Causes, types, treatment and prevention of bedsores on the tailbone

The Doctors called a bedsore death of soft tissues (muscles, subcutaneous fat and skin) as a result of violations of blood circulation, innervation and lymphatic movement when squeezing parts of the body or due to continuous contact with a solid surface.

Most Often the soft tissue suffer from bedridden patients, but the sores can appear as a result of long seats wheelchair users, and in cases of violation of the innervation of the tissues, and prolonged compression of the field of bone protrusions.

History and epidemiology

The First serious study of necrotic ulcers resulting from pressure, was conducted by Ambroise Pare (1585). He proved that the removal of pressure from the patient space is crucial to successful treatment. After 300 years, the Browne-Scar revealed a negative influence of humidity on the skin in bedridden patients. To the list of factors contributing to the emergence of pressure sores, in 1940, Dr. Munro added disorders of the autonomic nervous system.

In subsequent years, physicians have devised methods of surgical treatment of pressure sores, and only toward the end of the twentieth century, their eyes focused on prevention. As before, the doctors connected to the process of treatment of necrotic ulcers at the stage of surgical intervention, but until then, the responsibility for the health of the skin of the patient lies with the nursing staff.

In 1990 and Branden Morris (USA) studied the prevalence of problems in patients of hospitals. It was found that in developed countries such complications are getting about 16% of patients are bedridden. According to S. K. Akshulakov, in local hospital statistics for spinal patients is in the range 20-90%.

Necrotic ulcers in the coccyx area account for about 36% of all cases of bedsores. The effect is that patients, lying on his back, measured the highest pressure in the coccyx area is about 40-60 mm Hg.PT. It is noteworthy that in those medical institutions where patients are cared for by specially trained nurses, the prevalence of ulcers decreases to 8.1%.
Cure decubitus ulcer of the coccyx is very difficult, therefore basic attention is given to the prevention of disease.

risk Factors and causes of education

Pressure ulcers in the coccyx area in patients with limited mobility appear in:

• continuous pressure on the coccyx;
• power shift
• humidity
• friction.

The Pathological process develops faster in malnourished or elderly people, with poor nutrition and poor care, the incontinence of urine and feces. At risk are patients with diabetes, paraplegia, parkinsonism. Men are more likely to get a bedsore on the tailbone than women.

In 1961, M. The Shoal has identified the critical indicators of the pressure at which necrosis begins. It turned out that the two-hour load of 70 mm Hg.PT. Causes irreversible changes in the soft tissues. However, several five-minute breaks in the pressure retain the original condition of the skin and muscles.

Necrosis exacerbate displacement, humidity and friction. The first factor leads to the flexion and tension of the vessels in the coccyx area. Even at low operating pressures of the offset leads to the appearance of bedsores. To protect the patient from the negative impact of displacement is possible, by removing the high pillows at the head.

Friction can be caused in the awkward moment of pulling the sheets from under patient. This procedure leads to desquamation of the protective layer of the skin and gives the start for the emergence of bedsores.

Witkowski and Parish in 1982 proved that the moisture of the skin accelerates the appearance of pressure ulcers.

In poor hygienic care of bed sores can develop due to folds in linen, wrong techniques of movement, means of fixation, high pillows, bed rails, applying cytotoxic agents.

Classification of pressure ulcers

Previously in medical practice used the classification of pressure ulcers, based on the stages of the clinical course pathology by P. V. Balic and G. O. Kogan. Since 1975, more practical is the way to organize that allows you to choose an effective treatment for ulcers. International Committee on health care policy and research (Agency for Health Care Policy and Research, AHCPR) in 1992 recommended a four-tiered classification.

In the second stage, as a rule, the infection of wounds by bacteria (streptococci, staphylococci). Festering bedsores converted to erysipelas, and in severe cases – sepsis or gas gangrene.

The Risk of complications is assessed by the Norton scale (1962), Waterlow (1985), Braden (1987), Medley (1991). The most popular was the Norton scale (table 2).

		B				D		E
Physical state		Mental ability		Activity		Mobility		Incontinence
Good	4	Clear	4	Walking without help	4	Complete	4	No	4
Satisfactory	3	Apathy	3	Walks	3	Slightly limited	3	Sometimes	3
Poor	2	confused	2	Confined to a wheelchair	2	Very limited	2	Often marked by urinary incontinence	2
Very poor	1	Stupidity	1	Recumbent	1	fixed	1	Often marked incontinence of urine and feces	1

When assessing the degree of risk the total number of points equal to 20 indicates a low probability of formation of bedsores. 5 points suggest high probability of complications.

Prevention

When caring for immobile patients should concentrate on events:

• to reduce pressure on the coccyx;
• to ensure a comfortable posture without any slipping with cushions
• regular turning of the patient;
• monitoring the skin in the coccyx area;
• maintain cleanliness of the body and bed of the patient;
• to maintain normal humidity of the skin (obsushivaniya if necessary, treatment or moisturizer);
• to ensure a complete diet, rich in protein food, iron-containing vegetables.

With the deterioration of the soft tissue in the area of the coccyx, the patient complains of tingling, loss of sensitivity in this place. Dysfunction of the nerve endings are associated with stagnation of blood and lymph in the area of pressure. After 2 hours since the first symptoms can develop bedsores.

