Ouch! Cleaning A Foot Puncture Wound

Some times bad things happen, like for example foot puncture wounds. I was painfully reminded of this a few days ago. So to make lemonade out of lemons, here are some instructions for cleaning a foot puncture wound if medical care isn’t available.

Clean wound appropriately and immediately, keep tetanus vaccination up to date

Yesterday, I stepped on a nail. I’m pretty clumsy so this is nothing new to me and I’ve had a tetanus shot. I was wearing sandals (Teva-style sport sandals) and it really barely punctured the skin. I’d cleaned it immediately but it’s still a bit sore and swollen today so I cleaned it again and bandaged with antibiotic ointment and am keeping an eye on it.

These kind of injuries are what we don’t think enough about if there is no medical care available for whatever reason. Even minor puncture wounds can be life threatening if not treated appropriately. A lot of us are like…meh, rub some dirt in it…it will be OK!

Guys, I’m looking at you! I do it too though and I know better.

Many years ago, I stepped off the patio and onto a piece of bone our dog had been gnawing on and it left a triangular puncture wound. I cleaned and dressed it the best I could. It wasn’t all that deep. It was right in the arch of my foot.

I went to work that evening and started feeling icky. I checked my foot and I had red streaks going from the wound, up my foot and progressing up my leg. If you ever see this, you need to seek/start care immediately, this can become life threatening quickly. The red streaks move towards the heart and indicate infection progressing. I left work and went to the ER, where they performed the same treatment as below, removing the flap of skin and flushing/debriding it well, and prescribed antibiotics. Less than 4 hours had elapsed. In less than 4 hours, I’d developed a life threatening complication.)

Foot wound care / cleaning instructions

So, I thought I’d share some instructions for care. I was an EMT and nursing student some years ago now but am not current, therefore I’m including a link with instructions rather than providing my own. I’ve pulled out some of the pertinent info.

*Disclaimer – in no way should this be interpreted as medical advice and you should not try to self administer antibiotics or avoid medical care if it is available. This is specifically for a situation where appropriate medical care is not available. Some of us do stock antibiotics for such a situation, and it’s important to know which antibiotics you are most likely to need and how to use them.

You should also keep a record of which family members react to which antibiotics. My daughter is severely allergic to sulfa antibiotics, so I always write on the bottle of any sulfa antibiotics “do not give to ____” and I also include that in any instructions that I keep around. In an emergency, you may not be thinking clearly and don’t want to give an antibiotic that may kill that person.

You might not need ALL these tools, the instruments, it depends on the condition of the wound, whether you need to cut skin away, etc.

What they say, what I say

Let’s look at some foot wound care information from Podiatry Today. First I’ll give what they say, then I will add my two cents worth.

“If there is no evidence of a retained foreign body and the wound is superficial, small and one discovers it in less than six hours, it is reasonable to cleanse the wound with saline (preferably with a large 20 cc syringe), and cover it with a sterile dressing”

-in simpler terms, use a clean (preferably sterile) syringe and sterile saline if possible. If not, boil water and treat sufficiently and use that. Boil the syringe too, if it’s not sterile. Clean the skin around the wound with an alcohol swab and then draw up the saline in the syringe and squirt it forcefully into the wound. This may hurt, depending on the severity of the wound, but generally isn’t too painful. Repeat until the wound looks as clean as possible. Bandage with sterile dressing. If sterile dressings aren’t available, boil the cleanest fabric you can find and use that. A rolling boil at 30 minutes is necessary. You may need to clean the fabric before boiling.

“When a puncture wound presents in the delayed treatment setting, is deep or has significant clinical contamination, one should perform incision and drainage. If there is a retained foreign body, triangulation with fluoroscopy and/or ultrasound can be helpful. Nonetheless, all necrotic/non-viable soft tissue and bone should have aggressive debridement with high pressure pulse lavage.23 Sharply incise jagged skin edges to decrease the chance of skin necrosis. Pack the wounds open or closed over a drain.”

-In simpler terms, if it’s been more than 6 hours, is very deep or is very contaminated, you will want to try to open it up and clean it. You will want to try to sterilize any tools you use as well as possible, using alcohol and boiling. Cut away flaps of skin, jagged edges, you can usually tell what is “dead skin” vs what is still healthy. It may look dry or discolored or you will be able to see where it is a flap. Cut it as close as possible to the healthy skin and use the same method of flushing it out as above, but with as much pressure as you can manage.

The saline or water needs to hit the tissue with as much force as possible to knock loose debris. In clinic/hospital, this is done with equipment that shoots the saline out at higher velocity but outside of that, you will have to use a syringe. You won’t be able to install a drain, so it’s best to leave the wound open and change dressing/irrigate the wound as often as possible.

“Patients who present early (less than six hours) with a clean, non-infected puncture wound with no medical comorbidities should receive clinical treatment. In this setting, empiric antibiotics are not required. However, if a patient does have certain risk factors for developing infection, presents in the delayed treatment setting or presents with a grossly contaminated wound, provide antibiotics.”

-in simpler terms, try to get to it within 6 hours. A simple puncture with no other health factors, like diabetes, should be able to be cleaned as instructed above, and shouldn’t need antibiotics.

“First-generation cephalosporins such as cephalexin (Keflex, Aspen Pharmacare) or cefadroxil (Duricef) are sufficient for most superficial puncture wounds. If the wound is grossly contaminated and/or a metallic object has penetrated the skin or shoe, adjust empiric antibiotics accordingly. Typical anti-Pseudomonas antibiotics include ciprofloxacin (Cipro, Bayer) or levofloxacin (Levaquin, Janssen Pharmaceuticals)”

-in simpler terms, antibiotics like Keflex are usually enough but for more complicated wounds, Cipro may be needed.

“Broad-spectrum antibiotics are also a good idea for the patient with diabetes or for a dirty wound. Amoxicillin/clavulanic acid (Augmentin, GlaxoSmithKline), trimethoprim/sulfamethoxazole or combination antibiotics such as clindamycin and ciprofloxacin provide appropriate bacterial coverage”

– pretty self explanatory, for diabetics or dirty wounds, amoxicillin may be necessary.

The fiddly bits

**always try to stop and clean it immediately. Don’t wait. The longer you wait, the higher the risk of complication.

****try to always keep your tetanus vax (unless contraindicated or other valid reason) up to date so that you have coverage for as long as possible if the ability to get one suddenly becomes impossible, for whatever reason. It would suck to have the Stuff Hit The Fan bigly and you realize your tetanus is expired or only good for another year at most.