Decubitus

The reason why - Limited sensory

Due non-existent or just partly-existing sensory below the lesion your body is not able to tell your brain if a position feels uncomfortable or even painful. So the brain has no clue what's going on down there in the body and therefore cannot react to it and tell the responsible muscles to please move the body to a less uncomfortable position and thus release the pressure on that part.

Some of you will now rightfully say that you notice it because of increased spasticity, that you have to position yourself differently. For those of you who have spasticity, this can be a very helpful tool - nevertheless mentioned and following points are important.

Regularly remove pressure from the vulnerable (at risk) areas

Probably you often heard during Rehab that you need to release pressure, for example by sitting in the wheelchair every 15-20 Minutes for at least 30 Seconds, even better 1 Minute or 2. But often affected people don’t know exactly why this is important to do - and if people don’t know enough about something - often they don’t take it seriously enough. And that’s why around 50% of patients with SCI at least once have a serious Decubitus during their lifetime and this is often not only self-inflicted but also due to a lack of training and information on the part of professionals (Rehab and after Rehab).

So why every 15 - 20 Minutes? - Because there is constant mechanical pressure on the skin and the tissue from inside (bone)  and outside (per example, hard surface) which is higher than the blood pressure of the blood vessels itself, which are responsible for the blood circulation of this area. Because of this the blood can not get through as it does normally and the tissue and muscles are not supplied with enough blood anymore. And if this lasts over 40 Minutes without relieving the pressure  that can (not will) already be enough to cause lasting damage to the tissue….

By telling this we don’t want to cause fear - we want to point out that there are good reasons to keep this in mind.

How long you can sit in the wheelchair, lay on your back in the bed, or do whatever without giving a Decubitus a shot - is depending on a lot of different things, such as blood circulation in general, function and so on.

We are not the experts - but talk to the experts your Nurses, Therapists, Doctors and get knowledge of them - this will help you a lot specially during time.

Normal situation of skin:

Development of a pressure sore:

List of Layers: [2]

1. Bone
2. Musculature
3. Fat tissue
4. Blood vessels
5. under skin
6. top skin
7. pinched blood vessel
8. Developing decubitus due to -
9. emerging pressure

How to figure out if something goes in the wrong direction?

Regular inspection of the skin vulnerable (at risk) areas, by visual (looking) and haptic (palpating with fingers) inspection

What can be warning signals?

Visual:

1. The skin and or tissue are blushed or even red
2. The skin and tissue ar looking dark
3. Open skin (wound)

Haptic:

1. The skin feel rough
2. The skin feels more warm or even hot
3. The skin and tissue feel different than on the other side (per example other problem sitting bone left, compare it with the right sitting bone same area)
4. Open skin (wound)

Others:

1. An emerging spasticity
2. Unusual sweating

How a pressure sore and then a Decubitus develops /Stages of Decubitus

A decubitus always starts with a reddening skin area!

Normal condition of the skin (normal findings)

The finger is removed and the discoloration of the pressure point goes away after some time.

Starting pressure sore

The pressure point remains reddened, even if you take the pressure away.

Classification of Decubitus

Normal skin condition 

Grade 1: A reddening that cannot be pushed away → can be treated at home with the right bandages and disinfectants/get professional advice 

Non-blanchable redness with intact skin, usually over a bony prominence. In darkly pigmented skin, fading may not be visible or may be somewhat less visible. However, the color may differ from the surrounding skin. The area may be painful, indurated, soft, warmer or colder than the surrounding tissue.

Grade 2: Partial loss of skin → can be treated at home with the right bandages and disinfectants/get professional advice

Partial destruction of the skin into the dermis, which appears as a flat open ulcer with a red to pink wound bed without coatings. May also present as an intact or open/ruptured serum-filled blister. This later changes to a shiny or dry, flat ulcer without necrotic (dead) tissue.

