One-liner#
Evaluate wound concerns to identify infection requiring antibiotics, assess healing problems, determine need for debridement or advanced wound care, and know when to refer for surgical or wound care specialist management.
Quick nav#
- Red flags / send to ED
- Key history
- Focused exam
- Differential (quick pattern recognition)
- Workup
- Initial management
- Management by diagnosis
- Follow-up
- Patient instructions
- Smartphrase snippets
Red flags / send to ED#
- Signs of sepsis: fever, tachycardia, hypotension, altered mental status
- Rapidly spreading cellulitis with systemic symptoms
- Crepitus or gas in tissues → necrotizing fasciitis
- Exposed bone, tendon, or joint
- Severe pain out of proportion to exam
- Significant bleeding not controlled with pressure
- Animal or human bite with signs of deep infection
- Immunocompromised with wound infection
Key history#
Wound characteristics:
- Mechanism: trauma, surgical, pressure, venous, arterial, diabetic
- Duration: acute (<4 weeks) vs chronic (>4 weeks)
- Location: affects healing potential and infection risk
- Size: length, width, depth
- Previous treatments: what has been tried?
Healing concerns:
- Is it getting better, worse, or staying the same?
- Any drainage? Color, amount, odor
- Pain: improving or worsening?
- Signs of infection: redness, warmth, swelling, fever
Underlying conditions affecting healing:
- Diabetes (neuropathy, vascular disease, immune dysfunction)
- Peripheral arterial disease
- Venous insufficiency
- Immunosuppression
- Malnutrition
- Smoking
- Chronic steroid use
- Radiation history
Tetanus status:
- Last tetanus vaccine
- Wound type (clean vs contaminated, tetanus-prone)
For bites:
- Animal type (dog, cat, human, wild animal)
- Time since bite
- Provoked vs unprovoked (rabies risk)
- Location (hand bites high risk)
Focused exam#
Wound assessment:
- Location and size (measure in cm)
- Depth: superficial, partial thickness, full thickness
- Wound bed: granulation tissue (red, healthy), slough (yellow), eschar (black), necrotic tissue
- Wound edges: attached vs undermined, rolled (may indicate malignancy)
- Drainage: serous, serosanguinous, purulent; amount; odor
- Surrounding skin: erythema, induration, warmth, maceration
Signs of infection:
- Increased pain
- Expanding erythema (mark borders)
- Warmth
- Purulent drainage
- Fever
- Lymphangitis (red streaking)
- Regional lymphadenopathy
Vascular assessment (for lower extremity wounds):
- Pulses: dorsalis pedis, posterior tibial
- Capillary refill
- Skin temperature
- Hair loss, shiny skin (arterial insufficiency)
- Edema, varicosities, hemosiderin staining (venous insufficiency)
- ABI if arterial disease suspected
Neurologic assessment (diabetic wounds):
- Monofilament testing
- Vibration sense
- Protective sensation
Differential (quick pattern recognition)#
Common/likely (outpatient)#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Healing wound (normal) | “Is this healing okay?” | Improving; decreasing size; granulation tissue forming | Clean wound bed; pink granulation; decreasing drainage | Reassurance; continue current care |
| Wound infection (superficial) | “It’s red around it,” “draining pus” | Increasing erythema; purulent drainage; increased pain | Erythema; warmth; purulent drainage; no systemic symptoms | Wound care; oral antibiotics |
| Venous leg ulcer | “Ulcer on my leg,” “swelling” | Medial malleolus; venous insufficiency; shallow | Shallow ulcer; irregular borders; surrounding stasis changes | Compression; wound care; treat venous disease |
| Pressure ulcer | “Bedsore,” “from sitting/lying” | Over bony prominence; immobility; elderly/debilitated | Ulcer over sacrum, heel, ischium; staged by depth | Pressure relief; wound care; nutrition |
| Diabetic foot ulcer | “Sore on my foot,” “didn’t feel it” | Diabetic; neuropathy; plantar surface or pressure points | Punched-out ulcer; callus; neuropathy on exam | Offloading; wound care; vascular assessment |
| Surgical wound dehiscence | “Incision opened up” | Post-surgical; wound edges separated | Wound edges separated; may see deeper tissues | Assess depth; wound care; may need surgical evaluation |
