Deep tissue injury: the state of the science

Published on October 7, 2014   48 min
0:04
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.
0:56
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.
2:32
The original definition of deep tissue injury still exists today. It was finalized in 2007 and is "purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear." The diagram that you see on the slide depicts deep tissue injury fairly well in that there is damage at the level of the bone-muscle interface by the time that you see purple skin up on top, which makes it a unique pressure ulcer in that it actually moves from the bottom to the top. It works from the inside to the outside, rather than our older thinking that a stage I could evolve into a stage II, and II into a III and III into a IV. So this is the upside-down theory of pressure ulcer formation.
3:25
We went on to describe deep tissue injury and everything we really knew about deep tissue injury in 2007. And that wasn't a lot. We knew that, from a tactile perspective, they were much like a stage I. They could be firm or mushy or boggy. Depending on where you saw them in the trajectory, they might initially be cool, and then, as they started to necrose, they would become warmer. We knew for sure they were painful. We had lots and lots of clinical experience with patients with DTIs that these patients complained bitterly of the pain. The pain was ischemic in nature, intense in nature, requiring pretty high-level narcotics to manage it. We also knew it was difficult to see these deep tissue injuries in patients with darker skin tones. We knew that there was an evolutionary step in the process of DTI in which there was a thin blister that developed. And it looked like a sunburn that the epidermis had peeled off. In some of the cases that I had seen, these wounds became completely necrotic. And there was this slippery eschar sitting on the top of them. And we knew, of course, that they could evolve very quickly into full-thickness ulcers even if we did all the right things, because the damage had already been done by the time you saw purple tissue.
4:45
Some of you are familiar with Dr. Koziak's model from the 1950s. And I realize it's a very outdated model. But I think it speaks to the idea of deep tissue injury fairly well. So I want to use it. I recognize its age. What Dr. Koziak said was that, at intense amounts of pressure, you could get a pressure ulcer in a very short period of time. And it would take a longer period of time if the pressure intensity was not as high. It would take a longer duration. The concept of intensity and duration are still true in the deep tissue injury story. And what we're seeing today is that ulcers are developing when pressures are intense in fairly short amount of time. And we're still seeing, of course, the standard, classic stage I to II to III to IV evolution. But I think the two ulcers are different. And where I really want to focus your attention is where the purple circle is. And that's right at three hours, because that's where the curve starts to change. And what we're seeing is that patients who've been in the operating room for three hours is when they start to show signs of pressure ulcers from the OR. So that's perhaps our key time frame is that three-hour window of time when pressures are fairly intense. And the operating room tables, of course, are not known to be luxurious places where you sink in. They're pretty hard. We don't know the time to ulcerate on the MRI table. We don't know the time to ulcerate on a concrete floor. And yet, we know that those surfaces are extremely hard. And so we'd expect the time to be even shorter.
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Deep tissue injury: the state of the science

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