Management of human and animal bite wounds

One of the most common problems facing the emergency department physician is the management of bite wounds. Therapy for these common injuries is ill-defined and often controversial. This article outlines treatment guidelines for the emergency physician for dog bites, cat bites, rabies, snake bites, and human bites.     

Dog bites in children: Epidemiology,microbiology, and penicillin prophylactic therapy

Fifty-five children with nonfacial dog bites were prospectively studied. Patients were assigned to an experimental group receiving oral penicillin or a control group receiving local wound care only. Wounds were cultured for anaerobic and aerobic flora prior to cleansing. Results showed that most children were bitten on an extremity by a familiar dog, sustained simple injuries, and sought prompt medical attention. The overall infection rate was 3.6%, with one patient in each group developing an infection. The most frequently recovered organisms were normal skin flora. No Pasteurella multocida were isolated. Forty percent of cultures yielded potential pathogens. Despite this finding, initial cultures of dog bite wounds had no value in predicting subsequent infection. This study suggests that routine use of prophylactic penicillin is not required for simple nonfacial dog bites in children.     

Managing Law Enforcement (K–9) Dog Bites in the Emergency Department

Objective: To review the types of injuries due to law enforcement (K–9) dog bites and address related management issues.
Methods: A case series of law enforcement dog bite victims is reported and related literature reviewed.
Results: Law enforcement dogs are taught a bite–and–hold technique for subduing individuals suspected of felony crimes. This bite–and–hold technique's greater applied force results in a unique spectrum of injuries, including deep puncture wounds, severe crush injuries, large tissue avulsions and lacerations, wounds necessitating surgical debridement, bony injuries ranging from cortical violations to displaced fractures, neurovascular damage, and other wounds at high risk for infection. The four reported cases highlight the types of injuries and complications associated with law enforcement dog bites.
Conclusion: Attention to potential deep injuries of nerves, vessels, and the musculoskeletal system is essential with law enforcement dog bites. Injuries associated both with pursuit and arrest and with the bites themselves must be identified and assessed. Guidelines for the ED treatment of patients with law enforcement dog bite injuries are proposed.     

Orthopedic pitfalls in the ED: fight bite

Clenched fist injuries to the mouth ("fight bite") are notorious for being the worst human bites. These are often treated as minor injuries, without the recognition that the joint capsule, the extensor tendon, or the deep fascial spaces may have been violated and contaminated with oral bacteria. Significant morbidity can result from late presentation or inadequate initial management. The emergency physician needs to remain vigilant for complications associated with closed fist injury. This review article examines the clinical presentation, diagnostic techniques, and management options applicable to the emergency physician in the treatment of fight bite.     

Emergency Department Visits for Pediatric Trampoline-related Injuries: An Update

Objectives: To describe the epidemiology of emergency department (ED) visits for trampoline-related injuries among U.S. children from January 1, 2000, to December 31, 2005, using the National Electronic Injury Surveillance System (NEISS) and to compare recent trampoline injury demographics and injury characteristics with those previously published for 1990–1995 using the same data source.
Methods: A stratified probability sample of U.S. hospitals providing emergency services in NEISS was utilized for 2000–2005. Nonfatal trampoline-related injury visits to the ED were analyzed for patients from 0 to 18 years of age.
Results: In 2000–2005, there was a mean of 88,563 ED visits per year for trampoline-related injuries among 0–18-year-olds, 95% of which occurred at home. This represents a significantly increased number of visits compared with 1990–1995, when there was an average of 41,600 visits per year. Primary diagnosis and principal body part affected remained similar between the two study periods.
Conclusions: ED visits for trampoline-related injuries in 2000–2005 increased in frequency by 113% over the number of visits for 1990–1995. Trampoline use at home continues to be a significant source of childhood injury morbidity.     

