Management of Minor Dog Bite Wound - Literature review Example

Running Head: MANAGEMENT OF MINOR DOG BITE WOUND Management of Minor Dog Bite Wound of the Under the guidance of submission Introduction Dog bites are a problem all over the world. In the United Kingdom itself, each year, about 250,000 people attend to the emergency units following minor bites by dogs (Morgan and Palmer, 2007). According to figures obtained by Liberal Democrats (Cole, 2008), there has been a rise by 43% in the number of patients attending accident and emergency departments in the United Kingdom following dog bite. For the under-18 category, the rise is almost a whopping 18% (Cole, 2008). About 50% of the dog bites are due to dogs owned by the family or neighbors of the victim (Presutti, 2001). In majority of the cases, children are the victims (Weiss, Friedman and Coben, 1998). Though majority of dog bites are not dangerous, the risk of contracting the deadly rabies infection makes management of dog bite wounds very crucial. In this article, management of minor dog bite wound will be elaborated based on review of literature pertaining to this topic. History taking Elaborate history must be taken in a patient with dog bite to assess the risk of infection. History taking can be done simultaneously with wound irrigation. It is important to ascertain the presence of certain medical conditions which increase the risk of infection following dog bite. These are chronic diseases, diabetes mellitus, liver dysfunction, asplenia, systemic lupus erythematosus, immunosuppression, presence of prosthetic object in the body and previous mastectomy (Lewis and Stiles, 1995; cited in Presutti, 2001). Tetanus immunization status of the victim, presence of allergies and intake of any medication must also be enquired and noted. Other than medical history of the patient, other details like how the injury occurred, timing of the injury, whether the dog resorted to biting following provocation, immunization status of the dog, health condition of the dog and the ownership of the animal must also be enquired (Presutti, 2001). According to a study by Jarrett (1991), Alsatian breeds are the most commonly involved group in dog bites. Physical examination The clinical stability of the patient must be evaluated and noted. The location and the extent of the wound must be recorded. The wound must be classified and any damage to the surrounding skin and structures like vessels, nerves, joints and bones must be evaluated and noted. In cases where litigation may be involved like due to infliction from an unleashed dog, photographs of the wound may be taken and diagrams may be noted in the medical history sheet (Presutti, 2001). Management Initial wound management The first step in the management of dog bite wound would be to assess the medical stability of the patient. Thereafter, thorough irrigation of the wound must be done with normal saline or Ringers lactate solution (Presutti, 2001). Tap water is as effective as saline and can be employed for irrigation at home (Garth and Harris, 2009). Copious and timely irrigation reduces the rate of infection of the wound (Presutti, 2001). Any devitalized or necrotic tissue must be debrided (Oehler, Velez, Mizrachi, et al, 2009). In case the wound is near a joint or if there is any suspicion of fracture, radiographic evaluation must be resorted to (Oehler, Velez, Mizrachi, et al, 2009). Innjuries due to dog bite occur most commonly in the hand or arm (about 45%). In children, head and neck is the most commonly inflicted region (CDC, 2003). Because of the presence of rounded teeth and able jaws, bites by dogs cause crushing type of wounds (Garth and Harris, 2009). Whether to close dog bite wounds or not is a much debated topic. Experts opine that wounds which are more than 24 hour old, puncture wound and wounds with clinical evidence of infection must not be closed immediately and must be allowed to heal with secondary intention (Presutti, 2001). Wounds in the immunocompromised also must be left open (Stevens, Bisno, Chamber, 2009). Delayed primary closure may be considered in some cases. Some physicians prefer to close wounds which are on face (Javaid, Feldberg and Gipson, 1998) and those which are less than eight hours old (Presutti, 2001). This is because, due to absence of dependent edema, facial wounds heal rapidly after primary closure. According to Suarez, Lopez-Guttierrez, Burgos, et al (2007), primary closure of dog bite wounds improves both the aesthetic and functional aspects and at the same time, reduces the number of surgical procedures related to the wound later. Dog bite injuries to face can can lead to cosmetic sequelae (Mendez, Gomez, Somoza, et al, 2002). In a retrospective study by Javaid, Feldberg and Gipson, (1998), the authors opined that for face wounds, primary repair following wound toileting is the best method of treating dog bite wounds. Wolff (1998) opines that animal bites on face do not need routine antibiotic prophylaxis and they should be managed based on the criteria for a esthetic reconstructive facial surgery.Gabutt and Jenner (2005) reviewed studies pertaining to management of dog bite related wounds for the purpose of evidence-based practice. In their study, they found that there is only study which has investigated infection rates in bite wounds treated with primary closure against non-closure in a randomized control manner. Results of this particular study revealed that infection rates between primarily closed wounds and non-closed wounds were similar except in hand wounds in which the rate of