Common injuries and accidents

22 Jan 08

Nail injuries

• With an avulsed nail, protect the nail bed with soft paraffin and gauze, check tetanus status and give antibiotic prophylaxis (flucloxacillin 250mg qds for five days). Partially avulsed nails need removing under ring block to exclude an underlying nail bed injury. Replace the avulsed nail in its usual position to act as a splint to the nail matrix.

• Subungual haematoma: a blow to the finger can cause bleeding under the nail, and be very painful because of pressure build-up. Relieve by trephining a hole through the nail using a 19-gauge needle (no force required – just twist the needle as it rests vertically on the nail) or a heated point (such as that of a paper clip or cautery instrument). This is of benefit up to two days after injury.

Bites

Animal bites

About 200,000 people are bitten by dogs each year in the UK.

Animal bites are contaminated and wound infection is common. Clean carefully with soap and water. Check tetanus status.

tetanus algorithm

Do not suture unless cosmetically essential and there is minimal tissue damage, and refer if in doubt. Give prophylaxis against infection (co-amoxiclav or erythromycin).

Human bites

Human bites are especially prone to infection, especially with anaerobic organisms. Give prophylaxis against infection (co-amoxiclav or flucloxacillin/ erythromycin and metronidazole). Also consider risk of hepatitis B and HIV. If HIV prophylaxis is indicated, it needs to be started immediately, and refer urgently to A&E for local policy implementation.

Note that punch injuries over the knuckles are often associated with tooth lacerations and may indicate involvement of the underlying MCP joint – refer to A&E.

Snake bites

The adder is the only poisonous snake in the UK. Bites are only rarely lethal. Attempt to identify the snake species and refer the patient urgently to hospital. Do not apply a tourniquet or try cutting or sucking the wound.

Air gun pellets

Refer for X-ray. These can be difficult to remove and may be left in place if not in a harmful position. If in a joint, refer for removal.

Fish hooks

Infiltrate with lidocaine. Push the hook forwards through the skin until the barb is exposed. Cut the barb off and then ease the hook back through the skin the same way it entered.

Foreign bodies

Coin or other foreign body ingestion

Most coins will pass through the gut without any problems. If asymptomatic, they can be left to take their course (advise checking stools to ensure passed).

If symptomatic refer for X-ray and consideration for endoscopic removal. If there is any indication of aspiration refer urgently.

Foreign bodies in the ear

This is most common in children. Try to remove with forceps but avoid pushing objects deeper into the canal and causing damage. Don’t poke around with forceps in an uncooperative child. Removal under general anaesthetic may be needed. Insects can be drowned in oil and syringed out.

Foreign bodies in the nose

This is common in young children. Refer all children with unilateral offensive discharge for exploration under general anaesthetic.

Do not try to remove a foreign body yourself unless the object is very superficial and the child co-operative. You might push the object further in and cause trauma.

Removal of ticks

Use a commercially available tick remover or place a large blob of petroleum jelly over the tick. It suffocates over a few hours and can be removed easily with a pair of tweezers.

Seaside stings

Weaver fish sting

The fish lurks under the sand so is usually trodden on, causing the patient severe foot pain.

• Immerse the affected area in uncomfortably hot (but not scalding) water.

• Give analgesia. Pain resolves after two to three days.

Jellyfish sting

• Remove the patient from the sea as soon as possible.

• Scrape or wash adherent tentacles off.

• Alcoholic solutions including suntan lotions should not be applied because they may cause further discharge of stinging hairs.

• Ice packs reduce pain and a slurry of baking soda (sodium bicarbonate), but not vinegar, may be useful for treating stings from UK species.

Removing a tight ring

• Wind cotton tape around the finger advancing towards the ring.

• Thread tape through the ring and pull on this end to unwind the tape (levers ring over PIP joint).

• If unsuccessful, use a ring cutter.

This is an extract from Emergencies in Primary Care published by Oxford University Press, edited by Dr Chantal Simon, Dr Karen O’Reilly, Dr Robin Proctor and Dr John Buckmaster. To order a copy go to www.oup.co.uk ISBN:978-0-19-857068-4 or click on the link on the right of this screen