Characteristics of dog bites among nursing students and knowledge about their emergency management

IOANNIDOU C., GALANIS P., TSOUMAKAS K. & PAVLOPOULOU I.D. (2012) Characteristics of dog bites among nursing students and knowledge about their emergency management. International Nursing Review 59 , 245–251 Background: Dog bites represent a significant health concern leading to a variety of consequences. Nursing students should be appropriately educated in order to manage and help prevent such injuries. Aim: This paper is the first to report the lifetime experience and characteristics of dog bites among Greek nursing students and their knowledge in managing the above injuries. Methods: A cross‐sectional quantitative study was performed using an anonymous questionnaire distributed to first and fourth year nursing students from April though June 2009. A knowledge score based on key questions was set on a scale from 0 to 7, to assess their competence on bite injuries management. Results: Of 237 nursing students recruited, 56 (23.6%) had experienced a dog bite. Men outnumbered women as dog bite victims [n = 15 (39.5%) vs. n = 41 (20.6%), P = 0.012]. Mean age at the attack was 11.1 (standard deviation = 5.6) years and legs sustained the majority of injuries (n = 31; 55.4%). Most bites (n = 39; 69.9%) involved a dog known to the victim, were provoked (n = 30; 53.6%) and occurred in a public place (n = 35; 62.5%). Ten (17.9%) of the victims sustained a moderate or severe injury. The majority (67.9%) of students answered correctly to less than or equal to three out of seven key knowledge questions. After multiple linear regression analysis, previous educational course attendance was the only factor associated with increased score (b = 0.48, standard deviation = 0.17, 95% confidence interval = 0.12–0.84, P = 0.009). Conclusions: Dog bites were common and presented characteristic patterns among nursing students, but knowledge in their management was suboptimal. Improved education should be provided during undergraduate studies.     

Endocarditis due to Staphylococcus aureus after minor dog bite

Living in a society of animal lovers, the dangers are often not always apparent. Injury from bites and scratches is an occupational hazard for those people who work with animals. Despite the high risk of secondary wound infection as a result of an animal bite, many patients do not receive treatment with an antimicrobial medication. This report describes a case of a previously fit and well 66-year-old female dog handler who, after an apparently minor dog bite to the hand, developed fulminant acute Staphylococcus aureus endocarditis and life-threatening aortic regurgitation. This article discusses the microbiology behind dog bites and highlights the need for proper wound hygiene and consideration of prophylactic broad-spectrum antibiotics to prevent potentially fatal outcomes as a result of what initially seem to be minor injuries.     

Emergency Department Visits for Sledding Injuries in Children in the United States in 2001/2002

Objectives: To describe the characteristics of nonfatal sledding-related injuries in U.S. children resulting in emergency department (ED) visits in 2001/2002 and to explore the implications of these findings for injury prevention efforts.
Methods: A stratified probability sample of U.S. hospitals providing emergency services in the National Electronic Injury Surveillance System–All Injury Program was utilized for 2001/2002. ED visits resulting from injuries involving sleds, snow discs, snow tubes, and toboggans were analyzed for patients 19 years of age or younger.
Results: In 2001/2002, there were an estimated 57,866 ED visits for sledding-related injuries in the United States for all age groups. Of these, 41,272 (71%) occurred in patients 19 years of age or younger, 58% of whom were male. The highest number of injuries occurred in children between five and 14 years of age (74%), and the injuries were most often caused by falls or collisions (75%). The head or neck was the most frequently injured body region among those 0–9 years of age, while the extremities were injured most commonly among those 10–19 years of age. Head and neck injuries occurred in 56% (95% confidence interval [CI] = 32% to 81%) of children 0–4 years of age versus 19% (95% CI = 9% to 29%) of patients 15–19 years of age. Nine percent (95% CI = 6% to 12%) of patients sustained a traumatic brain injury. Three percent (95% CI = 1% to 5%) of patients required admission to the hospital.
Conclusions: Sledding injuries resulting in ED visits predominantly affect children and are a source of measurable morbidity in this population. An increase in injury prevention efforts for this activity is warranted.     

Incidence of injuries caused by dogs and cats treated in emergency departments in a major Italian city

Objective: This study aimed to estimate the incidence and characteristics of injuries caused by dogs and cats in the population of a major Italian city.

