Management of Deep Tissue Injury
The best approach to manage deep tissue injury (DTI) is to thoroughly irrigate the wound with clean water, apply antibiotic ointment with an occlusive dressing, and protect the area from further pressure or trauma. 1
Understanding Deep Tissue Injury
Deep tissue injury (DTI) is a serious type of pressure injury that begins in the muscle closest to the bone and may not be visible in its early stages. Its hallmark is rapid deterioration despite appropriate preventive interventions 2. DTIs appear most commonly on the skin over the coccyx or sacrum, buttocks, and heels 2.
The pathophysiology of DTI involves two primary mechanisms:
- Direct deformation damage - occurs within minutes from high but physiologically relevant strains 3
- Ischemic damage - results from blood vessel occlusion and takes several hours to develop 3
Initial Assessment and Management
Wound Cleaning and Irrigation
- Thoroughly irrigate the wound with a large volume of clean water (warm or room temperature) until all foreign matter is removed 1
- Cold water is as effective as warm water but less comfortable for the patient 1
- If running water is unavailable, use any source of clean water 1
Wound Dressing
- Apply antibiotic ointment or cream to superficial injuries (if no known allergies) 1
- Cover with a clean occlusive dressing to promote healing and reduce infection risk 1
- Loose covering of the wound with sterile dressing is recommended for burn-like injuries 1
Protection from Further Injury
- Protect the area from additional pressure or trauma as DTI tissues are extremely vulnerable to further injury 1
- Apply bulky dressings to provide a protective layer that insulates the tissue and shields from external contaminants 1
- Use loose, circumferential wrapping to allow for expansion as swelling increases 1
Advanced Management Strategies
For Extensive Tissue Loss or Damage
- Surgical exploration and limited debridement of non-viable tissue is recommended for extensive tissue loss from infection, shearing injuries, or burns 1
- Genital skin and other well-vascularized tissues with marginal viability may survive due to collateral blood flow 1
- Multiple procedures may be required prior to definitive reconstructive procedures 1
Wound Management Options
- Gauze dressings with frequent changes 1
- Silver sulfadiazine or topical antibiotic with occlusive dressing 1
- Negative pressure dressings for appropriate wounds 1
Hemostatic Management for Associated Bleeding
- Direct pressure is the primary method to control bleeding 1
- For wounds with significant bleeding that doesn't respond to direct pressure, hemostatic agents may be considered 1
- Options include:
Monitoring and Follow-up
Signs of Infection or Deterioration
- Monitor for signs of infection including increasing pain, redness, swelling, warmth, or purulent drainage 1
- Watch for progressive tissue necrosis which may indicate deep infection 1
Differential Diagnosis Considerations
- DTI can be difficult to distinguish from other conditions including stage 2 pressure ulcers, incontinence-associated dermatitis, skin tears, bruising, hematoma, and vascular insufficiency 4
- In light-skinned patients, look for purple or maroon tissue discoloration with defined borders 4
- In dark-skinned patients, assess for persistent erythema and hyperpigmentation rather than blanching 4
Common Pitfalls and Cautions
- Avoid using elevation or pressure points to control bleeding as these are less effective than direct pressure 1
- Do not apply ice directly to deep tissue injuries as it can produce tissue ischemia 1
- Avoid prolonged cold exposure to small injuries or brief exposure to large injuries as this can cause further tissue damage and hypothermia 1
- Recognize that visual assessment alone may not identify patients at risk of deep tissue damage 5
- Be aware that most DTIs are avoidable, but various intrinsic and extrinsic factors can contribute to their development 5