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Animal Bites in Emergency Medicine Treatment & Management

  • Author: Alisha Perkins Garth, MD; Chief Editor: Joe Alcock, MD, MS  more...
 
Updated: May 16, 2016
 

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.[16]

Encourage patients to seek prompt care.

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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 that has not been 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 a key means of infection prevention. A 19-gauge blunt needle and a 35-mL 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.[16] Heavily contaminated bite wounds require more irrigation. Large dirty wounds may require irrigation in the operating room. If available, povidone-iodine solution has been shown to be virucidal and is recommended for irrigation by the US Centers for Disease Control (CDC) if there is concern for rabies. A 10% solution can be diluted (10 or 20:1) and used to both cleanse the surface of the wound as well to irrigate.[17] Additionally, isotonic sodium chloride solution or tap water is a safe, widely available, effective, and inexpensive irrigating solution. Few of the numerous other solutions and mixtures of saline and antibiotics have any advantages over tap water or saline.[16] 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.

It may be difficult to appropriately irrigate small puncture wounds, especially those inflicted by the teeth of a cat. Given that these have a higher rate of infection, consideration should be given to opening the wound with a 15-blade scalpel and creating a 1-1.5cm incision that can be well irrigated and left open to heal by secondary intention.[18]

Studies estimate the rate of infection of non – high-risk mammalian bites to be approximately 6-8% when closed primarily.[19, 20, 21] A study of dog bites showed improved cosmetic scores and no increased risk of infection with primary closure of wounds in multiple anatomic locations with provision of prophylactic antibiotics.[19]

Facial wounds have a low risk of infection even when closed primarily due to their increased blood supply.[9, 22, 19] A randomized clinical trial showed no increased risk of infection (without the use of prophylactic antibiotics) and improved wound healing times with primary closure of facial wounds from dog bites.[22] Given the cosmetic implications of facial wounds, primary closure is therefore advisable.

Primary closure should only be considered in bite wounds that can be cleansed effectively. Bite wounds to the hands and lower extremities, with a delay in presentation (>8-12 hours old), or in immunocompromised hosts, generally should be left open or treated by delayed primary closure.[9] Closure management decisions should be at the discretion of the provider after discussion with the patient and consultation with specialists if available. Deep sutures should be avoided because they can act as a nidus for infection.

If a bite wound involves the hand, consider immobilizing the hand 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 Rabies and 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[23] :

  • 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 has occurred, radiography is indicated (MRI or CT may also be indicated)
  • Initiate prophylactic antibiotics in selected cases (based on type and specific animal species involved)
  • If methicillin-resistant Staphylococcus aureus (MRSA) is suspected, first-line antibiotics include trimethoprim-sulfamethoxazole, doxycycline, minocycline, and clindamycin [24]
  • Hospitalization is indicated if fever, sepsis, spreading cellulitis, severe edema, crush injury, or loss of function is present; also consider hospitalization for 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 (see Tetanus for further recommendations)
  • Assess the need for rabies vaccine and immunoglobulin (see Rabies for further recommendations)

For additional information, see Medscape's Wound Management Resource Center.

Further inpatient care and transfer

Patients with infected animal bites may need inpatient care. This depends on the general health of the patient, the extent and nature of the infection, and the patient's likely degree of compliance.

Consider admitting patients with hand bites that become infected (generally those involving deep structures). Consider consultation with the hand surgery service if deep infection, such as involving the tendon sheath or other structures, is suspected, as surgical irrigation may be indicated.

Patients who require extensive repair or prolonged inpatient care may need transfer to a tertiary care facility.

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Consultations

Extensive wounds, those involving tissue loss, or those involving complex structures may require plastic surgery consultation.

If the skull is penetrated, neurosurgery consultation is indicated.

Local public health authorities should be notified of all bites and may help with recommendations for rabies prophylaxis.

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Complications

Complications of bite wounds may include the following:

  • Wound infection
  • Sepsis
  • Cosmetic deformity
  • Loss of limb
  • Loss of function
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Prevention

Pediatric patients who have been bitten remain at risk if the dog, cat, or other animal that bit them continues to be aggressive or is located where another bite could occur. To prevent further incidents, the animal should be moved to another location.

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Long-Term Monitoring

Close follow-up care is essential in animal bite wounds. Reevaluate a low-risk bite for signs of infection within 48 hours and a high-risk bite within 24 hours.

In some centers that have an observation unit, admission to that area for direct clinical observation and repeat doses of parenteral antibiotics can be considered on a case-by-case basis.

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Contributor Information and Disclosures
Author

Alisha Perkins Garth, MD Staff Physician, St Joseph Hospital

Alisha Perkins Garth, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Clifford S Spanierman, MD Consulting Staff, Departments of Emergency Medicine and Pediatrics, Lutheran General Hospital of Oak Brook, Advocate Health System

Disclosure: Nothing to disclose.

N Stuart Harris, MD, MFA, FACEP Chief, Division of Wilderness Medicine, Massachusetts General Hospital (MGH). Fellowship Director, MGH Wilderness Medicine Fellowship. Attending Physician, MGH. Assistant Professor in Surgery, Harvard Medical School.

N Stuart Harris, MD, MFA, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Massachusetts Medical Society, International Society for Mountain Medicine

Disclosure: Nothing to disclose.

Renee N Salas, MD, MS Fellow in Wilderness Medicine, Attending Emergency Medicine Physician, Massachusetts General Hospital; Clinical Instructor of Surgery, Harvard Medical School

Renee N Salas, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, Wilderness Medical Society, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

James Steven Walker, DO, MS Clinical Professor of Surgery, Department of Surgery, University of Oklahoma College of Medicine

James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Robert M McNamara, MD, FAAEM Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. US Pet Ownership and Demographic Sourcebook. 2012.

