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Treating the silent, unresponsive patient
Alzheimer’s patient with history of hypercholesterolemia presents with wounds to bilateral lower extremities.
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An 83-year-old woman presents to the clinic for evaluation of wounds to her bilateral lower extremities. She is accompanied by her husband, daughter and caretaker. During the encounter the patient is observed to be alert, but silent and unresponsive.
Her family relates that the right heel ulcer has been present for three months and the left heel ulcer present for six weeks. Her past medial history is significant for Alzheimer’s disease and hypercholesterolemia. The family denied her having any outward signs of infection such as nausea, vomiting, fever, chills, demonstrable loss of appetite or hospitalization in past month for any other health problems.
Physical examination revealed that she is afebrile with stable vital signs. Lower extremity examination showed bilateral heel ulcers. The ulcers are full-thickness in nature with thickened necrotic eschar (Figures 1, 2). There is drainage from both wounds, right worse than left with mild redness to the periwound areas. Tenderness is suspected due to mild retraction of the foot upon palpation. No malodor is noted. Radiographs taken were negative for evidence of osteomyelitis.
Based upon the history and pictures, what is your diagnosis?
- Pressure ulcers
- Ischemic ulcers
- Gangrene
- Neuropathic ulcers
Patris ToneyCASE DISCUSSION
Due to the patient suffering with Alzheimer’s, she is unable to communicate with her family the discomfort of constant pressure to her heel secondary to her sedentary position. As a result, the patient developed pressure ulcerations to her heels. The wounds were treated with an enzymatic debriding agent, which was changed daily by the caretaker and family, along with oral antibiosis for infection.
After several weeks, the necrotic cap sloughed revealing deep, full thickness, soft tissue probing ulcerations bilaterally with palpable, but non-exposed bone to the right heel with heavy drainage and mild malodor. Wound beds exhibited slough along with salamander-colored granulation tissue (Figures 3, 4). The patient was placed on antibiotics and a negative pressure device was ordered for the right heel to fill in the defect. The left heel was dressed using a collagen matrix dressing with every other day dressing changes. Following weeks of rotation of negative pressure therapy and collagen dressings with offloading, the wounds healed (Figures 5, 6).
Figures 1 and 2: Initial presentation of the left (1) and right (2) heels. Predominately necrotic eschar with mild periwound cellulitis.
Figures 3 and 4: Bilateral heel ulcers left (3) and right (4) following sloughing of the necrotic eschar. Note the appearances of the underlying wound beds and the soft tissue extension. Area of palpable, but non-exposed bone.
Figures 5 and 6: Wound healing facilitated with assistance of negative pressure therapy and collagen wound dressings to the left (5) and right (6) heels after 12 weeks along with offloading of heels.
Source: Patris Toney
Debilitating, painful ulcers
Pressure ulcers are quite debilitating and painful. They are attributed to constant pressure to an area, whether associated with a prominence or not. The heel is the most common among the lower extremity although the toes can be affected. Other areas include the sacrum, elbows, knees, head, shoulders and other parts of the body. This pathology is found among individuals who are afflicted by some form of deformity, which may capture their body in a fixed position, or among individuals who reside in an unresponsive or vegetative state of existence. Their conditions leave them vulnerable due to their inability to fully, expressively communicate with others.
The length of exposure needed to cause skin tissue damage varies from individual to individual and is dependent upon other factors as well. And while time is a marker, there is no timeframe by which the pressure ulcers are labeled, but are primarily categorized by physical presentation. Accordingly, pressure ulcers have been staged based upon overall wound appearances. In stage one, the affected area is seen to be mottled, red or pink in coloration, with failure to blanch and remains present after the offending pressure source is removed. Induration may also be present as well as potential associated increased warmth. In stage 2, the affected area may appear as a blister or superficial compromise of the skin’s integrity with or without associated tissue necrosis and/or drainage. Mottling of the skin is also usually present. As the pressure persists, further compromise of the skin’s integrity occurs with development of full-thickness loss of tissue without extension through the fascial layers as seen in stage 3. Necrosis may or may not be present. At its worst, in stage 4, full-thickness compromise is seen with demonstrable tissue damage and necrosis with extension through the fascial planes and potentially down to bone. Bone infection is highly plausible along with soft tissue draining sinus tracts and soft tissue undermining. As the stages progress, the risk and severity of infection increases.
Treatment of these wounds is multifocal and will fail if the pressure itself is not removed. This can be achieved by using egg-foam crate boot or other offloading boot to suspend the heel. If the patient is ambulatory, then heel offloading shoes should be prescribed. Additional treatments focus on removal of the necrotic eschar, if present, along with cultivation of healthy granulation tissue with the eventual goal of complete epithelialization.
In the presence of cellulitis, oral antibiosis is needed. Nutritional status should also be assessed and supplemented if deficient. Home care and the bedding are among factors to be evaluated. Of all treatments, prevention is best. For clinicians dealing with patients of such caliber or physical state, full examination of the body as well as detailed, in-depth questioning of their quality of life among those present and caring for the patient is important to detect as well as prevent such occurrences. Suspicion should be high in this patient population by virtue of their inability to communicate pain as well as their inability to care for themselves and to process and react and adjust to the life of positional dormancy.
Patris Toney, DPM, MPH, is a Fellow in the Center for Lower Extremity Ambulatory Research, and a Fellow at the National Center for Limb Preservation, III.