Management of bite wounds in the head and neck

An estimated 50% of people in the United States will incur an animal or human bite wound at least once in their lifetimes. Although the majority of these individuals do not seek medical attention, bite wounds to the head and neck are a common reason for emergency department visits. Facial bites are complex injuries due to the functional and cosmetic nature of the area, as well as the unique polymicrobial infection potential that exists. We present a review of the epidemiology and microbiology of bite injuries to the head and neck and provide evidence-based recommendations regarding surgical wound closure and antibiotic therapy.     

Natural course of the human bite wound: incidence of infection and complications in 434 bites and 803 lacerations in the same group of patients

Human bites and common lacerations are frequent in certain residential groups in institutions for the care of developmentally disabled individuals. We screened the records of such an institution and studied the course and outcome of 434 human bite wounds and 803 lacerations in the same group of clients. Infection developed in 13.4% of the lacerations, and 17.7% of the bite wounds (chi 2 = 3.474; p greater than 0.06). Prophylactic antibiotics were administered after 14.0% of the bite wounds, and 3.2% of the lacerations. Infection supervened after prophylactic antibiotics in 29.5% of the bites and 34.6% of the lacerations. No patient with a bite wound required debridement, initial or subsequent surgical intervention other than wound closure, admission to hospital, or intravenous antibiotics. There is no recorded instance of a bite wound complication other than immediate loss of tissue. These data substantiate a higher incidence of infection in human bite wounds, but they are scant support for admonition that such wounds are indication for routine antimicrobial prophylaxis or aggressive surgical intervention.     

Successful treatment of acute head and neck dog bite wounds without antibiotics

Dog bites continue to be the most common bite injury in the United States. We previously reported a series of 61 patients with 215 dog bite wounds. Of these, 55 patients had 188 dog bite wounds of the head and neck area which were treated with copious saline pressure irrigation, meticulous wound and wound edge debridement, repeated copious saline pressure irrigation, adequate antibiotic coverage, wound closure, and close postoperative monitoring. A wound infection rate of .53% and a patient infection rate of 1.8% were obtained using this protocol. Our present study uses the same protocol with the exclusion of antibiotic coverage. Our series of 49 patients with 145 head and neck wounds reveals a wound infection rate of 1.4% and a patient infection rate of 4%. This is not statistically significantly different from the outcome of the previous study.     

Dog and cat bites to the hand: treatment and cost assessment

PURPOSE: To assess the demographic patterns, clinical morbidity, and treatment costs associated with domestic animal bites to the hand. METHODS: A retrospective review was performed on 111 patients who suffered either a dog or cat bite to the hand. Demographic data were collected for both the patient and the animal involved. RESULTS: The patient population had suffered 71 dog bites and 40 cat bites. Two scenarios were identified that increased the likelihood of a bite: (1) attempting to separate fighting animals and (2) attempting to aid an injured animal. More than half of the victims (61 of 111) were bitten by an animal with which they were familiar. Bite injuries ranged from relatively minor wounds to major injuries that included open fractures, persistent deep infection including osteomyelitis, nerve laceration, tendon laceration, or tissue loss. Approximately two thirds of patients required hospital admission at least for intravenous antibiotics. Approximately one third of animal bite victims required at least 1 surgical procedure. Thirteen patients required long-term intravenous antibiotics and/or multiple surgeries and incurred medical expenses in excess of dollar 77,000. CONCLUSIONS: Domestic animal bites to the hand are common injuries that can produce considerable morbidity. Stray animals did not account for the majority of incidents. Bite prevention strategies should focus on careful handling of animals that are fighting or injured. Animal bite wounds often require intravenous antibiotics and hospitalization and the cost of care for deep infections can be enormous. Our patient population was selected from a small geographic area over a relatively short collection period, suggesting that domestic animal bite injuries may represent a major public health issue. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic, Level IV.     

