Children love animals. They are cuddly and cute and, often, a great source of reciprocal love and affection. Unfortunately, that is not always the case. Young children (and, let’s be honest, even adults) can misinterpret the intentions of an animal and end up on the wrong side of sharp talons and fangs. Even the beloved family dog can lead to significant injuries that require your expert attention! Let us take a minute to review the basic management of Animal Bite Wounds:

Animal Bite Wounds: Basics

• Animal bite wounds are a common cause of visits Emergency Departments [Garvey, 2015]
• The overwhelming preponderance (~90%) of bites are from dogs.
• Infection rates after bite:
  • Cats – as high as 50%
  • Dogs – 5-15%

• Zoo animals and “Non-traditional” pets bites are also important to consider:
  • Ex: horses, ferrets, iguanas, exotic reptiles
  • Ownership of “exotic animals” has been discouraged [“Bite Wounds”; AAP Redbook 31st Edition]

• Parental education is important!
  • Whenever the opportunity arises, educate families and patients about animal bite prevention. [Agrawal, 2017; Gielen, 2012]
  • It is not “just stay away from strays,” as family / known pets are often the animal that injuries a child.

Animal Bite Wounds: Management Essentials

• Manage the Pain!
  • Intranasal pain meds!
  • Local anesthesia and/or Procedural Sedation (ex, Nitrous Oxide, Ketamine, or Propofol)

• Clean the wound!
  • Obviously this is important to help decrease infection risk. Do not overlook this step, even for punctures.
  • Irrigate with copious volume with moderate pressure.
  • Remove all debris.
  • Some will require OR debridement, irrigation, and closure, but delayed wound care can increase complications. [Agrawal, 2017]

• Evaluate for Foreign Bodies
  • Part of cleaning the wound, but deserves specific attention.
  • Animals with “fine teeth” (ex, cats) can leave fragments of teeth behind.
  • Scrutinize X-rays for FBs, not just bony injury.

• Search for Underlying Injuries
  • Assess for nerve, tendon, and vascular injury.
  • Examine the wound while taking the mobile body part through the full range of motion.

• Selective Closure of Wounds
  • Primary Closure has been successfully performed for cosmetically sensitive areas (ex, Face). [Agrawal, 2017]
  • Delayed or Loose Closure for wounds that are higher risk for infection:
    • Hands and Feet
    • Deep wound that penetrate multiple tissue layers (more difficult to clean).
  • DO NOT CLOSE ANY BITE WOUNDS WITH TISSUE ADHESIVE!

• Vaccinate when Appropriate!
  • Tetanus for all bite wounds
  • Rabies for rabies prone bites
  • Consider Hepatitis B Vaccination for Human Bites (Humans are often the worse animals to deal with).

• Determine whether empiric antibiotics are required.
  • Often the biggest question is whether to start antibiotics.
  • Not all bite wounds require empiric antibiotics, but… well… most do.
  • No empiric antibiotics are needed for scratches or excoriations.
  • See Below.

• Follow-up Examination.
  • It is always good to monitor for signs of evolving infection, especially if not starting antibiotics.
  • Have the patient return with 48 hours or sooner if symptoms develop.

Animal Bite Wounds: Empiric Antibiotics

• The following should be treated empirically: [“Bite Wounds”; AAP Redbook 31st Edition]
  • Moderate / Severe Wounds 
  • Swollen Wounds (more prone to infection)
  • Crush Wounds (ex, large dog bite)
  • Puncture Wounds
  • All Cat Bite Wounds
  • Facial Wound that is deep or closed primarily
  • Hand and Foot Wounds
  • Genital Wounds
  • Wounds in Immunocompromised Patient (ex, Liver Disease, Nephrotic Syndrome, Asplenia)
  • Wounds presenting with Signs of Infection

• Augmentin saves the day!… most of the time. [“Bite Wounds”; AAP Redbook 31st Edition]
  • Most wounds are polymicrobial:
    • Flora from the biting animal’s mouth plus,
    • Skin flora from the patient
  • Augmentin is first line therapy for:
    • Dog, cat, and mammal bite wounds
    • Reptile bite wounds
    • Human bite wounds (most humans can be classified as mammals… but, some are reptiles)
  • For Penicillin allergic patients, use Clindamycin PLUS either:
    • Extended spectrum cephalosporin (ex, cefpodoxime, cefotaxime, ceftriaxone) or
    • Trimethoprim-sulfamethoxazole
  • Consider MRSA coverage for:
    • Severe bite wounds and/or
    • In patient known to be colonized with MRSA

• Empiric treatment course can be 3-5 days long.

Moral of the Morsel

• Do what you do for all wounds! Clean with Copious Fluid, Check for FBs, Check for Underlying Injuries!
• Don’t forget Tetanus and Rabies! Immunize when you have the opportunity and need to.
• Consider Closure Carefully! If there isn’t a cosmetic concern, consider loose or delayed closure.
• Augmentin! It covers most of the bad mouth flora.

References