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Bite Wounds
Although often treated by the emergency room (ER) physician, bite wounds are also treatment issues for the plastic surgeon because they often occur on the hands and face or can be the cause of significant soft tissue destruction on the body.
• Irrigate all wounds copiously with NS
• DéBride devitalized tissue
• Drain any fluid collections
• Determine if tetanus prophylaxis is indicated
• Leave all wounds open except those on the face
• Evaluate the need for antibiotics
Bites
Human
Human mouths contain some of the most concentrated and varied bacteria. Organisms include Eikenella, Staphylococcus, Streptococcus viridans, and Bacteroides. The general principles of contaminated wound management apply to all human bite wounds as mentioned above. In the acute bite, the wound must be assessed fully and irrigated copiously. The patient should be placed on appropriate prophylactic antibiotics and followed closely for any signs of infection.
The initial injury often appears minor to the patient; thus no care is sought until an infection develops. It is important to fully assess the patient in the ER and advise on hospital admission, IV antibiotics, and possible operative management when necessary.
Bite injuries require careful evaluation for a deep infection because of the relatively benign presentation of their appearance. At times, due to the close proximity of the skin and underlying structures, nerve and tendon injuries may also be present. Also, due to the inherent depth penetration by the tooth or fang, microorganisms easily seed the depth of wounds, allowing rapid dissemination along the deep planes of the fascia and subcutaneous tissue. Therefore, rule out a deep injury even when the presentation is a minor wound such as an abrasion.
• Evaluate wound for depth, foreign body, drainage, cellulitis
• Assess for crepitus (subcutaneous emphysema; C + S), which would indicate gas-forming organisms along the deep planes
• I + D and irrigate
• Pack wound
• Treat with antibiotics
Closed-Fist Injury (Fight Bite)
With closed-fist injuries, the force of the blow to the mouth will often break the skin enough to lacerate or infect the extensor tendon and contaminate the underlying joint, such as the metacarpophalangeal joint, with bacteria from the mouth. When the hand is placed back into a neutral position, the bacteria can be displaced, resulting in more proximal contamination. Aggressive irrigation and débridement in the operating room should be considered for grossly contaminated wounds and those that present late.
• Obtain hand series (rule out metacarpal head fracture, osteomyelitis, and dental foreign body)
• Evaluate the integrity of the extensor and flexor tendons (flexor tenosynovitis)
• Analyze purulent drainage (culture and sensitivities)
• Assess for crepitus
• Assess for loss of joint height, which would indicate metacarpal head fracture
• Irrigate site (if a joint is involved, irrigation in an operating room may be required)
• Treat with antibiotics
Antibiotics
First Line | Augmentin (GlaxoSmithKline, Mississauga, Ontario, Canada) Adult: 875 mg PO b.i.d. × 7 days Pediatric: 45 kg/day PO b.i.d. × 7 days |
Alternatives | Unasyn 1.5 g IV q6h (Pfizer Pharmaceuticals, New York, NY) Moxifloxacin 400 mg PO q.d. × 7 days Clindamycin 450 mg PO q.i.d. + Bactrim (Roche Pharmaceuticals, Nutley, NJ) DS PO b.i.d. × 7 days |
Cat
Cat bites are deeply penetrating wounds that are heavily contaminated, and approximately 80% of wounds become infected. Organisms include Pasteurella multocida and Staphylococcus species. Irrigate heavily, wash daily, treat with antibiotics, and see below for rabies vaccinatation criteria. Evaluate for tetanus prophylaxis. Do not close the wound.
Antibiotics
First Line | Augmentin Adult: 875 mg PO b.i.d. × 7 days Pediatric: 45 kg/day PO b.i.d. × 7 days |
Alternatives | Doxycycline 100 mg PO b.i.d. × 7 days Cefuroxime 0.5 g PO b.i.d. × 7 days |
Dog
Dog bites constitute 80 to 90% of all animal bites. Organisms include Pasteurella multocida, Bacteroides, Streptococcus viridans, Fusobacterium, and Capnocytophaga. Massive force can often cause significant avulsion injuries; however, due to the lower bacterial count, infection is not seen as frequently as in cats. Large avulsion injuries can be reapproximated loosely as long as the wound can be packed and allowed to drain should an infection ensue. Elevate and treat with antibiotics. See below for rabies vaccination criteria. Evaluate for tetanus prophylaxis.
Antibiotics
First Line | Augmentin Adult: 875 mg PO b.i.d. × 7 days Pediatric: 45 kg/day PO b.i.d. × 7 days |