Acute paediatric bite injuries treated on inpatient basis: A 10-year retrospective study and criteria for hospital admission

Abstract

The aim of this study was to evaluate the acute bite wounds in children treated on an inpatient basis over a 10-year period and the criteria for inpatient treatment. This study comprised all acute mammalian bite injuries in relation to all paediatric bite injuries seen at the Emergency Surgical Department (ESD). Inclusion criteria were: aged between 0–18 years; acute human or animal bite injuries (presenting for the first time); and inpatient treatment. Exclusion criteria were: bite wounds treated elsewhere and referred for complications; bites treated on an outpatient basis referred for complications; and all insect bites. Over 10 years, 12,948 children were seen at the ESD. There were 167 children (0.77%) with mammalian bite wounds. Twelve of them responded to the inclusion criteria. They presented 7.18% of all mammalian bite injuries and 0.09% of all paediatric emergency visits at the ESD. The average age was 3.82 ± 1.63 years (from 1.3–7 years). The time elapsed between the accident to the wound debridement was 118.64 ± 101.39 minutes. There were 10 dogs, one horse, and one rabbit bite. Surgical treatment comprised debridement, saline irrigation, and primary closure or reconstruction. All patients received antibiotics in the postoperative period. The average hospital stay was 5.92 ± 2.39 days. In one case a partial distal flap necrosis occurred. Animal bite injuries treated on an inpatient basis are predominantly dog bites in young children under 10 years of age, with deep, extended, and commonly multiple injuries. Only 7% of paediatric bite injuries require inpatient treatment.     

Cat And Dog Bites. What To Do?

Inroduction: Domestic animal bites are quite common, but mostly cause minor lesions, for which no medical help is sought. The objective of this study is to define the complications resulting from cat and dog bites that lead to hospital admission. This analysis led to updated guidelines for the treatment of dog and cat bites in humans. Patients and methods: The emergency department (ED) data of our hospital for the year 2004 were retrospectively analysed, seeking patients that presented with bite wounds from either cat or dog. The patient files were reviewed. Results: 34 patients, bitten by cats or dogs, presented to our ED in 2004. 73.5% of them (n = 25) consulted within 24 hours after the bite. In 11 of these patients (44.0%), primary closure of the wound was performed after thorough rinsing and evaluation of the dead space. All these patients were given prophylactic antibiotics. In none of these did the wounds need to be reopened afterwards. Nine patients (26.5%) did not present to the ED until after the day they were bitten. In all these patients, the bite wounds were located on the hand (n = 6) or forearm (n = 3). They all consulted because of complications. The main symptoms were limited and there was painful mobilisation of fingers and wrist, and swelling and redness in the area of the bite wound. Their wounds were thoroughly explored and in 6 of these nine late-presenting patients, a tendon lesion or a purulent flexor tenosynovitis was diagnosed. These six patients needed admission for further management. The mean admission duration was 6 days (range 4 to 10 days). None of the admitted patients showed any signs of limited mobility or disability during follow-up after discharge. Conclusion: While cat and dog bites often cause minor lesions that can be treated by thorough wound care if presented early, the importance of possible late complications should not be overlooked. Patients that present with the symptoms of tissue infection due to a cat or dog bite should be examined adequately and may need admission. Due to aggressive treatment, we had no serious or disabling complications in our population after discharge.     

The prevention of wound infection after head and neck resections: a pilot study using gentamicin impregnated beads

A pilot study of 16 patients undergoing major head and neck resections is presented. At the end of surgery gentamicin (Garamycin) chains are inserted into the wound prior to skin closure and left in place for 48 hours. The rate of wound infection is shown to be low (6.25% requiring antibiotics, 18.75% overall); there have been no complications from use of the chains.     

Auricle injury due to human bite – A rare case report and review literature

Traumatic auricular amputation due to human bite is not a common event. Bite wounds are always considered to be complex injuries contaminated with unique poly-microbial inoculum. Human bites are as serious as animal bites because they induce a higher incidence of infectious complications. In bite wounds to the face, infectious complications can create more difficulties than the initial tissue damage itself for the task of restoring an esthetic appearance. In this case report a young male patient had ear lobule injury on interpersonal violence and amputation of ear lobule results. Due to delay in presentation and high chances of infection wound healing by secondary intention achieved.     

Surgical delay in the management of dog bite injuries in children,does it increase the risk of infection?