Grade 3: Loss of skin → can be treated at home with the right bandages and disinfectants (get professional advice) or even needs to be treated at the hospital

Destruction of all skin layers, underlying fat layer may be visible, but no bones, muscles or tendons. Caution: There may be a coating that obscures the depth of tissue damage. Tunnels and cavities may be present, which are difficult to see and feel from the outside. A grade 3 pressure ulcer by location. In addition, extremely deep "grade 3 wounds" can occur on particularly obese parts of the body.

Bones and tendons are not visible or palpable.

Grade 4: Complete loss of skin and/or tissue → needs to be treated at the hospital

Total tissue loss with exposed bone, tendon, or muscle. Coating and eschar (crust-like dried, dead skin tissue) may be present. Tunnels and cavities are often present. The depth of a grade 4 pressure ulcer depends on the location. "Grade 4 wounds” may spread into muscles or under or supporting structures (fascia, tendons, or joint capsules), easily causing osteomyelitis or osteitis (bacterial infection, bone inflammation). Bones or tendons are visible or palpable.

Not possible to classify anymore  → needs to be treated at the hospital

Complete skin and tissue loss, unknown depth of wound covered by coating (yellow, dark yellow, gray, green, or brown) and wound crust/scab in wound bed. [1]

Treatment of Decubitus at different stages

The treatment of a pressure sore can be either conservative (Grade 1-3) or surgical (Grade 3 and 4). That means with a Decubitus Grad 3 or 4 you’ll likely need to go into a stationary stay in a specialized clinic. As more severe a Decubitus, as longer the time to cure - so it makes sense not to let it get that far.

Conservative treatment

The conservative treatment but you need the right Cleaning and dressing material to avoid an infection of the wound and thus help it cure.

Treatment principles: TIME - it takes time!

• T = Tissue removal (clean the wound)
• I = Infection control (bringing the infection under control)
• M = Moisture management (absorb wound secretions, stimulation of granulation)
• E = Edge protection Epithelialization (protection of the wound edge and Epithelialization)

Surgical treatment

Takes a lot of time as well and means most likely laying in the bed for weeks - nothing worth to experience in our opinion. [2]

What can you do help avoiding Decubitus or cure it faster when occurs?

Point one is helping specially to avoid or helping cure Decubitus on coccyx and sitting legs -points two till six are helpful for every kind of Decubitus.

1. Change positioning in the wheelchair

Depending on motor skills, the following options are possible for paraplegics and quadriplegics to relieve the coccyx and sitting legs:

• Sitting position in wheelchair without special pressure relief (avoid if a Deku already occurred)

• Pressure relief by bending the upper body forward

• Weight relief by bending to the side creates pressure relief of the opposite buttocks

• Pressure relief by supporting on the bed, sofa or table

• Lifting in a wheelchair - it makes sense to vary the different options to protect the shoulders.

• Even a slight tilt forward helps to change the pressure on the buttocks.

• If trunk stability is limited, hooking with the arm can be helpful to shift the weight to the side to relieve pressure.

• Position changes by experienced people can be a tool.

[2]

2. Try to add more breaks during your day laying on the belly or on the side - depending on where the decubitus is located to avoid having pressure on the Decubitus area.

Bearings which can help to avoid decubitus and get in comfortable position:

• Prone position

• Supine position

• Lateral position

• 30 degrees body positioning

• 135 degrees body positioning

• Upper body positioning

• Foot positioning

[2]

3. If you use any dense surfaces during your daily routine such as going to the toilet, showering, driving a car etc. - try to use additional pillows which make the surface even softer. this helps a lot.

4. Use a even softer pillow temporarily - maybe it’s even possible borrow or rent it for a while

5. Eat more protein during that time that helps your body curing faster skin and tissue

6. Change position during sleep to limit the time pressure is on the same area for to long

How to position in the wheelchair and sitting positions in general

Pressure ratios in sitting position without paraplegia/quadriplegia

Pressure ratios in sitting position for most people with paraplegia/quadriplegia, which mostly have limited trunk stability (to sit upright) and have less tissue around the hip, buttocks and leg

Sitting in bed with headboard raised causes sharpening forces which can lead to decubitus