Haemodynamic-Focused Bedside Ultrasound Enhances Early Detection of Sacral Pressure Injuries in Immobilised Polytrauma Patients.

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Learn more: PMC Disclaimer | PMC Copyright Notice Int Wound J . 2026 Jun 4;23(6):e70966. doi: 10.1111/iwj.70966 Haemodynamic‐Focused Bedside Ultrasound Enhances Early Detection of Sacral Pressure Injuries in Immobilised Polytrauma Patients Jing Chen 1 , Yi diWen 1 , Dongxu Zhu 1 , Yan Du 1, ✉ , Luo Yuan 2, ✉ Author information Article notes Copyright and License information 1 Ultrasonography Department of Chongqing Emergency Medical Center, Chongqing, China 2 Department of Cardiothoracic Surgery of Chongqing Emergency Medical Center, Chongqing, China * Correspondence: Yan Du ( 845825927@qq.com ), Luo Yuan ( luoyuan1724@163.com ) ✉ Corresponding author. Revised 2026 Feb 25; Received 2025 Aug 8; Accepted 2026 May 25; Collection date 2026 Jun. © 2026 The Author(s). International Wound Journal published by Medicalhelplines.com Inc and John Wiley & Sons Ltd. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made. PMC Copyright notice PMCID: PMC13238523  PMID: 42242745 ABSTRACT Early detection of sacral pressure injuries (PIs) in immobilised polytrauma patients remains challenging. This study evaluated ultrahigh‐frequency (UHF) ultrasound combining structural and haemodynamic parameters for early PI diagnosis. In a prospective cohort of 73 polytrauma patients (Injury Severity Score 16–25), daily sacrococcygeal assessments were performed over 15 days using UHF ultrasound (Mindray Resona 11; L20‐5 s probe). Parameters included 2D morphology, perfusion (colour power angiography [CPA]), flow metrics (peak systolic velocity [PSV]), Braden Scale and inflammatory markers. PI incidence was 27.4% ( n = 20; all stage I/II). Haemodynamic markers outperformed 2D ultrasound: CPA grade ≥ 1 (AUC = 0.858, 80.0% sensitivity) and PSV > 5.55 cm/s (AUC = 0.841, 95.0% sensitivity). Combined CPA + PSV achieved superior accuracy (AUC = 0.922). Systemic inflammation showed no intergroup differences. UHF ultrasound detects early PIs by capturing ischaemia‐reperfusion changes. The CPA + PSV protocol provides nurses with a rapid (< 5 min), sensitive bedside tool to guide proactive interventions. Keywords: early diagnosis, haemodynamics, nursing assessment, point‐of‐care ultrasound, polytrauma, pressure injury Highlights UHF ultrasound detects early sacral pressure injury. CPA grade ≥ 1 and PSV > 5.55 cm/s signal incipient PI. CPA + PSV combination: 0.922 AUC, 80.0% sensitivity. A 5 min protocol guides proactive nursing interventions. 1. Introduction Pressure injury (PI) represents localised damage to the skin and/or underlying soft tissue, typically over bony prominences, resulting from prolonged pressure or pressure combined with shear [ 1 ]. These injuries significantly impact healthcare systems by extending hospital stays, escalating care costs and potentially increasing patient mortality [ 2 ]. Patients sustaining severe multiple injuries (major trauma) constitute a high‐risk cohort for PI due to critical illness, prolonged immobilisation and multifactorial physiological compromise [ 3 ]. Early‐stage PI manifests subtly, complicating timely identification and intervention, which is critical since stage 1 injuries remain largely reversible with prompt management [ 4 ]. Ultrasound has emerged as a valuable bedside tool for PI assessment, offering non‐invasive, real‐time evaluation of tissue integrity [ 5 ]. Current clinical practice primarily utilises two‐dimensional (2D) ultrasound to monitor morphological changes in pressure‐prone areas [ 6 ]. However, emerging evidence indicates that 2D findings—such as soft tissue thickening, oedema or architectural disruption—may persist even after ischemic injury resolution, limiting their specificity for active pathology [ 7 ]. Concurrently, other imaging modalities like photoacoustic imaging (PAI) are being explored for their ability to provide functional metabolic data, such as haemoglobin concentration and oxygen saturation, offering insights into tissue viability [ 8 , 9 ]. Crucially, ischaemia–reperfusion injury underpins PI pathogenesis, characterised by reduced local vascular perfusion and impaired microcirculation [ 10 , 11 ]. This suggests that haemodynamic monitoring may offer superior sensitivity for early PI detection compared to structural imaging alone. The sacrococcygeal region is particularly vulnerable in immobilised polytrauma patients due to sustained pressure exposure during supine positioning [ 3 ]. This study therefore aimed to: 1. Characterise ultrahigh‐frequency (UHF) ultrasound features of early sacrococcygeal PI in major trauma patients. 