A 95-year-old community-dwelling woman became poorly responsive with refusal to feed over 2 days and was referred to the hospital on the initiative of her caretaker. She was a frail woman with a history of multimorbidity, including severe Alzheimer's dementia and recurrent falls. Two weeks before she fell, she sustained a C1 vertebral fracture and was discharged home with a neck support collar, remaining bedridden since. Before admission, she gradually deteriorated without fever or complaints of pain, until she became stuporous. On examination, the collar was removed, revealing a 3-cm round stage 2 chin pressure ulcer with purulent discharge and surrounding skin–soft tissue infection (Fig. 1). She was afebrile and stable with otherwise unremarkable examination. Chest X-ray and basic tests were normal, other than increased blood urea nitrogen (24.4 mg/dL, N 8–23) and C-reactive protein (6.9 mg/L, N 0–5). She improved with intravenous fluids and topical wound care, and was discharged back home with an Aspen cervical collar, restricting motion while providing broad contact below her chin ulcer.

Pressure ulcers often develop in bedridden older adults, mostly over the sacrum/coccyx, heels and hips, strongly associated with immobility, malnutrition and incontinence. They have been linked with a twofold increase in length of hospital stay, fourfold increase in costs and a fivefold increase in mortality.¹

Medical device-related pressure injuries (MDRPI) are less well known, but have been reported with respiratory devices (most common: endotracheal tubes or noninvasive ventilation masks); urinary catheters; nasogastric tubes; and underneath straps, cervical collars and splints. They are now acknowledged as important patient safety events and nursing-quality indicators,² although this mainly applies to intensive care unit (ICU) patients where the reported prevalence of MDRPI (skin or mucous membranes) can reach 27.9–34%.³ Thus, most studies identified in a recent meta-analysis involved younger trauma patients,² and pressure ulcers under cervical collars used long term for cervical spine immobilization were usually limited to younger ICU trauma patients.^{2, 4}

However, iatrogenic pressure ulcers in atypical locations have also been reported in older adults, and one prospective study noted an incidence of 5.7% among chronic geriatric inpatients.⁵ Iatrogenic pressure ulcer on the chin is unusual in older adult patients, especially when not associated with ICU admission. The increasing use of the prone position with acute respiratory distress syndrome and COVID-19 might increase the risk of pressure injury on the chin, independent of the use of devices.

Risk factors for MDRPI include patient-related factors (e.g. older age, diabetes, edema), treatment-related factors (e.g. use of vasoconstrictors, prone position) and device-related factors (e.g. longer duration of use, number of devices). Typically, a patient has several MDRPI risk factors (e.g. 2.8 ± 1.5 per patient in one study). Risk factors in older patients are similar, but aging changes in the skin, and frequent immobility, malnutrition, compromised circulation and clouded sensorium make them significantly more vulnerable.

Our report is a reminder that, albeit unusual, pressure ulcers can develop in atypical locations in older adults, with or without ICU admission, adding to the wide spectrum of healthcare-associated harm,⁶ and highlighting the need to always remove and examine under every medical device of older patients seen in the emergency department.

一名 95 岁的社区居民妇女出现反应迟钝，拒绝进食超过 2 天，在看护人的倡议下被转往医院。她是一位身体虚弱的女性，有多种疾病史，包括严重的阿尔茨海默氏痴呆症和反复跌倒。在她摔倒前两周，她发生了 C1 椎体骨折，带着颈部支撑项圈出院回家，此后一直卧床不起。入院前，她的病情逐渐恶化，没有发烧或疼痛主诉，直到昏迷不醒。检查后，取下项圈，发现下巴有一个 3 厘米的圆形 2 期压疮，有脓性分泌物，周围有皮肤软组织感染（图 1）。她没有发烧，病情稳定，其他检查均无异常。胸部 X 光检查和基本检查正常，但血尿素氮（24.4 mg/dL，N 8-23）和 C 反应蛋白（6.9 mg/L，N 0-5）增加。通过静脉输液和局部伤口护理，她的情况有所改善，出院时戴着阿斯彭颈托，限制活动，同时在下巴溃疡下方提供广泛的接触。

压疮通常发生在卧床不起的老年人身上，主要发生在骶骨/尾骨、脚后跟和臀部，与不动、营养不良和失禁密切相关。它们与住院时间增加两倍、费用增加四倍以及死亡率增加五倍有关。¹

医疗器械相关的压力性损伤 (MDRPI) 不太为人所知，但已有呼吸设备（最常见：气管插管或无创通气面罩）的报道；导尿管；鼻胃管；以及带子、颈托和夹板下面。它们现在被认为是重要的患者安全事件和护理质量指标，²尽管这主要适用于重症监护病房 (ICU) 患者，据报道，那里的 MDRPI（皮肤或粘膜）患病率可达 27.9-34%。³因此，最近的一项荟萃​​分析发现，大多数研究涉及年轻的创伤患者，²长期使用颈托固定颈椎的压疮通常仅限于年轻的 ICU 创伤患者。^{2, 4}

然而，老年人中也有非典型部位发生医源性压疮的报道，一项前瞻性研究指出，慢性老年住院患者的发生率为 5.7%。⁵下巴医源性压疮在老年患者中并不常见，尤其是在与 ICU 入住无关的情况下。急性呼吸窘迫综合征和 COVID-19 患者越来越多地使用俯卧位，这可能会增加下巴压力损伤的风险，与设备的使用无关。

MDRPI的危险因素包括患者相关因素（例如年龄较大、糖尿病、水肿）、治疗相关因素（例如使用血管收缩剂、俯卧位）和设备相关因素（例如较长的使用时间、设备数量）。通常，患者有多个 MDRPI 危险因素（例如，一项研究中每位患者有 2.8 ± 1.5 个）。老年患者的危险因素相似，但皮肤的老化变化、频繁不动、营养不良、血液循环受损和感觉器官浑浊使他们更容易受到伤害。

我们的报告提醒人们，尽管不寻常，但压疮可能会在老年人的非典型部位发生，无论是否入住 ICU，从而增加与医疗保健相关的广泛伤害，⁶并强调需要始终在每个部位进行切除和检查。在急诊室看到的老年患者的医疗设备。