17. Treatment of Skin Breakdown

Treat Stage I or II wounds with standard wound care. Treat Stage III or IV wounds with specialist / surgical intervention.

The Problem

Approximately 75% of pressure injuries in the SCI population are Stage I or II (no deeper than the dermis), and can be managed conservatively. The remaining 25% are Stage III or IV (extending to subcutaneous fat, muscle or bone), and require specialized management. Severe pressure injuries can lead to decreased mobility, loss of independence, amputation, and even fatal infections. Pressure injuries are most effectively treated when diagnosed and treated early.

Evidence-based Best Practice

Standard wound care for Stage I and II injuries includes cleansing, debridement and infection management. A wide array of dressings is available, such as hydrocolloid, transparent film, hydrogel, alginate, foam, silver, silicone, collagen matrix, honey and iodine. Referral to rehabilitation is recommended for seating and activity protocols. Referral to a dietician may be beneficial, since nutritional status can significantly affect healing, especially energy and protein needs.

For Stage III and IV injuries, prompt referral to a surgeon is indicated, as discovery and treatment of possible osteomyelitis is a priority. A variety of biophysical modalities may also be considered, including electrical stimulation, electromagnetic agents, pulsed radio frequency, phototherapy (laser, infrared, ultraviolet), ultrasound and negative pressure therapy. Evidence is building for electrical stimulation, but standardization of administration protocols is needed.

Telephone and video conferencing have been highly effective in making specialized wound care more accessible to community clinicians, with good rates of agreement with in-person specialist care.

Key Reference

Scovil, C. Y., Delparte, J. J., Walia, S., Walia, S., . . . SCI KMN Group. (2019). Implementation of pressure injury prevention best practices across 6 canadian rehabilitation sites: Results from the spinal cord injury knowledge mobilization network. Archives of Physical Medicine and Rehabilitation, 100(2), 327-335. doi:10.1016/j.apmr.2018.07.444

Actionable Nuggets (4th ed., 2019)

Additional References (since 2016)

Houghton PE, Campbell KE and CPG Panel (2013). Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. A resource handbook for Clinicians. Accessed at http://www.onf.org

Wong, A., Goh, G., Banks, M. D., & Bauer, J. D. (2019). Economic evaluation of nutrition support in the prevention and treatment of pressure ulcers in acute and chronic care settings: A systematic review.Journal of Parenteral and Enteral Nutrition, 43(3), 376-400. doi:10.1002/jpen.1431