infection was higher. The same study also reported that delay in presentation to doctor beyond 10 hours was associated with an increased risk of infection. Thus, it is evident that dog bite wounds must be left open when they occur in hands or when the patient is seen late because of increased chances of infection. According to Correira (2003), primary closure must be considered only when cosmetic concerns outweigh the risk of wound infection. Infected wounds must be thoroughly evaluated by sending pus or secretions from the wound for both aerobic and anerobic cultures. Affectation of any other surrounding structures must be dealt with appropriately. Deep wounds are best handled by plastic surgeons or maxillofacial surgeons or even surgeons (Presutti, 2001). Antibiotics Infection is one of the important complications of dog bite wound. About 15- 20% of dog bite wounds get infected (Presutti, 2001). Infection is mainly caused due to organisms which dwell in the oral cavity of the dog and also in the skin of the victim (Brook, 2009). In about two-third of cases, anaerobes have been identified (Brook, 2009). Presence of chronic medical condition like diabetes mellitus increases the chances of the wound getting infected. Also, certain types of wounds like crush injuries, wounds in the hand and puncture wounds have increased risk of getting infected. The most common pathogens which infect dog bite wounds are Staphylococcus aureus and Pasteurella multocida. Other organisms inlcude Streptoccoccus species, corynebacterium species, etc. The most common anerobic organisms which infect dog bite wounds are species of fusobacterium, bacteroides and veillonella (Presutti, 2001). Thus, it is appropriate to administer prophylactic antibiotics for 3- 7days for dog bite wounds beyong superficial abrasions. frant cellulitis necessitates a 10- 14 day antibiotic regimen. the anitbiotic of choice would be amoxicillin-clavulanate potassium. Those who are allergic to penicillin can be given doxycycline. Other drugs which may be administered are clindamycin and cetriaxone. Clindamycin is mostly given as a combination with fluoroquinolone or trimethoprim-sulfamethoxazole. Ceftriaxone is given intramuscularly and is chosen in those with suspected non-compliance (Gilbert, Moellering, Eliopus, et al, 2007). Tetanus prophylaxis must be provided as recommended by CDC or WHO (Presutti, 2001). Some researchers argue against the prophylactic use of antibiotics even in lacerated wounds (Chaudary, Macnamara and Clark, 2004 and Wolff, 1998). Hospitalisation The most common causes of hospitalisation following dog bite is severe infection like cellulitis, sepsis or even arthritis (Oehler, Velez, Mizrachi, et al, 2009). Other complications include local abscess, lymphangitis, tenosynovitis, osteomyelitis, endocarditis, brain abscess, meningitis and disseminated intravascular coagulation (Brook, 2009). Other causes of hospitalisation include presence of deep wounds or crush injuries or serious injuries in the head and neck (Oehler, Velez, Mizrachi, et al, 2009). Assessing risk of rabies Lethal encephalitis caused due to rabies virus, which is a type of Lyssa virus is known as rabies. The virus gets transmitted from animals like dogs to human beings mainly through bite wounds. Other mechanisms of transmission are licking of mucous membranes of human beings and scratching (Bourhy, Goudal, Mailles, et al, 2009). Despite aggressive measures to control rabies, the incidence of rabies continues, although in a limited manner. In 2005, it was reported that the annual incidence in UK is 5 cases (Bourhy, Dacheux, Strady, et al, 2005). Risk of contracting rabies must be evaluated soon after initial treatment of the wound. This is because rabies is a fatal disease which spreads very easily through contamination with infected saliva. Rabies is a serious risk when a rabid animal is let loose and hence conditions of the around the attack must always be documented (Presutti, 2001). Bites from non-provoked dogs are at a greater risk of development of rabies than those from provoked dogs. If the owner of the dog is reliable and the vaccination status of the dog is known then the dog may simply be observed for about 10 days. If the vaccination status is unreliable or unknown, then observation by a veterinary surgeon is necessary. In case the dog cannot be observed for 10 days or if the animal does not appear healthy, rabies vaccination is a must. Post-exposure prophylaxis against rabies The first dose of rabies immunization must be given within 48 hours after bite. Subsequent immunizations may be discontinued in case observation of the dog has proved that the animal is healthy. Post-exposure prophylaxis depends on the type of contact with dog. Basically, there are 3 types of contact (WHO, 2009). Category I – touching or feeding animals, licks on the skin Category II - nibbling of uncovered skin, minor scratches or abrasions without bleeding, licks on broken skin Category III – single or multiple transdermal bites or scratches, contamination of mucous membrane with saliva from licks; exposure to bat bites or scratches Table-1: Types of contact in dog bite (WHO, 2009). For category-1, no vaccine therapy is required. Those who fall into category-2 will need immediate vaccination. Victims who fall into category-3 will require both vaccination and rabies immunoglobulin. Of course, vaccine therapy must be done after thorough washing, irrigation and flushing of the wound (WHO, 2009). The dose, site and duration of vaccination depends on the vaccine-type. One dose of cell-derived