Methods: The clinical records of all patients attending the emergency department (ED) were obtained from the two main hospitals of the city, covering an estimated population of over half a million. A case was defined as a patient admitted for bite or scratch injuries caused by dogs, cats, or other mammals between 1 January 2000 and 31 December 2002. For each case, the information collected included age and sex of the patient, the anatomical site of the injury, and the species of the animal involved.

Results: The average yearly incidence of dog and cat bite/scratches was 58.4 and 17.9 cases per 100 000 residents, respectively. Admissions peaked during the summer months. Dogs accounted for 76.9% and cats for 19.7% of cases. Dog injuries were significantly more common in males and younger individuals. Children younger than 9 years had a significantly higher risk of being bitten on the head, face, or neck. Conversely, injuries from cats were significantly more common in females and older people.

Conclusions: Surveillance of injuries caused by dogs and cats could provide useful information for planning and evaluating public health interventions. Collection of data from hospital EDs may be an appropriate, simple, and quick tool for monitoring the phenomenon and evaluating the associated risk factors.

     

Prevention and treatment of dog bites

Almost one half of all dog bites involve an animal owned by the victim's family or neighbors. A large percentage of dog bite victims are children. Although some breeds of dogs have been identified as being more aggressive than other breeds, any dog may attack when threatened. All dog bites carry a risk of infection, but immediate copious irrigation can significantly decrease that risk. Assessment for the risk of tetanus and rabies virus infection, and subsequent selection of prophylactic antibiotics, are essential in the management of dog bites. The dog bite injury should be documented with photographs and diagrams when appropriate. Family physicians should educate parents and children on ways to prevent dog bites.     

The use of therapeutic plasmapheresis in the treatment of poisoned and snake bite victims: an academic emergency department's experiences

The objective of this study is to describe the clinical status, procedural interventions, and outcomes of critically ill patients with poisoning and snake bite injuries presenting to a tertiary-care emergency department for treatment with therapeutic plasmapheresis. Records of 20 patients who presented to our academic emergency department over a 2-year period and who underwent plasmapheresis for poisoning or snake bite were retrospectively reviewed. Plasmapheresis was performed using centrifugation technology via an intravenous antecubital venous or subclavian vein catheter access. Human albumin or fresh frozen plasma were used as replacement fluids. Data extracted from the patient record included demographic data, clinical status, and outcome measures. Sixteen patients underwent plasmapheresis because of toxicity from snake bite. Three patients were treated for drug poisoning (phenytoin, theophylline, bipyridene HCl) and one patient for mushroom poisoning. Haematologic parameters such as platelet count, PT, and INR resolved rapidly in victims of snake bite injuries after treatment with plasmapheresis. Loss of limbs did not occur in these cases. Seven patients required admission to the intensive care unit. One patient with mushroom poisoning died. Mean length of hospital stay was 14.3 days (range 3-28 days) for all cases. Plasmapheresis was a clinically effective and safe approach in the treatment of snake bite envenomation and other drug poisoning victims especially in the management of hematologic problems and in limb preservation/salvage strategies. In addition to established conventional therapies, emergency physicians should consider plasmapheresis among the therapeutic options in treatment strategies for selected toxicologic emergencies.     

Low-Income Mothers' Perceptions of Health in Their Children With Growth Delay

ISSUES AND PURPOSE. Parental characteristics are the strongest predictor of poor health for children. This study examined how low-income mothers of children with growth delay define health for their children, and the behaviors they use to monitor their children's health.
DESIGN AND METHODS. Naturalistic design using Kleinman's Explanatory Model approach and interviews with 22 mothers.
RESULTS. Mothers consider nutritious food as a primary contributor to their children's health and consider healthy children to be chubby. Other indicators of health include children's energy levels, provision of nutritious food, and physical and mental activity balanced with rest.
PRACTICE IMPLICATIONS. A mother's explanatory model of health for her child can guide health promotion targeted to the mother's beliefs.     

