462.A 40-year-old man presents to the ED with a left foot puncture wound
from stepping on a rusty nail. His last tetanus vaccine was during childhood,
which resulted in a severe allergic reaction and a prolonged hospital stay. Which
of the following is true regarding tetanus immunization in this patient?
a. Give tetanus toxoid.
b. Give tetanus immunoglobulin.
c. Give tetanus immunoglobulin and toxoid.
d. Give neither tetanus toxoid nor immunoglobulin since he has had an allergic
reaction in the past.
e. Give tetanus toxoid and immunoglobulin with diphenhydramine.
463.A 5-year-old boy is brought to the ED by his mom for a forehead lacer-
ation. She reports that he slipped on ice and hit his head. There was no loss of
consciousness. The child is alert and active. He has a 3-cm-forehead laceration
which crosses the hairline. What is the most appropriate method of wound
closure in this patient?
a. Shave the hair surrounding the laceration and close with interrupted sutures.
b. Shave the hair surrounding the laceration and close with topical skin adhesive
(Dermabond).
c. Close with staples.
d. Close with Steri-Strips.
e. Close with interrupted sutures.
464.A 12-year-old girl presents to the ED with a left index finger laceration.
She sustained the injury when her friend accidentally closed the car door on
her finger. She has a semicircular laceration distal to the distal interphalangeal
(DIP) joint on the volar surface of the left second digit. Sensation distal to
the laceration is intact. Range of motion at the DIP joint is intact. The patient
hopes to be a hand model in the future and is extremely anxious about the
cosmetic result. Which of the following is the best method to provide anes-
thesia in this patient?
a. Application of a tourniquet to control bleeding and irrigation of the wound
with 3 cc of lidocaine
b. Local infiltration through the wound margins with 3 cc of lidocaine
c. Local infiltration through the wound margins with 3 cc of lidocaine with
epinephrine
d. A digital block at the base of the proximal phalanx with 3 cc of lidocaine
e. A digital block at the base of the proximal phalanx with 3 cc of lidocaine with
epinephrine
508 Emergency Medicine