Le traitement de l'escarre

Le traitement de l'escarre

 

 

 

                        

Ce travail n'a pas la prétention de tout dire sur l'escarre mais simplement de clarifier le traitement, qu'il soit préventif ou curatif.

 

Il faut savoir que ce traitement doit être l'affaire de tous : médecins, infirmiers, aides-soignants, brancardiers, kinésithérapeutes, personnel de nuit  ...

 

Définition de l'escarre

 

C'est une gangrène ischémique qui siège aux points de contact d'un sujet couché.  L'évolution de la lésion va se faire en deux phases :

 

·        Thrombose artério-veineuse des vaisseaux locaux.

·        Infarctus des parties molles.

 

Causes de l'escarre

 

L'escarre est due à la compression des tissus mous entre les deux plans durs que sont :

 

·        L'os du sujet d'un côté.

 

·        Le plan du lit, le plâtre, l'appareil orthopédique, de l'autre.

 

L'apparition de l'escarre est favorisée par :

 

·        Un mauvais état général.

 

·        Une perte de la sensibilité qui supprime la sensation d'inconfort et la douleur.

 

·        Une perte de la mobilité.

 

 

Localisations de l'escarre

 

Elles dépendent de la position du malade :

- Décubitus dorsal sacrum, coude, omoplate, occiput.

- Décubitus ventral épines illiaques, rotules.

- Décubitus latéral: trochanter, malléole, tête péronière.

- Station assise : ischions.

 

Nous envisagerons dans un premier temps, le traitement préventif qui, correctement appliqué, évite dans tous les cas l'apparition de la lésion.  Ensuite, nous étudierons le traitement de l'escarre constituée.

 

1. Les moyens de prévention

 

·        Le matelas spécial : il a pour but de diminuer la compression des tissus mous entre le malade et le plan du lit.

 

Il existe de nombreux modèles de matelas: au minimum une couverture, au mieux dans les conditions habituelles le :

- Matelas d'eau : efficace mais l'eau doit être tiède, le poids est important, la stabilité précaire nécessite la mise en place de ridelles.

- Matelas alternating : d'efficacité limitée, en particulier si le malade est lourd.

- Matelas décubitex en mousse rainurée.

- Lit fluidisé : parfait mais très onéreux et fragile.

- Matelas composé de blocs de mousse amovibles.

 

Selon les disponibilités, d'autres moyens sont éventuellement possibles.

 

Quelle que soit l'efficacité du matelas utilisé, il faudra toujours utiliser les autres moyens de prévention qui sont :

 

·        Le massage trophique : il s'agit d'un pétrissage circulaire qui doit être profond et mobiliser les plans superficiels sur le plan profond.  Il doit être effectué toutes les trois heures au moins, quatre fois par vingt-quatre heures, en se faisant aider par les membres de la famille.

 

·        L'hygiène cutanée : toilette au savon, séchage et friction à l'alcool à 60' (il ne faut pas laisser macérer le malade dans l'urine).

 

·        Les manoeuvres de retournement, astreignantes mais essentielles, de jour comme de nuit, en semaine comme le dimanche.  Le retournement doit être effectué toutes les trois heures, au besoin avec la participation de la famille.  Les positions qui s'offrent à nous sont: décubitus dorsal, ventral, latéral d'un côté puis de l'autre.  La station assise lorsqu'elle est supportée.

 

Certaines pathologies peuvent contre-indiquer certaines positions mais aucune ne peut empêcher totalement cette technique.  L'association retournements, massages et hygiène constituent les moyens de prévention fondamentaux.

 

2. Les moyens curatifs

 

Nous allons étudier les différents moyens qui s'offrent à nous avant de voir les indications, puis enfin la réalisation du pansement lui-même.

 

a. Les moyens

 

·   Les instruments chirurgicaux

 

Ils permettent: l'excision des parties nécrosées, le décapage, la mise à plat d'une phlyctène...

 

·   Les savons

 

·   Les antiseptiques

 

- L'éther ne doit servir qu'à dégraisser la peau qui reçoit le sparadrap.

 

-L'alcool à 60°, son seul usage est la friction.

 

- Le mercurochrome est à bannir car il empêche la surveillance ultérieure de la coloration des téguments.

 

- L'eau oxygénée est efficace vis-à-vis des germes anaérobies.

 

- L'alcool iodé est efficace sur la pyodermite à staphylocoques,

 

- Les ammoniums quaternaires (Cétavlon®, Mercryl®) doivent être utilisés préférentiellement.  Ils nettoient la plaie et détruisent les germes.

 

- Les antibiotiques locaux : leur emploi est à éviter le plus longtemps possible.  Ils ne sont éventuellement utiles qu'en cas d'infection évidente et peuvent être remplacés par le sucre.

 

- Les topiques : il y en a de deux sortes - ceux qui favorisent l'inflammation : Trypsine, Elase®, Païkinase®, gras : Vaseline, Biafine, Tulle gras, humides : sérum salé hypertonique, Dakin;

- ceux qui luttent contre l'inflammation sec : gaze stérile,

cortisone : Corticotulle®.

 

- Les produits favorisant la régénération tissulaire : placenta frais, extraits placentaires, pâtes vitaminées.  Leur effet est discutable.  On peut les utiliser en cas d'arrêt de l'épidermisation ou sur une lésion chronique.

 

- La mésothérapie d'effet discuté : à raison de deux séances par semaine de multiponctures de la plaie avec un mélange de 3 cc de Procaïne, 1 cc de Fonzylane®, 1 cc de Péridil-Héparine® .

 

- Le chaud et le froid: il s'agit d'une stimulation de la circulation capillaire au niveau de l'escarre par le froid (glace), puis le chaud (sèchecheveux).

 

b. Les indications

 

Le traitement dépendra du stade évolutif de la lésion.

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