Treating pressure ulcers

The case shown here in this picture was noted associated with an 89-year-old debilitated nursing home resident. He has no evidence of bacteremia or osteomyelitis. Which of the following is an acceptable treatment?

  • A) application of povidone-iodine gauze two times per day
  • B) application of hydrogen peroxide 3 times per day
  • C) systemic antibiotics for 7 to 10 days
  • D) keeping the area clean and dry until granulation tissue forms
  • E) surgical debridement

 The answer is E. (Surgical débridement)
When treating this pressure ulcer, it is important to maintain a moist environment while keeping the surrounding skin dry. This can be accomplished by loosely packing the ulcer with saline-moistened gauze. Topical antimicrobials such as silver sulfadiazine cream may be helpful in ulcers that appear infected. Topical antiseptics such as povidone-iodine or hydrogen peroxide should be not be used in the treatment of pressure ulcers. Systemic antibiotics should be reserved for serious infections (e.g., bacteremia, osteomyelitis). A 2-week trial of topical antimicrobials may be considered for ulcers that do not appear infected but are not improving. Although most patients are successfully managed without surgery, procedures may be appropriate in patients whose quality of life would be markedly improved by rapid wound closure. Stage 3 and 4 ulcers with necrotic tissue should be débrided. Ulcers with minimal exudate that are not infected can be covered with an occlusive dressing to promote autolytic débridement. Ulcers with thick exudate, slough, or loose necrotic tissue should undergo mechanical débridement. Options include wet-to-dry dressings, hydrotherapy, wound irrigation, and scrubbing the wound with gauze. Ulcers with evidence of cellulitis or deep infection should undergo sharp débridement with a scalpel or scissors. Ulcers with a thick eschar or extensive necrotic tissue should undergo sharp débridement as well. However, a thick, dry eschar covering a heel ulcer should generally be left intact. Patients without access to surgical inter-ventions (such as in a long-term care setting) or those who may not be acceptable surgery candidates can be treated with enzymatic débriding agents. Wound débridement should stop once necrotic tissue has been removed and granulation tissue is present.

Illustration of Lumbar Hernia

Lumbar hernia "hernia in the lumbar region" or may be called Bleichner's Hernia is quite uncommon as compared to other ventral abdominal wall hernias, 1.5% of all abdominal hernias. note that 25% of all lumbar hernias have a traumatic etiology.
These occur more commonly in males and are twice as common on the left than the right side. Patients are usually between 50 to 70 years old. These hernias can occur anywhere within the lumbar region but are more common through the superior lumbar triangle (of Grynfeltt-Lesshaft)

So, Lumbar hernia has 2 anatomical types:
1-Petit's hernia: a hernia through Petit's triangle (inferior lumbar triangle). It is named after French surgeon Jean Louis Petit (1674–1750).
2-Grynfeltt's hernia: a hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle). It is named after physician Joseph Grynfeltt (1840–1913).

**Patients with lumbar hernia are usually asymptomatic but may complain of backache, flank pain or a dragging sensation. These hernias have a natural history of a gradual increase in size over time.

Left lumbar hernia .

The differential considerations :
At this stage include the differential considerations includes lipoma, soft tissue tumors, hematoma or abscess.

Illustrated Cephalohematoma Vs Caput succedaneum

Cephalohematoma is a collection of blood under the periosteum of a skull bone "very tough tissue covering that encapsulates bones"
Because of its location, it is impossible for cephalohematoma to cross suture lines. If more than one bone is affected, there will be a separation between the two areas at the suture line as seen in this photo at the left where  the sagittal suture separates the bilateral parietal cephalohematomas.

Unlike cephalohematoma; A caput succedaneum is caused by the mechanical trauma of the initial portion of scalp pushing through a narrowed cervix. The swelling may be on any portion of the scalp, may cross the midline (as opposed to a cephalhematoma), and may be discolored because of slight bleeding in the area. There may also be molding of the head, which is common in association with a caput succedaneum.
A cephalohematoma in a 1-week-old newborn with a right parietal bump by vacuum extractor . A plain skull X-ray lateral view revealing the linear skull fracture on the right parietal area .

Appearance of Sunset sign in infant eyes

 The sclera are visible between the upper eyelid and the iris,Sunsetting sign is seen usually in hydrocephalus due to loss of upward conjugate gaze caused by raised intracranial pressure (ICP)

The setting-sun phenomenon is an ophthalmologic sign in young children resulting from upward-gaze paresis. In this condition, the eyes appear driven downward, the sclera may be seen between the upper eyelid and the iris, and part of the lower pupil may be covered by the lower eyelid. Pathogenesis of this sign is not well understood, but it seems to be related to aqueductal distention with compression of periaqueductal structures secondary to increased intracranial pressure.
However, it can also be transiently elicited in healthy infants up to 7 months of age by changes of position or removal of light (benign setting-sun phenomenon). The benign form might represent immaturity of the reflex systems controlling eye movements.

When persistent, this sign is one of the most frequent markers of elevated intracranial pressure, appearing in 40% of children with hydrocephalus (whatever the cause of Hydrocephalus as obstructive, communicating, Dandy-Walker anomaly/syndrome) and in 13% of patients with ventriculoperitoneal shunt dysfunction. It is an earlier sign of hydrocephalus than enlarged head circumference, full fontanelle, separation of sutures, irritability or vomiting. Consequently, this sign is a valuable early warning of an entity requiring prompt neuroimaging and urgent surgical intervention.

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