Dog bites are contaminated wounds and convention dictates that any surgical treatment should be performed at the earliest opportunity. This practice, however, may be in direct conflict with NCEPOD guidelines to reduce night time operating. We audited our treatment of dog bite injuries in children over a 5-year period (1998-2002) to determine whether delaying surgery to conform to operating guidelines increased the incidence of infection. A retrospective case note study identified 118 patients admitted to Sheffield Children's Hospital with dog bite injuries. Details of their injury, treatment and outcome were recorded. There were 70 males and 48 females and an average age of 6.6 years (range 1-15 years). The most common type of injury was a single laceration (32%) and the most frequent site of injury was the face (59%). The majority of wounds (68%) were cleaned and dressed before theatre and 89% were closed directly after minimal debridement. All patients received prophylactic antibiotics. Of the 114 patients that required surgery, 57 (50%) were operated on within 12 h of their injury and 57 (50%) after 12 h. There were three cases of infection in the early group (<12 h) and none in the delayed group (>12 h). We suggest that delaying the surgical treatment of dog bites in children to avoid operating at night does not increase the infection rate.     

Scrotal dog bites

PURPOSE: Dog bites to the scrotum are rare but they potentially result in morbidity if improperly managed. MATERIALS AND METHODS: Between 1991 and 1999 we treated 4 men and 3 boys with dog bites to the scrotum. All 7 patients presented to the emergency department shortly after the injury. Of the 4 adults 3 were ingesting alcohol and 2 were obviously intoxicated, and 1 had a T4 spinal cord injury and was bitten during sleep. Of the children 2 were apparently bitten without provocation, while a 5-year-old boy was bitten when the family dog was disturbed while eating. RESULTS: All wounds were explored, irrigated and débrided. There was no involvement of the testes or spermatic cord. Each wound was closed primarily and 5 healed without sequelae. The spinal cord injured man had partial dehiscence of the incision and in another man superficial hematoma required drainage. Each patient received antibiotics and tetanus prophylaxis but none required rabies inoculation. CONCLUSIONS: Although there are reports of devastating scrotal injuries from dog bites, most such wounds may be treated by careful inspection for intrascrotal injuries followed by débridement and closure. Antimicrobial prophylaxis should be administered, as for any bite wound.     

Management of facial and periocular dog bites: a review of 104 cases

Background

Dog bites are a frequent cause of facial and periocular injuries in both children and adults. This aim of this study is to review current practice in the management of facial and periorbital dog bite injuries and to examine the current evidence-base for such treatment strategies.

Methods

Five hundred eighty-seven patients with dog bite injuries requiring surgical intervention were identified from operating theatre records in one tertiary centre over a 9-year period. A retrospective case note review of 104 patients with facial and periorbital dog bite injuries was performed. Data on patient demographics, type of injury, treatment, and outcome was collected and analysed.

Results

The majority of patients were children, with a mean age of 11 years (range 1–91 years). Injuries involved the cheek in 57 cases (55 %), eyelids in 17 cases (16 %), lips in 24 cases (23 %) and nose in 8 cases (8 %). No facial fractures, canalicular, or globe injuries were recorded. All patients underwent irrigation, debridement, and primary wound closure. Surgical repair occurred within 24 h in 19 cases (18.2 %), within 48 h in 71 cases (68.3 %) and within 5 days in 14 cases (13.4 %). Three patients (2.9 %) developed a wound infection. Two patients (1.9 %) required scar revision surgery.

Conclusions

Periorbital and facial dog bite injuries may result in considerable morbidity. However, the majority of injuries are superficial and canalicular injury and bony injury is uncommon. Early wound irrigation, debridement and primary closure results in a good cosmetic outcome with a low risk of infection.

Level of Evidence:

Level IV, risk/prognostic study.     

Dog bite injuries in children--a review of data from a South African paediatric trauma unit.

