Pressure Ulcers

Pressure Ulcers (Latin decubitus), as the very name indicates, represent a trophic disorder, located mainly on the sacrum, buttocks, scapulae, elbows, heels, and characterized by gangrenous changes, significant peripheral spread, and deep involvement of adjacent tissues. In the development of pressure ulcers, the corresponding area of skin first begins to pale, then becomes cyanotic, desquamation (dry gangrene), excoriation, and ulceration appear. Due to the присоединяющейся infection (from the bed, linen, feces, etc.), the process quite quickly takes on a gangrenous character (wet gangrene). Although pressure ulcers do not represent an independent disease, but are rather b. ch. only a concomitant process in various diseases, nevertheless in some cases they can still lead to a fatal outcome.-By their origin, pressure ulcers can be divided into two types: exogenous pressure ulcers, arising from mechanical causes of local character (pressure, compression, strangulation, etc.), and endogenous pressure ulcers, the mechanism of development of which is associated with the localization of the disease in the nervous system or with a general weakening of trophic functions. 1. Exogenous pressure ulcers can form from prolonged pressure on the skin or its compression by apparatuses, corsets, bandages, prostheses, and other objects of therapeutic influence or as a result of traumatic injuries. In these cases, under the influence of pressure or compression, local ischemia, disturbance of nutrition, and finally tissue necrosis develop. Usually, when applying apparatuses and prostheses, pressure ulcers develop on the dorsum of the foot, on the heel, above the Achilles tendon, on the greater trochanter, on the crest of the tibia, on the head of the fibula, and other places. Of the mucous membranes, the mucous membrane of the trachea after tracheotomy (see Laringostomia) and the mucous membrane of the urethra due to the pressure of a metal catheter are exposed to the danger of pressure ulcers forming. Although with negligent care the development of pressure ulcers can reach significant tissue destruction, nevertheless pressure ulcers of exogenous origin are not so dangerous to life and are amenable to treatment. 2. Endogenous pressure ulcers can in turn be divided into two types: 1) pressure ulcers forming as a result of a general weakening of the organism on the basis of an infectious or other suffering in severe patients, who are forced b. ch. to lie in one position or are unable to change it due to weakness. In this case, the mechanical factor in the form of pressure gives an impetus to the formation of a pressure ulcer, which develops subsequently due to the absence of resistance and general weakness of the organism, including mainly trophic impulses, under the influence of general infection, intoxication, etc. 2) Another type of endogenous pressure ulcer is the so-called neurotic pressure ulcer, in the formation and development of which the direct role is played by the поражение самой нервной tissue and which can develop not only in places subject to pressure. Samuel, who described this pressure ulcer in 1860, notes the following three phases of development: the erythema phase, which is followed quite quickly by the formation of blisters (vesicular phase), the red-brown contents of which empty, exposing red and purple bleeding wounds (necrosis phase), which connect with each other. In this period, usually due to the untidiness of patients, their bed, incontinence of urine and feces, purulent infection joins very quickly, and decubital gangrene, penetrating inside, captures the subcutaneous fat, muscles, and in a few days reaches the bones. The whole process proceeds very quickly: erythema appears sometimes within a few hours or within 3-4 days following the поражение of nervous tissue; in 24 hours the process passes into necrosis, and after 48 hours - this is already gangrene. Samuel, who described this pressure ulcer, was also the author of the theory of the trophic function of the nervous system, advocating the existence of independent trophic nerves, acting centrifugally on tissues and regulating their nutritive processes. Somewhat later in 1868, Charcot confirmed this opinion, localizing trophic centers in the anterior horns of the spinal cord. Kocher, Monakow, Oppenheim, Leyden and others considered mechanical pressure and subsequent infection the source of the occurrence of pressure ulcers. Cas-sirer, Achard and Levy, Muller advanced the causes of the formation of pressure ulcers, but converged mainly in the opinion that поражение of the nervous system is obligatory for their formation.-There were also followers of the vasomotor theory, according to which the expansion of vessels (neuroparalytic hyperemia of Schiff) plays the role of a predisposing factor for the development of inflammatory processes in tissues; on the other hand, the influence of neuroirritative ischemia (Brown-Séquard) can lead to the development of gangrene. Dejerine and Leloire found in the vicinity of pressure ulcers changes in nervous tissue in the form of parenchymatous neuritis and considered that the cause of the occurrence of pressure ulcers is disturbances of trophic function of the central nervous system and that external pressure plays only the role of a random cause. In 1908, Jacobson discovered that the source of sympathetic fibers governing trophic function are special cells of the spinal cord located in the lateral horns of thoracic segments. Brusilovsky, on the basis of clinical observation and pathohistological research on a large material, established that in inflammatory diseases of the spinal cord, the patho-anatomical equivalent of a pressure ulcer in the sacrococcygeal region is поражение of the sympathetic group of cells in the lateral horns of the spinal cord, and the side of поражение of this group corresponds to the side of the pressure ulcer, and the place of поражение corresponds to the level of Dxn-Li and Lii. Control cases confirmed these positions. It is interesting to note that in the pathohistological examination of cases of pressure ulcers in multiple sclerosis, plaques were found exactly in the place of location of the sympathetic group of cells in the lateral horns.