| Minor bite wound | “Dog/cat bit me” | Animal bite; superficial; no signs of deep infection | Puncture or laceration; minimal surrounding erythema | Wound care; prophylactic antibiotics for high-risk |
Can’t-miss / urgent#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Wound infection (deep/spreading) | “Getting worse fast,” “fever,” “red streaks” | Rapidly spreading; systemic symptoms; lymphangitis | Expanding erythema; lymphangitis; fever; toxic appearance | IV antibiotics; possible hospitalization |
| Necrotizing fasciitis | “Worst pain ever,” “skin turning dark” | Pain out of proportion; rapid progression; systemic toxicity | Dusky skin; crepitus; bullae; pain beyond erythema | ED immediately; surgical emergency |
| Osteomyelitis | “Wound won’t heal,” “can see bone” | Chronic wound; exposed bone; probe-to-bone positive | Exposed bone; probe reaches bone; chronic drainage | X-ray; MRI; infectious disease/surgery referral |
| Arterial ulcer | “Painful ulcer,” “poor circulation” | Distal location; severe pain; absent pulses | Punched-out ulcer; pale base; absent pulses; cool foot | ABI; vascular surgery referral |
| Infected bite (deep) | “Bite getting worse,” “hand swollen” | Hand bite; cat bite (deep puncture); rapid progression | Significant swelling; limited ROM; purulent drainage | IV antibiotics; hand surgery if hand involved |
| Malignant wound (Marjolin ulcer) | “Ulcer for years,” “edges look funny” | Chronic non-healing wound; rolled edges; bleeding | Rolled, heaped edges; friable tissue; chronic wound | Biopsy; oncology referral |
Workup#
Most wounds are assessed clinically. Testing is for suspected infection, non-healing wounds, or vascular assessment.
| Test | When to order | Notes |
|---|---|---|
| Wound culture | Purulent drainage; treatment failure; immunocompromised | Swab purulent material or tissue; surface swabs less useful |
| CBC, BMP | Systemic infection; chronic wounds | WBC, renal function |
| HbA1c | Diabetic foot ulcer | Assess glycemic control |
| Albumin, prealbumin | Chronic non-healing wound | Assess nutritional status |
| X-ray | Suspected osteomyelitis; foreign body | Gas in soft tissue; bone changes |
| MRI | Suspected osteomyelitis (X-ray negative) | Most sensitive for osteomyelitis |
| ABI (ankle-brachial index) | Lower extremity wound; suspected PAD | ABI <0.9 = PAD; <0.5 = severe (compression contraindicated) |
| Doppler ultrasound | Suspected DVT; venous insufficiency assessment | Venous reflux; DVT |
Probe-to-bone test:
- For diabetic foot ulcers
- Sterile metal probe inserted into wound
- If bone is felt, high likelihood of osteomyelitis (positive predictive value ~90% in high-risk wounds)
Initial management#
Basic wound care principles:
- Cleanse: Normal saline or tap water irrigation
- Debride: Remove necrotic tissue (if appropriate)
- Dress: Moist wound healing; match dressing to wound characteristics
- Protect: Offload pressure; compression for venous; protect from trauma
Wound dressing selection:
| Wound type | Dressing choice | Notes |
|---|---|---|
| Clean, granulating | Foam, hydrocolloid | Maintain moisture; protect |
| Dry, necrotic | Hydrogel, hydrocolloid | Add moisture; autolytic debridement |
| Heavily draining | Alginate, foam | Absorb excess moisture |
| Infected | Antimicrobial (silver, iodine) | Reduce bioburden |
| Shallow, low exudate | Non-adherent gauze, film | Simple coverage |
Management by diagnosis#
Wound infection (superficial cellulitis)#
Education:
- Bacterial infection of wound and surrounding skin
- Needs antibiotics; wound care alone insufficient
- Should improve within 48-72 hours of antibiotics
Treatment:
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Cephalexin | 500 mg QID x 7-10 days | Cephalosporin allergy | None | $ | First-line for non-purulent |
| TMP-SMX DS | 1-2 tabs BID x 7-10 days | Sulfa allergy; pregnancy | Cr, K+ | $ | Add or substitute if MRSA suspected |
| Doxycycline | 100 mg BID x 7-10 days | Pregnancy | None | $ | MRSA coverage |
| Amoxicillin-clavulanate | 875/125 mg BID x 7-10 days | Penicillin allergy | None | $ | For bite wounds |
Follow-up: 48-72 hours to ensure improvement.