2. Evaluate the diagnostic utility of UHF‐derived perfusion parameters. 3. Propose a refined imaging protocol for early PI detection. By integrating structural and haemodynamic UHF markers, we seek to establish a more sensitive, clinically feasible approach for incipient PI diagnosis. 2. Materials and Methods 2.1. Study Design and Population This prospective observational study consecutively enrolled adult patients (≥ 18 years old) presenting with severe multiple injuries (polytrauma) at our tertiary trauma centre between November 2023 and January 2024. Polytrauma was defined as injury to two or more anatomical regions resulting from a single mechanical event, with an injury severity score (ISS) ranging from 16 to 25. Eligible participants were required to meet all of the following criteria: an anticipated hospital stay exceeding 15 days, availability of complete clinical documentation, immobilisation necessitating assisted posture adjustment and willingness to undergo serial sacrococcygeal ultrasound examinations. Exclusion criteria included pre‐existing sacrococcygeal PIs or local infections, contraindications to ultrasound assessment and comorbidities known to influence PI risk (e.g., diabetes, hypertension or malignancies). The study was approved by the Ethics Committee of our Center (approval number: RS202411). Written informed consent was obtained from all conscious patients; for unconscious patients, consent was provided by their legal representatives. 2.2. Group Classification All enrolled patients underwent daily standardised assessments for 15 consecutive days post‐admission. These assessments included both clinical skin inspection and bedside ultrasound examination of the sacrococcygeal region. Patients who developed a PI during this observation period, staged according to the 2019 International Clinical Practice Guidelines, were assigned to the PI group. Those who did not develop a PI comprised the non‐PI group. Based on our longitudinal data, the characteristic ultrasonographic changes (e.g., elevated CPA grade and PSV) were typically detectable 1–3 days prior to the clinical diagnosis of a PI. 2.3. Ultrasound Protocol Ultrasound examinations were performed using a Mindray Resona 11 system equipped with a linear high‐frequency L20‐5 s transducer (frequency range: 11.5–20 MHz). With the patient placed in a standardised lateral decubitus position to relieve local tissue pressure, a generous layer of ultrasound transmission gel was applied to ensure optimal acoustic coupling. The probe was held perpendicular to the skin surface with minimal pressure to avoid altering tissue architecture or perfusion. A systematic scanning protocol was followed (Figure 1 ). Two‐dimensional (2D) imaging was first conducted by sweeping the probe in longitudinal and transverse planes across the sacrococcygeal region. The subcutaneous tissue was evaluated for the following predefined features: heterogeneous echogenicity, loss of fascial continuity (architectural disorganisation) and the presence of hypoechoic foci. Each feature was scored as present (1) or absent (0) based on established criteria [ 10 ]. FIGURE 1. Open in a new tab Schematic of the standardised bedside ultrasound scanning protocol for the sacrococcygeal region. (A) Side‐view schematic depicting the patient in a lateral decubitus position, assisted by a nurse to maintain posture, with the ultrasound probe applied to the sacrococcygeal area. (B) Top‐down anatomical view illustrating the precise probe placement over the sacrum, with the orange box representing the longitudinal and the blue box representing the transverse scanning plane relative to the spine. Subsequently, Doppler analysis was performed. Blood flow was assessed semi‐quantitatively using colour Doppler flow imaging (CDFI) and