How to manage a leg ulcer in the emergency room?

Emergency Department Management of Leg Ulcers

Immediately assess ulcer severity and stability to determine disposition: severely complicated ulcers with signs of deep infection, ischemia, or systemic toxicity require hospital admission within 24 hours, while stable uncomplicated ulcers can be managed as outpatients with close follow-up. 1

Initial Triage and Risk Stratification

Assess for "red flag" signs requiring urgent specialist referral:

• Signs of infection: Hyperemia around wound, cellulitis, purulent drainage, wet gangrene, edema, pain, fever 1
• Signs of ischemia: New areas of necrosis or gangrene, rest pain, hyperemia of the foot, ankle pressure <50 mmHg or ABI <0.5 1, 2
• Wound progression: Extension of ulcer size, involvement of soft tissues/bone, exposed bone or joint 1, 2

Classify ulcer stability: 1

• Stable ulcer: Healing or not healing but not progressing
• Unstable ulcer: Progressing due to infection, ischemia, or increasing in size/depth

Determine Ulcer Etiology

Perform vascular assessment to differentiate venous from arterial disease:

• Check foot pulses and ankle-brachial index (ABI) 2
• Screen for peripheral neuropathy using 10g monofilament test and/or 128 Hz tuning fork in diabetic patients 2
• Venous ulcers typically present with lower leg location, surrounding hyperpigmentation, and edema 3, 4
• Arterial ulcers present with absent pulses, cool extremity, and require revascularization before compression 3, 5

Immediate ED Management

For Infected Ulcers:

Start empiric antibiotics immediately for moderate-to-severe infections: 2

• Mild infections: Oral antibiotics targeting Staphylococcus aureus and streptococci
• Moderate-to-severe infections: Broad-spectrum parenteral antibiotics
• Perform surgical debridement when abscess, gas, or necrotizing fasciitis is present 3

For Diabetic Foot Ulcers:

Perform sharp debridement of necrotic tissue and surrounding callus 2

Apply appropriate offloading: 1, 2

• Non-removable knee-high device (total contact cast or non-removable walker) for neuropathic plantar forefoot/midfoot ulcers
• Removable offloading devices for non-plantar ulcers

For Venous Ulcers:

Apply compression therapy (20-40 mm Hg) combined with wound bed preparation 3

Critical caveat: Do not apply full compression if ABI <0.6 without revascularization—this indicates significant arterial disease 3

Compression parameters: 3

• Minimum 20-30 mm Hg for standard venous disease
• 30-40 mm Hg for severe disease (C5-C6)
• Reduce to 20-30 mm Hg if ABI 0.6-0.9
• Exercise extreme caution with ABI <0.6

For Behçet's Syndrome Leg Ulcers:

Coordinate with dermatology and vascular surgery as these may require immunosuppressives, antibiotics if infected, debridement, or compression bandaging 1

Disposition Criteria

Admit to Hospital (Within 24 Hours):

Severely complicated ulcers requiring: 1

• Deep infection with systemic signs
• Critical ischemia requiring urgent revascularization
• Exposed bone/joint with osteomyelitis
• Necrotizing infection

Refer to Specialist (Within 48-72 Hours):

Complicated or unstable ulcers with: 1

• Progressive infection despite initial treatment
• Worsening ischemia
• Ulcers failing to improve with standard care
• Need for surgical debridement or revascularization

Discharge with Outpatient Follow-up:

Stable uncomplicated ulcers that: 1

• Show no signs of infection or ischemia
• Do not require immediate surgery
• Can be managed with compression/offloading
• Have adequate vascular supply

Arrange follow-up within 1-3 months for patients with history of foot ulceration 2

Wound Care Instructions at Discharge

Provide specific self-care education: 2

• Examine feet daily and contact provider if new lesions develop
• Do not walk barefoot or in thin-soled slippers
• Wash feet daily with careful drying between toes
• Use emollients for dry skin
• Cut toenails straight across

For venous ulcers: Maintain compression therapy continuously and elevate legs when resting 3, 5

For diabetic ulcers: Continue offloading device use and monitor for signs of infection 2

Common Pitfalls to Avoid

• Do not use topical antimicrobial dressings routinely—they provide no benefit in venous ulcer management 3
• Do not delay treatment of infection—foot infections can progress rapidly, increasing amputation and death risk 3
• Do not discharge patients with compression therapy interrupted for MRSA screening without reinstating it before discharge 6
• Do not assume all leg ulcers are venous—coexisting arterial insufficiency and diabetes are very common in elderly patients 7