Complicated, Chronic, and Aging Skin Wounds

Key Practice Points

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Deep cutaneous and necrotizing infections are often heralded by severe pain before skin signs appear.
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Microorganisms responsible for deep infections can include community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), group A Streptococcus, and clostridia, in addition to a variety of gram-positive, gram-negative, and anaerobic bacteria.
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Treatment of severe, deep necrotizing infection requires a combination of surgical débridement and broad-spectrum antibiotics.
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Sutured wounds have a low infection rate. Infection is recognized by increasing pain, cloudy or purulent discharge, and palpable tenderness.
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If a sutured wound becomes infected, all of the sutures have to be removed. Attempts to maintain some sutures will lead to continued infection even if antibiotics are prescribed.
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Chronic skin ulcers are most often caused by diabetes, peripheral arterial or venous disease, and pressure.
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The main responsibility of an emergency caregiver when confronted with a chronic skin ulcer is to assess for life-threatening or limb-threatening emergencies.
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The goals of the emergency caregiver are to begin the process of reducing necrotic tissue load and to disinfect the wound to prepare for the growth of granulation tissue.
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Reduction of tissue load can begin with wet-to-dry dressings, and disinfection can begin with antibiotic therapy.
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Skin tears most often occur in aging skin or skin compromised by drugs such as corticosteroids.
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Skin tears are often best closed with wound tapes or wound adhesives. Compromised skin does not hold sutures well.
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Like skin ulcers, skin tears that have led to tissue loss should be referred to specialists in chronic wound care.

Although acute wounds and lacerations compose the bulk of wound care problems that present to emergency and urgent care facilities, the patients with complicated and chronic wounds can present a variety of challenges. Rarely, a small, even trivial, wound can become infected with bacteria that cause deep cutaneous and necrotizing infections. These wounds require rapid, aggressive diagnosis and intervention.

Despite the best efforts to cleanse and repair lacerations, a few patients return with symptoms and signs of infection. The diagnosis of infection has to be confirmed and followed by the steps needed to treat the infection and to promote healing.

Patients with chronic skin ulceration, a condition that affects more than 2 million people in the United States annually, can require emergency care. The goals of that care are limited but important. Professionals best perform the ongoing care, with eventual healing occurring, in a setting designed for and with expertise in chronic wound care.

Finally, a challenging wound care problem is skin tears in aged patients or skin affected by drugs such as corticosteroids. Sutures do not hold well and can tear through compromised skin. Treatment choices include wound tapes and wound adhesives. If there is tissue loss, these patients, like those with skin ulcers, should be referred to caregivers with experience in complicated wounds.

Deep Cutaneous and Necrotizing Infections

The most feared complication of a laceration, puncture, or other traumatic wound is a deep cutaneous and necrotizing soft tissue infection. This complication is rare. These infections are more likely to occur in older patients with diabetes, vascular compromise, and other chronic, debilitating illnesses. For these patients, deep infections are caused by a variety of gram-positive, gram-negative, and anaerobic organisms. The lower extremity is the most commonly affected site. The perineum and surgical incisions also are vulnerable to these infections. The overlying skin becomes discolored and swollen and can evolve into blebs and exudative lesions. These patients require extensive evaluation, including radiographs of the involved site. Broad-spectrum antibiotics are administered. A surgical consultation is obtained as soon as possible if the infected area is life threatening or limb threatening.

In a young, healthy patient with a minor wound, the most important feature of a developing deep necrotizing and fascial infection is pain out of proportion to clinical findings. Patients may or may not present to a care facility at the time of the wounding. Within hours, however, they begin to complain of severe pain at the wound site. The surrounding skin and soft tissue are minimally involved. The most likely organisms to be present in this setting are beta-hemolytic streptococci or the clostridia. These infected wounds can progress to full toxic streptococcal syndrome or gas gangrene.

Because these infections are rare, they often are not recognized until skin changes occur and the patient exhibits systemic symptoms, including tachycardia, tachypnea, acidosis, and eventually hemodynamic instability. A high index of suspicion and a willingness to act early in the course may lessen the severity and improve the outcome.

Evaluation and Treatment

Whenever a deep, necrotizing infection is suspected after a laceration or other wound occurs, the following diagnostic and treatment steps are performed:

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Complete hematologic tests, including clotting studies, and biochemical profiles are obtained.
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Oxygen saturation is determined and oxygen supplementation is begun if indicated.
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Intravenous fluids are begun with normal saline or lactated Ringer’s solution.
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Radiographs of the involved area are taken to assess for foreign-body or gas formation.
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A Gram stain is performed on any exudates or bleb fluid to determine the presence of organisms. Gram-positive rods can be present in clostridial infections, and gram-positive cocci are indicative of beta-hemolytic streptococci.
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Broad-spectrum antibiotics, such as piperacillin/tazobactam, or clindamycin/gentamicin, are administered. In cases in which the diagnosis of clostridia is confirmed, high-dose penicillin is given. It is important to note that prompt administration of antibiotics can improve outcome.
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A surgical consultation is obtained. Immediate surgical intervention may be necessary as a limb-saving or lifesaving measure.
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In cases of suspected or confirmed clostridial myonecrosis or gas gangrene, hyperbaric oxygen has been shown to be an effective adjunct. If available, consultation with an hyperbaric oxygen specialist is recommended.

Infections of Laceration Repair

Approximately 3% to 6% of wounds and lacerations treated in an emergency department (ED) become infected. Signs of infection include increasing pain and tenderness of the wounded area, redness spreading away from the wound edges, and discharge or pus formation. Most patients return to the original facility or caregiver for treatment.

Before any action is taken, the diagnosis of infection needs to be confirmed. Patients react differently to healing wounds. Normal discomfort for most can be very painful for others. All wounds exude a small amount of thin, bloody material for 1 or 2 days. A narrow margin of erythema is normal. When to declare these findings abnormal and consistent with infection can be a judgment call. Sometimes, when the diagnosis is unclear, the patient can be reexamined in 24 hours. If a true infection is present, it becomes apparent in the next 24 to 48 hours. Some clinicians place the patient on antibiotics during that period in an attempt to stop an early infection. If an infection has become established, however, antibiotics are unlikely to suppress it while the sutures are still in place.

Management of Infected Lacerations

When an infection has been diagnosed, the following guidelines are suggested:

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Removal of sutures: Sutures act as foreign bodies. In the face of infection, all sutures, including deep and skin closure sutures, must be removed. Attempts to remove only some of the sutures or every other one only prolong the infection.
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Cleaning and irrigation: When sutures are removed, the wound is drained and irrigated to remove any collection of pus or infected exudates.
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Wound exploration: The wound is explored for retained foreign material or debris.
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Antibiotic therapy: Because most infections are caused by Staphylococcus aureus or streptococci, a first-generation cephalosporin, cephalexin, can be administered for 7 to 10 days. If there is significant cellulitis, therapy can be started with a dose of intravenous cefazolin. In the event of allergy to β-lactam antibiotics, clindamycin or a macrolide can be substituted. If CA-MRSA is suspected, trimethoprim/sulfamethoxazole (TMP/SMX) or tetracyline can be substituted or added. Local sensitivities to CA-MRSA can dictate the appropriate antibiotic.
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Home care: The wound is cleansed daily with soap and water. Hydrogen peroxide can be added or used alone. Cotton swabs or small sterile sponges can be used to remove debris and exudates until the infection is brought under control. The wound is covered with a gauze pad and tape between cleanings.
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Consultation: Wounds in cosmetically unimportant locations can be left to heal by secondary intention. If cosmesis is a concern, the patient can be referred to a plastic surgeon for further care.