What is the plan of care for a patient with wound dehiscence, considering their past medical history and potential underlying conditions that may impact wound healing?

Wound Dehiscence Plan of Care

Immediate Assessment and Stabilization

The first priority is to assess wound depth, extent of tissue necrosis, presence of exposed structures, and evaluate for signs of infection including increasing pain, erythema, warmth, purulent discharge, or systemic signs. 1, 2

• Measure ankle-brachial index (ABI) immediately if lower extremity wounds are present, as inadequate perfusion prevents healing regardless of local wound care—critical thresholds requiring urgent vascular intervention include ABI <0.5, ankle pressure <50 mmHg, toe pressure <30 mmHg, or TcPO2 <25 mmHg 1, 3
• Document wound measurements and photograph for serial comparison during weekly reassessments 1
• Obtain wound cultures from debrided tissue base (not surface swabs) to guide antibiotic therapy 2

Common pitfall: Do not apply compression if ABI <0.5 or ankle pressure <50 mmHg, as this indicates critical arterial disease and compression will cause tissue necrosis 2

Infection Management

Switch to parenteral antibiotics immediately for severe infections, as virtually all severe infections require IV therapy, at least initially. 3

• Empiric broad-spectrum coverage should target both gram-positive organisms (including MRSA) and gram-negative bacteria 3
• Continue antibiotics for 2-4 weeks for moderate to severe soft tissue infections, depending on adequacy of debridement and wound vascularity 3
• Perform sharp debridement of necrotic tissue and purulent material to remove biofilm and nonviable tissue 2, 3

Wound Care Protocol

After debridement, apply appropriate dressings to maintain a moist wound environment while controlling drainage and exudate. 2

• Perform serial sharp debridement of all nonviable tissue and callus at each visit 3
• Negative Pressure Wound Therapy (NPWT) should be strongly considered for deeper wounds, especially after debridement, to accelerate healing and promote granulation tissue formation 4, 1
• Apply NPWT to clean, debrided wound beds when primary or delayed secondary closure is not feasible 4
• Consider NPWT if wounds show no improvement after 4 weeks of standard care 1

Evidence note: The AHA/ACC guidelines demonstrate that NPWT is helpful to achieve wound healing after revascularization and minor amputation when primary closure is not feasible, with one study showing 100% limb salvage at 3 years when complete wound healing was achieved 4

Medical Optimization

Smoking cessation is mandatory and non-negotiable, as smoking profoundly impairs wound healing through vasoconstriction and tissue hypoxia. 1, 3

• Optimize nutritional status with adequate protein intake 1
• Optimize glycemic control if diabetic with target HbA1c <7% 1, 3
• Control pain adequately to improve patient compliance and quality of life 1
• Manage edema if present in lower extremity wounds 1

Risk stratification: The number of wound dehiscences increases significantly when risk factors accumulate—hypoalbuminemia, anemia, malnutrition, chronic lung disease, emergency procedure, vomiting, prolonged intestinal paralysis, and increased coughing are all significant risk factors 5

Interdisciplinary Team Coordination

An interdisciplinary care team should evaluate and provide comprehensive care to achieve complete wound healing. 4

• Coordinate care through wound care specialists, infectious disease, vascular surgery, and potentially plastic surgery for complex wounds 1, 3
• The team should include functions such as wound care, infection management, orthotics, and prosthetics 4
• Revascularization must precede or occur concurrently with wound healing efforts, as inadequate perfusion prevents healing regardless of other interventions 3

Follow-Up and Monitoring

Reassess wounds at least weekly to evaluate healing progress and adjust treatment. 1, 3

• Monitor for signs of biofilm, persistent infection, or deterioration requiring treatment modification 1, 3
• Monitor for systemic signs of worsening infection including fever, tachycardia, or spreading erythema 3
• Evaluate for early warning signs of complications at each visit 6

Adjunctive Therapies

• Intermittent pneumatic compression devices may be considered to augment wound healing in refractory cases, with potential benefit in decreased amputation rates and improved quality of life 4
• Hyperbaric oxygen therapy effectiveness is unknown, with limited evidence showing decreased ulcer area at 6 weeks but no significant differences in complete healing or amputation rates 4
• Biologics (skin substitutes, cell-based therapies) can be considered for non-healing wounds after 6 weeks of optimal therapy 2

Critical caveat: To date, there are no RCTs or high-quality studies focused on wound healing adjuncts in limbs with severe PAD (topical cytokine ointments, skin substitutes, cell-based therapies) 4

Disposition Decisions

• Admit if severe infection with systemic signs, inability to comply with outpatient wound care, or need for IV antibiotics 2
• Discharge with close wound care follow-up if infection is controlled and patient can comply with therapy 2
• Bedside treatment under local anesthesia in a protected environment on the ward may be safe, effective, and well-tolerated for patients refusing further surgery under general anesthesia, with similar success rates but reduced costs and shorter antibiotic courses 7