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Approach to the Critical Patient
Initial triage and escalation
High risk states
Sepsis physiology
Fever
Hypothermia
Tachycardia
Hypotension
Necrotizing soft tissue infection concern
Pain out of proportion
Rapid progression hours to days
Crepitus
Osteomyelitis concern
Exposed bone
Probe to bone positive
Critical ischemia concern
Cool mottled limb
Absent distal pulses
Uncontrolled bleeding
Anticoagulant use
Coagulopathy
Immediate actions when unstable
Airway and breathing support if altered or respiratory distress
Oxygen for hypoxemia
Noninvasive ventilation consideration for fatigue
Circulation support for shock
IV access
Crystalloid bolus for hypotension
Vasopressor if fluid refractory
Broad infection evaluation if systemic signs
Blood cultures before antibiotics if feasible
Lactate for hypoperfusion
Early consultation triggers
Surgery for suspected necrotizing infection
Orthopedics or plastics for deep wound with exposed bone
Wound care team for staging and dressing plan
Key decision points
Care pathway selection
Prevention focus
At risk skin
Stage 1 injury
Local wound management focus
Stage 2 injury
No systemic infection
Deep infection pathway
Stage 3 injury
Stage 4 injury
Undermining or tunneling
Surgical pathway
Extensive necrosis
Unstageable injury with eschar and infection
Flap candidacy evaluation needed
Hemodynamic and pain priorities
Targets and monitoring
Perfusion maintenance
Mean arterial pressure goal individualized
Urine output monitoring if critically ill
Pain control
Rest pain
Dressing change pain
Neuropathic features
History
Risk profile and timeline
Pressure injury context
Duration of immobility
Bedbound status
Wheelchair dependence
Onset timeline
First skin change date
Rapid progression days
Precipitating factors
Recent hospitalization
Recent surgery
Recent device placement
Prior pressure injuries
Prior locations
Prior flap surgery
Predisposing conditions
Neurologic impairment
Spinal cord injury
Stroke
Sedation
Perfusion impairment
Peripheral arterial disease
Heart failure
Shock history
Metabolic conditions
Diabetes
Chronic kidney disease
Malnutrition risk
Weight loss
Low intake
Dysphagia
Moisture exposure
Urinary incontinence
Fecal incontinence
Heavy perspiration
Infection and complication features
Local infection features
Increasing pain
New pain in insensate region concern
Pain with minimal manipulation
Drainage change
Increased volume
Purulent character
Odor change
New foul odor
Persistent odor after cleansing
Surrounding skin change
New erythema
Spreading warmth
Systemic features
Fever or chills
New fevers
Rigors
Weakness or confusion
Delirium
Lethargy
Poor intake
Dehydration risk
Hypoglycemia risk
Care environment and equipment
Current prevention measures
Repositioning pattern
Bed turns frequency
Chair weight shifts frequency
Support surface
Standard foam mattress
High specification foam
Alternating pressure surface
Skin care routine
Barrier creams
Cleansing products
Offloading devices
Heel protectors
Seat cushion type
Social and functional considerations
Caregiver availability
Home support
Facility support
Ability to perform offloading
Upper extremity strength
Cognitive capacity
Physical Exam
Whole patient assessment
Physiologic status
Vital signs
Fever
Hypotension
Tachycardia
Hydration
Dry mucosa
Orthostasis
Nutrition appearance
Cachexia
Edema
Skin survey
High risk sites
Sacrum and coccyx
Heels
Trochanters
Ischial tuberosities
Occiput
Device contact points
Wound assessment and staging
Pressure injury characterization
Location and laterality
Bony prominence association
Device related location
Measurements
Length
Width
Depth
Wound bed tissue
Granulation
Slough
Eschar
Wound edges and spaces
Undermining
Tunneling
Sinus tracts
Exudate
Amount
Color
Viscosity
Surrounding skin
Erythema
Maceration
Induration
Pain response
Tenderness
Allodynia
Staging features
Stage 1 features
Intact skin with nonblanchable erythema
Color change compared with adjacent skin
Stage 2 features
Partial thickness skin loss
Exposed dermis
Stage 3 features
Full thickness skin loss
Adipose visible