Dog bites in Tea Tree Gully

Dog bite injury is a common reason for presentation to emergency departments. However the nature of this problem in Australia has not been closely studied and a number of unresolved questions remain regarding management options. This prospective study of 101 cases was undertaken to collect demographic information about victims and assailants, to describe the spectrum of injury seen and to report outcome following a standard management protocol. In common with other studies, young males were bitten most frequently, usually by German Shepherds, Heelers and Terriers. Nearly half (48%) of the facial injuries occurred in children under 10 years old. The infection rate in this study, using wound cleansing and prophylactic penicillin in all cases, was only 4%. Wound swabs on presentation were unhelpful. Controversies still exist regarding wound closure and the use of prophylactic antibiotics.     

Pediatric Tree House–Related Injuries Treated in Emergency Departments in the United States: 1990–2006

Objectives:  The objective was to describe the epidemiology of tree house–related injuries in the United States among children and adolescents.
Methods:  The authors conducted a retrospective analysis using data from the National Electronic Injury Surveillance System for patients ≤19 years who were treated in an emergency department (ED) for a tree house–related injury from 1990 through 2006.
Results:  An estimated 47,351 patients ≤19 years of age were treated in EDs for tree house–related injuries over the 17-year study period. Fractures were the most common diagnosis (36.6%), and the upper extremities were the most commonly injured body part (38.8%). The odds of sustaining a head injury were increased for children aged <5 years. Falls were the most common injury mechanism (78.6%) and increased the odds of sustaining a fracture. Falls or jumps from a height ≥10 feet occurred in 29.3% of cases for which height of the fall/jump was recorded. Boys had significantly higher odds of falling or jumping from a height of ≥10 ft than girls, and children 10 to 19 years old also had significantly higher odds of falling or jumping from a height of ≥10 feet, compared to those 9 years old and younger. The odds of hospitalization were tripled if the patient fell or jumped from ≥10 feet and nearly tripled if the patient sustained a fracture.
Conclusions:  This study examined tree house–related injuries on a national level. Tree house safety deserves special attention because of the potential for serious injury or death due to falls from great heights, as well as the absence of national or regional safety standards. The authors provide safety and prevention recommendations based on the successful standards developed for playground equipment.     

Rearing the Child Who Is Technology Dependent: Perceptions of Parents and Home Care Nurses

ISSUES AND PURPOSE. Most children who are dependent on technology for survival live with their families at home. This study explores the perceptions of parents and home care nurses regarding rearing the technology-dependent child.
DESIGN AND METHODS. In this qualitative study, interviews were conducted with 16 parents whose child is technology dependent and 15 registered nurses who provided home care.
RESULTS. Rearing the child who is technology dependent is similar to but different from raising other children. Parental communication and negotiation of child-rearing expectations with home care nurses is essential.
PRACTICE IMPLICATIONS. Improved collaboration and communication between parents and nurses may reduce parental stress and enhance development for children who are dependent on technology.     

荆门市729例0~6岁儿童非故意伤害病例特征分析

目的了解荆门市0~6岁儿童非故意伤害流行状况,为制定荆门市0~6岁儿童伤害干预策略提供科学依据。方法对2016—2019年荆门市三家伤害哨点监测医院门(急)诊首次就诊上报的0~6岁儿童伤害病例进行分析。结果共报告729例0~6岁儿童非故意伤害病例,男女比例为1.72∶1。伤害发生原因前三位分别为跌倒/坠落、机动车交通伤害和刀/锐器伤,分别占总伤害病例的61.45%、10.15%、7.00%;伤害发生地点以家中为主(65.02%)、伤害发生时的活动以玩耍为主(63.92%)。伤害性质以锐器伤、咬伤、开放伤为主,共占总病例的81.62%。一年中伤害发生的高峰期在7~9月,三个月伤害病例数占总病例数的32.37%;一天中9:00—10:00、10:00—11:00、15:00—16:00和16:00—17:00是发生伤害病例最多的时间段,共占总伤害病例数的38.13%。结论荆门市0~6岁儿童以跌倒/坠落为主的非故意伤害发生率较高,应根据伤害发生的原因、性质、时间等有针对性地制定相应的评估和干预措施,减少0~6岁儿童非故意伤害的发生。