What is the treatment for a 13-year-old with a wound from a nail stab?

Treatment for a 13-Year-Old with a Nail Stab Wound

For a 13-year-old with a nail puncture wound, immediately irrigate the wound with sterile saline, ensure tetanus prophylaxis is current (administer 0.5 mL intramuscularly if outdated or unknown), and prescribe amoxicillin-clavulanate 625 mg three times daily for 5-7 days to prevent infection from polymicrobial contamination. 1

Immediate Wound Management

Wound Cleansing and Debridement

• Irrigate the wound thoroughly with sterile normal saline without additives—avoid iodine or antibiotic-containing solutions as they provide no additional benefit 1
• Remove superficial debris carefully; deeper debridement is usually unnecessary and should be avoided to prevent wound enlargement 1
• Do not close puncture wounds primarily—infected wounds should never be sutured 1

Elevation and Supportive Care

• Elevate the injured body part, especially if swollen, during the first few days after injury to accelerate healing 1
• Use a sling for upper extremity injuries or passive elevation methods 1

Antibiotic Prophylaxis

First-Line Antibiotic Therapy

Prescribe amoxicillin-clavulanate (Augmentin) as the preferred antibiotic for puncture wounds in adolescents:

• Dosage: 625 mg orally three times daily for 5-7 days 1, 2
• This combination provides coverage against the polymicrobial flora typical of puncture wounds, including Staphylococcus aureus, Streptococcus species, and anaerobes 1
• Amoxicillin-clavulanate has proven significantly more effective than amoxicillin alone in reducing pain and swelling after traumatic wounds 3

Alternative Antibiotic Options (if allergic to penicillin)

• Doxycycline 100 mg orally twice daily for 7 days (appropriate for adolescents over 8 years) 1
• Avoid first-generation cephalosporins (cephalexin), macrolides (erythromycin), and clindamycin alone as they have poor activity against common wound pathogens 1

Duration of Therapy

• Standard duration is 5-7 days, but extend treatment if the infection has not improved within this timeframe 1
• Consider a single initial dose of parenteral antibiotic before starting oral therapy if there are signs of early infection 1

Tetanus Prophylaxis

Verify tetanus immunization status immediately:

• If tetanus vaccination is outdated or unknown, administer 0.5 mL tetanus toxoid intramuscularly 1
• This is critical for all puncture wounds, particularly those contaminated with soil or rust 1

Follow-Up Care

Initial Follow-Up (24-48 Hours)

• Schedule follow-up within 24 hours either by phone or office visit to assess wound progression 1
• Monitor for signs of infection: increasing pain, redness, swelling, warmth, purulent drainage, or fever 1
• Pain disproportionate to injury severity, especially near bones or joints, suggests periosteal penetration or deeper infection requiring immediate evaluation 1

Indications for Hospitalization

• Consider hospitalization if:
  • Infection progresses despite appropriate antibiotic therapy 1
  • Signs of systemic infection develop (fever, altered mental status, hemodynamic instability) 1
  • Deep tissue involvement is suspected (septic arthritis, osteomyelitis, tendonitis) 1
  • Hand or foot wounds with significant involvement, as these are often more serious 1

Extended Follow-Up (7 Days)

• Reassess wound healing at 7 days 1
• If complications develop (osteomyelitis, septic arthritis), prolonged therapy is required: 4-6 weeks for osteomyelitis, 3-4 weeks for septic arthritis 1

Common Pitfalls to Avoid

• Never use first-generation cephalosporins or clindamycin monotherapy for puncture wounds—they lack adequate coverage for Pasteurella and other common pathogens 1
• Do not suture puncture wounds—this increases infection risk by trapping bacteria in deeper tissues 1
• Do not delay tetanus prophylaxis—this is a critical preventive measure that must be addressed at the initial visit 1
• Do not dismiss hand or foot wounds as minor—these locations have higher complication rates including osteomyelitis and septic arthritis 1