MANAGEMENT OF DOG BITES

Management of dog bites entails the following:

Thorough history taking

 A thorough history is essential for any patient presenting with a dog bite.
Temporal factors surrounding the incident are critical.
 Knowing how long the wound has been open is a key factor in deciding the
course of action.
 The more time that passes between the injury and the wound repair, the
greater the potential for infection and complications.
 Knowing the breed of dog involved can also aid in predicting the extent of
injury. For example, some dogs clench their jaws when they bite, resulting in
deep puncture and crush wounds.
 Other dogs produce a “hole-and-tear” effect as the canine teeth anchor the
victim while the dog violently swings its head from side to side, causing more
extensive shearing-type injuries.
 The jaws of a large dog can exert pressure >450 pounds per square inch.
 Bites from larger dogs most often involve the arms and legs in adults and the
face and scalp in children.
 Understanding the events leading up to the incident can lend insight as to the
type and extent of the injury as well.

Medical history assesment

 The patient’s medical history also needs to be closely evaluated.

 Those who are immunosuppressed because of prior splenectomy or ongoing
steroid therapy are at higher risk for complications.
 Comorbidities, such as diabetes, medication history, and allergies, must be
noted.
 The provider must also inquire about previous therapy for the dog bite. Has
the victim sought treatment at an urgent-care center before seeing the
primary-care provider? Knowing the extent of previous treatment (especially
 with regard to antibiotic use) is significant in preventing superinfection with
resistant organisms.

Physical exam

Clinicians must be alert to the ABCs, i.e., the examination and maintenance of a
patient’s Airway, Breathing, and Circulation.

Physical exam begins with the patient’s general appearance and a full set of vital
signs to include pain assessment.

Vital signs should be frequently re-assessed.

Next, examine and assess the bite wound;This begins with a description of the
injury location (i.e., face, hands, legs, etc.).

If possible, take pictures to help carefully document the wound.

Make sure to measure length and depth of the wound and classify it.
Classification categories include abrasion, puncture, laceration, avulsion, or crush.
Include the amount of devitalized tissue, which helps give an idea as to the extent
of injury.

Note any injury to other anatomic structures. This includes (but is not limited to)
tendon, nerve, bone, and/or ligament damage.

Also look for signs and symptoms of infection.

Note any fever, chills, body aches, nausea, vomiting, weakness, pain, erythema,
exudates, edema, heat, or foul odors coming from the injury.

A thorough neurovascular and musculoskeletal exam (including range of motion)

should be performed.

Absent pulses distal to a bite wound can indicate vascular injury or be a sign of
compartment syndrome.

Consult a surgeon for more serious wounds (particularly those involving the
hand).
Puncture wounds that appear superficial are often very deep and penetrate
deeper anatomic structures. Serious complications can arise quickly if these are
not treated adequately.

Ancillary testing
Even though thorough history and physical are the cornerstones of the diagnosis
and management of dog-bite wounds, ancillary tests can be valuable tools in
deciding a plan of action.

Consider radiographic evaluation if fracture, presence of foreign body, or

infection is suspected.

Since the depth of puncture wounds can be deceiving, those close to bones and
joints usually require radiographic studies.

X-rays are also indicated if the bite has penetrated the joint capsule or if septic
arthritis is a concern.

Osteomyelitis can be seen on x-ray; however, osteomyelitis usually occurs several

days after a dog bite, while septic joints can occur quite rapidly.

Consider a referral for vascular evaluation if there is a possibility of vascular

injury; crush injuries have a higher propensity for vascular compromise than other
wounds.

Culturing the wound is necessary only if infection is suspected.

Pasteurella multocida is the most common and most virulent organism

responsible for infected dog-bite wounds.

Infection caused by P. multocida will usually show signs and symptoms within 24
hours.

Since different organisms grow at variable rates, wound cultures should be kept
for at least seven days.
 If you suspect the infection is systemic, a complete blood count and blood
cultures would also be prudent.

If compartment syndrome is suspected, wick measurements or arterial line

system manometers and other intracompartmental pressure monitors can be
used.

