Pressure Sores

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Decubitus ulcers

  • Stage I – well circumscribed, nonblanching erythema
  • Stage II – partial thickness skin loss
  • Stage III – full thickness skin loss involving subcutaneous tissue down to muscle fascia
  • Stage IV – through muscle, to bone, with undermining or sinus tracts


  • chronic osteo
    • *bone biopsy is gold standard
    • gadolinium MRI > WBC scan > CT/ t99 triphasic bone scan
    • ESR/CRP


  • Stage I-II – nonsurgical
    • protective barriers
    • maintain moist wound environment
  • III-IV
    • Debridement
    • Dressings to encourage healing
    • Reconstructive surgery

Reconstruction – goal is to design with possibility for future re-advancement

  • Trochanteric – TFL
  • Sacral – lumbosacral
  • Gluteal/ischial – VY advancements
  • OK to use muscle if non-ambulatory
  • Posterior thigh flap
    • Pedicle: inferior gluteal artery
    • structure: fasciocutaneous – VY, or superiorly based tongue flap
      • severs all connections from semitendinosus/semimembranosus/biceps femoris to skin so cannot use any of those as musculocutaneous flaps

Risk factors of flap dehiscence – young age (<45), history of same site surgery failure, albumin <3.5, hb a1c >6
Risk factors of recurrence – *paraplegia, age >70, immobility, poor nutrition, low BMI, anemia, ESRD, cerebrovascular disease, recent hip fracture within 3mo, ischial wound, previous same site surgery failure, hb a1c >6


  • ideal protein intake 1.5-3g/kg/day
  • incontinence and nutritional/vitamin supplementation NOT associated with improved healing or recurrence
  • autonomic dysreflexia – headache/hypertension/bradycardia/flushing/sweating due to uncontrolled sympathetic response to a stimulus, usually in paraplegics above T6
    • simuli include: bladder distention, rectal distention, musculoskeletal injury, pregnancy/labo
  • administration of succinylcholine in paraplegics may cause hyperkalemia (upregulated receptors in damaged muscles) –> peak T waves –> treat with calcium to stabilize cellular membranes, then bicarb and glucose/insulin to offset the acidosis and bring K back into cells
  • with adults/dependents who come in for decubitus ulcer evaluation, be on the lookout for “elder abuse” etc. especially with unexplained bruising or neglect –> report to APS/CPS

ACAPS Inservice exam questions 2013-2020

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