Stage 4 features
Full thickness skin and tissue loss
Exposed fascia
Exposed muscle
Exposed tendon
Exposed bone
Unstageable features
Obscured depth by slough
Obscured depth by eschar
Deep tissue pressure injury features
Persistent nonblanchable deep red discoloration
Purple discoloration
Maroon discoloration
Blood filled blister
Mucosal membrane pressure injury features
Device related mucosal injury
Staging not applicable
Neurovascular and infection exam
Perfusion assessment
Peripheral pulses
Dorsalis pedis palpation
Posterior tibial palpation
Capillary refill
Delayed refill
Asymmetry
Limb temperature
Cool extremity
Asymmetric warmth
Infection depth assessment
Cellulitis
Expanding erythema
Lymphangitic streaking
Abscess
Fluctuance
Focal tenderness
Necrotizing infection
Bullae
Skin anesthesia
Crepitus
Bone involvement
Visible bone
Probe to bone response
Differential Diagnosis
Mimics and alternative etiologies
Skin breakdown differentials
Moisture associated skin damage
Incontinence associated dermatitis
Intertriginous dermatitis
Friction injury
Sheet shear injury
Transfer related abrasion
Skin tears
Fragile geriatric skin
Steroid related skin fragility
Burns
Thermal contact injury
Chemical irritant injury
Allergic contact dermatitis
Adhesive reaction
Topical product reaction
Ulcer differentials by location
Venous leg ulcer
Gaiter area predominance
Edema
Arterial ulcer
Distal toes
Punched out edges
Diabetic foot ulcer
Plantar surface
Peripheral neuropathy
Vasculitic ulcer
Purpura
Livedo
Pyoderma gangrenosum
Pathergy
Violaceous undermined border
Malignancy in chronic ulcer
Marjolin ulcer concern
Rolled edges
Coding aligned problem list
Common codes
ICD-10 CM L89 series pressure ulcer by site and stage
L89.0 elbow region
L89.1 upper back
L89.2 lower back
L89.3 buttock
L89.4 hip
L89.5 ankle
L89.6 other site
L89.8 other site
L89.9 unspecified site
SNOMED CT concepts
Pressure ulcer disorder
Pressure injury stage finding
Medical device related pressure injury
Laboratory Tests
Baseline and nutrition risk
Metabolic and nutrition labs
Serum albumin for chronic malnutrition risk
Low values as severity marker
Limited utility as isolated nutrition marker
Electrolytes for dehydration risk
Sodium abnormalities
Potassium abnormalities
Creatinine for renal dosing needs
Antibiotic adjustment planning
Contrast imaging planning
HbA1c for glycemic burden
Poor control risk for impaired healing
Hyperglycemia association with infection risk
Infection evaluation
Infection labs when clinically infected
Complete blood count for leukocytosis
Leukocytosis supportive not diagnostic
Normal count in immunosuppressed states
C reactive protein for inflammation trend
Baseline for treatment response
Nonspecific elevation
Erythrocyte sedimentation rate for osteomyelitis support
Higher values increase suspicion
Nonspecific elevation
Lactate for hypoperfusion
Elevated values support sepsis physiology
Trend for resuscitation response
Blood cultures when systemic signs
Higher yield in sepsis
Pre antibiotic collection when feasible
Microbiology sampling
Wound microbiology principles
Superficial swab limitations
Colonization representation
Poor correlation with deep infection
Deep tissue culture value
After debridement sampling
Targeted antibiotic selection support
Bone culture and histopathology
Reference standard for osteomyelitis diagnosis
Guidance for prolonged antibiotic selection
Diagnostic Tests
Scoring Systems
Risk and healing assessment tools
Braden Scale
Sensory perception domain
Moisture domain
Activity domain
Mobility domain
Nutrition domain
Friction and shear domain
PUSH tool
Surface area component
Exudate amount component
Tissue type component
Bates Jensen Wound Assessment Tool
Size and depth items
Edges and undermining items
Application cautions
Tool scores not sole basis for support surface selection
Clinical judgment integration
MRI
MRI indications and limitations
Osteomyelitis evaluation
Persistent deep ulcer with exposed bone
Refractory to optimized offloading and wound care
Deep soft tissue infection evaluation
Abscess extent delineation
Sinus tract mapping
Contraindications and barriers
