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Jan Nio A.


Dog bites typically cause a crushing-type wound because of their rounded teeth and strong jaws. An adult dog can exert 200 pounds per square inch (psi) of pressure, with some large dogs able to exert 450 psi. Such extreme pressure may damage deeper structures such as bones, vessels, tendons, muscle, and nerves. The sharp pointed teeth of cats usually cause puncture wounds and lacerations that may inoculate bacteria into deep tissues. Infections caused by cat bites generally develop faster than those of dogs. Limited literature is available on other mammalian bites. Monkey bites have a notorious reputation based largely on anecdotal reports. Several cases of unprovoked attacks on young children and infants by domesticated ferrets have been documented. The bites of foxes, raccoons, skunks, bats, dogs, and cats have been clearly linked to rabies exposure. Bites from large herbivores generally have a significant crush element because of the force involved. Bites of the hand generally have a high risk for infection because of the relatively poor blood supply of many structures in the hand and

anatomic considerations that make adequate cleansing of the wound difficult. In general, the better the vascular supply and the easier the wound is to clean (ie, laceration vs puncture), the lower the risk of infection. A major concern in all bite wounds is subsequent infection. Infections can be caused by nearly any group of pathogens (bacteria, viruses, rickettsia, spirochetes, fungi). At least 64 species of bacteria are found in the canine mouth, causing nearly all infections to be mixed. Common bacteria involved in bite wound infections include the following:

Dog bites Staphylococcus species Streptococcus species Eikenella species Pasteurella species Proteus species Klebsiella species Haemophilus species Enterobacter species DF-2 or Capnocytophaga canimorsus Bacteroides species Moraxella species Corynebacterium species Neisseria species Fusobacterium species Prevotella species Porphyromonas species Cat bites Pasteurella species

Actinomyces species Propionibacterium species Bacteroides species Fusobacterium species Clostridium species Wolinella species Peptostreptococcus species Staphylococcus species Streptococcus species Herbivore bites Actinobacillus lignieresii Actinobacillus suis Pasteurella multocida Pasteurella caballi Staphylococcus hyicus subsp hyicus Swine bites Pasteurella aerogenes Pasteurella multocida Bacteroides species Proteus species Actinobacillus suis Streptococcus species Flavobacterium species Mycoplasma species Rodent bites - Rat-bite fever Streptobacillus moniliformis Spirillum minus Primates Bacteroides species Fusobacterium species Eikenella corrodens Streptococcus species Enterococcus species Staphylococcus species Enterobacteriaceae Simian herpes virus Large reptiles (crocodiles, alligators) Aeromonas hydrophila Pseudomonas pseudomallei Pseudomonas aeruginosa Proteus species Enterococcus species Clostridium species

Complications Complications of bite wounds may include the following: Wound infection Sepsis Cosmetic deformity Loss of limb Loss of function

Mortality/Morbidity Dog attacks kill approximately 1020 people annually in the United States. Most of these fatalities, unfortunately, are young children. While local infection and cellulitis are the leading causes of morbidity, sepsis is a potential complication of bite wounds, particularly C canimorsus (DF-2) sepsis in immunocompromised individuals. Pasteurella multocida infection (the most common pathogen contracted from cat bites) also may be complicated by sepsis. Meningitis, osteomyelitis, te nosynovitis, abscesses, pneumonia, endocarditis, and septic arthritis are additional concerns in bite wounds. When rabies occurs, it is almost uniformly fatal (Rabies). Sex Women are more frequently bitten by cats, whereas men are more often bitten by dogs (despite being man's best friend). Age

Peak incidence of animal bites occurs among children aged 5-9 years. History History for animal bites should include the following:

Causes Bite wounds from cats and dogs can occur without provocation, but provoked bites, such as disturbing animals while they are eating, are more common. Older animals often are less tolerant of disturbances, especially by children. Most dog bites involve a dog that belongs to the family or friend of the victim and approximately half occur on the pet owner's property. Certainly, unprovoked bites by wild or sick-appearing animals (most notably by dogs, cats, raccoons, foxes, skunks, and bats) further raise underlying concerns about likelihood of rabies exposure. Laboratory Studies Fresh bite wounds without signs of infection do not need to be cultured. Infected bite wounds should be cultured to help guide future antibiotic therapy. Other laboratory tests are indicated as the patient's condition dictates (eg, CBC and blood cultures for patients with sepsis). If C canimorsus sepsis is suspected, examine the peripheral smear for the organism, a bacillus. Imaging Studies Radiography is indicated if any concerns exist that deep structures are at risk (eg, hand wounds; deep punctures; crushing bites, especially over joints). Occult fractures or osteomyelitis may be discovered.

