Spinal cord injury, pressure injury, and amputation

Posted by Nurse Linda in Life After Paralysis on April 08, 2019 # Health

Taking care of your skin is a priority with spinal cord injury. Decreased sensation and lack of movement is a combination that takes a toll on the skin. Diminished or absent sensation prevents a message from being sent to the brain telling your subconscious that you are uncomfortable, or that the blood flow to an area is being compromised. The brain can have difficulty sending messages through the affected area of the spinal cord to move your body as needed.

When sensation and activity are limited, the inside of the skin presses against the tissues inside your body. Especially dangerous are the areas of skin that are over bony prominences. These are the ending parts of bone that are typically rounded or pointed. Weight will cause the bone to press against the tissue inside the body leading to decreased blood flow through the capillaries and blood vessels. Lack of blood flow restricts oxygen to tissue. Without oxygen and nutrients to living tissue, internal tissue damage occurs. The damage will be internal at first, but as time passes, you will see a red area or open area on your skin.

Examples of bony prominences in the lower part of the body are on the tops of each toe, heels, inside and outside of the ankle, the knees, trochanters (hip bones), ischium (sitting bones), and the sacrum (tail bone.) On the back, each vertebra and shoulders can a create pressure injury. On the front of your body, the collar bones, ribs, sternum (chest bone), and iliac crests (front of pelvis) can create pressure areas if you lay on your stomach. Areas of pressure on the arms include knuckles, inside and outside of the wrists, elbows, and top of the arms are at risk. Your head is also vulnerable at the forehead, nose, chin, cheeks, ears, back of the head and occiput (at the bottom of the skull).

You might not think about some constricting areas when sitting or lying but clothing, catheters, leg bag straps, assistive devices, splints, and positioning equipment can cause a pressure injury. Sliding along a surface such as a sheet, mat or chair can lead to shearing anywhere on your body even where the bones do not press on your skin from the inside. Shearing occurs when layers of skin are separated, much like a rug burn. Medical issues from the pooling of blood from poor circulation or diabetes can lead to a venous stasis ulcer (a sore anywhere on the surface of the skin).

Moving your body either under your own power or having movement done for you by someone else is essential to avoiding a pressure injury. This must be done in 10-minute increments when sitting and at least every two hours when in bed. Special equipment is used to help disperse pressure but there is no equipment that can completely eliminate pressure. When you perform a pressure release, you are releasing the constriction in blood vessels which allows blood and nutrients to flow into your body tissues. You are also preserving those delicate capillaries from permanent closure.

Smoking or inhaling any product can lead to a pressure injury as well. Nicotine and other byproducts of smoking, vaping or other inhalants will bind with your red blood cells, taking the place where oxygen should be binding to those cells. Not only does this increase your risk of pressure injury but it will prevent your body from healing. Stopping smoking, vaping, or inhalants not only improves your skin but can prevent you from developing diseases such as lung cancer, bladder cancer, emphysema, chronic obstructive pulmonary, and others. Not inhaling chemicals also makes your skin look healthier. You can see people who smoke have much less pigment in their skin because the red blood cells are circulating nicotine and not oxygen and nutrients.

Sometimes, pressure injuries occur even under the best circumstances. A pressure injury can be a red spot that does not resolve quickly, a blister, an opening in the skin, an opening deep into the body, or sometimes an opening with a crusty top, like a scab. Once the skin has been damaged, a scar develops. Scars are not elastic like healthy skin. They do not have any ‘bounce’ like skin does. Therefore, there is no give to the scarred area. A second pressure injury at the area of the scar, that now is a particularly delicate area, is likely, so extra care and effort must be taken to avoid further damage. Once a pressure injury occurs, you are at a much higher risk for a second injury in the same spot.

When a pressure area is present, the only way to heal it is to stay completely off that area. No one likes to hear this news. Staying off the area does not let any further pressure maintain the pressure injury or reinjure the area. Some people will want to be on the area for just a few minutes a day but once you put pressure on the area, you have reinjured it. If you stayed off the area, the minute you put pressure back on the spot, you have reversed all your hard work in being off it.