Interventions
 Management of a dog bite includes treatment centered on local wounds as
well as consideration of antimicrobials, tetanus prophylaxis, and rabies
prophylaxis. Wound management is as important as use of antimicrobials in
preventing infection.
 It is estimated that infection rates can be reduced more than 80% with proper
irrigation. Overaggressive irrigation and debridement can increase wound
devitalization.
 Treatment begins with immobilization and elevation of the affected area.
 If the skin is intact, wash with soap and water.
 Open wounds need to be irrigated with normal saline at 250 mL/inch of
wound. An 18-gauge catheter attached to a 35-mL syringe will provide
adequate pressure for proper irrigation.
 Foreign debris needs to be completely removed from the wound to prevent
complications; however, not all wounds require surgical debridement.
 Only devitalized and necrotic tissue should be debrided. Puncture wounds
should not be debrided.
 Smooth wound edges are essential for optimal healing and cosmetic
appearance.
 Many wounds should not be closed. Those older than 24 hours with signs of
infection are best left to heal by secondary intention.
 Wounds with a high risk of complication and infection (e.g., hand and deep
puncture wounds) should also be allowed to heal by secondary intention.
 For cosmetic reasons, consult a plastic surgeon for the treatment of wounds of
the face, neck, or other highly visible areas.
 Not all wounds require antimicrobial prophylaxis. Indiscriminate prescription
of antibiotics increases the chance of adverse reactions and future resistance.
 Accordingly, antibiotics should be prescribed in the following situations:hand
injuries, genital injuries, puncture wounds, and wounds with bone and joint
involvement.
 Patients with such comorbid factors as immunosuppression, diabetes, and
asplenism also require antibiotics; In such cases, a broad-spectrum beta-
lactamase-resistant antibiotic should be utilized.
 Amoxicillin/clavulanate is the most effective treatment for these wounds
because of the high incidence of Pasteurella infection.
 For patients allergic to penicillin, doxycycline is a good alternative; however,
doxycycline should not be used during pregnancy or in children younger than 8
years.
 For pregnant patients allergic to penicillin, erythromycin may be substituted;
these patients should be monitored closely for increased failure rates.
 Another alternative for the pediatric population is the combination of
clindamycin and sulfamethoxazole-trimethoprim.
 Antibiotics administered for prophylaxis should be prescribed for five to seven
days. Patients with infected wounds require antibiotics for a total of 10-14
days. Patients may also need hospitalization for infected dog bites.
 Clinicians must also consider tetanus and rabies immune globulin (RIG)
administration.
 Patients should receive a tetanus toxoid if the last tetanus immunization was
given more than five years prior.
 Patients whose tetanus status is unknown or who have received fewer than
three lifetime tetanus immunizations should be given tetanus immunoglobulin
and diphtheria/tetanus toxoid or age-equivalent vaccine.
 RIG prophylaxis is prudent if the dog has no records documenting vaccination
status, cannot be captured for observation, or exhibits signs of rabies.
 RIG is dosed at 20 IU/kg of the patient’s body weight; If anatomically possible,
give at least half of the dose into the wound. The remainder should be
administered IM to the opposite extremity.
 Many patients will require only Over the counter analgesics for effective pain
management.
 For more severe pain, acetaminophen with codeine every four to six hours for
24 hours is an appropriate regimen.
 Emotional support should be extended to the patient and family as needed.

Education and follow-up/referral

The patient and family need to be educated on wound care at home.

To help reduce pain and swelling, apply ice to the affected area for 15 minutes
every hour for the first 24 hours

Keep the wound elevated and immobilized for 48 hours.

Wash the wound with soap and water and pat dry.

Do not soak the wound.

Instruct patients given antibiotics to take all the medication as prescribed without
skipping or doubling doses.

Tell the patient and family to return to the clinic if any signs or symptoms of
infection emerge or if severe pain continues beyond 24 hours.

Otherwise, patients should follow up with a primary-care provider within 48

hours.

Referral to multidisciplinary services, such as plastic surgery, orthopedics, and

wound-care specialists, should be made as indicated.

Finally, report the incident to animal control law.