Adjunctive Use of Noncontact Low-Frequency Ultrasound* for Treatment of Suspected Deep Tissue Injury: A Case Series

Background: As a fairly recent addition to the pressure ulcer staging system, suspected deep tissue injury (SDTI) is less well-studied than other pressure ulcers.^1,2,3 Consequently, the optimal therapy for resolving these underlying wounds to prevent progression to advanced-stage (Stage III and IV) pressure ulcers remains uncertain.^4.5

Treatment Protocol:  Standard SDTI treatment protocol at our institution included repositioning schedule; assistive repositioning turning devices; trypsin-balsam-of-Peru ointment^† twice daily with optional soft-silicone bordered foam;^‡ appropriate support surfaces including static-air overlay** added to ICU beds; dietetic consultation; heel-off-loading boots; and institutional Braden Scale Prevention Policy. However, this protocol often did not prevent progression to advanced-stage pressure ulcer. In March 2009, for SDTI identified within 3-4 days of onset, we added noncontact low-frequency ultrasound* (NLFU) daily for 5 days, then every other day until healed to our SDTI treatment protocol.

Case Series:  Four case studies will be presented. (1) 80-year-old woman status post CABG and MVR had an SDTI (4 x 6 cm) of the coccyx. (2) 28-year-old woman status post drug overdose with frequent seizures was admitted with an SDTI (9 x 5 cm) on the coccyx/buttocks. (3) 90-year-old woman status post trochanteric nailing had an SDTI (5 x 5 cm) on the right buttock. (4) 78-year-old man with history of multiple recent hospitalizations following CABG had an SDTI (2 x 1.4 cm) of the left heel. Outcomes: In all 4 cases, areas of SDTI showed similar progression and ultimately were classified as Stage II pressure ulcers. Within 1 to 2 weeks, dark purple/maroon discoloration dulled and then progressed to fibrin crust, scale or flaky epidermis that sloughed off revealing a pink, moist wound bed or re-epithelialization.
Conclusion: Combination of SDTI treatment protocol and NLFU appears to have minimized the extent of tissue infarction, which in turn, hastened the healing process.