- Accidental tattoo: Asphalt, dirt, grease and other
debris may be ground into an abrasion. A local anaesthetic such
as 2% topical
lidocaine or local injection of lidocaine will facilitate scrubbing.
Imbedded particles should be picked out. Polysporin or Vaseline
will gradually dissolve asphalt.
- Puncture wounds, lacerations:
Foreign bodies are all too easy to miss. A detailed history should
heighten clinical suspicion. A ‘foreign
body sensation’ experienced by the patient should be taken
seriously. Localised sharp pain when palpating over a puncture is
a useful sign of the possible existence of a foreign body.
||A plain x-ray (best if under-penetrated to improve
the contrast between foreign body and the tissue) can be useful.
Metal and glass > 2mm are usually seen on plain x-ray. Wood
is seldom seen well on x-ray.
||Ultrasound is occasionally useful.
||Wood and plant material such as thorns may be seen on CT when
plain radiography has failed to detect them. However, CT can
still miss foreign bodies.
||MRI is not widely used to detect foreign bodies in the soft
The bottom line is that, although imaging is useful, it is better
to also look in the wound.
Generally, if the foreign body is readily visible through the existing
wound, it should be removed in the Emergency Department. If removal
appears difficult, or surgical exploration is contemplated for co-existent
tendon or nerve injury, then a plastic surgeon should be consulted
prior to removal. Consultation should be considered for exploratory
surgery to remove those deep foreign bodies not readily visible in
the wound and are not readily located.
High-pressure injection injuries are particularly dangerous. Paints,
oil or grease injected into the hand can spread along the fascial
planes as high as the elbow. The entry wound may appear innocuous.
Extensive cleaning and debridement is required. Amputation is common.
Certain non-visible foreign bodies may be managed expectantly. Small
foreign bodies of relatively non-reactive materials, such as metal,
may be left in place and simply followed. Pain, functional impairment,
or infection would warrant their removal. There is potential for
migration of a foreign body in some body sites thus causing functional
impairment (this is especially true of the hand). As a general rule,
foreign bodies in a weight bearing location require removal.
Foreign bodies with a high propensity for infection, for
example wood, must be removed in total.
``Use of antibiotics should be individualized based on the degree
of bacterial contamination, the presence of infection-potentiating
factors, such as soil, the mechanism of injury, and the presence
or absence of host predisposition to infection. In general, decontamination
is far more important than antibiotics. Prophylactic antibiotics
should be used in most human, dog, and cat bites, intraoral lacerations,
open fractures, and exposed joints or tendons.`` From Management
of lacerations in the emergency department. O. Capellan and J.
Hollander Emergency Medicine Clinics of North America. Volume 21,
Number 1, February 2003
Dog and cat bites are prone to infection. Staphylococcus, Streptococcus,
Pasturella multicida, various gram negatives and anaerobic bacteria
have all been cultured from such infected wounds.
||The principles of management of bite wounds include
proper wound cleansing and debridement. Facial wounds should
be closed, but in general, others should be left open. A plastic
surgeon should be consulted, especially for wounds that penetrate
joint space, tendon sheath, or into deep muscular tissue. Multiple
studies have supported the use of prophylactic antibiotics in
the management of bite wounds. Use prophylactic antibiotics for
full-thickness skin punctures.
|Animal Bites (from the Sanford guide 2003)
|Dogs and other wild animals
|Clindamycin + ciprofloxacin in adults
Clindamycin + Septra for children
bites are considered amongst the most dangerous. Infection rates
are as high as 50%. Usually a mixed flora is cultured. Staph,
strep, gram negatives and anaerobes have all been cultured. Additionally,
in 10-30% of such infections, an organism called Ekinella corrodans
is cultured. Ekinella corrodans is sensitive to penicillin but
is resistant to semi-synthetic penicillins.
A common location for the human bite is over the knuckles. This
injury is usually sustained when a closed fist strikes the teeth
of an opponent. There is frequently penetratation of the tendon sheath
and/or the joint space. The hand must be examined with the fingers
in a flexed position so that the deeper structures are in the identical
position that they were when the injury was sustained. Only in that
position can injury to the underlying structures be visualised through
the open skin wound. Sometimes a foreign body such as a broken tooth
is found in the wound.
All such injuries should be referred to the plastic surgeons
Includes closed fist injuries
|Early : Clavulin
Late: cefoxitin IV, Ticarcillin/Valvulanate IV, Pip/Tazo IV
|Clindamycin + cipro (adults)
Clindamycin _+ Septra (children)
Another good source of information regarding the treatment of
infectious diseases, including mammalian bites, is the John Hopkins
Disease site at http://hopkins-abxguide.org/.
Rabies is a particularly dangerous RNA virus. In
North America, the rabies reservoir is principally in skunks, racoons,
bats. The incubation period is 20-90 days, and is shorter if the
virus is introduced through a facial wound.
Local wound care with good cleansing is very important.
Both active (vaccine) and passive (immunoglobulin) immunisation
is available. Human diploid cell vaccines have few side effects but
The following chart can help determine management:
||Assume rabid, begin treatment pending analysis of animal. Consult
with Public Health.
||Assume animal rabid, start and complete treatment. Consult
||Evaluate each situation for risk. May need to observe animal
for 10 days.
If rabid then treat patient. Discuss with Public Health.
||Evaluate each situation – consult Public Health
Lagomorphs (rabbits and hares)
The Canadian Immunization Guide – 6th Edition – 2002
is available at
http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/cig-gci/ and contains up-to-date information on the rabies vaccines that are