Treatment of Deep Tissue Pressure Injury
Prompt surgical debridement of all necrotic tissue is the cornerstone of treatment for deep tissue injury, combined with appropriate wound care and infection control measures. 1
Initial Assessment and Diagnosis
- Deep tissue pressure injuries (DTPIs) begin in the muscle closest to the bone and may not be visible in early stages 2
- Most commonly appear on the skin over the coccyx/sacrum, buttocks, and heels 2
- Hallmark is rapid deterioration despite preventive interventions
- Assessment should include:
- Extent and depth of tissue damage
- Signs of infection (erythema, warmth, purulent discharge)
- Vascular status of the affected area
- Presence of undermining or tunneling
Treatment Algorithm
Step 1: Surgical Debridement
- Remove all necrotic tissue completely 1, 3
- Key surgical debridement techniques include:
- Exposing areas of undermining by excising overlying tissue
- Removing callus from wound edges
- Removing all grossly infected tissue
- Obtaining deep tissue biopsy after debridement for culture and pathology 3
Step 2: Infection Control
- Start empiric antibiotic therapy for infected wounds targeting Staphylococcus aureus 1
- For moderate to severe infections:
- Consider broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic organisms
- Reassess after 48-72 hours to evaluate response 4
- Duration of antibiotic therapy:
- 10-14 days for uncomplicated infections
- Longer courses may be needed for complex cases 4
Step 3: Wound Management
- Ensure frequent wound inspection
- Perform regular wound debridement as needed 1
- Control exudate and maintain moist wound environment 1
- Consider negative pressure wound therapy for post-operative wounds 1
- For wounds with significant exudate, silver-containing dressings may be beneficial 4
Step 4: Pressure Offloading
- Complete pressure relief of the affected area is essential
- Use appropriate support surfaces, positioning devices, and frequent repositioning
- Limit standing and walking as needed 1
- Consider total contact casting for plantar ulcers 1
Step 5: Vascular Assessment and Management
- Evaluate peripheral circulation, especially for wounds on extremities
- For compromised circulation (ankle brachial index <0.6, toe pressures <50 mmHg, or TcPO₂ <30 mmHg), consider revascularization 1
Step 6: Metabolic Control
- Optimize diabetes control if applicable (blood glucose <8 mmol/L or <140 mg/dL) 1
- Address malnutrition and edema 1
Special Considerations
- For Fournier's gangrene (severe perineal infection), more aggressive surgical approach is required with complete removal of all necrotic tissue and possible multiple surgical revisions 1
- For diabetic foot infections, consider early surgical intervention (within 24-48 hours) combined with antibiotics 1
- For fracture-related infections, surgical management depends on fracture stability and may require implant retention or exchange 1
Monitoring and Follow-up
- Reassess wound every 48-72 hours initially
- If no improvement after 4 weeks of appropriate therapy, reevaluate treatment approach 1
- Monitor for complications including sepsis, which can have mortality rates as high as 68% in severe pressure ulcers 3
Treatment Pitfalls to Avoid
- Inadequate debridement - failure to remove all necrotic tissue leads to persistent infection 4
- Delayed surgical intervention - especially critical in necrotizing infections 1
- Inappropriate antibiotic selection - consider local resistance patterns and adjust based on culture results 1
- Failure to offload pressure - continued pressure will prevent healing regardless of other interventions
- Overlooking vascular compromise - revascularization may be necessary for healing 1
Surgical debridement has been shown to be safe despite medical comorbidities in patients with severe pressure ulcers 3, and novel debridement modalities such as hydrosurgery and plasma-mediated bipolar radiofrequency ablation have shown promise for infected wounds 5.