Non MRI compatible implants
Severe claustrophobia
Interpretation pearls
Marrow edema as sensitive finding
Correlation with clinical and culture data
CT
CT applications
Gas in soft tissues
Necrotizing infection support
Surgical consultation trigger
Abscess detection
Pelvic and perirectal collections
Deep undermining extent
Bone cortical destruction
Chronic osteomyelitis features
Lower sensitivity than MRI for early disease
Contrast considerations
Renal function review before IV contrast
Allergy history review
Ultrasound
Point of care ultrasound uses
Soft tissue abscess
Drainable fluid collection identification
Cellulitis cobblestoning pattern
Guidance for procedures
Abscess aspiration guidance
Vascular access guidance
Lower extremity vascular screening adjunct
Venous thrombosis evaluation in immobilized patients
Perfusion assessment adjunct with Doppler
Disposition
Admission and level of care
Inpatient indications
Systemic infection
Sepsis physiology
Bacteremia concern
Deep infection
Suspected osteomyelitis
Abscess requiring drainage
Necrotizing infection concern
Rapid progression
Crepitus
Uncontrolled pain
Opioid requiring pain
Dressing change intolerance
Inability to offload
No safe repositioning support
Severe contractures without equipment
Major comorbidity decompensation
Heart failure exacerbation
Renal failure with metabolic derangements
Higher acuity indications
Shock
Vasopressor requirement
Persistent lactate elevation
Rapidly spreading infection
Extensive cellulitis
Concern for surgical source control
Outpatient management criteria
Discharge readiness
Hemodynamic stability
No shock physiology
No escalating oxygen needs
No systemic infection
Afebrile or stable baseline
No delirium
Offloading plan feasible
Support surface available
Repositioning assistance available
Wound care plan feasible
Dressing supplies secured
Follow up arranged
Transfer and consultation
Transfer triggers
Need for complex flap reconstruction
Stage 4 with large dead space
Recurrent ulcer after prior flap
Specialized imaging or surgery access limitations
MRI unavailable when urgently needed
Surgical team unavailable for source control
Consultation triggers
Surgery
Debridement need
Abscess drainage need
Infectious diseases
Suspected osteomyelitis
Multidrug resistant organism history
Nutrition
Severe malnutrition concern
Enteral access consideration
Treatment
Pressure redistribution and prevention bundle
Offloading and repositioning
Repositioning schedule
High risk adults reposition at least every 4 hours
Children and youth reposition more frequently than every 4 hours
Head of bed minimization
Shear reduction
Aspiration risk balance
Heel offloading
Heel suspension device
Pillow under calves with heels floating
Wheelchair pressure relief
Weight shifts every 15 to 30 minutes when able
Limit sitting duration if ulcer on ischium or sacrum
Support surfaces
High specification foam mattress
Baseline for established pressure injury
Limited efficacy if repositioning absent
Dynamic support surface
Refractory pressure injury
Inability to reposition adequately
Seat cushion selection
Pressure redistributing cushion
Fit assessment to pelvis and posture
Local wound care
Cleansing and moisture balance
Cleansing fluid selection
Normal saline
Potable water when appropriate
Avoidance of cytotoxic solutions for routine care
Hydrogen peroxide routine avoidance
Iodine routine avoidance on healthy granulation
Moist wound healing principles
Excess exudate control
Desiccation avoidance
Debridement selection
Autolytic debridement
Occlusive dressing approach
Avoid in overt infection
Mechanical debridement
Low pressure irrigation
Wet to dry routine avoidance
Enzymatic debridement
Collagenase use for slough
Avoid with exposed tendon without protection
Sharp or surgical debridement
Extensive necrosis
Rapid infection source control need
Dressing selection by wound characteristics
Foam dressing
Moderate exudate
Cushioning and protection
Hydrocolloid dressing
Low to moderate exudate
Autolytic debridement support
Alginate dressing
Heavy exudate
Bleeding control adjunct
Hydrofiber dressing