Venous leg ulcer#
Education:
- Caused by chronic venous insufficiency
- Compression is the most important treatment
- Healing takes weeks to months
- High recurrence rate without ongoing compression
Treatment:
- Compression therapy (most important):
- Compression stockings 30-40 mmHg
- Multilayer compression bandages (Unna boot)
- Contraindicated if ABI <0.5 (severe PAD)
- Wound care: moist wound healing; debride slough
- Leg elevation: above heart level when possible
- Treat infection: if present
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Pentoxifylline | 400 mg TID | Recent bleeding; caffeine-like side effects | None | $ | May improve healing; adjunct to compression |
Follow-up: Weekly initially for dressing changes; vascular surgery referral for refractory or severe venous disease.
Diabetic foot ulcer#
Education:
- Caused by neuropathy, vascular disease, and immune dysfunction
- High risk of infection and amputation
- Offloading is critical
- Glycemic control affects healing
Treatment:
- Offloading (most important): total contact cast, removable cast walker, therapeutic footwear
- Wound care: debridement of callus and necrotic tissue; moist wound healing
- Vascular assessment: ABI; vascular surgery if PAD
- Infection management: antibiotics if infected
- Glycemic control: optimize HbA1c
Infection classification and treatment:
| Severity | Features | Treatment |
|---|---|---|
| Uninfected | No signs of infection | Wound care only |
| Mild | <2 cm erythema; superficial | Oral antibiotics x 1-2 weeks |
| Moderate | >2 cm erythema; deep tissue | Oral or IV antibiotics; possible hospitalization |
| Severe | Systemic signs; limb-threatening | Hospitalization; IV antibiotics; surgical evaluation |
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Amoxicillin-clavulanate | 875/125 mg BID | Penicillin allergy | None | $ | Mild infection; covers common pathogens |
| TMP-SMX DS + amoxicillin-clavulanate | TMP-SMX 1-2 tabs BID + amox-clav 875 mg BID | Allergies | Cr, K+ | $ | If MRSA suspected |
| Clindamycin | 300-450 mg TID | C. diff history | Diarrhea | $ | Alternative for penicillin allergy |
Follow-up: Weekly until healing; podiatry and/or wound care referral; vascular surgery if PAD.
Pressure ulcer#
Education:
- Caused by prolonged pressure over bony prominences
- Prevention is key: repositioning, pressure-relieving surfaces
- Healing requires addressing underlying cause
- Nutrition important for healing
Staging:
| Stage | Description | Management |
|---|---|---|
| Stage 1 | Intact skin; non-blanchable erythema | Pressure relief; moisturize; monitor |
| Stage 2 | Partial thickness; blister or shallow ulcer | Pressure relief; moist wound healing |
| Stage 3 | Full thickness; subcutaneous fat visible | Pressure relief; debridement; advanced wound care |
| Stage 4 | Full thickness; bone/tendon/muscle exposed | Surgical evaluation; advanced wound care |
| Unstageable | Obscured by slough/eschar | Debridement to determine stage |
Treatment:
- Pressure relief: repositioning Q2H; pressure-relieving mattress; cushions
- Wound care: debridement; moist wound healing; appropriate dressings
- Nutrition: protein supplementation; correct deficiencies
- Treat infection: if present
Follow-up: Weekly; wound care or surgery referral for stage 3-4.
