Punctre Wounds I - Dr. Michel

Most common puncture wound site?

Plantar MTPJs & heels

Risk factors of puncture wounds?

• Location of puncture

• Depth of puncture

• Shoes vs. barefoot

• Object causing puncture/retained object

• Wound contamination

• Delay of presentation & treatment

• Co-morbidities

What is zone 1 (Patzakis) of the plantar foot?

Metatarsal necks to distal phalanges

What is zone 2 (Patzakis) of the plantar foot?

Distal aspect of calcaneus to metatarsal necks

What is zone 3 (Patzakis) of the plantar foot?

Plantar aspect of calcaneus

What zone needs hospitalization?

1 & 3

What is at highest risk for osteomyelitis?

Forefoot punctures

What are risk factors of a puncture wound with shoes on?

• Retained foreign bodies

• Pseudomonas contamination

• Osteomyelitis

What is the most common culprit of puncture wounds?

Nails

Who gets most dog bites (30-50%)?

Children aged 5-14

What type of treatments should be considered for human bites?

• Hepatitis B

• HIV

• Tetanus

What can transmit leprosy, rabies, tapeworms, or salmonella from their bites?

Armadillos

What puncture wound can present as serrated, stiletto-type knife wound from their bites?

Stingrays

Who’s bites can result in a risk of weakness, muscle aches, shock, paralysis, respiratory failure, & even death?

Sea urchins

What should be remembered about wound status?

• Neurovascular status

• Involvement of tendons, joints, & muscles

• Cleanliness of environment

• Left over fragments

When can noninfected wounds caused by clean objects be closed?

6-18hrs of injury.

What are wounds >6hrs with increasing pain & erythema at risk for?

Infection

What is the interval from injury to surgery in DM patients?

13.3 days (vs. 6.9) most likely due to peripheral sensory neuropathy

Who are high risk patients?

• Cancer

• Transplant patients - immunosuppressed

• Advanced or untreated HIV pts

• Patients on high dose corticosteroids (>20 mg prednisone or equivalent for more than 2 weeks)

• Metabolic conditions (i.e., DM)

• Peripheral arterial disease

• Peripheral neuropathy

• Advanced age (aged 80+ years)

• Alcohol - or substance abuse-dependent

• Long or post-COVID

What are morbidities in high risk patients?

• Risk for occult infection

• Inadequate/lack of I&D

• Inappropriate antibiotic coverage

• Inadequate tetanus immunization

• Level of vascular disease not considered

• Poor monitoring until completely healed

What are the goals of puncture wound treatment?

• Contaminated → clean wound

• Reduce risk of infection - antibiotics as necessary

• Prevent tetanus - tetanus prophylaxis

What are treatment options?

• I&D

• Incision alone

• Debridement

• Observation

What is not always possible with treatment?

Excision of foreign object - surgeon should stop within 30 minutes if the object can’t be removed

What are the characteristics of a Tetanus infection?

• Generalized rigidity

• Convulsive spasms of skeletal muscles

• Lockjaw

What is the wound risk for tetanus?

• >6hrs old

• Presence of devitalized, denervated, ischemic tissue

• Contaminated

Patients with updated status (completed primary series or booster in more than 5yrs) should what?

Receive tetanus toxoid vaccine (0.5 mL)

Patients who have not completed primary series or not updated should what?

Receive tetanus toxoid vaccine & tetanus immune globulin

What is the CDC recommendation booster for tetanus?

Every 10yrs for those with complete immunization status - Diphtheria-tetanus toxold (Id) or diphtheria toxoid-tetanus toxoid-acellular pertussis vaccine (Tdap)

What is the recommendation for adults not preciously vaccinated against tetanus & diphtheria?

• Series of 3 vaccines

  • At least one Tdap

  • Other 2 can either be Td or Tdap vaccines

• Preferred schedule

  • Initial Tdap vaccine dose

  • Followed by a Td or Tdap vaccine dose 4 weeks later, &

  • Final Td or Tap vaccine dose 6-12 months later

If the wound is clean & tetanus prone & the patient has received 3 or more doses of the vaccine & is up to date, what do they require?

