Deep tissue injury: the state of the science

Published on October 7, 2014   48 min
The patient you're seeing on the slide is the poster child for the concept of deep tissue injury. This is a patient who was admitted to the hospital for an elective laparoscopic cholecystectomy and was left on a bedpan for no one really knows how long. But obviously, the deep tissue injury occurred at that time, because you could see the remnant, if you will, the imprint, of the bedpan up on the upper buttocks on the left-hand side of the screen. This patient died of this wound. It became completely necrotic, and she required diverting colostomy, multiple debridements, and died of sepsis from the wound. So what she taught us was that this problem that we today call deep tissue injury is actually a very serious problem and could lead to fatalities in pressure ulcers.
The idea of deep tissue injury was studied by the National Pressure Ulcer Advisory Panel. Myself and Richard Bennett were the original two investigators. And we decided to look at the history of deep tissue injury. And so we went back as far as Dr. Paget's work in 1874. And we found something interesting. We found that, even back in 1874, he described a skin problem that was purple when it first showed up. And purple was not in the original definition of pressure ulcers. As you well know, it talked about non-blanchable erythema. But Dr. Paget saw purple skin. And he also said that the deeper tissue dies, the muscle and the bone. And when it sloughs, the place behind is empty. So it told us, even back as far as 1874, that there was another phenomenon around. Dr. Groth, during World War II, created a pressure ulcer with a pressure plate and muscle. And due to the rate of deterioration, he said they were malignant by nature. Dr. Shea talked about closed pressure ulcers. They were never described in the staging systems that came into play in the later 1970s. And of course, we had a lot of clinical records to look at in which people were calling these wounds "purple" pressure ulcers or bruises over intact skin. Some people thought they were cautery burns when they saw them coming out of the operating room. But in all instances, they evolved into full-thickness ulcers.