Medication Summary
The goal of pharmacotherapy is to reduce pain and to prevent infection. If not updated, tetanus immunization is indicated.
Antibiotics
Class Summary
Therapy must cover all likely pathogens in the context of the clinical setting. The prophylactic use of antibiotics is indicated depending on mechanism and extent of injury, such as for crush injuries and human or animal bites. Although the benefit of prophylactic antibiotics has not been proven, even if an open fracture of the distal phalanx is present, to be safe many clinicians still prescribe a first-generation cephalosporin when bone or joint are exposed below a nailbed injury. A large, randomized controlled study may be necessary in the future to examine the utility of antibiotics in such circumstances.
Cephalexin (Keflex, Biocef)
First-generation cephalosporin that inhibits bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls. Acceptable alternative to penicillin and may be useful in patients with minor penicillin allergies.
Nonsteroidal anti-inflammatory agents (NSAIDs)
Class Summary
NSAIDs are commonly used for relief of mild to moderate pain. Effects of NSAIDs in treating pain tend to be patient specific, but ibuprofen is usually the drug of choice (DOC) for initial therapy. Other options include ketoprofen, flurbiprofen, and naproxen.
Ibuprofen (Ibuprin, Advil, Motrin)
Usually DOC for treatment of mild to moderate pain if no contraindications exist. Decreases inflammatory reactions and pain by inhibiting the activity of the enzyme cyclooxygenase, resulting in diminished prostaglandin synthesis.
Flurbiprofen (Ansaid)
Has analgesic, antipyretic, and anti-inflammatory effects. Decreases inflammatory reactions and pain by inhibiting the activity of the enzyme cyclooxygenase, resulting in diminished prostaglandin synthesis.
Ketoprofen (Oruvail, Orudis, Actron)
Used for relief of mild to moderate pain and inflammation. For patients with a small body size, elderly persons, and those with renal or liver disease, initially administer small dosages. Doses >75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patients' responses.
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderate pain. Decreases inflammatory reactions and pain by inhibiting the activity of the enzyme cyclooxygenase, resulting in diminished prostaglandin synthesis.
Analgesics
Class Summary
These agents are reserved for those with moderate to severe pain. They should be prescribed in the setting of those who have contraindications to NSAIDS, or for breakthrough pain while using NSAIDS. Current practice dictates a short course of use.
Acetaminophen (Tylenol, Panadol, Aspirin-free Anacin)
DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Acetaminophen and codeine (Tylenol #3)
Drug combination indicated for treatment of mild to moderate pain.
Hydrocodone bitartrate and acetaminophen (Vicodin, Norco)
Drug combination indicated for the relief of moderate to severe pain.
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for the relief of moderate to severe pain. DOC for aspirin-hypersensitive patients.
Toxoid
Class Summary
This agent is used for tetanus immunization. Administer booster injection in previously immunized individuals to prevent this potentially lethal syndrome.
Tetanus toxoid adsorbed or fluid
Used to induce active immunity against tetanus in selected patients. The immunizing agent of choice for most adults and children aged > 7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. May administer into deltoid or midlateral thigh muscles in children and adults. In infants, preferred site of administration is the mid thigh laterally.
Immunoglobulins
Class Summary
Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin (Hyper-Tet).
Tetanus immune globulin (TIG)
Used for passive immunization of persons with wounds that may be contaminated with tetanus spores.
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Trephination of a subungual hematoma.
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Nailbed repair.
