Definition of eschar: it is a pressure ulcer resulting from ischemic necrosis of an area of ​​skin for too long under pressure from the bone level and a hard surface.
· A pressure ulcer can occur in any subject that has lost the ability to perform transfers of support: Classic bedsore.
· "3:00 to constitute a pressure ulcer, three months to heal."
· It is a serious illness for in its impact, psychological, and the complications that can cause death in 10% of cases.
· It is a common pathology:
- 75% for paralyzed with the + frequent causes: traumatic paraplegia or SEP
- 30% in geriatric
- 3-5% in hospital
it is an economically heavy pathology (€ 20,000 to treat a significant eschar)

Pathophysiology:
The occurrence of pressure ulcers is never inevitable. Only prevention is effective + + +, and we need a better understanding of the pathophysiology, and educate caregivers, the patient and family.
The capillary pressure is 30 mm Hg. Supine pressure is 40 mmHg in the sacrum view 95 mmHg at the greater trochanter and the ischial 500 mmHg when sitting. It is thus understood ischemia resulting.

Movement Disorders Disturbed sensation







From mobility ↓



Ischemia
 


Slough

Evolutionary stages of pressure ulcers (Pathology):
· Consensus Conference 2001 (see illustrations attached)

- Stage I: skin erythema on an apparently intact skin does not disappear after the lifting of the pressure; in cases of pigmented skin: color change, induration, edema, heat are the indicators. Reversible stage.
- Stage II: tissue loss involving the epidermis and the dermis, in part, posing as a blister, abrasion or superficial ulceration. Due to lesions of endarteritis: irreversible stage.
- Stage III: defect involving the subcutaneous tissue with or without peeling device but not exceeding the fascia of the underlying muscles. Stage wet or dry necrosis.
- Stage IV: defect reaching and exceeding the fascia and may involve bones, joints, muscles tendon.

· Should enrich this classification of a stage 0: intact skin but bedsore risk.

· The infection of pressure ulcers is characterized as follows:
o 2 symptoms must be present: redness, tenderness or swelling of the wound edges
o and one of the following observations: bacteria isolated from the culture liquid obtained by aspiration or biopsy of the edge of the ulcer; organisms isolated from blood cultures. Infection is asserted beyond of 10 5 organisms / ml.


Risk factors for occurrence of pressure ulcers or bedsores etiologies:
the main risk factors of pressure ulcers are explanatory and can be classified into extrinsic and intrinsic factors or mechanical or clinical factor:
- Extrinsic factors:
· Still + + +
· Pressure, shear
· Maceration
· Rubbing cloth
· Plaster
- Intrinsic factors:
· General causes:
o nutritional deficiencies + + +: MPE hypoprotidemia Syndrome
o dehydration
o Anemia
o infection, acute disease
o severe chronic disease and terminal phases
o age (skin fragility)
o history of bedsores
o decrease in circulatory flow: vascular disease (arterial)
o urinary and fecal incontinence
o neurological disorder bordering on immobility

· Local trophic causes
o especially among the paraplegic + +: due to
§ loss sensibilitéÞ ↓ pain (motor paralysis has few eschar because the sensitivity is maintained),
§ and lower limb spasticity resulting in a vicious circle
§ and ↓ of tissue resistance to the pressure with micro thrombosis
o elective areas of support are well on risk areas:
§ supine: 30% sacrum, heels 30%, occiput (post surgery), scapula, elbow
§ lateral decubitus: 30% trochanter, lateral malleolus, inner knees, leg side face
§ sitting: ischium, sacrum buttocks, dorsal region lateralized
§ but all areas of the body can be affected (bedsores on nasal or urinary catheter, for example)
o the skin condition from (atrophic skin in the elderly)
We particularly note immobilization and undernutrition as a predictor of the risk of bedsores.
In some clinical situations, some factors are more specific:
- In neurology, orthopedics and traumatology three key risk factors:
· pressure
· Loss of mobility
· Neurological deficit with spasticity, incontinence, lack of patient cooperation. In case of reconstructive surgery, age, smoking, corticosteroid therapy, diabetes, disorders of microcirculation and coagulation are pejorative for healing.
- Geriatrics, the particular fragility of the skin and subcutaneous tissue and the protido-calorie insufficiency increase the risk of pressure ulcers in case of cardiovascular diseases, hypotension or hyperthermia
- In intensive care, the frequency of collapse, the severity of the initial state, fecal incontinence, anemia and length of stay are predictors of the risk of bedsores.



One can select three etiological circumstances bedsores:
- Eschar "accidental" related to a temporary condition of mobility and / or consciousness:
· Comas (metabolic, barbiturates, ethyl, traumatic ...)
- Eschar "neurological" consequence of a chronic pathology motor and / or sensory:
· Paraplegia
- Eschar "multifactorial" of the subject polypathologique, confined to bed and / or chair:
· The most frequent case of the elderly.