Time and location of event Type of animal and its status (ie, health, rabies vaccination history, behavior, whereabouts) Circumstances surrounding the bite (ie, provoked or defensive bite versus unprovoked bite) Location of bites (most commonly on the upper extremities and face) Prehospital treatment Patients medical history (immunocompromise, peripheral vascular disease, diabetes, tetanus and rabies vaccination history) Physical Major resuscitation rarely is required. Because patients typically are children, reassurance and parental presence may facilitate examination. Where applicable, consider the following:

Distal neurovascular status Tendon or tendon sheath involvement Bone injury, particularly of the skull in infants and young children Joint space violation Visceral injury Foreign bodies (eg, teeth) in the wound Significant damage due to bites is shown in the images below.

Radiographs may find foreign bodies in the wound (eg, teeth). Children who have been bitten in the head should be examined for bony penetration with plain films or CT scan. If the child was shaken, consider cervical spine evaluation. Prehospital Care Obtaining the history of the bite event is of major importance, including home treatment of wounds, body parts involved, and other symptoms (see History). Rinse bite wounds, if possible, and cover with a sterile dressing. Tap water has been shown to be as effective for irrigation as sterile saline. Encourage patients to seek prompt care. Emergency Department Care Most bite wounds can be treated in the ED. Essentials of treatment are inspection, debridement, irrigation, and closure, if indicated. Complete trauma evaluation occasionally is indicated.

Carefully inspect bite wounds to identify deep injury and devitalized tissue. Obtaining an adequate inspection of a bite wound without it first being anesthetized is nearly impossible. Care should be taken to visualize the bottom of the wound and, if applicable, to examine the wound through a range of motion. Debridement is an effective means of preventing infection. Removing devitalized tissue, particulate matter, and clots

prevents these from becoming a source of infection, much like any foreign body. Clean surgical wound edges result in smaller scars and promote faster healing. Irrigation is another important means of infection prevention. A 19-gauge blunt needle and a 35mL syringe provide adequate pressure (7 psi) and volume to clean most bite wounds. In general, 100-200 mL of irrigation solution per inch of wound is required. Heavily contaminated bite wounds require more irrigation. Large dirty wounds may require irrigation in the operating room. Isotonic sodium chloride solution is a safe, available, effective, and inexpensive irrigating solution. Few of the numerous other solutions and mixtures of saline and antibiotics have any advantages over saline. If a shieldlike device is used, take care to prevent the irrigating solution from returning to the wound, which decreases the effectiveness of the irrigation. Primary closure may be considered in limited bite wounds that can be cleansed effectively (this excludes puncture wounds, ie, cat bites). Other wounds are best treated by delayed primary closure. Facial wounds, because of the excellent blood supply, are at low risk for infection, even if closed primarily, but the risk of superinfection must be discussed with the patient prior to closure. Bite wounds to the hands and lower extremities, with a delay in presentation, or in immunocompromised hosts, generally should be left open.

If a bite wound involves the hand, consider immobilizing in a bulky dressing or splint to limit use and promote elevation. Consider tetanus and rabies prophylaxis for all wounds. Antirabies treatment may be indicated for bites by dogs and cats whose rabies status can not be obtained, or in foxes, bats, raccoons, or skunks in the Americas (see Rabiesand Tetanus for treatment and dosing information). Oehler et al have established a wound management strategy following animal bites to prevent severe complications that include the following steps.