the more sensitive colour power angiography (CPA), with perfusion graded from 0 to 3 according to the Adler classification [ 11 ]. For quantitative spectral Doppler analysis, the pulse‐wave Doppler sample volume was placed over representative arterial vessels within the region of interest (ROI). The following parameters were measured from the spectral waveform: peak systolic velocity (PSV). Image analysis and quantification were performed as follows. The ROI for both semi‐quantitative and quantitative Doppler analysis was defined as the subcutaneous tissue layer overlying the sacral bone within the scanned field. For semi‐quantitative grading (CDFI/CPA), the entire ROI visible in a single still frame was assessed. For quantitative spectral Doppler analysis, the pulse‐wave Doppler sample volume (fixed at 1.5 mm) was placed over colour flow signals within the ROI. Vessel selection criteria: If multiple discrete arterial signals (characterised by pulsatile flow synchronous with the cardiac cycle) were present, the vessel with the strongest and most consistent colour filling on CPA and the highest Doppler spectral waveform was selected for measurement, as it was considered to represent the dominant local haemodynamic response. PSV were measured offline from stored cine loops by the same sonographer, with the average value calculated over three consecutive cardiac cycles. All scans were conducted by an experienced sonographer who was blinded to the patients' clinical assessments. 2.4. Clinical and Laboratory Measures The risk of developing a PI was assessed daily using the Braden Scale, which evaluates six subscales: sensory perception, moisture, activity, mobility, nutrition and friction/shear. Inflammatory status was monitored via laboratory testing. The peak recorded values of the following markers during the observation period were collected for analysis: serum amyloid A (SAA), procalcitonin (PCT), interleukin‐6 (IL‐6), high‐sensitivity C‐reactive protein (hs‐CRP), absolute neutrophil count (NE) and white blood cell count (WBC). 2.5. Statistical Analysis Data analysis was performed using SPSS software (version 27.0). The normality of continuous variables was assessed with the Shapiro–Wilk test. Normally distributed data are presented as mean ± standard deviation and were compared using the independent samples t ‐test. Non‐normally distributed data are presented as median with interquartile range (IQR) and were compared using the Mann–Whitney U test. Categorical variables are expressed as counts and percentages and were compared using the Chi‐squared test or Fisher's exact test, as appropriate. The diagnostic performance of individual and combined ultrasound indices for detecting PI was evaluated by constructing receiver operating characteristic (ROC) curves, with areas under the curve (AUC) compared using the DeLong method. Statistical significance was set at a two‐tailed p‐value of < 0.05. A post‐hoc power analysis was conducted using G Power software (version 3.1) to justify the sample size. Based on the observed large effect size (Cohen's d = 0.85) for the primary haemodynamic parameter (PSV), with an alpha level of 0.05 and the final group sizes (PI: n = 20, non‐PI: n = 53), the analysis indicated a statistical power of 96% (1‐ β = 0.96), confirming that the study was sufficiently powered to detect significant group differences. 3. Results 3.1. Study Population Characteristics A total of 73 patients with severe multiple injuries were enrolled. The cohort had a mean age of 48.1 ± 12.5 years (36 male, 37 female). PI developed in 27.4% (20/73) of participants during the observation period, all classified as early‐stage PI (Stage I/II). No significant differences were observed in gender distribution ( χ 2 = 0.2, p = 0.651) or mean age between PI (49.8 ± 10.9 years) and non‐PI groups (47.5 ± 13.1 years; t = −0.681, p = 0.498). The Braden Scale score was significantly higher in the PI group (median 16.0, IQR 14.0–18.0) versus non‐PI group (median 13.0, IQR 12.0–15.5; Z = −3.0, p = 0.002). 