What are the symptoms of sepsis from a large non-healing wound and how is it managed?

Symptoms of Sepsis from a Large Non-Healing Wound

Sepsis from a large non-healing wound presents with systemic signs of organ dysfunction including altered mental status, hypotension (MAP <65 mmHg), tachypnea, tachycardia, fever or hypothermia, and elevated lactate, requiring immediate recognition and aggressive resuscitation with fluids, antibiotics, and source control. 1

Clinical Recognition of Sepsis

Systemic Signs of Organ Dysfunction

• Cardiovascular: Hypotension with mean arterial pressure <70 mmHg, requiring vasopressor support, and tachycardia 1
• Neurological: Altered mental status, confusion, or decreased level of consciousness 1
• Respiratory: Tachypnea, increased work of breathing, or hypoxemia requiring oxygen supplementation 1
• Metabolic: Elevated serum lactate levels (particularly >2 mmol/L), indicating tissue hypoperfusion 1, 2
• Renal: Decreased urine output (<0.5 mL/kg/hr) or rising creatinine 1
• Hematologic: Thrombocytopenia or coagulopathy 1

Local Wound Signs Suggesting Infection

• Increasing pain disproportionate to the wound appearance, which may indicate deeper tissue involvement 1
• Progressive erythema, warmth, and swelling extending beyond the wound margins 3
• Purulent discharge with foul odor from the wound 1
• Subcutaneous crepitations suggesting gas-forming organisms 1
• Patches of skin necrosis or gangrene around the wound 1
• Wound breakdown or failure to show healing progress despite appropriate care 3

Critical Pitfall: Severely malnourished or immunocompromised patients may exhibit an "adynamic" form of sepsis with hypothermia, leukopenia, and somnolence rather than classic fever and leukocytosis, leading to delayed recognition and increased mortality 1

Immediate Management Priorities

Early Resuscitation (Within First Hour)

• Fluid resuscitation must be prompt and aggressive, starting with a minimum of 30 mL/kg of crystalloid solution (either balanced crystalloids or normal saline) 1, 2
• Continue fluid administration as long as hemodynamic parameters improve, monitoring for signs of fluid overload 1
• Patients with large surgical wounds lose substantial fluids, proteins, and electrolytes, requiring ongoing replacement 1

Vasopressor Support

• Norepinephrine is the first-line vasopressor when fluid resuscitation alone fails to maintain MAP ≥65 mmHg 1, 2
• Add vasopressin (0.03 units/minute) if additional support is needed to raise MAP or decrease norepinephrine requirements 1
• Epinephrine should be added if hypotension persists despite norepinephrine and vasopressin 1, 2
• Vasopressors can be safely administered through a peripheral 20-gauge or larger IV line when central access is unavailable 2
• Consider hydrocortisone (up to 300 mg/day) for refractory septic shock requiring escalating vasopressor doses 1, 2

Antimicrobial Therapy

• Empirical broad-spectrum antibiotics must be administered as soon as possible after obtaining blood cultures, as delays are associated with increased mortality 1, 2
• Obtain cultures of infected fluid and wound tissues during initial surgical debridement to guide antibiotic de-escalation 1

Source Control

• Surgical debridement of the infected wound must be early and aggressive, continuing into healthy-appearing tissue to halt progression of infection 1
• Source control intervention should be implemented as soon as medically and logistically practical after diagnosis 1
• For necrotizing infections, radical surgical debridement of the entire affected area is mandatory 1

Ongoing Wound Management After Sepsis Control

Wound Care Protocol

• Perform serial debridement of non-viable tissue using surgical, sharp, autolytic, or mechanical techniques 3
• Maintain a moist wound environment with appropriate dressings to control exudate while avoiding maceration 3
• Consider negative pressure wound therapy (NPWT) after complete removal of necrosis to accelerate healing and promote granulation tissue 1, 3
• Implement strict pressure offloading with specialized mattresses and turning schedules every 2-3 hours for gluteal or pressure-related wounds 3

Monitoring and Reassessment

• Monitor resuscitation targets including MAP ≥65 mmHg, mental status normalization, capillary refill time, lactate clearance, and urine output 2
• Reassess wounds at least weekly to monitor healing progress and adjust treatment 3
• Watch for signs of persistent or recurrent infection requiring additional debridement 3

Systemic Optimization

• Optimize glycemic control in diabetic patients, as hyperglycemia impairs wound healing 3
• Ensure adequate nutritional support with appropriate protein intake to support healing and immune function 1, 3
• Address cardiovascular risk factors and encourage smoking cessation 3

Key Evidence Note: The 2018 World Society of Emergency Surgery guidelines emphasize that supportive treatment must be early and aggressive to halt inflammatory progression, with fluid resuscitation and analgesia as mainstays combined with vasoactive agents and organ support as needed 1. The 2025 emergency medicine literature confirms norepinephrine as first-line vasopressor with rapid antimicrobial administration being critical for survival 2.