Treatment for pressure injuries might be provided by your healthcare professional, a home health nurse, or a wound care specialist. You or your family member might be asked to change the dressing if the area is open. Sometimes ‘packing’ is required. Packing is placing a dressing inside the wound to allow it to heal from the inside to the outside of the body. Your skin will want to close to protect the inside of the body from germs entering. That is the job of your skin. However, closing the outer skin over a wound too soon can lead to reopening the skin, multiplying bacteria, or an abscess. Most of the damage from a pressure injury is inside your body. Therefore, the internal wound must be healed and treated first.

Non-healing wounds can be unpleasant. Your time and activities are restricted. If you need surgery to heal a wound, you absolutely cannot put pressure on the area as it will not heal. Most individuals will have to be completely off the affected area for 6-8 months for the surgery site to heal. That can mean time in bed if the areas for sitting are affected.

As restrictive as this is, it is always a shock to be told you might need an amputation due to a slow or nonhealing wound. Payors are sometimes hesitant about long term wound care. The worse excuse I have heard is ‘to amputate because you aren’t using that part of your body anyway and it would be easier to transfer without that leg.’ That sickens me. No one wants to lose a body part.

Surgery is provided when the wound is on the head or torso. Amputation might be performed when the wound is on an extremity especially if it is not healing quickly. Pressure injuries are very costly as it takes time to heal them. Amputation is performed at the location where the blood supply is best. For example, suppose you have a pressure injury on your big toe. It is a small area, but it is the farthest spot on the body from the heart which makes healing more difficult. The force of blood pulsing through to your toe is the weakest. If amputation is suggested, blood flow studies will be conducted to see where your blood flow is the healthiest. This could be at your knee or even at your hip. Therefore, the amputation for that little pressure injury on your toe could be much higher at your knee, thigh or hip because that is where the amputated area will heal the best.

This is a shocking blog and not one meant to frighten you but rather to educate you. It is the reality of pressure injury outcomes. Here is the good news. You can refuse the amputation opting for wound treatment. However, if you choose this option, you have to know your risks. If gangrene has set in, you will need to remove the affected tissue. Gangrene has to be removed or it spreads.

If a wound is slow to heal, conservative treatment will work but it will take time, even years before healing might occur. That is a long time to risk infection or the consequences of loss of fluid from excessive drainage. It can be a challenge to find someone to change your dressings as often as needed. However, these are your choices.

If you are faced with the possibility of amputation, you will need to be strong to fight for your rights. It should be easy to have your wishes respected, but that is not always the case. You will need to be strong against pressure, but you also need to be reasonable about the benefits and risks of treatment. You might even need to change healthcare professionals to find one that is willing to work with you on conservative treatment.

Be aware of treatment options or ask if you have tried every option. Ask for a wound specialist if you do not have one. Ask about different treatment plans such as wet to dry dressings, packing, medications that can remove old tissue in the wound, wound vacuum therapy that draws secretions out of the wound, antibiotics, the list goes on. Review your seating and bed surfaces to ensure you are on the best pressure dispersing equipment for your needs. Often people are either not using pressure dispersing equipment or their bodies have changed over time (as we all do) but they are still using older or worn out equipment. You may even need a different chair for better support and positioning.

Wound healing depends significantly on your behaviors. You will need to stop smoking. This is hard to do. There are medications, counseling, and support groups that can help. Stop drinking alcohol and sugary drinks. Eat a healthy diet. If you have diabetes, be sure your blood sugar is under control at all times. Add activity to your body to increase circulation. Do not apply any rubbing alcohol or massage to the affected area; this does not increase circulation, it only adds more pressure. Absolutely, you will need to stay off the pressure area. This will have a significant impact on your lifestyle and work. It is easier to stay off a wound for a few weeks or months than for much longer. This all sounds quite harsh but remember; you are saving your arm or leg.

This is a very pointed blog. However, pressure injury is very serious. The best defense is prevention of a pressure area in the first place. Be aware of negative situations for your skin. It is easier to prevent a pressure injury than to try to heal one.

Pediatric Consideration: Pressure injuries do not have age limits. Younger skin is much easier to manage; however, pressure injury is a significant complication of diseases and trauma where body sensation is reduced. Young children cannot effectively look for pressure injuries because they don’t have the conceptualization of them. Starting a habit of looking at the skin together, even with the youngest child will make it easier to transition to their own review. Make it a part of your child’s normal activities. Adolescents often don’t check their skin due to peer pressure-no one else is checking theirs. This can be a challenge as the adult understands the risks more clearly. Making skin checks a matter of fact part of life can help reduce perceived parental nagging.

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