Pencil Point Puncture
The patient presents after being stabbed or stuck with a sharp pencil point. He may be openly or unconsciously worried about lead poisoning. A small puncture wound lined with graphite tattooing will be present (Figure 150-1). The pencil tip may or may not be present, visible, or palpable. If the puncture wound is palpated, an underlying pencil point may give the patient a foreign body sensation.
What To Do:
Reassure the patient or parent that there is no danger of lead poisoning. Pencil “leads” are made of clay and graphite, which is primarily carbon and nontoxic.
Conduct a full examination, including sensory and motor function of the affected area.
Obtain a thorough history relating to the injury, and assess the patient’s risk of developing complications, which are rare.
Palpate and inspect for a foreign body. If uncertain, obtain a radiograph or ultrasonogram to rule out the presence of a foreign body. Most often, there is no foreign body; there are only the embedded black graphite particles.
Administer local anesthesia if necessary; then thoroughly scrub the wound.
To reduce the amount of tattooing, the wound may be scraped (dermabraded) with the tip of a scalpel blade (Figure 150-2). Always administer local anesthesia using lidocaine (1% with or without epinephrine) before scraping wound.
Warn the patient or family about signs of infection (increasing pain, redness, swelling, red streaking,) and inform them that there may be a permanent black tattoo that can be removed later if the resulting mark is cosmetically unacceptable (Figure 150-3).
Administer tetanus prophylaxis, if necessary (see Appendix H).
What Not To Do:
Do not excise the entire wound on the initial visit.
It is unwise to excise the entire wound, because the resultant scar might be more unsightly than the tattoo. If a superficial pencil tip foreign body exists, see Chapter 154 for an easy removal technique. Most of these wounds do not contain a foreign body but only the appearance of one. Tattoo prevention should be the clinician’s primary concern. If tattooing is present and of cosmetic concern, the patient may benefit from a referral to a dermatologist for removal.
Rarely, deep punctures or foreign bodies may require exploratory surgery in the operating room.