patients who are immunocompromised or are likely to be noncompliant. Administer tetanus booster (if none given in past year) or initiate primary series in nonvaccinated individuals Assess the need for rabies vaccine and immunoglobulin Medication Summary This is one of most controversial subjects in wound care. Remember that proper wound care (inspection, debridement, irrigation, closure, if indicated) reduces infection more than antibiotics. In general, low-risk wounds do not require prophylactic antibiotics. However, therapy is recommended for high-risk wounds (eg, cat bites that are a true puncture, bites to the hand, massive crush injury, late presentation, poor general health). The goal of initial therapy is to cover staphylococci, streptococci, anaerobes, and Pasteurella species. Prophylactic antibiotics may be given for a 3- to 5-day course. The first-line oral therapy is amoxicillinclavulanate. For higher risk infections, a first dose of intravenous antibiotic may be given (ie, ampicillin-sulbactam, ticarcillin-clavulanate, piperacillintazobactam, or a carbapenem). Other combinations of oral therapy include cefuroxime plus clindamycin or metronidazole, a fluoroquinolone plus clindamycin or metronidazole, sulfamethoxazole and trimethoprim plus clindamycin or metronidazole, penicillin plus clindamycin or metronidazole,

Culture for aerobes and anaerobes if abscess, severe cellulitis, devitalized tissue, or sepsis is present. Use saline solution for wound irrigation. Debride necrotic tissue and remove any foreign bodies. If fracture or bone penetration, radiography is indicated (MRI or CT may also be indicated). Initiate prophylactic antibiotics in selected cases (based on type and specific animal involved). If methicillinresistant Staphylococcus aureus (MRSA) is suspected, firstline antibiotics include trimethoprim-sulfamethoxazole, doxycycline, minocycline, and clindamycin. Hospitalization is indicated if fever, sepsis, spreading cellulitis, severe edema, crush injury, or loss of function is present. Also consider hospitalization for

amoxicillin plus clindamycin or metronidazole and less effective azithromycin or doxycycline plus clindamycin or metronidazole. If the wound is infected on presentation, a course of 10 days or longer is recommended. For monkey bites, postexposure prophylaxis valacyclovir or acyclovir should be given for 14 days.

Toxoids Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap, Adacel, Boostrix)
Promotes active immunity to

Antiviral agents These agents inhibit viral replication. Acyclovir (Zovirax)

Has activity against a

number of herpesviruses, including herpes virus B. Primarily available in preparations for PO and IV use. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks. Early initiation of therapy is imperative. Valacyclovir (Valtrex)
Hydrochloride salt of the L-

diphtheria, tetanus, and pertussis by inducing production of specific neutralizing antibodies and antitoxins. Indicated for active booster immunization for tetanus, diphtheria, and pertussis prevention for persons aged 10-64 y (Adacel approved for 11-64 y, Boostrix approved for 10-18 y). Preferred vaccine for adolescents scheduled for booster. Tetanus toxoid
Used to induce active

immunity against tetanus in selected patients. The immunizing agent of choice for most adults and children > 7 years are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life. Immune Globulin Indicated in previously unvaccinated individuals to provide passive immunity to tetanus when individuals become exposed. Tetanus immune globulin (HyperTET S/D) Used for passive immunization of any person with a wound that might be

valyl ester of acyclovir. Rapidly converted into acyclovir after prompt absorption from the gut via first-pass intestinal or hepatic metabolism. An alternative to acyclovir for prophylaxis (or possibly treatment).

contaminated with tetanus spores. Rabies Immune Globulin (Imogam Rabies-HT, HyperRab S/D) Provides passive protection to individuals exposed to rabies virus. About 1/2 the dose should be administered into and around the bite wound as much as possible (given anatomic constraints), and the rest given intramuscularly at a site remote from the vaccine administration area in the gluteal or deltoid muscle. Vaccine, Inactivated Virus Inactivated forms of virus that promote immunity by inducing an active immune response.

postexposure patients of all age groups; also used for preexposure immunization in both primary series and booster dose. Fourteen days after initiating immunization series, antirabies antibody titers reach levels well above minimal protective level of 0.5 IU/mL. Vaccine must be injected IM and never SC, ID, or IV. In adults, inject into deltoid muscle area. In small children, administer into anterolateral zone of thigh. Rabies vaccine adsorbed (RVA; BioPort Corp under US Department of Defense contract for military use only)

Rabies vaccine (Rabavert, Imovax Rabies Vaccine)

Inactivated form of virus grown in primary cultures of chicken fibroblasts; offers active immunity and, when used in combination with human rabies immune globulin (HRIG) and local wound treatment, protects

Inactivated virus vaccine, which promotes immunity by inducing active immune response. May be given IM only, never ID.