Trauma Patient Suffers Severe Infection Due to Inadequate Wound Cleaning

Case Overview

This case involves a man who injured his hand while working with a potato harvester at a large factory farm. The man was seen at a local emergency room where the wound was closed using sutures, following which he was discharged with a prescription for antibiotics. A week later, the man returned to the ER with complaints of severe pain in his hand. Doctors elected to perform an exploration of the man’s wound. During the exploration, doctors discovered the presence of dirt and plant matter that had not been removed from the would before it had been closed. The man was immediately hospitalized and placed on broad spectrum antibiotics, however he suffered significant tissue damage as a result of the infection.

Questions to the Pediatrics expert and their responses

How often do you treat dirty injuries?

I see dirty wounds a few times per month.

Have you ever had a patient develop this complication?

I have not personally had a patient develop a severe infection from a wound that I irrigated and repaired.

What would be the standard of care for closing this type of wound?

Timing of wound closure should be within 6 hours of the wound. In general, wounds that are clean with minimal devitalization can be closed primarily. If this was not done initially, it would be possible to 'convert' a contaminated wound with aggressive cleansing to a fresh-appearing wound with no signs of debris. Only then could primary closure be considered. If it cannot be accomplished due to contamination or deep wounds, then OR debridement should be considered to facilitate primary closure. Alternatively, you could do delayed primary closure in which as much cleaning as possible is done, the wound is covered with gauze, PO abx are given and the wound is reassessed in 4-5 days. If it doesn't appear infected at that point, then you can do the repair. Cleansing of any wound should not be considered complete until there are no visible contaminants and the tissue appears pink and viable.

About the expert

This highly-qualified pediatric emergency medicine expert earned her BS and MEd from the University of Florida. She additionally earned her MD from Eastern Virginia Medical School. After completing a residency in emergency medicine, this expert went on to complete a fellowship in pediatric emergency medicine at the Cincinnati Children's Hospital Medical Center. She is board certified in emergency medicine and pediatric emergency medicine and remains active in her field as a member of the Society for Academic Emergency Medicine and the American College of Emergency Physicians. In addition, she has published 15 journal articles/abstracts and has given numerous lectures and presentations. Formerly, this expert was an emergency medicine physician and an assistant professor of both emergency medicine and pediatrics at the University of Cincinnati Hospital. Additionally, she served as an assistant professor at the University of Florida and an attending physician at the affiliated medical center. Currently, this expert is an associate professor at a top university in Florida. At the affiliated medical center, she additionally serves as the medical director of the pediatric emergency department and the division chief of pediatric emergency medicine.