Management of Deep Tissue Injury (DTI) of the Heel

Initial Assessment and Management

The American College of Cardiology recommends thoroughly assessing the wound to determine depth, extent, and presence of infection, using a sterile blunt probe to measure depth and check for exposed bone 3
Evaluate vascular status by checking pedal pulses; if pulses are diminished, consider vascular studies (ABI, TcPO2) to determine if revascularization is needed, as recommended by the American College of Cardiology 2, 3
Assess for peripheral neuropathy using a 10-g monofilament test, as neuropathy affects wound healing and treatment approach, according to Clinical Infectious Diseases 3

Implement immediate pressure relief using appropriate offloading devices, such as heel-relief shoes, as recommended by the American Diabetes Association 1, 4
Total contact casting or non-removable walkers may be used for severe cases to ensure compliance with offloading, according to the American College of Cardiology 2, 4

Debride necrotic, non-viable tissue while preserving viable tissue, as recommended by the American Diabetes Association 4, 5
Apply appropriate wound dressings based on wound characteristics, such as continuously moistened saline gauze for dry or necrotic wounds, according to Clinical Infectious Diseases 6, 4
Use hydrogels for dry/necrotic wounds to facilitate autolysis, as recommended by Clinical Infectious Diseases 6
Use alginates for exudative wounds, according to Clinical Infectious Diseases 6
Use hydrocolloids for absorbing exudate and facilitating autolysis, as recommended by Clinical Infectious Diseases 6

If infection is present, obtain tissue samples for culture prior to initiating antibiotic therapy, as recommended by Clinical Infectious Diseases 3, 5
Provide appropriate antibiotic therapy based on culture results, according to Clinical Infectious Diseases 7, 8
For moderate to severe infections, consider early surgical intervention (within 24-48 hours) to remove infected and necrotic tissue, as recommended by the American Diabetes Association 8

Consider surgical consultation for deep abscesses or compartment syndrome, according to the American Diabetes Association 5
Consider surgical consultation for necrotizing soft tissue infections, as recommended by the American Diabetes Association 5, 8
Consider surgical consultation for osteomyelitis with spreading soft tissue infection, according to the American Diabetes Association 5
Consider surgical consultation for severe ischemia with infection, as recommended by Clinical Infectious Diseases 6, 8

If ischemia is present, urgent vascular specialist consultation is recommended, according to the American College of Cardiology 2, 8
Revascularization (endovascular or bypass) may be needed before definitive wound management in cases of severe ischemia, as recommended by the American College of Cardiology 2, 5

Regularly measure and document wound size, extent of surrounding cellulitis, and quality/quantity of drainage, as recommended by Clinical Infectious Diseases 3
Reassess the wound weekly to evaluate healing progress and adjust treatment plan accordingly, according to the American Diabetes Association 4, 5
Once healed, implement a comprehensive prevention program to reduce recurrence risk, as recommended by the American Diabetes Association 4