›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 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
›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
17Disposition/dispo29
Admission and higher level of care criteria
›Admission and higher level of care criteria
›ICU or resuscitation level
›Septic shock physiology
›Necrotizing infection concern
›Inpatient admission
›Deep space infection
›Suspected septic arthritis
›Suspected osteomyelitis
›Uncontrolled pain requiring IV opioids
›Observation pathway
›Moderate cellulitis needing IV antibiotics
›Need for serial neurovascular exams
Discharge criteria
›Discharge criteria
›Clinical stability
›Normal or improving vital signs
›No systemic toxicity
›Local exam stability
›No rapidly progressive erythema
›Neurovascularly intact
›Plan reliability
›Follow up within 24 to 72 hours
›Return precautions understood
Follow up timing
›Follow up timing
›Wound check
›24 to 48 hours for high risk wounds
›48 to 72 hours for low risk wounds
›Specialty follow up
›Hand surgery for hand punctures with deep concern
›Orthopedics for plantar puncture with bone or joint concern
18Discharge Instructions/di27
Copy discharge instructions
›Copy discharge instructions
›Today you were seen for a puncture wound
›We checked for signs of infection and deep injury
›A foreign body may not always be visible at first visit
›Wound care
›Keep the area clean and dry for the first day
›Then wash gently with soap and water daily
›Do not soak in a bath or hot tub until healing
›Pain control
›Acetaminophen as directed on the label
›Ibuprofen as directed on the label if safe for you
›Antibiotics
›Take exactly as prescribed until finished
›Return if you cannot keep medicines down
›Activity
›Limit use of the injured area for 24 to 48 hours
›Elevate when resting to reduce swelling
›Return to the emergency department now for
›Fever
›Rapidly worsening redness or swelling
›Pus or bad smelling drainage
›Increasing pain especially pain with stretching the area
›Numbness or weakness
›Fingers or toes becoming cold or pale
›Follow up
›See your clinician for a wound check within the recommended timeframe
›If you were told there may be a retained foreign body, follow up even if symptoms improve
19References/r19
Guidelines and key evidence
›Guidelines and key evidence
›CDC Clinical Guidance for Wound Management to Prevent Tetanus 2025
›Tetanus vaccination and TIG based on wound type and immunization history
›Antibiotics not recommended solely to prevent tetanus
›Public Health Agency of Canada Canadian Immunization Guide Tetanus toxoid and TIg dosing
›TIg adult dose example 250 units IM
›Local protocol dependent
›Infectious Diseases Society of America Practice Guidelines for Skin and Soft Tissue Infections 2014 update
›Classification and management framework for cellulitis and abscess
›Severity based disposition considerations
›American College of Emergency Physicians Sonoguide Foreign Body Localization 2020
›Ultrasound useful for radiolucent foreign bodies
›Reported sensitivity 79 to 100 percent and specificity 86 to 100 percent in experienced hands
›NICE Guideline NG184 Human and animal bites antimicrobial prescribing 2020
›Antibiotic indications for infected bite wounds
›Risk factor based prophylaxis concepts
›Manthey et al Annals of Emergency Medicine Ultrasound versus radiography for soft tissue foreign bodies 1996
›Radiography high sensitivity for radiopaque foreign bodies
›Radiography poor detection of radiolucent foreign bodies
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.