BACKGROUND AND OBJECTIVE: Dog bites are a major cause of preventable traumatic injury in the paediatric population. We aimed to determine the epidemiology of dog bite injuries in a group of South African children with a view to developing potential preventive strategies. DESIGN, SETTING, SUBJECTS: A retrospective review was done of patients presenting with dog bite injuries to the trauma unit at the Red Cross War Memorial Children's Hospital in Cape Town over a 13.5-year period. RESULTS: We identified 1,871 children treated for 2,021 dog bite injuries during the study period. Dog bites accounted for 1.5% of all trauma unit presentations. Male children accounted for 68% of the patients. Children under 6 years of age were more likely to have sustained injuries to the head, face or neck, while children older than 6 years more commonly received injuries to the perineum, buttocks, legs or feet. Younger children were more likely to be attacked at home and older children outside the home. The most frequent injuries were superficial, and the majority of patients were treated with simple medication, dressing or suturing. There were no dog bite-related fatalities. CONCLUSION: The relationship between the geographical location of dog attacks on children and the age groups attacked suggests that strategies to prevent dog bites should target both parents supervising younger children at home, and older children who encounter dogs outside the home.     

Cat bites of the hand

BACKGROUND: Cat bites are the second most common mammalian bites. Cat bites of the hand in particular represent a potentially devastating problem in terms of wound infection and long-term disability if not treated appropriately. The purpose of the present study is to give an overview of demographics, management and follow up of the patients with cat bite injuries of the hand treated at the Royal Hobart Hospital. METHODS: Retrospective and prospective data of all patients with cat bites of the hand seen at the Royal Hobart Hospital for a period of 3 years (January 2000 to April 2003) were collected. Demographics, anatomical site, presentation, assessment, investigations, management and follow up of the patients with this type of injury were analysed. The accuracy of the obtained data was checked by analysing questionnaires returned by our patients. RESULTS: Forty-one patients were treated for cat bites of the hand. Twenty-six were managed in the department of emergency medicine and 15 were admitted and managed by the department of plastic and reconstructive surgery. Five of 15 admitted patients required surgery. Compliance was not a major problem in our study as very few patients were lost to follow up. Almost all patients had close follow up and extensive hand physiotherapy achieving overall good long-term results. Out of 39 patients who were sent questionnaires only one indicated long-term problems with the hand (response rate 46%). CONCLUSION: Appropriate early treatment of cat bites of the hand is the key to success. Treatment with antibiotics, surgical drainage, debridement and copious irrigation, and use of corticosteroids in some cases, proved to be effective. Hand elevation and intensive physiotherapy after a short period of immobilization is critical. We believe that prophylactic antibiotics should be given even in case of a minor infection following cat bites of the hand. Clear guidelines for clinical recognition of infection, hospital admission and management are provided in our study.     

Hand infections in hospitalized patients

Two hundred hospital admissions for hand infections are reviewed with regard to the causes of infection, modes of effective therapy and causes of residual impairment. Patients with human bite injuries and those who delayed seeking treatment most frequently had severe injuries. Appropriate antibiotics and prompt surgical therapy of hand abscesses are essential.     

Swine bites of the hand

Severe infections of the hand may follow bites by swine who carry a wide range of gram-negative and gram-positive flora. Early treatment must be primarily surgical, with prompt and thorough wound cleansing, superficial and deep debridement of the wound, drainage, and delayed closure of wounds only after cultures show no bacterial growth. Appropriate antibiotics are especially important with local or systemic symptoms of infection, as well as prophylactically. An illustrative case is presented.     

Management of pediatric snake bites: Are we doing too much?

Background

The optimal management of children with snake bite injuries is not well defined. The purpose of this study was to review the use of antivenom, diagnostic tests, and antibiotics in children bitten by venomous snakes in a specific geographic region (Southeast Texas).

Methods

This is a retrospective single-center review of all patients with snake bite injury from 1/2006 to 6/2012. An envenomated bite was defined as causing edema, discoloration of the skin, necrosis, or systemic effects. The severity of injury was scored using a novel 4-point scale based on initial physical examination alone.

Results

One hundred fifty-one children (mean age 8.4 ± 4.3 years) were treated for a snake bite. There were no mortalities. Lower extremity injuries were most common (60%). Most bites were from copperheads (43%). Envenomation was evident in 82% (average wound score: 2.61 ± 0.81). The median hospital stay for admitted patients (79%) was 2 days (range 1–7). Four patients required surgery for complications of the snake bite. Fifty-two children (34%) received CroFab, with one allergic reaction. 22/135 (16%) had evidence of coagulopathy. Seventy-two children (48%) received IV antibiotics.

