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Management of puncture wounds


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Can those of you who work in the ER share some of your advice on the management of puncture wounds? There doesn't seem to be any clear consensus on how these wounds are to be managed. Obviously the wounds need to be cleaned and any foreign bodies removed as well as having tetanus updated, but how far do you go with exploring a wound if you are not sure if a foreign body is present? For example, if someone has a puncture wound through the sole of the shoe, and no foreign body is visible and the patient doesn't  know how deep the puncture went or if there is any foreign material, what would you do in this scenario? I have heard some people core the wound, and others widen the wound until they are able to see the full length of the puncture. These methods also carry their own risks so I am just curious what those who have experience with this would do. And does anyone ever routinely use ultrasound for searching for foreign bodies in these types of scenarios? Thank you for the help.  

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Why do you recommend not irrigating under pressure? There are a number of good studies that show irrigating at high pressure (defined as 70psi or greater) had a significant reduction in likelihood of developing bacterial infections requiring antibiotics.

 

Agree completely with X-ray to r/o foreign body. One of the top 10 causes for litigation is retained foreign body. Even if the item isn't considered radio-opaque, I shoot the x-ray.

 

 

 

Xray to r/o FB or Fx
Do not irrigate under pressure EVER, never EVER
 

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beattie228 can you point me in the direction of those studies? I have read that irrigating under pressure can force foreign material deeper into the wound. Some sources advocate making an incision to widen the wound and gently irrigating it. I have also read some sources that say not to routinely get x-rays while others do. Every source I've read or listened to says the only evidence for treating puncture wounds is anecdotal and there is no agreed upon method for managing them, so that is why I'm curious what others do. 

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Most puncture wounds are not debris-ridden.  Most are dog-bites, nail punctures, knife wounds, etc and don't need extensive debridement.  If it is a "small opening" puncture then I don't try to flush/rinse them out.  Not gonna overpressurize a nail puncture wound by forcing 60cc of water into it via syringe.  I do my best to r/o FBs (through hx, x-ray, or US), give abx and order good follow up.

 

I had a blast injury recently with several pieces of shrapnel FBs that I wound up opening up the wounds more to retrieve the shrapnel.  Very dirty wounds, copiously flushed everything I could and gave heavy abx & f/u.  

 

Every case is different.  

 

Oh, and don't forget about pseudomonas coverage for punctures through socks.  

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Why do you recommend not irrigating under pressure? There are a number of good studies that show irrigating at high pressure (defined as 70psi or greater) had a significant reduction in likelihood of developing bacterial infections requiring antibiotics.

 

Agree completely with X-ray to r/o foreign body. One of the top 10 causes for litigation is retained foreign body. Even if the item isn't considered radio-opaque, I shoot the x-ray.

 

earlier in my career  I did it a few times and every single time they got infected.... I know because I saw them come back....  then did some reading and promptly stopped 

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