Seven high-risk wounds

ED nurses should be on the lookout for wounds at high risk for infection, says Robert Herr, MD, MBA, FACEP, an emergency medicine consultant based in Salt Lake City, UT. Wounds at high risk are more likely to become infected, heal improperly, and potentially cause systemic complications.

When you’re managing a high-risk wound, it’s not a time to cut corners, he adds. "In the ED, flexibility is important and there are times you can cut corners. For example, a clean knife laceration on clean skin might not require irrigation—but when you have a wound at risk for infection, it’s essential to be extremely thorough in your management."

Here are seven types of wounds at risk for infection with tips for managing them.

1. Old wounds. The propensity for infection is directly related to number of contaminating bacteria in the wound edges, says Herr. "The bacteria begin to proliferate after about eight hours, so any wound older than 12 hours runs a higher risk of infection," he notes. Steristrips should be used to close old wounds, which shouldn’t be sutured closed.

2. Bites. "Animal or human bites inoculates a tremendous amount of bacteria into the wound," says Herr.

3. Puncture wounds. These may appear as tiny wounds on the surface but can be deep underneath—with foreign matter penetrated. "Nails sticking through a tennis shoe might drive bits of tennis shoe into the wound," says Herr. "In some cases, puncture wounds might need to be opened up surgically, creating an incision." Sometimes prophylactic antibiotics are used.

4. Patients prone to infection. Immunosup-pressed patients include the elderly, those taking cortical steroids, smokers, and diabetics. It’s especially important to reduce the risk of infection in immunocompromised patients, Herr advises.

5. Wounds contaminated by soil. Silicates in soil are direct inhibitors of wound immunity, says Herr. "Wounds with soil are infected a hundred-fold times the rate of other wounds," he notes. "It’s absolutely critical that all the soil be washed off the wound because of the chemical constituents of soil."

6. Wounds with foreign bodies. Any foreign body can increase the risk of infection, especially if it is overlooked. Wound exploration alone can’t rule out a foreign body, says Herr. "Ask the patient if anything could have broken off in the wound," he recommends.

When a patient came to the ED after putting his arm through a plate glass window, and presented with a small cut in his distal forearm, at first it didn’t appear any foreign body was present in the wound. "I explored the wound and found absolutely no glass in it, irrigated it, and was about to suture it closed when I asked the patient if there was any possibility glass could have broken off into the wound," Herr recalls. When the patient explained that the glass had shattered into a number of pieces, a radiograph revealed a piece of glass displaced 15 centimeters from the entrance site of the wound, high up in the patient’s proximal forearm, which needed to be surgically removed by a plastic surgeon.,

A common misconception is that glass won’t show up on X-rays, says Herr. "It does show up 90% of time," he notes. "Wood, plastic, and 10% of glass will not show up on X-ray. In those cases, ultrasound could be helpful locating a foreign body."

7. Burns. It’s especially important to describe symptoms of infection to patients and encourage them to seek appropriate follow-up care, says Barbara Birmingham, RN, clinical coordinator for trauma and burns service for the University of Alabama at Birmingham. After cleaning, apply silver sulfadiazine, a burn cream which soothes the wound, she recommends. "Impregnate the gauze with it, and put gauze on wound. That way, the person cleaning the wound next day has a easier time. Putting the creme directly on the wound is faster, but trying to clean it the next day is hard, especially if the patient is in lot of pain."