Conclusion

Despite a high rate of envenomated bites in Southeast Texas, significant morbidity is rare. Children with an envenomation score of 1 or 2 are unlikely to be coagulopathic, suggesting that laboratory investigation should be reserved for patients with higher scores. The indications for the administration of CroFab deserve further prospective study.     

Head and neck injuries after leopard attack: Presentation and management

Leopard attacks on humans are reported most often from the Indian subcontinent. The bite wounds are complex injuries infected with polymicrobial inoculum and may present as punctures, abrasions, lacerations or avulsions. The presentation and acceptable treatment of these injuries vary according to the wound. We hereby describe the clinical presentation and treatment of a male victim with leopard bite injuries on the head and neck region. As bite injuries are commonly found on and around the face, maxillofacial surgeons should be familiar with the therapy. Through thorough clinical and radiological examination, it is essential to prevent missing any hidden injuries, which can easily turn lethal. To benefit the rural population, more health facilities need to be established in remote areas.     

The management of human bite injuries of the hand.

Three hundred twenty-seven bite injuries of the hand were reviewed for incidence of infectious complications. A policy to hospitalize all patients with human bite injuries was maintained, but noncompliance was high. Patients with uninfected or superficially infected bites (131) were hospitalized and treated with parenteral penicillin, cephalosporins, or clindamycin (mean duration, 45 hours). Among the 62 patients not lost to followup three minor septic complications occurred. Of similar patients not hospitalized (134), only two thirds received antibiotic therapy but no complications were observed. These data suggest that human bite hand infections can be averted and that established superficial infections can be successfully treated with outpatient antibiotic therapy. Of the 62 patients with moderately to severely infected human bites, 77% were injured by striking an opponent; 52% suffered injury over metacarpophalangeal joints. The mean delay in seeking medical attention was 2 1/2 days, compared to 1/2 day in the less severely infected group. Of the patients with more seriously infected bites, 94% received parenteral antibiotic therapy. Of 30 patients with known outcome in the latter group 27% suffered complications (stiffness; recurrent infection; other infectious complication), confirming the high morbidity of established deep hand infections secondary to human bites.     

Characteristic and outcomes of human and animal bites in Malawi

IntroductionBites are an important contributor to traumatic injury worldwide. In low- and middle-income countries, data regarding bite injuries outside of rabies is limited. Therefore, we sought to describe the injury characteristics and outcomes of bites in Lilongwe, Malawi, and determine risk factors for animals and human bites.MethodsWe performed a retrospective analysis of the Kamuzu Central Hospital trauma registry from 2008-2018. We performed Bivariate analyses comparing bite to non-bite trauma and human to animal bites. Multivariable Poisson regression modeling then estimated risk factors for bites.ResultsA total of 124,394 patients were captured by the registry, of which 3,680 (3%) had a bite injury mechanism. Human bites accounted for 14.5% of bite injuries, and animals represented the remaining 85.5%. In rare cases, animal bite victims had serious complications, such as amputation (n = 6, 0.2%), orthopedic procedures (n = 5, 0.2%), and death (n = 7, 0.2%). Risk factors for an animal bite included being on a farm, field, or lake and being at home, whereas risk factors for a human bite included alcohol use and being at home.ConclusionAnimal bite injuries in Malawi can confer a risk of serious complications, such as amputation and, in rare cases, death. Alcohol-associated, in-home interpersonal violence is a significant risk factor for human bite injuries. Further studies are needed to identify risk factors for complications and mortality.     

Open fractures of the tibia: a review of one hundred and two cases

One hundred and two consecutive open fractures of the tibial shaft were treated from 1970 to 1976. Four required primary amputation. The remainder received standardized wound care, consisting of surgical débridement and delayed primary wound closure. Soft-tissue injuries were classified according to severity, because the initial injury was the most important prognostic factor. All patients received a seventy-two-hour course of parenteral antibiotics. Fifty-six fractures were managed with cast immobilization, thirty-five with rigid internal fixation, and seven with rigid external pin fixation. The over-all rates of infection (15 per cent) and delayed union (13 per cent) are not directly comparable to other series because one must consider the severity of each injury when analyzing results. Management of the fracture itself should be individualized. The risk of primary wound closure does not appear to be warranted.