Additional dose if the last vaccine was more than 10yrs ago

If the wound is severe & contaminated & the patient has received 3 or more doses of the vaccine & is up to date, what do they require?

• Additional dose was more than 5yrs ago

• 250 U human TIG IM

If the wound is unknown what do they require?

• Administer 3 doses of Td or Tap (Tdap should be one of the doses)

• Ist dose and 2nd dose should be administered 4 weeks apart

• 3rd dose should be given 6-12 mo later

• Administer with TIG

What are the functions of Tetanus immune globulin (TIG)?

• Provides temporary immunity by directly providing antitoxin

• Assists in removal of unbound tetanus toxin

• Does not affect toxin bound to nerve endings

• Should be administered with toxoid

  Indications

What are indications of TIG?

• Severe wounds & with fewer than 3 doses of tetanus toxoid

• Highly compromised patients with concerning wounds, regardless of immunization history

Who are higher risk Tetanus patients?

• Advanced age

• Injection drug users

• Rural populations

• Immigrant populations

• Uninsured persons

Who is more likely to have protective antibody levels?

• History of military service

• Higher education levels

• Higher incomes

• Medical insurance

What is Rabies?

Spread via bite/scratch from a rabid animal that infects the CNS

• Advanced symptoms = cerebral dysfunction, anxiety, confusion, agitation, insomnia, delirium, difficulty swallowing, excessive salivation, hallucinations, & hydrophobia

What is the Rabies post exposure prophylaxis (PEP) regimen?

• One dose rabies immune globulim & 4 doses rabies vaccine

• 14 day period

• Administer within 72hrs of exposure

What is the human rabies immune globulin (RIG) dose?

20 IU ½ IM & ½ at infiltrated site

When should the mL human diploid cell vaccine (HDCV) be given in conjunction with RIG?

• Day of rabies exposure

• Day 3, 7, & 14

What is Patzakis classification?

• Compared site of injury, condition of penetrating nail, and type of footwear

• Determined variables in complication rates

According to Patzakis what is early hospital admission criteria?

• Patients with deep puncture wounds in zone 1

• Patients with history bone penetration in zone 2 & 3 at time of injury

What is Resnick & Fallat’s classification?

Based on depth & severity of injury

What is a Resnick & Fallat type I?

Superficial cutaneous penetration

• Clean wound penetrating epidermis and/or dermis without signs of infection

• Manage with twice daily cleansing, nonWB status, weekly follow-up

What is a Resnick & Fallat type II?

Subcutaneous or articular involvement

• No signs or symptoms of infection

• Penetration of subcutaneous tissue or joint

• Treatment recommendations

  • Anesthesia

  • Sterile prep

  • Wound exploration

  • Cultures

  • Pack wound open

What is a Resnick & Fallat type IIIA?

Established soft tissue infection with retained foreign body. Treatment:

• Anesthesia

• Sterile prep

• Wound exploration

• Cultures

• Open wound packing

What is a Resnick & Fallat type IIIB?

Foreign object penetration into bone.

Treatment:

• Immediate surgical excision of foreign object

• Debridement of soft tissue and bone

• Lavage

• Open wound packing

• IV antibiotics

What is a Resnick & Fallat type IV?

Osteomyelitis secondary to puncture.

Treatment:

• Surgical debridement

• Possible bone resection

• IV antibiotics

What is Krych & Lavery classification?

• Assigns wound score based on H&P

• Based on wound size, shape, depth

• Accounts for age of wound, radiographic findings, shoe gear at time of injury

What is a Krych & Lavery score between 1-4?

• Low risk wound

• Local cleansing & observation

What is a Krych & Lavery score between 5-8?

• Moderate risk wound

• I&D

• Staph, strep antibiotic coverage

What is a Krych & Lavery score between 9 or higher?

• High risk wound

• Hospitilization

• I&D

• IV Antibiotics for pseudomonas coverage

• Wound lavage