This is the second visit in two weeks for an elderly gentleman who is concerned about his legs being red and swollen. During the first visit, he was diagnosed with cellulitis and placed on cephalexin. Today, he notes worsening swelling and a blister forming near his left ankle. The pain makes it difficult for him to ambulate unassisted through his home.

Nearly 10 million Medicare beneficiaries suffer from chronic wounds at an annual cost of almost $25 billion, a number that will likely grow as the population ages. About three percent of emergency department (ED) visits are due to skin and soft tissue infections, but data are lacking on the contribution of chronic wounds to this number. The impact of early-stage wounds, including those at risk of progression, is also poorly studied and may go unnoticed. This lack of awareness is unfortunate since such skin findings are often precursors of chronic disease that, if recognized and appropriately cared for, can offset future morbidity.

Poorly healing wounds are primarily the result of chronic venous insufficiency, peripheral (arterial) vascular disease, prolonged pressure-point skin injury, or neuropathy secondary to vascular disease or diabetes. These wounds do not progress promptly through the normal healing process, typically stalling in the inflammatory phase, resulting in poor healing. Older persons; smokers; overweight, wheelchair-dependent, or bed-bound individuals; and those who are impoverished suffer higher rates of chronic wounds.

Emergency physicians should routinely inspect the skin of high-risk individuals for poorly healing wounds or skin changes that place them at risk for disease progression. Once identified, they must protect the skin from further injury. This includes keeping skin clean and dry, applying barrier cream to irritated areas and moisturizers to dry skin, and off-loading pressure points and positioning (and repositioning) the patient in the ED to avoid pressure injuries. Finally, clinicians must appropriately dress wounds to protect them from further injury.

Wound Awareness, Intervention

Emergency physicians should watch for evidence of skin injury, infection, signs of vascular insufficiency, and the healing state of existing wounds in ED patients. The location of the lesion often provides clues to the cause of the problem. A wound over the sacral area or heels in an immobile patient infers the likelihood of a pressure injury, whereas one on the lower leg signals a vascular etiology. Specific wound characteristics are particularly helpful in guiding the next steps in management. For example, the depth and viability of the wound base indicate the degree of chronicity, the need for debridement, and the importance of offloading and tissue protection to support healing. Evidence of infection suggests the necessity for further testing and antimicrobial medication. Additionally, lower leg edema invokes consideration for applying compression dressings or stockings.