rabies vaccine of atleast 2.5 IU must be administered intramuscularly on days 0, 3, 7, 14 and 30. If the abbreviated multisite schedule is followed, then the regimen is 2-1-1. One dose is given each on the right arm and left arm on day-zero and on Day 7 and day 21, a single doe is given over the deltoid muscle. This regimen has shown to elicit an early antibody response and is useful in cases when rabies immunoglobulin is not administered. The cell-line derived vaccines can also be given through intradermal route. The 8-site intradermal regimen (8-0-4-0-1-1) is useful for human diploid cell vaccine and purified chick embryo cell vaccine. This regimen is useful when no rabies immunoglobulin is available. The 2-site regime (2-2-2-0-1-1) is useful with vero cell vaccine and purified chick embryo cell vaccine. Brain-tissues are not recommended for use any more (WHO, 2009). Those who have already received vaccination following a previous dog bite or have been given pre-exposure prophylaxis will need only 3 doses intramuscularly (WHO, 2009). The recommended dose for rabies immunoglobulin is "a single dose of 20 IU per kg of body weight for human anti-rabies immunoglobulin, and 40 IU per kg of body weight for heterologous (equine) immunoglobulin; the first dose of vaccine should be inoculated at the same time as the immunoglobulin, but in a different part of the body" (WHO, 2009). The immunoglobulin must be administered after testing for hypersensitivity (WHO, 2009). Follow-up Immobilization and elevation of the affected area must be advised to the patient. It is better to reexamine the wounds after about 1-2 days, especially if the area of involvement is hand. Prevention of dog bites Since many complications are involved with dog bites, the best approach is to prevent it. Prevention is possible by proper education and provision of adequate information from veterinarians and primary health care physicians (Presutti, 2001). Both children and adults must be educated. While acquiring dogs as pets, it is preferable to adopt puppies younger than 4 months old, especially when there are children at home. This is because, the behavior of older dogs is highly unpredictable. Also, breed-specific information must be sought before adopting a dog. Some breeds are dangerous and can attack even if trained properly. Some are banned from acquiring. Dogs which are trainable and reliable are known as family dogs and such dogs must be adopted. Examples of family dogs are Boxer, Dalmatian, Spaniel and Irish Setter. Other than acquiring safe dogs, one most possess appropriate behavior so that dogs are not provoked to bite. Running and screaming around the animal, hugging and kissing the animal and direct eye contact with that of the dog trigger aggression from the dog. When chased or confronted with an aggressive dog, instead of screaming and running around, one must assume a stand still posture with fists under the neck, feet placed together and arms pressed against the chest (Presutti, 2001). If the person falls on the ground, he must lie down still with face in down position and fists behind the neck. The forearms must cover the ears. These ‘still’ postures will make the dog lose interest in the chase game and subside aggression (Presutti, 2001). Government and local authorities and organizations play an important role in the prevention of dog bites. In the UK, the Liberal Democrat has reported a need to review the Dangerous Dogs Act in the wake of many teenagers possessing certain harmful breeds of dogs just for the purpose of "badge of honor" (Cole, 2008). According to the 1991 Act, Japanese Tosa, Dogo Argentino, the pit bull terrier and Fila Brasileiro are banned from being owned (Cole, 2008). To keep a check on owning dangerous dogs, Metropolitan Police of UK, Greater London Authority, Battersea Dogs Home and RSPCA have launched a joint campaign (Cole, 2008). Conclusion Dog bites are one of the common causes for attendance to emergency departments. Due to risk of contracting wound infection, rabies and other complications, even minor wounds must be dealt with care and concern. The most important step would be thorough irrigation and removal of devitalized tissue. Other issues to be dealt with are, antibiotic prophylaxis, tetanus prophylaxis and post-exposure rabies vaccination. Prevention is better than cure and this can be enhanced by appropriate education and measures by government and local organizations. References Bourhy, H., Goudal, M., Mailles, A., Sadkowska-Todys, M., Dacheux, L., Zeller, H. (2009). Is there a need for anti-rabies vaccine and immunoglobulins rationing in Europe? Euro Surveill., 14(13). pii: 19166 Bourhy, H., Dacheux, L., Strady, C., Mailles, A. (2005). Rabies in Europe in 2005. Euro Surveill., 10(11), 213-6. Brook, I. (2009). Management of human and animal bite wound infection: an overview. Curr Infect Dis Rep., 2(5), 389-95. Center for Dosease Control or CDC. (2001). Nonfatal Dog Bite--Related Injuries Treated in Hospital Emergency Departments --- United States, 2001. Retrieved on October 7th, 2009 from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5226a1.htm Cole, R. (2008). Hospital admissions for Dog Bites Soar. Sky News Onlined. Dated February 27. Retrieved on October 7th, 2009 from http://news.sky.com/skynews/Home/UK-News/Big-Rise-In-Hospital-Admissions-For-Dog-Bites/Article/20080241307149?lpos=UK_News_Article_Related_Content_Region_4&lid=ARTICLE_1307149_Big_Rise_In_Hospital_Admissions_For_Dog_Bites Chaudhry, M.A., Macnamara, A.F., Clark, S. (2004). 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