Deep Tissue Injury Management
For deep tissue injury (DTI) without eschar, the primary management strategy involves appropriate wound dressings selected based on wound characteristics, strict pressure relief through off-loading, and vigilant monitoring for infection—avoiding premature debridement of stable tissue. 1
Initial Assessment
Wound Evaluation:
- Measure depth and extent using a sterile, blunt metal probe, documenting any foreign bodies, soft-tissue abscesses, or palpable bone 1
- Document wound size, extent of surrounding cellulitis, and quality/quantity of drainage at each assessment 1
- Assess arterial supply to the affected area; if dorsalis pedis and posterior tibial pulses are palpable, arterial supply is generally adequate 1
Risk Factor Recognition:
- DTIs most commonly appear over the coccyx/sacrum, buttocks, and heels 2
- Patients who develop DTIs are typically older with lower body mass index compared to those with other pressure injuries 2
- The hallmark of DTI is rapid deterioration despite appropriate preventive interventions 2
Wound Care Protocol
Dressing Selection Based on Wound Characteristics:
- Dry wounds: Use continuously moistened saline gauze or hydrogels to facilitate autolysis 1
- Minimal exudate: Apply films for moistening dry wounds 1
- Exudative wounds: Use alginates for drying exudative wounds or foams for absorption 1
- Moderate exudate with autolysis needs: Apply hydrocolloids to absorb exudate and facilitate autolysis 1
The selection should be based on the size, depth, and nature of the wound (dry, exudative, or purulent) 1
Pressure Relief (Critical Component)
Off-Loading Requirements:
- Ensure complete pressure relief from the affected area through appropriate off-loading techniques 1
- This is non-negotiable as DTIs originate in deep muscle tissue closest to bone and require elimination of causative pressure 2
Monitoring and Infection Surveillance
Regular Assessment Parameters:
- Monitor for signs of infection including erythema, warmth, swelling, purulent drainage, and odor 1
- Surface temperature changes may indicate DTI progression: initial increase of ~0.5°C during inflammation, followed by ~0.2°C decrease with persistent ischemia 3
If Infection Develops:
- Obtain specimens for culture before initiating antibiotic therapy 1
- Attempt to obtain tissue samples rather than superficial swab specimens for accurate culture results 1
- Consider broad-spectrum antibiotics effective against both aerobic and anaerobic organisms for infected DTIs 1
Critical Pitfalls to Avoid
Do Not:
- Avoid premature debridement of stable tissue in DTI without eschar, as this leads to unnecessary tissue damage 1
- Do not use topical antimicrobials for treating clinically uninfected wounds 1
- For suspected ischemic wounds, debridement may be relatively contraindicated until vascular status is clarified 1
Indications for Surgical Consultation
Urgent Surgical Intervention Required For:
- Spreading soft tissue infection or progressive tissue destruction 1
- Deep abscesses 1
- Compartment syndrome 1
- Necrotizing soft tissue infections 1
Vascular Specialist Referral:
- Consider if the affected limb appears ischemic 1
- Vascular assessment is essential before aggressive wound management in compromised circulation 1
Special Considerations
The pathophysiology of DTI involves injury beginning in muscle closest to bone, which may not be visible in early stages 2. This "bottom-up" injury pattern explains why surface appearance may not reflect the severity of underlying tissue damage. Temperature monitoring through thermographic imaging may detect incipient DTI before visible changes occur 3.