3.2. Ultrasonic Parameter Comparisons Significant differences in ultrasonographic features were observed between PI and non‐PI groups (Table 1 ). Two‐dimensional ultrasound revealed a higher prevalence of heterogeneous subcutaneous echoes, unclear tissue hierarchy, fascial discontinuity and hypoechoic foci in PI patients. Semi‐quantitative Doppler analysis showed significantly higher CDFI and CPA grades in the PI group, with a predominance of CPA Grades 2–3. Quantitative spectral Doppler demonstrated markedly elevated PSV in PI patients compared to non‐PI patients (median PSV 7.5 vs. 4.5 cm/s, p < 0.001). These haemodynamic alterations characterised early PIs, as exemplified by the increased microvascular perfusion on CPA compared to CDFI in a representative case (Figure 2 ) and the elevated PSV in a PI patient versus the normal flow spectrum in a non‐PI patient (Figure 3 ). No significant differences were found in other Doppler parameters or inflammatory biomarkers. TABLE 1. Comparison of ultrasonographic features between PI and non‐PI groups. Parameter Non‐PI group ( n = 53) PI group ( n = 20) χ 2 p 2D Ultrasound Heterogeneous echoes 23 (43.4) 16 (80.0) 7.8 0.005 Unclear tissue hierarchy 13 (24.5) 15 (75.0) 15.6 < 0.001 Fascial discontinuity 10 (18.9) 9 (45.0) 5.2 0.023 Hypoechoic foci 6 (11.3) 13 (65.0) 21.7 < 0.001 Colour Doppler flow imaging (CDFI) grade Grade 0 38 (71.7) 4 (20.0) 19.0 < 0.001 Grade 1 13 (24.5) 10 (50.0) Grade 2 1 (1.9) 4 (20.0) Grade 3 1 (1.9) 2 (10.0) Colour power angiography (CPA) grade Grade 0 25 (47.2) 1 (5.0) 28.0 < 0.001 Grade 1 17 (32.1) 3 (15.0) Grade 2 8 (15.1) 5 (25.0) Grade 3 3 (5.7) 11 (55.0) Open in a new tab FIGURE 2. Open in a new tab Comparison of CDFI and CPA in sacrocaudal blood flow in patients with early‐stage PI. Male, 51 years old, stage I PI, A was CDFI Grade 1, B was CPA Grade 3; PI, pressure injury; CDFI, colour Doppler flow imaging; CPA, colour power angiography. FIGURE 3. Open in a new tab Comparison of the PI and non‐PI sacrocaudal flow spectrum in patients with severe multiple injuries. (A) female, 53 years old, hospitalised for 36 days, no pressure injury in sacrocaudal; (B) female, 49 years old, hospitalised for 27 days, sacrocaudal Stage I pressure injury. 3.3. Correlation and Diagnostic Performance Spearman correlation analysis revealed positive associations between Braden scores and PSV ( r = 0.3, p = 0.007) as well as EDV ( r = 0.3, p = 0.030). CPA hyperperfusion (Figure 1 ) and elevated PSV (Figure 2 ) characterised early PIs. A negative correlation was observed between spectral pulsatility index values and SAA levels ( r = −0.3, p = 0.006). ROC analysis demonstrated that individual two‐dimensional ultrasound parameters showed moderate diagnostic efficacy (AUC range 0.631–0.793). Semi‐quantitative CPA grading achieved an AUC of 0.858 (95% C: 0.759–0.957) with 80.0% sensitivity and 79.2% specificity at Grade ≥ 1. Quantitative PSV measurement showed an AUC of 0.841 (95% CI: 0.745–0.937) with 95.0% sensitivity at a cut‐off > 5.55 cm/s. The combination of PSV and CPA significantly improved diagnostic performance (AUC 0.922, 95% CI: 0.852–0.991). The integrated approach incorporating all UHF ultrasound parameters achieved near‐perfect discrimination (AUC 0.998, 95% CI: 0.992–1.000) with 100.0% sensitivity and 96.2% specificity (Table 2 ). TABLE 2. Diagnostic efficacy of ultrasound parameters for early‐stage PI. Parameter AUC (95% CI) p Sensitivity (%) Specificity (%) Cut‐off Braden scale score 0.730 (0.608 ~ 0.853) 0.003 80.0 56.6 ≤ 16 2D Ultrasound combined diagnosis 0.793 (0.664 ~ 0.923) < 0.001 65.0 90.6 — CPA grade 0.858 (0.759 ~ 0.957) < 0.001 80.0 79.2 ≥ 1 PSV 0.841 (0.745 ~ 0.9370) < 0.001 95.0 67.9 > 5.55 Combination of PSV and CPA 0.922 (0.852 ~ 0.9910) < 0.001 80.0 94.3 — Combination of 2D, CPA and PSV. 0.998 (0.992 ~ 1.003) < 0.001 100.0 96.2 — Open in a new tab Abbreviations: CPA, colour power angiography; PSV, peak systolic velocity. 