From the Guidelines
Management of a patient who stepped on a nail requires prompt attention to prevent infection and complications, with a focus on tetanus prophylaxis and wound care. The patient should be evaluated for the need for tetanus prophylaxis, as puncture wounds are considered tetanus-prone injuries, especially if the wound is contaminated with soil or feces 1.
Wound Care
- Clean the wound thoroughly with soap and water, then apply an antiseptic solution like povidone-iodine.
- Control bleeding with direct pressure.
- For deep puncture wounds, consider antibiotic prophylaxis with amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days, or clindamycin 300 mg four times daily for penicillin-allergic patients, as the depth of the puncture wound creates an ideal environment for anaerobic bacteria like Clostridium tetani to thrive 1.
Tetanus Prophylaxis
- Administer Td (tetanus-diphtheria) or Tdap (tetanus-diphtheria-acellular pertussis) if the patient hasn't been vaccinated within the past 5 years or has an unknown vaccination history.
Pain Management and Monitoring
- Elevate the foot to reduce swelling and administer analgesics like acetaminophen 650 mg every 6 hours or ibuprofen 400-600 mg every 6-8 hours as needed for pain.
- The wound should be monitored for signs of infection including increasing pain, redness, swelling, warmth, or purulent discharge.
- Patients should seek immediate medical attention if these symptoms develop or if they have diabetes, peripheral vascular disease, or immunocompromise, as these conditions increase infection risk 1.
From the Research
Management of Patient Who Stepped on Nail
- The management of a patient who stepped on a nail involves preventing and managing wound infection, as well as considering the risk of tetanus infection 2, 3.
- Wound infection can be defined as the presence and proliferation of microorganisms leading to a local or systemic response in an individual, and can be associated with delayed healing and increased healthcare costs 2.
- Identifying and managing wound infection early can contribute to faster wound healing and reduce the risk of negative outcomes 2.
- In cases where the patient is at risk of tetanus infection, pharmacotherapy options such as Metronidazole and benzodiazepine may be considered 3.
- The route of tetanus vaccine administration, either intramuscular or subcutaneous, may also be considered, particularly in anticoagulated patients 4.
Specific Considerations
- For patients with nail bed and fingertip injuries, primary management in the emergency department may involve simple trephination for subungual hematomas, repair of nail bed lacerations using dissolvable suture or octyl-2-cyanoacrylate, and treatment of amputations with a variety of techniques 5.
- The use of personal protective equipment, such as gloves and masks, is also important when providing nail care to patients to prevent the transmission of infections 6.
- Future research is needed to contribute to a national consensus guideline for best practices and protections at all levels of nail care in the acute care and community settings 6.