Approach to critical patient first 5 minutes
›Approach to critical patient first 5 minutes
›Monitoring
›Cardiac monitor if systemic toxicity
›Continuous pulse oximetry if ill appearing
›IV access
›Two large bore IV if sepsis concern
›Single IV if moderate infection risk
›Early antibiotics timing
›Within 1 hour if septic shock physiology
›After cultures if stable and cultures indicated
Analgesia and local anesthesia
›Analgesia and local anesthesia
›Oral analgesia
›Acetaminophen 1000 mg PO once then every 6 to 8 hours as needed
›Ibuprofen 400 mg PO once then every 6 to 8 hours as needed
›Local anesthesia options
›Lidocaine 1 percent local infiltration
›Regional block for digits when appropriate
Wound care and foreign body management
›Wound care and foreign body management
›Irrigation principles
›Copious irrigation with sterile saline
›Avoid high pressure irrigation in small punctures if tissue dissection risk
›Exploration strategy
›Imaging guided localization if not visualized
›Avoid blind deep probing near neurovascular bundles
›Foreign body removal
›Superficial visible object removal
›Surgical consult for deep or high risk location removal
Antibiotics and prophylaxis
›Antibiotics and prophylaxis
›No routine prophylaxis for uncomplicated clean superficial puncture
›Shared decision if high risk host
›Close follow up plan required
›Prophylaxis or treatment indications
›Gross contamination
›Delayed presentation
›Hand or foot puncture
›Diabetes or immunocompromise
›Adult oral options for non bite puncture cellulitis coverage
›Cephalexin 500 mg PO every 6 hours
›Clindamycin 300 mg PO every 6 to 8 hours for beta lactam allergy
›MRSA risk options local protocol dependent
›TMP SMX one double strength tablet PO every 12 hours plus beta lactam for streptococci
›Doxycycline 100 mg PO every 12 hours plus beta lactam for streptococci
›Plantar puncture through shoe pseudomonas risk local protocol dependent
›Ciprofloxacin 500 mg PO every 12 hours adult only
›Orthopedics and infectious diseases input if bone or joint involvement concern
›Bite related puncture coverage
›Amoxicillin clavulanate 875 mg PO every 12 hours adult
›Alternative regimen local protocol dependent if penicillin allergy
›Tetanus prophylaxis
›Tetanus prone wound category
›Puncture wound considered tetanus prone
›Contaminated wound increases risk
›Vaccine logic
›If unknown or incomplete primary series then tetanus vaccine plus TIG
›If completed primary series then booster timing based on wound type and time since last dose
›TIG dosing examples
›Adults and age 7 and older 250 units IM
›Local protocol dependent product availability
›Reassessment loop
›Timing
›Recheck pain and neurovascular status after anesthesia and procedures
›Repeat exam within 30 to 60 minutes if concern for progression
›Triggers
›Increasing pain
›New numbness
›Expanding erythema