Excellent tools for prevention of pressure ulcers can be:

• 0.5 percent solution of ammonia;
• 2 percent solution of camphor alcohol;
• to a 1% solution of salicylic alcohol;
• a decoction of calendula.

First symptoms of the disease

Upon examination of the skin decubitus ulcer of the coccyx first stage can be defined as a bluish-red spot without defined boundaries in place protruding bones. Check your skin colour. In place of formation of bedsores body temperature is not increased, but may be slightly reduced.

In the second stage, a bedsore can be covered with skin scales or purulent bubbles.

Conservative treatment for stages I and II

Success in treatment of pressure sores on the coccyx provides early detection of stagnant places and adequate care for them. In the early stages the main objective of therapy is to protect the sore from infection. Efforts also are directed at correction of water-electrolyte balance and treatment of diseases that contribute to the formation of ulcers.

When the first symptoms of bedsores:

1. you Must carefully monitor the cleanliness of the body and underwear of the patient. Daily to change the bed. Wash the sore with soap and clean water and dry with a special absorbent wipes, process cream. Immediately remove contamination from defecation, urine, wound exudate, sweat.
2. to Ensure that you change positions every 2 hours, using a special cushion to relieve tension between the support and the coccyx. Practice turning the patient supine at 30° instead of continued reliance on the back.
3. Plot with signs of stagnation are not being massaged with friction, and easy to stroke.
4. of Bedridden patients should be provided with bed with special anti-bedsore mattresses. Balloon devices are equipped with silent compressors for injecting air into different sections that provides the change of rigidity of the mattress. Sedentary patients to change position offered gel, air or foam cushions.

first stage for the treatment of bedsores using saline, a 25% solution of MgSO4, 10% hypertonic NaCl solution with chymotrypsin, 0.5 percent aqueous solution of chlorhexidine digluconate and drugs, improving local circulation.

Since 1988 for these purposes, ceased to apply ion-exchange antiseptics (hexachlorophene, povidone-iodine, chlorhexidine). It has been proven that the drugs damage cell membranes of skin cells and contribute to the spread of bacterial infection. Not recommended to treat ulcers and usual remedies: hydrogen peroxide, iodine, brilliant green, and potassium permanganate.

From infection of the wound is covered with a special polyurethane film dressings. The pores of the film do not prevent gas exchange and evaporation of moisture from the surface, but do not miss the bacteria. Transparent dressing provides the ability to monitor the progress of healing of the skin.

second stage Also without surgical treatment of bedsore. Ligation is carried out in a separate room. The task of the specialist in the handling – deletepollution, removal of flakes and bubbles. The ulcer is covered with a special film-semi-impermeable foam, hydrocolloid or hydrogel dressings.

For the correction of violations of water and electrolyte balance using sodium chloride 0,9% solution for infusion. Topically used antimicrobial, antibacterial, anti-inflammatory agents. Oral your doctor may prescribe antibiotics, non-opioid analgesics and non-steroidal anti-inflammatory medicines (NSAIDs).

Surgical treatment options

third phase Conservative treatment will not be enough. The doctor will have to remove dead tissue, cleanse the ulcer crater from purulent exudate. Surgery is indicated for the treatment of both wet and dry necrosis.

After cleaning the bedsore conduct regular treatment of the wound with antiseptics. In Russia it is recommended to apply externally the following medications:

• bactericidal and fungicidal agents;
• enzyme therapy
• nekroliticescoe drugs;
• dehydrating medications;
• tools that improve the microcirculation;
• anti-inflammatories
• stimulants reduction processes.

For internal reception prescribe antibiotics, vitamins, immunomodulators.

In the treatment of pressure ulcers proven advantage of ointments based on water-soluble with sulfatiazola.

the fourth stage surgical treatment of pressure ulcers includes not only excision of necrosis, but also autologous skin graft. The list of medicines is not different from those prescribed for surgery in the third stage of the bedsore. To accelerate healing of a wound plug:

• UHF
• phonophoresis
• ULTRASONIC machining
• electrophoresis
• low-intensity laser radiation;
• d'arsonvalization;
• stimulation current;
• electroacupuncture.

Bedsores in the coccyx area are large in size. After excision of dead tissue, cleansing of the ulcer and removal of protruding parts of the coccyx is carried out moving the skin-muscle flap. Due to the rapid growth of new blood vessels in this area forecast operations favorable. However, to treat the decubitus ulcer of the coccyx difficult, it is better to put a maximum of efforts for prevention of necrosis.

references:

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2. Basque A.V. Surgical treatment of bedsores in patients with spinal cord injury // neurosurgery. – 2000. – No. 1. – P. 30-33.
3. Vorobyov A. A. The Treatment of bedsores in spinal patients / A. A. Vorobyov, Yu. M. Tupikov, Porowski S. V. // Bulletin of Volgograd scientific centre of Russian Academy of medical Sciences. – 2007. – No. 2. – Pp. 33-34.
4. Karpov G. V. Methods of treatment with trophic disorders. – K.: Health, 1991. – P. 301.
5. Klimiashvili A. D. Prevention and treatment of pressure ulcers // Russian medical journal. – 2004. – Vol. 12, No. 12. – P. 40-45.
6. musalatov Kh. A. Treatment of pressure sores in patients with spinal cord injuries and spinal cord // Medical care. – 2002. – No. 3. – P. 22-28.