- At high поражения of the spinal cord (traumatic injuries of the spinal cord, tumors), the formation of pressure ulcers can be explained by the поражение of pathways from the upper vegetative centers to the lateral horns of the spinal cord. Pressure ulcers occurring in diseases of the brain (hemorrhage, softening) are explained by the existence of a special hypothetical trophic center with a presumed localization in the central convolutions. In hemiplegies, pressure ulcers form on the buttock of the paralyzed side; in diseases of the spinal cord - more often in the sacral and coccygeal regions. Thus, the pathogenesis of pressure ulcers is dependent on the state of trophic centers; поражение is caused by centrifugal influences, while mechanical factors in the form of pressure or compression are not the main cause, but a certain, although completely necessary, condition. In infectious and toxic diseases, the general weakening of the organism exerts an undeniable influence on trophic functions, promoting the formation of pressure ulcers under unfavorable external conditions (pressure during immobile lying of the patient). Pressure ulcers of exogenous and endogenous character, besides the difference in the very pathogenesis (centripetal and centrifugal character), also differ in the course of the process. In exogenous pressure ulcers, a favorable outcome with proper preventive and therapeutic measures is the rule; in endogenous pressure ulcers, the favorable outcome depends to a significant extent on the course of the underlying disease. That is why endogenous pressure ulcers are essentially processes-symptoms, while exogenous pressure ulcers represent independent processes. The clinical picture of the latter is not so bright as in endogenous pressure ulcers; the course is not distinguished by such progressive capture of deep tissues; these pressure ulcers proceed according to the type of dry gangrene, the treatment time is significantly shorter.-The spread of pressure ulcers depends to a significant extent on the course of the underlying disease and preventive measures. Sex does not matter in the development of pressure ulcers; later ages predominate.-Along with neurotic pressure ulcers, other endogenous pressure ulcers appear most often in severely ill and exhausted persons, who lie immobile on their backs, in septic processes, in a fall of cardiac activity, and in constitutional diseases, especially in diabetes. The clinical picture of neurotic and endogenous pressure ulcers is expressed significantly more strongly and proceeds according to the type of wet gangrene. B. ch. without any subjective phenomena on areas of skin covering the projecting bony parts facing the plane of the bed, first of all in the sacral and coccygeal regions, as well as on the scapulae and heels, and in the lateral position - above the greater trochanters of the femur, circulatory deterioration occurs, manifested by a long-lasting pale spot under finger pressure in the midst of a cold, bluish-purple colored zone. Sometimes, however, stasis goes so far that no spot appears even under finger pressure. In the dark-purple edematous focus and in any case in its upper macerated layers, a blackening spot appears after several days or weeks with an increasing febrile state, which hardens and retreats inward [see separate table (t.

[XXVI, st. 687-688], fig. 6]; when the edges are damaged, a dirty-brown, foul-smelling secretion appears, sometimes with droplets of fat. An inserted probe finds significant cavities under the upper gangrenous covering, so that after the slough is removed, a discolored focus filled with putrid necrotic masses is discovered, which spreads to neighboring skin areas and often reaches the bone. Only where these dead parts of the skin have not yet separated from their subcutaneous parts is there only insignificant bleeding upon their removal. The undermined edges of the wound dry up and turn a darkish color, while the adjacent parts acquire the appearance of raw skin with ecchymoses. Such pressure ulcers can reach a size of 1-2 palms, especially in the sacral area, and depending on the general condition and the underlying disease, can be precursors of death. The onset of pressure ulcers is difficult to predict depending on the underlying disease. Their toxic action on the whole body and the spread of local infection sometimes prove sufficient to cause a fatal outcome in a severely ill patient. Such an outcome, however, remains a rare case. With proper attention and timely recognition and treatment, provided the tissues are not too weakened in their resistance to the process, the development of pressure ulcers can be stopped. If the organism has the strength to resist, after the separation of the dead parts, fresh abundant granulations develop, which can close even large defects in a relatively short time. A pale, flat, immobile scar marks the former site of a pressure ulcer. Nowhere else is prevention as important as with pressure ulcers. Parts of the body especially susceptible to pressure ulcers must be protected by air rings (rubber, inflated circles), water pillows, and movable pads. The skin of the patient should be washed once or twice a day with cold water and soap and wiped with alcoholic solutions, and then dusted. If the patient complains of pressure from the brace or hardened bandage, they must be replaced immediately. Lying on the back of a long-term patient should be replaced by lying on the side for at least one hour during the day. In the event that pressure ulcers nevertheless appear despite the preventive measures taken, moist compresses must in no case be applied, as they provoke moist gangrene. The preventive measures mentioned above must be applied especially energetically in such cases. If necrosis nevertheless occurs, only dry means should be applied and the area should be covered with a soft cotton pad. If the necrosis is delimited, the dead skin is removed with scissors and forceps, and the resulting wound is treated with ointment dressings and soap baths. In the occurrence of moist gangrene, recognized by the separation of foul-smelling secretion, the dead part of the skin is removed and the undermined edges are split around the circumference. The resulting wound is closed with gauze soaked in camphor wine, aluminum acetate, or Sol. Kalii hyperm. 1%. These dressings are changed twice a day and covered with impervious (waxed, etc.) paper. If the dead parts have separated on their own and the wound has cleared, it should be treated with ointment dressings. In all these cases it is required that the patient leave the bed as soon as possible, and it is necessary to increase blood circulation throughout the body using baths and at least passive movements. Incidentally, it should be noted that the mysterious rise in temperature in the postoperative period, which finds no explanation in the underlying disease and in the state of the surgical wound, often indicates poor care and the resulting infected pressure ulcer. Therefore, the direct duty of the physician in such cases is unremitting observation of the favorite sites of pressure ulcers, especially the sacral area.