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.

Wound management in the ED is only a starting point, and appropriate referral and follow-up are key to an improved outcome. In the interim, dressing chronic and high-risk wounds in the ED contributes towards establishing a nontraumatic, moist environment that promotes healing, absorbs excessive exudate, minimizes infection, and reduces pain. Thousands of dressing options and combinations are available, each with unique characteristics that suit specific wounds, budgets, and home care capabilities. Such nuance relies on wound care specialists, but initial dressing selection can be simplified in the short term. Generally, a dry wound requires a dressing that retains moisture, while exudative ones should be covered with a dressing that enhances moisture absorption to maintain an ideal healing environment. Dressing options to consider in the ED include the following:

• Non-woven gauze dressings impregnated with petroleum, saline, or zinc salts are the most versatile for nearly all wound types. They require an overlying (secondary) dressing to secure them to the surrounding skin and should be changed daily. Avoid using dry dressings or wet-to-dry bandages, which can damage open wounds. Examples include Adaptic, Xeroform, Telfa, and Dermagen.
• Foam dressings are ideal for multiple types of chronic wounds that are mild to moderately exudative, such as diabetic ulcers, venous ulcers, and pressure injuries. They are available in various sizes and configurations, and can stay in place in uninfected wounds for up to five days. They should be avoided in dry wounds (arterial ulcers) or necrotic wounds with an eschar. Examples include Mepilex, Tegaderm, and Optifoam.
• Hydrogel dressings are preferred for minor burns, partial- and full-thickness wounds, wounds with necrosis, and deep wounds with tunneling or sinus tracts. Compared with other dressing types, hydrogels lack inherent antimicrobial properties, are expensive, and require frequent changes, particularly in heavily exuding wounds. Examples include Kerralite Cool, Medihoney, and DynaGel.
• Film dressings are thin sheets of a transparent polymer coated with an adhesive that promotes a moist, healing environment while protecting the wound from mechanical trauma and bacterial invasion. They are ideal for superficial wounds, minor burns, lacerations, stage I and II pressure injuries, superficial skin ulcers (blisters), minimally infected wounds, and for securing other dressing types. They can remain in place for up to seven days. Examples include Tegaderm and Opsite.

 Conclusion

Poorly healing wounds pose a significant burden on health care systems and personal well-being, and their presence as a harbinger of severe morbidity and mortality must be appreciated. Emergency physicians are experienced health care detectives well versed in the importance of early recognition, initial assessment, stabilization, and referral of patients with new-onset or progressive disease. Effective wound management emphasizes maintaining skin integrity, integrating infection control, and providing an appropriate wound environment through tailored dressing selection.

The ED is not a substitute for outpatient wound management but rather the gateway for where many patients enter the health care system. Emergency physicians will need to weigh the severity of the wound and infection status to determine if inpatient versus outpatient management is most appropriate. Social determinants, such as a history of poor medication compliance, housing insecurity, lack of a support system and transportation resources, comorbidities, or need for vascular intervention, may necessitate inpatient admission. Photographic documentation of the wound is helpful to enhance continuity of care. Implementing a thoughtful, cost-effective approach to ED wound care centered on optimizing wound healing and referral may improve patient outcomes, reduce admissions, and optimize resources.

Back to the patient. On closer exam, the patient’s blanching erythema of his lower legs was secondary to chronic venous insufficiency with concern for early-stage development of a skin ulcer. A foam dressing was placed over the ulcer on his left ankle, and compression dressings were applied to his lower legs to reduce swelling, transitioning to compression stockings in the coming days. The ED case manager arranged follow up in the wound care clinic in two days.

References                  

1. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value in Health. 2018;21(1):27-32.
2. Bluestein D, Javaheri A. Pressure ulcers: prevention, evaluation, and management. Am Fam Physician. 2008;78(10):1186-1194.
3. Glauser J. Wound management: Do we know anything for sure? Emergency Medicine News 2004;26(13):19.
4. Hoversten K, Kiemele L, Stolp A, et.al. Prevention, diagnosis, and management of chronic wounds in older adults. Mayo Clin Proc. 2020;95(9):2021-2034.