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.