The Answer is D. The image shows an unstageable pressure ulcer in an older patient for which the recommended therapy is surgical debridement.
Debridement of eschar is necessary in patients with unstageable pressure ulcers to assess the depth of the wound and promote wound healing.
This patient has a sacral decubitus pressure ulcer that is unstageable as seen in the image. The most appropriate treatment is surgical debridement. Unstageable pressure ulcers are characterized by full-thickness tissue loss in which the base of the ulcer is covered by slough or eschar. The black eschar at the base of the wound prevents adequate evaluation of wound depth and further impairs wound healing. Therefore, this patient should undergo debridement of the eschar to expose healthy, viable tissue in order to assess the depth of the wound, allow for wound staging, and promote healing. Debridement can be accomplished either surgically or with specialized dressings, such as saline wet-to-dry dressings or autolytic dressings.
Lymphomatous invasion of the skin is highly unlikely in this patient without other evidence of active disease following recent treatment; therefore, biopsy is not indicated. Do not biopsy this patient.
Antibiotics would be indicated in the case of an infected pressure ulcer; however, there is no evidence that this patient's wound is infected at this time. There is no visible drainage or pus, and there is no surrounding erythema to suggest cellulitis. Additionally, he has no systemic signs or symptoms of infection, no fever, no chills.
The goal environment for ideal wound healing is a moist wound bed that controls excess exudate. The wound bed should be neither too moist (macerated) nor too dry. Leaving a wound open to air to dry is rarely, if ever, appropriate management.
This patient is not a candidate for palliative care. Pressure ulcers are not terminal conditions and with appropriate care can be managed in the outpatient setting.
References
Schiffman J, Golinko MS, Yan A, Flattau A, Tomic-Canic M, Brem H. Operative debridement of pressure ulcers. World J Surg. 2009 Jul;33(7):1396-402. PMID: 19424752