  2. Centers for Disease Control and Prevention. Preventing Dog Bites. Available at http://www.cdc.gov/features/dog-bite-prevention/index.html. May 18, 2015; Accessed: May 16, 2016.

  3. Holmquist, L., MA, Elixhauser, A., PhD. Emergency Department Visits and Inpatient Stays Involving Dog Bites. Healthcare Cost and Utilization Project Statistical Briefs. Nov 2010. 101:[Full Text].

  4. Chambers GH, Payne JF. Treatment of dog bite wounds. Minn Med. 1969. 52:427-430. [Medline].

  5. Freer L. Bites and injuries inflicted by wild and domestic animals. Auerbach PS, ed. Wilderness Medicine. 5th ed. Mosby; 2007. 1133-55.

  6. Dire DJ. Cat bite wounds: risk factors for infection. Ann Emerg Med. 1991 Sep. 20(9):973-9. [Medline].

  7. Talan DA, Citron DM, Abrahamian FM, et al. Bacteriologic analysis of infected dog and cat bites. N Engl J Med. 1999 Jan 14. 340(2):85-92. [Medline].

  8. Abrahamian FM. Dog Bites: Bacteriology, Management, and Prevention. Curr Infect Dis Rep. 2000 Oct. 2(5):446-453. [Medline].

  9. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005 Nov 15. 41(10):1373-406. [Medline].

  10. Gilchrist J, Sacks JJ, White D, Kresnow MJ. Dog bites: still a problem?. Inj Prev. Oct 2008. 14(5):296-301. [Medline].

  11. Palacio J, Leon-Artozqui M, Pastor-Villalba E, Carrera-Martin F, Garcia-Belenguer S. Incidence of and risk factors for cat bites: a first step in prevention and treatment of feline aggression. J Feline Med Surg. 2007 Jun. 9(3):188-95. [Medline].

  12. Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA. 1998 Jan 7. 279(1):51-3. [Medline]. [Full Text].

  13. Sacks JJ, Lockwood R, Hornreich J, Sattin RW. Fatal dog attacks, 1989-1994. Pediatrics. Jun 1996. 97(6 Pt 1):891-895. [Medline].

  14. Animal People. Dog attack deaths and maimings, US and Canada. September 1982 to December 26, 2011. Dogsbite.org. Available at http://www.dogsbite.org/pdf/dog-attack-deaths-maimings-merritt-clifton-2011.pdf. Accessed: May 9, 2012.

  15. Patronek, G.J., Sacks, J.J., Delise, K.M., et al. Co-occurrence of potentially preventable factors in 256 dog bite-related fatalities in the United States (2000-2009). Journal of the American Veterinary Medical Association. 12. 243:1726-1736.

  16. Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Academic Emergency Medicine. May 2007. 14 (5):404-9. [Medline].

  17. Rupprecht, C.E., Briggs, D., Brown, C.M. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations from the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2010. 59:1-9.

  18. Trott A. Bite wounds. Wounds and Lacerations Emergency Care and Closure. 2nd ed. St Louis, Mo: Mosby-Year Book Inc; 1997. 265-84.

  19. Paschos, NK, Makris, EA, Gantsos, A, et al. Primary closure versus non-closure of dog bite wounds. a randomized controlled trial. Injury. 2014. 45(1):237-40.

  20. Maimaris, C., Quinton, DN. Dog-bite lacerations: A controlled trial of primary wound closure. Arch Emerg Med. 1988. 5:156.

  21. Chen, E., Hornig, S., Shepherd, SM. Primary closure of mammalian bites. Acad Emerg Med. 2000. 7:157.

  22. Rui-feng, C., Li-song, H., Ji-bo, Z., et al. Emergency treatment on facial laceration of dog bite wounds with immediate primary closure: a prospective randomized trial study. BMC Emerg Med. July 2013. 13 Supp 1:

  23. Oehler RL, Velez AP, Mizrachi M, Lamarche J, Gompf S. Bite-related and septic syndromes caused by cats and dogs. Lancet Infect Dis. 2009 Jul. 9(7):439-47.

  24. Liu, C., Bayer, A., Cosgrove, SE. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults in children. Clin Infect Dis. 2011. 52:1-38.

  25. Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med. 1994 Mar. 23(3):535-40. [Medline].

  26. [Guideline] Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014 Jul 15. 59(2):147-59. [Medline].

  27. Gilbert DN, Moellering RC, Eliopoulos FM, Sande MA, eds. Bites. The Sanford Guide to Antimicrobial Therapy. 37th ed. 2007. 46,47,140.

  28. Weber EJ. Mammalian bites. Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Mosby; 2006. 906-21.

 
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Animal bites. The devastating damage sustained by a preadolescent male during a dog attack. Almost lost in this photograph is the soft tissue damage to this victim's thigh. This patient required 2 units of O- blood and several liters of isotonic crystalloid. Repair of these wounds required a pediatric surgeon, an experienced orthopedic surgeon, and a plastic surgeon. Attacks such as these have caused a movement in some areas of the country to ban certain dog breeds.
Animal bites. Massive soft tissue damage of the right leg caused by a dog attack. This patient was transferred to a level one pediatric trauma center for care. At times, staff members may need counseling after caring for mauled patients.
Animal bites. Massive soft tissue damage of the lower left leg caused from a dog attack. Most of the fatalities from dog bites are children.
Animal bites. A different angle of the patient in Image 3 showing the massive soft tissue damage to this child's left lower leg.
Animal bites. Wounds to the left arm and hip inflicted during a dog attack.
 
 
 
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