Discussion
Arterial bleeding from a deep pressure ulcer is a rare occurrence. To our knowledge, no such cases have been reported in the available literature. The exact reason for this patient’s acute bleeding event remains uncertain, necessitating further discussion and investigation of potential underlying causes.
With iatrogenesis being the fifth leading cause of death in the world, a potential complication of wound care must not be overlooked (Peer 2018). Although acute life-threatening hemorrhage from chronic pressure ulcers is not common, exploring the potential causes and treatment options is critical to reduce the morbidity and mortality of patients affected by chronic ulcers. This patient’s acute bleeding event may have been precipitated by iatrogenic trauma during routine wound care. Standard wound care in deep wounds is frequently supplemented by the use of wooden adjuvants, such as cotton swab applicators. Medical personnel often blindly sweep, debride, and pack deep wounds with rigid objects, therein increasing the risk of damaging nearby structures. Bearing the nature of this patient’s wound in mind, being approximately 10 cm deep (Figure 1B) and with a poorly visualized base, the aforementioned iatrogenic injury during routine dressing changes is not an unlikely cause of his acute bleeding complication.
Separately, this patient’s acute bleeding event may have been a result of necrotic tissue creating friable areas in the vasculature and ultimately resulting in a multi-focal hemorrhage. The patient’s ITPW harbored a chronic infection. Chronically infected wounds may increase the risk of hemorrhage particularly when the necrotic tissue is not appropriately debrided (Yoshikawa 2002). This patient arrived at the hospital with metabolic encephalopathy and septic arthritis and was ultimately found to have a pseudomonal infection of his ITPW. Provided this history, the potential for a chronic smoldering infection in the ITPW with resultant necrotic and friable tissue is high.
Although clinical suspicion is often sufficient to diagnose vascular injury with external hemorrhage, determining the exact source of external bleeding is difficult when the vessel cannot be visualized. Soft signs of hemorrhage include a history of prehospital blood loss, diminished pulse, proximity to the large vessel or bony injury, and ipsilateral neurologic deficit. Hard signs include paresthesia, pulselessness, paralysis, pain, pallor, and poikilothermia (the six P’s). Hard signs indicate the need for urgent surgical intervention. Soft signs require further workup such as an ankle-brachial index, ultrasound, or angiography as the gold standard. In emergent acute hemorrhage, immediate bleeding control and rapid restoration of blood flow is the primary goal and extensive diagnostic workup should not delay treatment (Liu 2019).
When faced with acute hemorrhage, treatment options include conservative management, operative management, or endovascular repair. Operative treatment includes vascular suture or ligation, blood vessel prostheses, and grafts made of synthetic materials or the greater saphenous vein. Embolization, balloon dilation, and stent implantation are the main endovascular techniques (Liu 2019). Arterial ligation is suitable for most vascular injuries. A retrospective analysis found that embolization offers an effective and safe alternative to conventional operative care of traumatic arterial injuries (Whigham 2002). Although open surgical repair has been the gold standard for treating vascular trauma, the application of endovascular techniques may be more favorable in appropriately selected patients (Liu 2019).
In this case, the patient’s source of bleeding appeared to be multifocal from mixed arterial and venous sources. If a single, clearly identified arterial source of bleeding was identified, endovascular techniques such as embolization may have been appropriate. However, endovascular treatments are not an effective treatment for multifocal venous bleeding, so open operative care was the treatment of choice.
During the operation, the patient’s artery, likely the medial femoral circumflex artery, was ligated. Ligation of this artery was necessary to stop the arterial hemorrhage and avoid hypovolemic shock. The medial femoral circumflex artery is the main source of oxygenated blood to the head and neck of the femur. Disruption of this vessel is a well-known inciting factor for avascular necrosis of the femoral head and neck. Although compromising this patient’s medial femoral circumflex artery was necessary to save the patient’s life, this patient now has a risk of developing avascular necrosis. This potential complication must be addressed and investigated during follow-up in clinic. If the patient has evidence of avascular necrosis, such as increasing hip pain, an MRI will be warranted.
The definitive treatment for pressure wounds is often achieved via a skin flap or through primary intention. Although both of the options may be used to definitively treat this patient in the future, neither is appropriate in the setting of a chronic infection with evidence of necrotic tissue in the wound. Once the patient’s infection has cleared, necrotic tissue from his wounds has been debrided, and evidence of granulation tissue is noted, discussion of definitive treatment options may be appropriate.
Conclusion :
The number of immobilized persons is increasing given the continued advent of life-prolonging medical interventions in a growing population. As such, the prevalence of pressure ulcers continues to grow. Here we report a unique case of acute hemorrhage of a chronic right ischial tuberosity pressure wound, which necessitated emergent operative exploration and suture ligation of 8-10 vessels to successfully achieve hemostasis. Acute arterial hemorrhage of a chronic pressure wound is a rare but potentially fatal complication, which may require emergent operative interventions. We highlight this potential complication to promote appropriate wound care and prompt recognition of hemorrhagic chronic pressure wounds with the goal of reducing morbidity and mortality.