Review Question - QID 109026

This patient is being sedated for ventilation and develops an ulcer on his heel, most consistent with a pressure ulcer. The best next step in management is frequent repositioning to distribute pressure more evenly across the body.

Pressure ulcers result from ischemia due to constant compression, most commonly over bony prominences such as the calcaneus and sacrum. Patients who are immobilized for long periods of time, such as intubated and sedated patients, are at high risk. Diabetes and arterial or venous insufficiency are also risk factors. The ulcers may range from superficial erythema to full-thickness skin loss and exposure of underlying tendons and bones. The best first step in management is to reposition the patient every few hours in order to prevent one area from receiving excessive pressure. This will facilitate the healing process and also make it less likely for other ulcers to develop. In addition, strict glucose control in patients with diabetes is beneficial for wound healing. Further measures such as wound debridement and protective dressings may also be utilized for ulcers that involve the full thickness of the skin or more.

Figure A shows a chest radiograph with a lobar consolidation in the right middle lung field. Figure B shows a stage III pressure ulcer of the heel with full-thickness skin loss.

Incorrect Answers:
Answer 2: Topical lidocaine may be used for pain control in pressure ulcers, but this patient is currently sedated and likely would not benefit from this therapy. Oral opioid and non-opioid medications may also be used if the patient experiences significant pain.

Answer 3: Zinc supplementation has not been shown to be helpful for pressure ulcer healing. Nutritional status overall and protein optimization, specifically, are important for wound healing, but this patient is already on total parenteral nutrition. Additional supplementation is unlikely to be of use.

Answer 4: Initiating intravenous vancomycin would be appropriate to treat methicillin resistant staphylococcus aureus (MRSA) infection, which is a common cause of pressure ulcer infections. Although pressure ulcers are all colonized by bacteria, antibiotic therapy is only needed if there is clinical evidence of MRSA – for example, purulence, swelling, fever, and foul smell.

Answer 5: Obtaining a foot MRI would be the best next step if osteomyelitis were suspected. While pressure ulcers can spread to the underlying bone, this is more common in more severe ulcers with exposed tendons or bone. In this patient, conservative management with repositioning and supportive care should be tried first.

Bullet Summary:
Frequent repositioning is the best initial step in management for pressure ulcers.