Differential diagnosis of pressure ulcers:
· The radiation injury: no notion of bed rest, immobilization. ATCD radiotherapy. Necrotizing vasculitis wider that the apparent damage. Appear 10-20 years after the biopsy because often radiothérapieÞ epitheliomatous evolution.
· The cytosteatonecrosis: Septic infarction fatty masses. very deep.
· Rhabdomyolysis or cytonécrose: after IM injection of toxic
· The original ulcers and various traumatic wounds

 Preventive treatment + + +. This is the real treatment of pressure ulcers:
1. assess risk
2. implement the general preventive measures
3. use appropriate media
4. inform and educate the patient and his family

· 1 Start by identifying risk factors in stage 0: from the very first contact with the patient. Caregivers should be trained in the recognition of risk factors and trained in the use of risk identification scale.
The risk scale reproducible and validated for use, combined with an initial clinical assessment, allows the development of prevention strategies adapted to the level of risk. The most common scales are those of increased Norton, Waterlow, and Braden (see annex), Amiens scale modified poplars.

                                          Norton scale
2 · Implement general preventive measures:
No decrease pressure: patient facility
o avoid prolonged support by mobilizing, setting the chair (30 ° 60 ° tilt hazard!), verticalization and the resumption of early works
o planned position changes every two to three hours
o avoid shear and friction phenomena installation and proper patient handling
o the oblique lateral decubitus position at 30 ° to the plane of the bed is preferable to reduce the risk of trochanteric pressure sores.


No other care nursing: + + +
o Observe the skin and areas at risk ++
o fight against contractures (physiotherapy)
o protection of bearing zones with landfilling of hazardous areas (studding)
o maintaining personal hygiene and good skin condition: Air and regular changes.
o Massage and friction, ice on areas at risk applications should be avoided since the average ↓ micro circulatory flow. Prefer strokes of support barehanded points of use corn oil or grape seed, (Sanyrene R). Proscribe products which dry the skin and clog the pores: alcohol, water pastes.
o Avoid maceration.

n ensure good nutritional balance. The severity of pressure ulcers is correlated with undernutrition. Eschar non curable if severe malnutrition. Criteria of malnutrition:
o ingestas <20 kcal / kg / day
o weight loss> 10% in six months
o lymphopenia <1200 / mm3
o albumin <35 g / l prealbumin <200mg / l
n rapidly process associated pathologies, including infectious states of hyper catabolism officials.
- 3 Use suitable media:
o mattress:
· Foam mattress waffle kind CLINIPLOT for weight 50-100 kg; ineffective in heels
· FOAM mattress viscoelastic "memory" which increases the contact surface
· Mattress UAE, 37 ° C, heavy, heat to maintain (survival blanket)
· Static or sophisticated mattress AIR kind Nimbus pressure sensors
· FLUID BED: Risk déshydratationà offset by 1 liter of fluid intake
o mattress:
· Air static self excel, excel has
· Alternating at alternate air swelling
· In silicone fiber
o the chair:
· Foam cushion
· Gel pad (RestonR)
· Static air cushion
· Slip nets
o Indications:

Static support
No bedsores or moderate risk of bedsores
Patient can move and <15h / day in bed
Static support
Dynamic +
Patient with bedsores or high risk of bedsores
or> 15h / day in bed
Unable to move one
Dynamic Mattress
Eschar carrier patient
or> 20 hours / day in bed
Unable to move one

- Inform and educate 4: promoting patient involvement and his entourage to the prevention of pressure ulcers: self-monitoring, self mobilization with lifting exercises stimulate and promote hydration and nutrition, and help ensure the toilet made in the rules.

Medical treatment consists of pressure ulcers:

- Requires a multidisciplinary team work for both local treatment is generally taking into account the individual and the wound.
- General treatment:
· Nutrition
o correcting deficiencies, anemia, electrolyte disturbances, fluid intake> 1.5 l / day (except one)
o protein supplementation 2xNsoit à2,5g 1.2 / kg / day (difficult if severe renal impairment)
o calorie 35-45 kcal / kg / day:> 2000kcal / day
o 55% carbohydrate intake 50A of the contribution
o Vitamin C 500mg to 1000mg Vit / d
o Zn 25-50mg / day
· Treatment of tissue anoxia factors (diabetes)
· Monitoring the cognitive state and vigilance
· Anti-tetanus vaccination
· Prevent thromboembolism
· Eschar infected: make repeated bacterial samples with antibiotic susceptibility testing but only if complications on infected pressure ulcers, osteomyelitis, arthritis, or systemic signs (hyperthermia, sepsis)
· Manage the control of feces:
o sometimes poses a colostomy bag to the anus if gluteal bedsore.
o Often diarrhea causing bedsores so superinfection control intestinal disorders (residue-free diet, parenteral nutrition, exceptionally colostomy discharge).
· Pain + + +:
o it does not correlate to the size of the ulcer
o assess its cause
· Cyclic acute pain (in the care, mobilization of nursing: choice of analgesic treatment, to alleviate Actiskenan ® 3 times before carefully with suitable dressing suitable support, good positioning analgesic
· Staples Acute pain in a greater care (debridement Mechanical debridement of necrotic): Effective use of topical anesthetics Emla® only 5mm deep, using O² / NO Kalinox® when dressing.
· Chronic pain in persistent permanently idle: choice of continuous treatment, relaxation, to ensure dosing schedule painkillers
o assess its intensity through VAS scales Doloplus
- Local treatment:
· Describe the eschar: use bedsore dressing monitoring forms (see appendix) with:
o Location on drawing,
o measurement of the surface and the depth,
o lesion appearance perished,
o describe the color black yellow red rose,
o pain assessment and nutrition
· General principles of treatment:
o treatment of redness: Stage I
· Release the pressure with a change of position every two hours
· If necessary use a semi-permeable or transparent hydrocolloid movie
· Effleurages
o cleaning of the wound and principles of its periphery: stage II or higher
· physiological serum
· No antiseptic (except betadine possible if surgery)
o treatment of blister: vent contents and maintain the roof of the blister, cover with a hydrocolloid dressing or fat dressing if hemorrhagic blister cut the roof of the blister
o treatment of pressure ulcers consists of:
· Debridement is necessary on necrotic wounds and / or fibrinous: mechanically or by excision around Alginate dressings or hydrogel. Detergent dressing Flammazine every other day by protecting the periphery with a paste with water.
· If debridement performed pro-inflammatory dressing for a budding: + tulle dressing liquid Betadine
· Use of modern dressings depending on the condition of the wound (see table)
· Is important to respect the bacterial ecosystem of the wound swab No systematic infection only if:
· Stage of debridement: Gram germ - and anaerobic (pyocyaniques) naturally colonize the surface of the eschar. These germs stimulates the arrival of macrophages and polymorphonuclear that will cleanse the wound
· At the stage of budding: Gram germs - are replaced by Gram + bacteria Staphylococcus Streptococcus
· In case of temporary local antiseptic but never superinfection local antibiotic therapy. Systemic antibiotic therapy on outcome of susceptibility testing.

Appearance of the wound
Therapeutic Alternatives
Black and dry necrosis Presence
Mechanical debridement
Hydrogel + / Scarifications
enzymes
Presence of a fibrin wound or slough
Mechanical debridement
Hydrogel so little exudative
Alginate and Hydrofiber if very exudative
Wound anfractuous
Alginate locks
Hydrofibres locks
hydrocolloid paste
Wound very exudative
At the stage of debridement
Alginate
Hydrofibres

At the stage of Budding
Hydrocellular
foam

Bleeding wound
Alginate
Burgeoning wound
Fat dressing
Hydrocellular
foam
Excessive granulation
Corticotulle
Silver nitrate
Wound nearing epidermization
Hydrocolloid
Tulgras
transparent polyurethane movie
Hydrocellular
foam
Smelly wound
Coal dressing
Infected wounds
Alginate
Coal dressing
Hydrofibres

3 Surgical treatment:
surgery is needed if:
· Significant tissue necrosis
· Exposure of neurovascular axes, tendons or joint capsules
· Exposing the bone and infection

surgery is against-indicated in the elderly if:
· Eschar multifactorial
· Lack of implementation or ineffectiveness of recurrence prevention measures
the surgical indication is retained if:
· Patient in good condition because heavy bleeding and response
· Rénutri sick without cardiovascular problem
· Carrying a clean eschar
in case of intervention:
· The surgical procedure must be framed by a medical preparation and particularly harsh treatment
· Problem installing the sick for intervention to prevent the emergence of new pressure ulcers for long procedures
· In intraoperative and postoperative antibiotics for 8 days off adapted to antibiograms performed preoperatively
· Capillaro-protective treatment
· Calorie diet without residues
· Redons let up until the drying up of flows, cultivation tubing
· Support forbidden on the operated area for one month minimum unless sick fluidized bed. And changing the position of every two hours. The patient must endure the prone position
· First dressing made removal of redons between the 5th and 8th day
· Surgical indication based on the type of pressure ulcer and its location:
o sacrum, heels: spontaneous healing in the prone position
o ischion: responsible pyoderma, furunculosis bursitis to be punctured in some cases
o trochanter: often complicated coxofemoral arthritis, subluxation, dislocation of the femoral head requiring resection of the head and neck. Make an X-ray systematically basin to search osteitis arthritis subluxation, dislocation.
· The techniques used:
o in a first step
§ excision of the eschar pocket
§ excision of bone ostéitique
o secondly cover the cavity excised by a flap
§ pure skin
§ pure muscle
Musculocutaneous §
§ cutaneous fascia.

4 Treatments eschar at the stage of palliative care: pressure ulcers end of life.
This support requires the most objective evaluation possible prognosis of the patient and the prognosis of the eschar frequently reassessed team.
Respect for the person must carefully guide treatment choices at different stages of evolution of the underlying disease and the patient's general condition.
There are several objectives in this context premiums or the overall approach and individualized patient:
· Locally treat eschar being attentive to patient comfort as well as pain relief:
o minimize the extension of the eschar avoid the uncomfortable symptoms Complications
o therefore not a priority debridement
o dressing chosen for less frequent renewal
odor management o (flagyl: dressing coal)
· On a general level:
o keep the patient clean up and reduce the physical discomfort
o and psychological: relational dimension of care.
o possibly prevent the occurrence of new pressure ulcers but nutritional status must take second place here