“Clawed by tiger” is not something you get much in the ER, and meeting the tiger never happens. However, Pre-R is a different game. I was called to visit someone whose bengal tiger punctured his face, and following the repair Vanessa, Max and I got to meet the cuddly assailant. Every day’s different.

As for the handling of puncture wounds, the buzz words are a combo of what you’d consider for lacerations and animal bites, with even greater fear for trapped foreign matter and infection.

Red Flags:

• Any animal bite or clawing
• Associated fracture
• Tendon laceration
• Weakness/numbness
• Hand, neck, eye or joint penetration
• Suspected foreign body (tooth/claw?)
• Suspected deep neck, chest, abdomen penetration
• Spurting blood or expanding hematoma
• Old (>24 hours) bite with signs of infection like fevers, pain, pus, redness
• Chronic medical problems like diabetes, AIDS, cancer, transplants, taking steroids, etc.
• Through lip into mouth
• Rusty nail through shoe into a numb diabetic foot
• Puncture through clothing with embedded fabric
• High pressure water jet puncture

Happy Words

• Skin tear rather than puncture
• Easy to explore wound completely to its depths
• Superficial wound
• Vaccinations already up to date

We do our best to clean out punctures, but thankfully the days of “coring” wounds to clean them are gone today. We’re pretty liberal with X-rays or ultrasounds too unless we’re certain nothing is trapped.

Ultrasound is sometimes superior for organic matter like wood or sea urchin spines. If we’re certain something is trapped, we may go digging, but that’s often a path to swiss cheese. Watchful waiting is an alternative option. Foreign bodies often find their way out, or a pus pocket makes their location pretty clear. Bullets and shrapnel are frequently just left in place unless they’re easy pickings.

For most puncture wounds a topical antibiotic like bacitracin is applied along with a dressing. You’ll likely get a prophylactic antibiotic prescription as well. I’ve provided hundreds of these, but hard to tell how much good they’ve done. I wonder how much I’m actually treating charts more than patients. My gut feeling is that elevation of injuries, daily dressing changes, and close monitoring for infection, along with basic TLC, are most important. Certainly avoid walking on punctured feet.

And lastly, did you know you can get a tetanus shot at most pharmacies without a prescription? I learned that only this year through Pre-R.

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