Pressure Ulcers (Decubitus)

Symptoms

• Pain over a bony prominence in patients with intact sensation
• Often absent in patients with impaired sensation, leading to late presentation
• Discharge, malodor, surrounding cellulitis if infected
• Systemic signs (fever, leukocytosis) if osteomyelitis or sepsis develops

Signs / physical exam

• Stage 1: intact skin with non-blanchable erythema over a bony prominence
• Stage 2: partial-thickness loss of dermis presenting as an open shallow ulcer or intact/ruptured serum-filled blister
• Stage 3: full-thickness tissue loss with visible subcutaneous fat; bone, tendon, and muscle not exposed; may have slough or eschar; tunneling/undermining possible
• Stage 4: full-thickness loss with exposed bone, tendon, or muscle; high osteomyelitis risk
• Unstageable: full-thickness loss obscured by slough or eschar (must be debrided to stage)
• Deep tissue pressure injury: persistent non-blanchable deep red, maroon, or purple discoloration; may progress to dark blood-filled blister or open wound

Classic findings

Non-blanchable erythema or full-thickness ulcer over sacrum, ischium, heel, or greater trochanter in an immobile patient.

Diagnostic criteria

Diagnosis is clinical, staged per current National Pressure Injury Advisory Panel (NPIAP) 2016 staging system. Document stage, dimensions, undermining/tunneling, exudate, surrounding tissue, and signs of infection at each evaluation.

Labs

• CBC, BMP, prealbumin/albumin, glucose/HbA1c, vitamin D
• Wound culture not routinely indicated for surface colonization; quantitative cultures and bone biopsy for suspected osteomyelitis
• Blood cultures if systemic infection
• Braden Scale or other validated risk assessment on admission and at intervals

Imaging

• Plain radiograph for suspected osteomyelitis (early changes can be subtle)
• MRI is most sensitive for osteomyelitis and soft tissue extension
• Bone biopsy with culture and histology is the diagnostic gold standard for osteomyelitis

First-line

• Pressure redistribution: turn and reposition every 2 hours (every 4 hours on appropriate support surfaces), heel offloading with pillows or boots, head of bed ≤30° when possible
• High-specification support surfaces (foam, air-fluidized beds) for at-risk patients and those with existing ulcers
• Nutrition optimization: protein 1.2-1.5 g/kg/day, adequate calories, hydration; consider arginine and zinc supplementation in malnourished patients with Stage 3-4 ulcers (NUTRIS-PI and OUR trials)
• Moisture management: skin barriers, prompt cleansing after incontinence
• Wound care: gentle cleansing with normal saline; choose dressing by wound characteristics — hydrocolloid for clean Stage 2; alginate or foam for moderate exudate; hydrogel for dry/necrotic; antimicrobial silver or iodine dressings for critical colonization
• Debridement of necrotic tissue: sharp (most effective), autolytic, enzymatic (collagenase), or mechanical; do NOT debride stable, dry eschar on the heel without ischemic evaluation
• Treat infection: cellulitis with oral antibiotics (cephalexin, dicloxacillin; broaden for MRSA or polymicrobial wounds); osteomyelitis with culture-directed prolonged IV antibiotics (typically 6 weeks) and surgical debridement

Second-line / adjunct

• Negative-pressure wound therapy (NPWT) for Stage 3-4 wounds with significant tissue loss
• Surgical reconstruction (flap closure) for select Stage 3-4 wounds in appropriate candidates with controlled comorbidities and modifiable risk factors
• Adjuncts: electrical stimulation, ultrasound, biologic dressings, hyperbaric oxygen in selected cases
• Pain control with acetaminophen, NSAIDs (if appropriate), opioids for dressing changes
• Multidisciplinary team approach (wound care nursing, nutrition, PT/OT, plastic surgery)