A 72-year-old man presents to the urgent care clinic with right foot pain and swelling after a marine injury that occurred earlier that day. He reports walking barefoot in shallow coastal water along a Florida beach, when he felt a sudden sharp pain on the top of his right foot. He did not see the animal. He exited the water immediately and rinsed his foot with seawater. Pain improved slightly but persisted, prompting his visit to the urgent care. He denies chest pain, shortness of breath, nausea, vomiting, dizziness, weakness, or numbness.
Of note, his past medical history includes hypertension that is treated with lisinopril, and hyperlipidemia treated with atorvastatin. He reports no known allergies. On physical examination, his right foot is swollen with mild erythema surrounding a single puncture wound on the dorsal surface of the forefoot. There is no visible retained foreign body and no active bleeding. Other review of systems is unremarkable.
Which of the following is the most appropriate next step in management for this patient?
- Immediate transfer to the emergency department for antivenom administration
- Primary wound closure after irrigation and an over-the-counter antibiotic ointment
- Vinegar irrigation to neutralize venom, followed by cold packs
- Copious irrigation, hot water immersion for pain control, tetanus update, a prescription for an oral antibiotic, and close follow-up
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Correct answer: d. Copious irrigation, hot water immersion for pain control, tetanus update, a prescription for an oral antibiotic, and close follow-up
Patients with marine puncture wounds, including those in high-risk populations, do not automatically require ED transfer. In the case of this older patient, the clinician can be reasonably certain there is no retained stingray barb based on clinical signs: (a) it was only brief contact; (b) there was no visible barb in the wound; (c) the patient did not experience a sensation of deep impalement or an object breaking off; and (d) the patient was able to bear weight on his foot after the injury. Stable patients without retained foreign bodies or systemic symptoms can be safely managed in urgent care with aggressive local care, pain control, infection prevention, and close follow-up.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