Heavy exudate
Reduced maceration risk
Antimicrobial dressing
High bioburden concern
Short course reassessment
Negative pressure wound therapy
Indications
Stage 3 or stage 4 with depth
Heavy exudate requiring management
Contraindications
Untreated osteomyelitis without plan
Malignancy in wound bed
Technique considerations
Dead space fill
Seal integrity monitoring
Infection management
When antibiotics are indicated
Cellulitis around wound
Expanding erythema
Warmth and tenderness
Deep soft tissue infection
Abscess
Fasciitis concern
Osteomyelitis
Bone culture guided therapy
Surgical source control planning
When antibiotics are not indicated
Colonization without clinical infection
Odor alone after cleansing
Stable chronic drainage without cellulitis
Superficial swab growth without infection signs
Avoid antibiotic escalation based on swab alone
Focus on offloading and wound bed prep
Empiric antibiotics for severe infection
Broad coverage strategy
MRSA coverage for high risk
Gram negative coverage for deep ulcers
Anaerobe coverage for necrotic tissue
Vancomycin IV
Loading dose 20 to 25 mg per kg actual body weight for severe infection
Maintenance 15 to 20 mg per kg every 8 to 12 hours
Trough based monitoring per local protocol
Renal dose adjustment
Piperacillin tazobactam IV
4.5 g every 6 to 8 hours
Renal dose adjustment
Extended infusion per local protocol when available
Alternative for beta lactam allergy
Vancomycin IV
Same dosing framework
Therapeutic drug monitoring
Aztreonam IV
2 g every 8 hours
Renal dose adjustment
Metronidazole IV or PO
500 mg every 8 hours
Anaerobe coverage
Targeted antibiotics for mild cellulitis
Nonpurulent cellulitis
Cephalexin PO
500 mg four times daily
Typical duration 5 to 7 days
Clindamycin PO
300 to 450 mg three times daily
C difficile risk counseling
MRSA risk cellulitis
Doxycycline PO
100 mg twice daily
Avoid in pregnancy
Trimethoprim sulfamethoxazole PO
1 to 2 double strength tablets twice daily
Hyperkalemia risk monitoring
Pain and symptom management
Analgesia ladder
Acetaminophen PO
650 mg every 6 hours as needed
Maximum daily dose per local guidance
Ibuprofen PO
400 mg every 6 to 8 hours as needed
Avoid in renal injury and GI bleeding risk
Opioid for severe pain
Morphine PO
5 to 10 mg every 4 hours as needed
Constipation prophylaxis
Hydromorphone PO
1 to 2 mg every 4 to 6 hours as needed
Sedation monitoring
Dressing change pain control
Premedication timing
Oral analgesic 30 to 60 minutes prior
IV analgesic 10 to 20 minutes prior when inpatient
Topical anesthetic consideration
Lidocaine gel when appropriate
Avoid on large surface area without supervision
Nutrition and metabolic optimization
Nutritional support
Protein goals
Increased protein intake for healing
Renal disease tailored protein plan
Caloric adequacy
Dietitian guided plan
Enteral supplementation when intake poor
Micronutrients
Vitamin C adequacy
Zinc supplementation only if deficiency or high risk
Glycemic management
Hyperglycemia control
Basal bolus insulin inpatient when needed
Sick day plan outpatient
Surgical and advanced therapies
Source control procedures
Incision and drainage
Drainable abscess
Culture collection from deep tissue
Operative debridement
Extensive eschar with infection
Necrotizing infection concern
Reconstruction planning
Flap coverage evaluation
Large stage 4 defects
Recurrent ulcers despite optimization
Pre flap prerequisites
Offloading plan reliable
Nutrition optimization underway
Smoking cessation support
Special Populations
Pregnancy
Pregnancy considerations
Positioning constraints
Left lateral tilt in later pregnancy
Aortocaval compression avoidance
Medication safety
Avoid doxycycline
NSAID avoidance in third trimester
Infection escalation threshold
Lower threshold for sepsis evaluation
Obstetric consultation for systemic infection
Geriatric
Older adult considerations
Frailty and sarcopenia
High malnutrition prevalence
Higher recurrence risk
Polypharmacy
Anticoagulant associated bleeding risk
Sedative associated immobility risk
Skin fragility
Higher skin tear risk during dressing changes
Adhesive minimization
Pediatrics
