The approach to the management of this patient is multifaceted.

We have to
address the following concerns:
1) Stabilization of the patient who is actively bleeding by facilitating
hemostasis
2) Then we have to address the pain and discomfort of the patient
noting the level of pain experienced by the patient as to guide the
choice of analgesia
a. To optimize pain management, a thorough history and
assessment of pain is required prior to initiating treatment.
The pain intensity scale is a subjective grading of pain
severity by the patient
i. The numeric rating scale (NRS) is the most common
pain scale, evaluating pain from 0-10
ii. The Visual analog scale is suitable for children
iii. And we also have the verbal descriptor scale
b. To guide us in the selection of analgesia, we use the
Modified WHO Pain Ladder which is a three-step algorithm
for the management of acute and chronic pain.
i. in acute pain, it is initially treated with the strongest
analgesic for that intensity of pain and then stepped
down. Unlike the original WHO ladder which was
unidirectional (escalating) and only included the first
3 steps, other authors have since modified the ladder,
adding a 4th step.
1. Nonopioid analgesics are first-line agents
for pain; prescribe them alone for mild to
moderate pain and in combination
with opioids for severe pain. (Blondell RD,
Azadfard M et al.. Pharmacologic therapy
for acute pain.. Am Fam Physician. 2013;
87(11): p.766-72. pmid: 23939498)
2. For both opioid and nonopioid analgesics,
use the minimal effective dose for the
 shortest duration of time to minimize adverse
effects. Pain intensity scales should be used
in regular intervals to assess the success
of pain management.
c. In order to arrive at a prudent of choice of pain relief, we
have to understand the mechanism of pain and
inflammation, so that we will know at which points we can
intervene. central to this is the examination of the pain
pathway and the COX pathway.
i. Pain pathway
The central ascending pathway for sensation
consists of two systems: the spinothalamic
tract and the phylogenetically
older spinoreticulothalamic system. The first
pathway conducts the sensation of sharp,
stabbing pain; the second conveys deep,
poorly localized, burning pain.
1. Nociceptors detect a chemical, mechanical,
or thermal noxious stimulus → conversion
of stimulus to an electric signal (action
potential) → C fibers and Aδ fibers carry
afferent input to the dorsal horn of
the spinal cord
→ secondary nociceptive neurons in
the spinothalamic tract carry afferent input
to the thalamus in
the CNS → pain perception and a response
sent along efferent pathways, which results
in pain modulation and/or a reaction (Yam
M: Loh YC. General Pathways of Pain
Sensation and the Major Neurotransmitters
Involved in Pain Regulation. International
 Journal of Molecular Science. 2018.; )
2. Descending Systems and Pain. Certain
neurons within the brain, particularly within
the periaqueductal gray matter of the
midbrain, send descending axons to the
spinal cord. These descending, inhibitory
pathways suppress the transmission of pain
signals and can be activated with endorphins
and opiate drugs
ii. The Opioids

3) We assess the need for antibiotic prophylaxis of the patient and to

verify the Tetanus immunization status, in order to prevent the
development of infection as a result of the break in the skin barrier,
taking note of the usual pathogens involved and their antimicrobial
susceptibility with a special consideration on the patient’s allergy to
penicillins – that will guide us in the choice of antibiotics.
a. Antibiotic prophylaxis is warranted for our patient because:
i. of the nature of the wound; plantar wounds have a
high risk for infection due to the relatively poor
circulation of the foot compared to other areas of the
body
ii. the occupational risk involved – the patient is a
carpenter and they usually work on the ground, and
in the Philippines, there is an issue of the lack
of/improper use of Personal Protective Equipment
such as safety shoes, gloves, goggles and hard hat.