4. Discussion This study identified a clinically significant incidence of early‐stage sacrococcygeal PIs (27.4%) in immobilised patients with severe multiple injuries, attributable to prolonged mechanical stress and restricted mobility [ 12 ]. Vigilant nursing surveillance enabled timely intervention, preventing progression to advanced stages. While the Braden Scale remains a cornerstone for risk assessment [ 13 ], and its lower scores in the PI group ( p = 0.002) align with established institutional thresholds [ 14 ], its limited diagnostic accuracy (AUC = 0.730) in this cohort reflects inherent constraints. These include a finite set of assessed variables and susceptibility to assessor subjectivity [ 15 , 16 ]. These limitations underscore the need for objective adjunctive tools in high‐risk populations. Bedside two‐dimensional ultrasound effectively visualised subclinical tissue changes, such as oedema and architectural distortion [ 17 , 18 ]. Notably, a substantial proportion of non‐PI patients (56.2%) exhibited such abnormalities. This suggests these sonographic findings may represent reversible, pre‐pathological states [ 19 ], highlighting the dynamic nature of early tissue stress. The discrepancy between ultrasound signs and clinical PI incidence supports the use of imaging for proactive intervention before overt injury develops. Pathophysiologically, the observed elevation in CPA and CDFI grades within the PI group ( p < 0.001) supports the ischaemia–reperfusion injury model underlying PI development [ 20 , 21 ]. This is consistent with prior research comparing clinical and imaging techniques for PI assessment [ 22 ]. This is consistent with the understanding that abnormal sacrococcygeal blood flow is a causative factor in PI [ 23 ]. Initial pressure induces capillary occlusion and ischaemia; subsequent relief triggers a reactive hyperaemic response. The significantly increased PSV in PI patients signifies this pathological reperfusion, a maladaptive response involving endothelial dysfunction and altered microvascular resistance [ 24 , 25 , 26 ]. The superior sensitivity of CPA over CDFI for detecting low‐velocity flow likely accounts for its higher grading in our study, enhancing its utility for capturing early microcirculatory changes. In contrast to studies that have reported systemic inflammatory changes in other well‐defined high‐risk populations—such as older adults [ 27 ], perioperative patients [ 28 ], intubated patients in intensive care [ 29 ] or individuals with mobility limitations [ 30 ]—no significant differences in systemic inflammatory markers were observed in our cohort of trauma patients. This finding implies that in the absence of active infection, the early pathogenesis of PI in this specific population is predominantly driven by biomechanical factors, namely prolonged immobilisation and direct pressure [ 31 , 32 ], which precede and may occur independently of a detectable systemic inflammatory response. Regarding clinical translation, the combination of CPA and PSV achieved high diagnostic accuracy (AUC = 0.922) while maintaining feasibility for nursing workflows. We propose a simplified protocol for routine screening: a CPA grade ≥ 1 concurrent with a PSV > 5.55 cm/s should prompt intensified preventive measures (e.g., increased repositioning frequency, prophylactic dressings). For specialist confirmation or comprehensive assessment, a full ultrasound evaluation integrating 2D, Doppler and spectral parameters remains valuable. 5. Conclusion In immobilised polytrauma patients, prolonged mechanical stress significantly elevates the risk of early‐stage (I/II) sacrococcygeal PIs. While the Braden Scale provides essential risk stratification, its diagnostic limitations necessitate supplementary objective tools. Bedside UHF ultrasound, particularly the integration of semi‐quantitative CPA grading and quantitative PSV measurement, offers a sensitive and practical method for detecting the subclinical haemodynamic alterations characteristic of incipient PI. The observed hyperaemic pattern substantiates ischaemia–reperfusion injury as a key early mechanism. Implementing a rapid CPA + PSV protocol during routine care, supported by targeted training, can significantly enhance early detection and guide proactive, personalised interventions for this vulnerable population. Funding This work was supported by the Chongqing Science and Health Joint Medical Research Youth Project (2025QNXM015) and Open Research Project of the Chongqing Key Laboratory of Emergency Medicine (2023KFKT02). Conflicts of Interest The authors declare no conflicts of interest. Contributor Information Yan Du, Email: 845825927@qq.com. Luo Yuan, Email: luoyuan1724@163.com. 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