What is the treatment for a deep tissue injury (DTI) without eschar?

Management of Deep Tissue Injury (DTI) Without Eschar

For a deep tissue injury without eschar, the recommended treatment approach includes regular wound assessment, appropriate dressing selection, pressure offloading, and monitoring for signs of infection, while avoiding premature debridement of stable tissue.

Assessment and Identification

• Deep tissue pressure injury (DTPI) is a serious form of pressure injury that may initially remain invisible for up to 48 hours before progressing rapidly to full-thickness skin and soft tissue loss 1
• DTI typically presents as a maroon-purple discoloration of intact skin (89.9% of cases) or as a blood-filled blister 2
• Common locations include the sacrum (39.8%) and heel/Achilles region (28.9%) 2
• Use a sterile, blunt metal probe to measure the depth and extent of the wound, noting any foreign bodies, soft-tissue abscesses, or palpable bone 3

Treatment Approach

Wound Care Principles

• Select appropriate dressings based on the size, depth, and nature of the wound (dry, exudative, or purulent) 3
• For DTI without eschar, consider:
  • Continuously moistened saline gauze for dry wounds 3
  • Hydrogels for dry wounds to facilitate autolysis 3
  • Films (occlusive or semiocclusive) for moistening dry wounds 3
  • Alginates for drying exudative wounds 3
  • Hydrocolloids for absorbing exudate and facilitating autolysis 3
  • Foams for exudative wounds 3

Pressure Relief

• Ensure pressure relief from the affected area through appropriate off-loading techniques 4
• Implement pressure-redistributing devices or specialized footwear, particularly important for DTIs on weight-bearing surfaces 4

Monitoring and Documentation

• Regularly monitor for signs of infection (erythema, warmth, swelling, purulent drainage, odor) 4
• Document wound size, extent of surrounding cellulitis, and quality/quantity of drainage at each assessment 3
• Follow up regularly, as 66.4% of DTIs may completely resolve or progress toward resolution with appropriate care 2

Special Considerations

Infection Management

• If signs of infection develop, obtain specimens for culture before initiating antibiotic therapy 3
• Attempt to obtain tissue samples rather than superficial swab specimens for more accurate culture results 3
• For infected DTIs, consider broad-spectrum antibiotics effective against both aerobic and anaerobic organisms 3

Vascular Assessment

• Assess arterial supply to the affected area; if dorsalis pedis and posterior tibial pulses are palpable, arterial supply is generally adequate 3
• For suspected ischemic wounds, debridement may be relatively contraindicated 3
• Consider vascular specialist referral if the affected limb appears ischemic 4

Surgical Intervention

• Surgical consultation is recommended for DTIs with spreading soft tissue infection or progressive tissue destruction 3
• Urgent surgical intervention is necessary for deep abscesses, compartment syndrome, or necrotizing soft tissue infections 3

Pitfalls to Avoid

• Avoid premature debridement of stable tissue in DTI without eschar, as this can lead to unnecessary tissue damage 4
• Do not delay necessary surgical intervention when there are signs of spreading infection 4
• Avoid aggressive debridement of potentially ischemic wounds without proper vascular assessment 4
• Do not use topical antimicrobials for treating clinically uninfected wounds 3

Outcomes and Prognosis

• With appropriate care, approximately 66.4% of DTIs may completely resolve or progress toward resolution 2
• About 9.3% of DTIs may deteriorate to full-thickness tissue loss despite appropriate care 2
• Direct deformation damage can occur within minutes under high pressure, while ischemic damage takes several hours to develop 5