A 49-year-old woman with a history of multiple sclerosis and epilepsy is hospitalized due to recurrent seizures. Her multiple sclerosis is complicated by spastic paraplegia and urinary incontinence. The patient lives with her family, but as her disease has progressed it has become difficult for them to physically assist her and help in her care. As a result, she has missed several doses of medications, including her antiepileptics. The patient does not use alcohol, tobacco, or illicit drugs. Temperature is 36.6 C (97.9 F), blood pressure is 136/80 mm Hg, pulse is 75/min, and respirations are 16/min. BMI is 19.5 kg/m². Physical examination shows severe extensor spasticity in both lower extremities. Skin examination shows a 4×6 cm ulcerated area overlying the left ischial tuberosity. Devitalized tissue is present around the wound edges, but the base is clearly visible. The wound extends into the subcutaneous tissue, but no muscle, tendon, bone, or fascia is visible; there are no undermined areas or sinus tracts. The wound surface has no foul odor or exudate. The need for frequent turning is discussed with the nursing staff, and an air-fluidized bed is ordered. Which of the following additional measures is most appropriate for treatment of this patient's wound?

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Explanation: 11ec2b69_be7f_31e6_8f63_592950c5304a_MD0005_00 Pressure (decubitus) ulcers are caused by constant, unrelieved pressure, leading to reduced blood flow and necrosis of skin and subcutaneous tissues. They occur most commonly over bony prominences (eg, sacrum, ischial tuberosities, malleoli, heels). Risk factors include impaired mobility, malnutrition, abnormal mental status (eg, dementia), decreased skin perfusion, and reduced sensation. Pressure ulcers can be staged based on depth of involvement: Stage I ulcers are characterized by nonblanchable erythema of intact skin. Stage II ulcers are superficial ulcers causing a partial thickness loss of the epidermis, dermis, or both. Stage III ulcers are deeper ulcers causing a full thickness loss with damage to subcutaneous tissue that may extend to, but not through, any underlying fascia. Stage IV ulcers are very deep ulcers causing a full thickness loss with extensive tissue destruction that may damage adjacent muscle, bone, or supporting structures. This patient has a stage III pressure ulcer with tissue damage extending into the subcutaneous tissue but not through the underlying fascia. Full-thickness wounds (stages III and IV) require debridement of devitalized (ie, necrotic) tissue, and specialized wound dressings may be needed. By contrast, shallow ulcers (stages I and II), which do not extend into the subcutaneous tissue (unlike this patient's ulcer), can be managed with occlusive or semipermeable dressings to maintain a moist wound environment (Choice A). In addition, management of all pressure ulcers includes local wound care, repositioning of the patient to reduce pressure, pain control, and nutritional support. (Choice C) Systemic antibiotics are indicated for wounds complicated by deep infection (eg, cellulitis, osteomyelitis). This patient has no overt signs of infection, so antibiotics are not indicated. (Choice D) Dry gauze dressings are associated with delayed wound healing and increased scar formation and are not recommended. (Choice E) Localized infection may benefit from topical antiseptics (eg, silver sulfadiazine) to decrease bacterial load. Topical antiseptics can also be considered for wounds that do not improve as expected within 2-4 weeks, which may suggest subclinical infection. This patient has no indications for topical antimicrobial therapy. Topical antibiotics are associated with increased drug resistance and are not recommended in the absence of infection. Educational objective: Initial management of pressure ulcers includes local wound care, repositioning to reduce pressure, pain control, and nutritional support. Shallow ulcers are managed with occlusive or semipermeable dressings to maintain a moist wound environment. Full-thickness wounds require more complex care, including debridement of devitalized tissue and specialized wound dressings. References: Pressure ulcers: prevention, evaluation, and management. (http://www.ncbi.nlm.nih.gov/pubmed/19035067) Common questions about pressure ulcers. (http://www.ncbi.nlm.nih.gov/pubmed/26554282)

A 49-Year-Old Woman with a History of Multiple Sclerosis and Epilepsy