What is the protocol for managing a cut wound on the finger with active bleeding in a patient with unknown tetanus status and no other known past medical history?

Management of Finger Cut with Active Bleeding

For a finger laceration with active bleeding, immediately apply direct pressure with sterile gauze for 10-15 minutes while elevating the hand above heart level, then cleanse the wound with sterile normal saline, assess for deep structure injury, and administer tetanus prophylaxis if the patient's last booster was >5 years ago or status is unknown. 1, 2

Immediate Bleeding Control

• Apply direct local compression with gauze pads directly over the wound to control active hemorrhage 1
• Maintain firm pressure for 10-15 minutes without interruption, as this controls bleeding in the vast majority of cases 3
• Elevate the injured hand above heart level to reduce venous pressure and facilitate hemostasis 3
• If direct pressure fails or the wound involves significant arterial bleeding, consider applying an elastic adhesive dressing (ELAD) wrapped circumferentially around the finger with sufficient tension to stop bleeding without compromising distal circulation 4, 5
• A tourniquet may be applied as an adjunct for uncontrolled extremity bleeding in life-threatening situations, though this is rarely necessary for simple finger lacerations 1

Wound Assessment and Preparation

• Once bleeding is controlled, cleanse the wound thoroughly with sterile normal saline irrigation - there is no need for iodine or antibiotic-containing solutions 1
• Remove superficial debris during irrigation 1
• Assess for deep structure involvement: pain disproportionate to injury near bone/joint suggests periosteal penetration, requiring extended evaluation 1
• Examine for nerve or tendon injury, as hand wounds are often more serious than wounds to fleshy body parts and may require specialist consultation 1
• Perform cautious debridement only if necrotic tissue is present; avoid aggressive debridement that enlarges the wound unnecessarily 1, 6

Wound Closure Decision

• Do not close infected wounds or wounds with significant contamination 1
• For clean wounds presenting within 8 hours of injury, primary closure is controversial 1
• The preferred approach is wound margin approximation with Steri-Strips followed by delayed primary or secondary intention closure, provided there has been meticulous wound care and copious irrigation 1
• Facial wounds are an exception and may be closed primarily by a plastic surgeon after meticulous care 1

Tetanus Prophylaxis - Critical Component

This is where many clinicians make errors. The tetanus prophylaxis protocol depends on vaccination history and wound characteristics:

• For tetanus-prone wounds (contaminated, puncture wounds, or any wound with tissue devitalization): administer tetanus toxoid if the last dose was >5 years ago 1, 2
• For clean, minor wounds: booster only if last dose was >10 years ago 1
• If vaccination status is unknown or uncertain, administer tetanus toxoid (0.5 mL intramuscularly) - failure to vaccinate when needed could result in preventable illness, whereas unnecessary vaccination is unlikely to cause harm 1
• The case report of a 79-year-old woman who developed generalized tetanus despite proper vaccination history highlights the critical importance of post-exposure prophylaxis when the last booster exceeded 5 years 2
• Tetanus immunoglobulin (TIG) is indicated only for tetanus-prone wounds in patients who are unvaccinated or have received <3 doses of tetanus toxoid 1

Antibiotic Considerations

• Prophylactic antibiotics are generally not indicated for simple, clean finger lacerations that can be adequately cleaned 1
• Consider antibiotics for contaminated wounds, crush injuries, or wounds with delayed presentation 1
• If antibiotics are warranted, coverage should include common skin flora (Staphylococcus and Streptococcus species) 1

Follow-up and Monitoring

• Instruct the patient to watch for signs of infection: increasing pain, redness, swelling, purulent drainage, or fever 1
• Outpatients should be followed up within 24 hours either by phone or office visit 1
• If infection progresses despite appropriate care, hospitalization should be considered 1
• Infectious complications can include septic arthritis, osteomyelitis, subcutaneous abscess, and tendonitis, requiring prolonged therapy (4-6 weeks for osteomyelitis, 3-4 weeks for synovitis) 1

Common Pitfalls to Avoid

• Failing to administer tetanus prophylaxis when indicated - this is the most critical error, as tetanus remains a preventable but potentially fatal disease 1, 2
• Closing contaminated or infected wounds primarily, which increases infection risk 1
• Aggressive debridement that enlarges the wound unnecessarily 1
• Missing deep structure injuries (tendons, nerves, joints) that require specialist referral 1
• Inadequate wound irrigation before closure 1