›Re-explore for identifiable vessel
›If arterial spurting, urgent surgical control pathway
›Digital anesthesia
›Digital block technique
›Two-sided web space injection
›Aspirate before injection
›Total volume minimized to avoid compartment effect
›Lidocaine 1% without epinephrine
›Typical adult total dose 5 mL to 10 mL divided injections
›Maximum lidocaine dose 4.5 mg/kg without epinephrine
›Bupivacaine 0.25% option
›Longer duration analgesia
›Maximum bupivacaine dose 2.5 mg/kg
›If epinephrine-containing anesthetic used
›Avoid in severe peripheral vascular disease or vasospastic disease
›Phentolamine rescue plan available for prolonged blanching
›Systemic pain control
›Acetaminophen
›Adult 650 mg to 1000 mg PO every 6 to 8 hours
›Maximum 4000 mg per 24 hours
›If liver disease, lower maximum
›Ibuprofen
›Adult 400 mg to 600 mg PO every 6 to 8 hours
›Maximum 2400 mg per 24 hours for short course
›Avoid in CKD or GI bleed risk
›Opioid for breakthrough pain
›Hydromorphone PO
›1 mg to 2 mg PO every 4 to 6 hours as needed
›Avoid coadministration with sedatives
›Oxycodone PO
›5 mg PO every 4 to 6 hours as needed
›Lowest dose shortest duration strategy
›Antiemetic if opioid used
›Ondansetron ODT
›4 mg PO every 8 hours as needed
›QT prolongation risk review
›Antimicrobial strategy
›Low-risk clean distal fingertip without exposed bone
›No routine antibiotics for uncomplicated clean wounds in many pathways
›Shared decision based on contamination and follow-up reliability
›Exposed bone or open fracture concern
›First-generation cephalosporin typical
›If delayed presentation or heavy contamination, broaden coverage
›Suggested regimens
›Cephalexin PO
›500 mg PO every 6 hours for 3 to 5 days
›If penicillin anaphylaxis, avoid cephalosporin depending on local policy
›Clindamycin PO
›300 mg to 450 mg PO every 6 to 8 hours for 3 to 5 days
›C difficile risk counseling
›Amoxicillin-clavulanate PO for bite contamination
›875 mg PO every 12 hours for 3 to 5 days
›If allergy, alternative bite regimen per local guidance
›Evidence framing
›Antibiotics for grossly contaminated open injuries supported by expert consensus
›Routine antibiotics for clean distal fingertip injuries has mixed evidence and often not required
›Immunization
›Clean minor wound
›Booster if last dose 10 years or more
›Tetanus immune globulin if unimmunized
›Dirty or contaminated wound
›Booster if last dose 5 years or more
›Tetanus immune globulin if unimmunized or unknown status
Surgical consultation and replantation
›Consultation elements
›Candidate assessment
›Patient goals and occupational needs
›Comorbid vascular risk
›Mechanism severity
›Replantation general favoring factors
›Thumb
›Multiple digits
›Pediatric cases
›Clean sharp cut
›Replantation general limiting factors
›Prolonged warm ischemia beyond targets
›Severe crush or avulsion with long vessel injury
›Unstable patient or major competing injuries