium
  • Longer Duration of Surgery
  • Depression is Associated with Recurrence

Management

Prevention

  • Pressure Redistribution and Avoid Pressure on Bony Prominences – The Most Important Preventative Measure
    • Reposition Every 2 Hours
    • Use of Support Surfaces
  • Improve Mobility (PT/OT)
  • Avoid Excessive Dryness or Moisture
  • Improve Nutrition
  • Improve Skin Perfusion

Treatment

  • Unstageable or Deep Tissue Pressure Injury: First Debride to Evaluate the Injury Depth
  • Stage I: Primarily Preventative Measures
  • Stage II: Local Wound Care
  • Stage III-IV: Debridement of Necrotic Tissue and Possible Flap Coverage
    • Flaps Have Lower Recurrence Rates than Primary Intention
    • May Consider Negative-Pressure Wound Therapy (NPWT) Once Appropriate

References

  1. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016 Nov/Dec;43(6):585-597. (License: CC BY-NC-4.0)