What is the treatment for a stage 2 left heel pressure injury with necrotic tissue?

Treatment of Stage 2 Left Heel Pressure Injury with Necrotic Tissue

For a stage 2 left heel pressure injury with necrotic tissue, the primary treatment should include thorough debridement of all necrotic tissue, appropriate wound dressing selection, pressure offloading, and assessment for infection. 1

Initial Assessment and Management

• Inspect the ulcer thoroughly to determine the extent of necrosis and assess for signs of infection 1
• Evaluate vascular status, especially if healing is delayed (consider ankle pressure or ABI measurements) 1
• Cleanse and debride all necrotic tissue and surrounding callus to promote healing 1
• For heel ulcers with dry eschar but no signs of infection, it may be appropriate to leave the eschar in place until it softens enough to be more easily removed 1

Debridement Options

• Sharp debridement (with scalpel) is the preferred method for removing necrotic tissue in most cases 1
• For patients with bleeding disorders or when sharp debridement is contraindicated, consider:
  • Enzymatic debridement using collagenase or papain-urea preparations 2
  • Autolytic debridement using hydrogels or hydrocolloids 1
  • Mechanical debridement methods as appropriate 3
• Repeat debridement as needed until all necrotic tissue is removed 1

Wound Dressing Selection

• After debridement, select appropriate dressings based on wound characteristics:
  • For moderately exudative wounds: Alginates or foams 1
  • For dry wounds: Continuously moistened saline gauze or hydrogels 1
  • For maintenance of moist wound environment: Films or hydrocolloids 1
• Consider capillary dressings with semi-permeable film for difficult necrotic tissue 4
• Avoid silver or antimicrobial agent-containing dressings unless specifically indicated 1
• Do not use footbaths as they can cause skin maceration 1

Pressure Offloading

• For heel ulcers, ensure complete offloading of pressure from the affected area 1
• Consider shoe modifications, temporary footwear, or orthoses for non-plantar ulcers 1
• Instruct the patient to limit standing and walking, and to use crutches if necessary 1
• If other forms of biomechanical relief are not available, consider felted foam in combination with appropriate footwear 1

Infection Management

• Assess for signs of infection (increasing pain, erythema, warmth, purulent drainage) 1
• If infection is present:
  • For superficial infection: Start empiric oral antibiotic therapy targeted at S. aureus and streptococci 1
  • For deep infection: Consider parenteral broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 1
• For pressure ulcers with infection, recognize that they are typically polymicrobial 1

Advanced Therapies

• If the wound fails to show improvement with standard care:
  • Consider negative pressure wound therapy, particularly effective for deep pressure ulcers with soft necrotic tissue 5
  • Evaluate for vascular compromise and consider revascularization if indicated 1
  • Consider systemic hyperbaric oxygen treatment for poorly healing wounds 1

Patient Education and Follow-up

• Instruct the patient and caregivers on appropriate wound care and signs of worsening infection 1
• Implement regular follow-up to monitor healing progress 1
• Develop a prevention plan to avoid recurrence once healed 1

Special Considerations

• If the heel ulcer is not showing signs of healing within 6 weeks despite optimal management, evaluate for vascular compromise 1
• For diabetic patients with heel ulcers, be particularly vigilant about infection control and vascular assessment 1
• When managing pressure ulcers in elderly patients, consider their overall health status and comorbidities that may affect healing 1