By Lindsay D. Andronaco RN, BSN, CWCN, WOC, DAPWCA, FAACWS

Part 2 in a series on skin failure
For Part 1, Click Here

In March of 1989 the National Pressure Ulcer Advisory Panel (NPUAP) convened, during which Karen Lou Kennedy first described the Kennedy Terminal Ulcer (KTU) phenomenon. A KTU is an unavoidable skin breakdown or skin failure that is thought to be a perfusion problem exacerbated by vascular/profusion insufficiency, organ failure, and/or the dying process. A KTU is a visible sign, an explanation, of what is transpiring within the patient.

What Does Development of a Kennedy Terminal Ulcer Indicate?

As people are approaching the dying process, the internal organs may begin to slow down and go into multi-organ failure. Adequate skin perfusion requires 25-33% of cardiac output and if the body is medically compromised, you will notice signs of skin failure beginning to develop.

KTUs come on quickly and progress rapidly, often within hours. KTUs can be shaped like a pear or butterfly, with irregular borders. The ulcers are usually on the sacrum but can appear in other areas of the body. Generally, it starts out looking like a butterfly shaped deep tissue injury (DTI) or like an abrasion on the sacrum. KTUs then rapidly progress to become a full-thickness ulcer. KTUs become deeper and progress from red/purple, then turn to yellow, and then black/deep purple.

Treatment for a Kennedy Terminal Ulcer

The treatment for a KTU is the same as all other pressure ulcers. What you see is what you treat. When it is in the blanchable or non-blanchable intact skin stage, you will notice a purple area, similar to a DTI, that is irregular shaped. At this stage, relieve the pressure and protect the wound with a foam dressing. When it progresses to a partial-thickness ulcer, a hydrocolloid or foam dressing, or Trypsin-type ointment could be used. When it is a full-thickness wound, you could use a foam, gel, or hydrofiber/calcium alginate dressing to treat the ulcer. If there is slough or necrotic tissue you might want to consider a debridement method (enzymatic, autolytic, or mechanical). I personally treat conservatively and do not recommend sharp debridement unless it is a source of infection that is impacting the patient severely.

The majority of these ulcers do not improve. KTUs are generally thought to be a terminal sign for the patient. There have been patients thought to have a KTU and as they medically improved, the KTU reversed. However, most found with a KTU die within hours of development, or up to six weeks later. There have been few exceptions where patients have lived five or six months before passing.

*Off label use for Tripsin complex ointment

Sources:

Gentzkow GD, et al. Improved healing of pressure ulcers using Dermapulse, a new electrical stimulation device. Wounds. 1991;3(5):158-170.

Hiser B, Rochette J, Philbin S, et al. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy Wound Manage. 2006;52(2):48-59.

Kennedy-Evans K. Understanding the Kennedy Terminal Ulcer. Ostomy Wound Manage. 2009;55(9):6.

Kennedy Terminal Ulcer. Kennedy Terminal Ulcer Information and Warning Signs. Kennedy Terminal Ulcer. http://www.kennedyterminalulcer.com/. Accessed October 2, 2013.

Langemo D, Brown G. Skin fails too: Acute, chronic, and endstage skin failure. Adv. Skin and Wound Care. 2006;19(4):206-211.

National Pressure Ulcer Advisory Panel. Pressure Ulcer Category/Staging Illustrations. National Pressure Ulcer Advisory Panel. http://www.npuap.org/resources/educational-and-clinical-resources/press…. Accessed October 2, 2013.

Schank J. Kennedy Terminal Ulcer: The "Ah-Ha!" Moment and Diagnosis. Ostomy Wound Manage. 2009;55(9):40-44.

Sibbald RG, Krasner DL, Lutz JB, et al. The SCALE Expert Panel: Skin Changes At Life’s End. Final Consensus Document. October 1, 2009.

Yastrub D. Pressure or Pathology - Distinguishing Pressure Ulcers from the Kennedy Terminal Ulcer. Wound Ostomy Continence Nursing. 2010; 37 (3): 249-250.

About the Author
Lindsay (Prussman) Andronaco is board certified in wound care by the Wound Ostomy Continence Nursing Certification Board. She also is a Diplomate for the American Professional Wound Care Association. Her clinical focus is working with Diabetic Limb Salvage/Surgical/Plastic Reconstruction patients, though her interests and experience are varied and include surgical, urological and burn care, biotherapeutics and Kennedy Terminal Ulcer research. Lindsay is the 2011 recipient of the Dorland Health People's Award in the category of 'Wound Ostomy Continence nurse' and has been recognized in Case In Point Magazine as being one of the "Top People in Healthcare" for her "passionate leadership and an overall holistic approach to medicine."

Lindsay is board certified in wound care by the Wound Ostomy Continence Nursing Certification Board. She also is a Diplomate for the American Professional Wound Care Association. In 2011, Lindsay was honored with the Dorland Health People's Award in the category of 'Wound Ostomy Continence nurse.'

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.