Pediatric considerations
Higher device related injury burden
Nasal cannula and masks
Splints and casts
Support surface guidance
High specification mattress for children with ulcer
Specialist support surfaces when appropriate
Dosing and monitoring
Weight based antibiotic dosing
Analgesic dosing by weight
Safeguarding considerations
Nonaccidental injury evaluation when pattern inconsistent
Social work involvement when neglect concern
Background
Epidemiology
Frequency and burden
Hospital prevalence ranges
2.2 percent to 24.7 percent reported across studies
Higher prevalence in long term care and palliative settings
Global prevalence estimates
Pooled prevalence around 12.8 percent across 2008 to 2018 data
Regional variation across continents
Nursing home prevalence example
About 11 percent of nursing home residents reported with pressure ulcers in US 2004 data
Pathophysiology
Mechanisms of injury
Pressure intensity and duration
Capillary occlusion and ischemia
Reperfusion injury contribution
Shear forces
Deep tissue deformation
Microvascular compromise
Moisture and friction
Maceration increases susceptibility
Skin barrier breakdown
Injury phenotypes
Bony prominence injury
Sacral and heel predominance
Deep tissue involvement possible before skin breakdown
Medical device related injury
Localized to device contact area
Shape mirrors device
Therapeutic Considerations
Core principles
Pressure redistribution as primary therapy
Offloading effectiveness dependent on adherence
Support surface adjunct not replacement for repositioning
Wound bed preparation
Nonviable tissue removal
Moisture balance
Infection stewardship
Antibiotics for clinical infection only
Culture directed therapy preferred for deep infection
Guideline alignment
International Guideline third edition 2019
Prevention and treatment recommendations comprehensive
Evidence appraisal methodology described
NICE CG179
Risk assessment and prevention for all ages
Repositioning frequency guidance for high risk
Patient Discharge Instructions
copy discharge instructions
Home care plan
Offloading and positioning
Reposition at least every 4 hours if high risk adult
More frequent repositioning if child or teen at high risk
Skin care
Keep skin clean and dry
Barrier cream for incontinence
Dressing care
Keep dressing clean and dry
Dressing change schedule per wound care plan
Pain control
Use prescribed pain meds before dressing changes
Avoid exceeding acetaminophen daily maximum
Return to ED now
Infection warning signs
Fever
Spreading redness around wound
New pus drainage
Worsening foul odor after cleansing
Sepsis warning signs
Confusion
Fainting
Fast breathing
Severe weakness
Necrotizing infection warning signs
Rapid worsening pain
Skin turning purple or black quickly
Blistering
Bleeding concerns
Persistent bleeding soaking dressings
Black stools if on NSAIDs or anticoagulants
Follow up
Wound care clinic within 3 to 7 days
Earlier if stage 3 or stage 4
Earlier if new pain or drainage
Primary care for risk factor control
Diabetes management plan
Nutrition support plan
References
Guidelines and key sources
Core references
EPUAP NPIAP PPPIA Prevention and Treatment of Pressure Ulcers Injuries Clinical Practice Guideline International Guideline 2019
NICE CG179 Pressure ulcers prevention and management 2014 last reviewed 2018
NPIAP Pressure Injury Stages definitions document updated staging system
Wound Healing Society Guidelines for the Treatment of Pressure Ulcers 2023 update
RNAO Assessment and Management of Pressure Injuries clinical best practice guideline
Evidence and epidemiology sources
Hospital prevalence ranges 2.2 percent to 24.7 percent reported in recent review literature
Global prevalence estimate 12.8 percent across 2008 to 2018 pooled data
CDC nursing home pressure ulcer prevalence report 2004
Osteomyelitis considerations
Bone biopsy culture and histopathology as reference for osteomyelitis diagnosis in pressure ulcer contexts
MRI favored when osteomyelitis diagnosis remains in doubt after clinical and initial studies in related ulcer infection guidance
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.