Management of Nail Scratch Injury in a Child

Step 1 - Immediate First Aid (at home/school)

1. Control any bleeding - Apply gentle pressure with a clean cloth for 5-10 minutes. Do not lift the cloth repeatedly.
2. Wash the wound thoroughly - This is the single most important step:
   • Run clean running water over the scratch for at least 5 minutes
   • Then wash gently with soap and water
   • Remove any visible dirt or debris with a soft damp cloth
3. Do NOT apply iodine, hydrogen peroxide, or alcohol directly into the wound - these damage tissue and slow healing
4. Cover it - Apply an adhesive bandage or clean gauze once the wound is clean and dry

Step 2 - Take the Child to a Doctor

• Human nail scratches carry Staphylococcus aureus, Streptococcus species, and skin/oral anaerobes
• Infection can set in within 24-48 hours and may not be obvious at first
• The wound depth and extent need proper assessment

Step 3 - Clinical Assessment at the Clinic/ER

• Assess the type, depth, and location of the scratch (face, hand, or extremity)
• Check for signs of infection: redness, swelling, warmth, pus, foul odor, fever
• Check tetanus vaccination status (see below)
• Rule out child abuse or assault - a scratch from another child warrants a brief social history; if the injury is inconsistent with the history given, safeguarding must be considered
• Ask about the other child's health (e.g., skin infections, blood-borne illness concerns)

Step 4 - Wound Care at the Clinic

• Irrigate copiously with sterile saline or clean water under pressure
• Debride any devitalized tissue
• Do not primarily close a human scratch that is more than 12 hours old or shows signs of infection - allow it to heal by secondary intention or consider delayed closure
• Fresh, clean facial scratches may be closed primarily due to the excellent blood supply and cosmetic importance

Step 5 - Tetanus Prophylaxis

Step 6 - Antibiotics

• No infection present: Prophylactic antibiotics are not routinely required for a simple scratch from a healthy child, provided the wound was cleaned well
• If infection risk is high (deep scratch, delayed presentation >8-12 hours, hand wounds, immunocompromised child): consider amoxicillin-clavulanate (oral) for 3-5 days - this covers S. aureus, streptococci, and anaerobes
• If infection is already present (redness, swelling, pus): amoxicillin-clavulanate is first-line; in penicillin-allergic children, use trimethoprim-sulfamethoxazole + metronidazole

Step 7 - Signs to Watch for (Return Precautions)

• Increasing redness, warmth, swelling around the scratch
• Pus or discharge from the wound
• Red streaks spreading from the wound (lymphangitis)
• Swollen lymph nodes nearby
• Fever
• The child seems unwell or in increasing pain

Step 8 - Wound Follow-Up Care at Home

• Keep the area clean and dry
• Change the dressing daily
• Do not scratch or pick at the wound
• Keep the child's nails trimmed to prevent further self-injury
• Return for review in 48-72 hours if antibiotics were given, or earlier if worsening

Special Considerations

• Hand wounds carry a higher infection risk and may need a hand surgery consult if there is concern about tendon or joint involvement
• Facial scratches heal well due to good blood supply; cosmetic referral can be considered for deep facial lacerations
• Safeguarding: If the scratch was from deliberate assault (bullying, abuse), document the injury with a description or photograph, and follow local child protection protocols