Bite wounds#
Education:
- High infection risk, especially cat bites (deep punctures) and hand bites
- Human bites have highest infection rate
- Prophylactic antibiotics for high-risk bites
- Rabies assessment for wild animal bites
High-risk bites (prophylactic antibiotics indicated):
- Cat bites (all)
- Human bites
- Hand or foot bites
- Bites near joints or tendons
- Deep puncture wounds
- Immunocompromised patient
- Delayed presentation (>8 hours)
Treatment:
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Amoxicillin-clavulanate | 875/125 mg BID x 3-5 days (prophylaxis) or 7-10 days (infection) | Penicillin allergy | None | $ | First-line; covers Pasteurella, anaerobes, staph/strep |
| Doxycycline + metronidazole | Doxy 100 mg BID + metro 500 mg TID | Pregnancy (doxy) | None | $ | For penicillin allergy |
| TMP-SMX + metronidazole | TMP-SMX DS BID + metro 500 mg TID | Sulfa allergy | Cr, K+ | $ | Alternative for penicillin allergy |
Wound care:
- Copious irrigation
- Do NOT close puncture wounds or high-risk bites
- Delayed primary closure for clean wounds if needed
- Tetanus prophylaxis if indicated
Tetanus prophylaxis:
| Vaccination history | Clean, minor wound | Contaminated/tetanus-prone wound |
|---|---|---|
| Unknown or <3 doses | Tdap | Tdap + TIG |
| ≥3 doses, last <5 years | None | None |
| ≥3 doses, last 5-10 years | None | Tdap |
| ≥3 doses, last >10 years | Tdap | Tdap |
Tetanus-prone wounds: contaminated with dirt/feces/saliva, puncture wounds, avulsions, crush injuries, burns, frostbite
Rabies assessment:
- Dog/cat (known, vaccinated): observe animal 10 days; no prophylaxis if healthy
- Dog/cat (unknown/stray): consider prophylaxis; consult public health
- Wild animal (bat, raccoon, skunk, fox): assume rabid; prophylaxis indicated
- Rodents (squirrel, rat, mouse): rarely carry rabies; prophylaxis usually not needed
Follow-up: 24-48 hours for all bite wounds; sooner if worsening.
Follow-up#
- Wound infection: 48-72 hours to ensure improvement
- Venous ulcer: Weekly initially; then every 2-4 weeks
- Diabetic foot ulcer: Weekly until healing
- Pressure ulcer: Weekly; more frequent for stage 3-4
- Bite wounds: 24-48 hours
Return precautions:
- Increasing redness, swelling, or pain
- Red streaks going up the limb
- Fever or chills
- Pus or foul-smelling drainage
- Wound getting larger instead of smaller
- Numbness or inability to move the affected area
Patient instructions#
- Keep the wound clean. Gently wash with soap and water or saline daily.
- Change dressings as instructed. Keep the wound moist but not wet.
- Watch for signs of infection: increasing redness, swelling, warmth, pus, or fever.
- Take all antibiotics as prescribed, even if the wound looks better.
- Elevate the affected area when possible to reduce swelling.
- Do not smoke—smoking significantly slows wound healing.
- Eat a healthy diet with adequate protein to support healing.
- Keep follow-up appointments so we can monitor healing.
- Call the office or go to the ER if you develop fever, red streaks, severe pain, or the wound is getting worse.
Smartphrase snippets#
.WOUNDINFECTION
Wound infection at [location]. [Size] area of erythema, warmth, and [drainage type]. No systemic symptoms. Plan: wound care with [dressing], [antibiotic] x [duration]. Mark borders to monitor progression. Follow-up in 48-72 hours. Discussed return precautions.
.WOUNDCARE
Wound at [location], [size], [description of wound bed]. No signs of infection. Plan: wound care with [cleansing method], [dressing type], change every [frequency]. [Offloading/compression/elevation as appropriate]. Follow-up in [timeframe].
.BITEWOUND
[Animal] bite to [location]. [High-risk features present/absent]. Wound irrigated copiously. [Primary closure performed / Wound left open for delayed closure / Wound left to heal by secondary intention]. Tetanus [up to date / Tdap administered]. [Prophylactic antibiotics prescribed: amoxicillin-clavulanate x 3-5 days / No antibiotics indicated]. [Rabies assessment: low risk, no prophylaxis / public health consulted]. Follow-up in 24-48 hours.