Mammalian Bite Wounds in Children: Evidence-Based Management in the Emergency Department - Trauma EXTRA Supplement (Trauma CME and Pharmacology CME)

Table of Contents

 

About This Issue

Considerations in the ED management of animal bite wounds in children include the history of the injury, the type and location of the wound, and the patient’s individual risk factors for infection and other complications. In this issue, you will learn:

The etiology, pathophysiology, and microbiology of dog, cat, and human bite wounds in children

The indications for administration of prophylactic antibiotics and the recommended antibiotic therapy regimens for pediatric patients

When radiographs are indicated for bite wound injuries

The current evidence regarding primary closure of bite wounds

Guidelines for administration of tetanus or rabies vaccination, as well as post exposure prophylaxis for bloodborne pathogens

The role of the emergency clinician in prevention of animal bites in pediatric populations

The potential complications associated with mammalian bites, including emotional effects on children

Special considerations for wounds that require forensic evidence

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Epidemiology, Etiology, and Pathophysiology
   1. Dog Bites
   2. Cat Bites
   3. Human Bites
   4. Microbiology
6. Differential Diagnosis
7. Prehospital Care
   1. History
   2. Physical Examination
8. Diagnostic Studies
9. Treatment
   1. Antibiotic Treatment
      1. Dog and Cat Bites
      2. Human Bites
      3. Antibiotic Selection
      4. Treatment Duration
   2. Wound Management
      1. General Concepts
      2. Dog Bite Repair
      3. Human Bite Repair
      4. Repair of Facial Wounds
      5. Repair of Wounds to the Hands or Feet
      6. General Recommendations
   3. Tetanus
   4. Rabies
   5. Bloodborne Pathogens
      1. HIV
      2. Hepatitis B
      3. Hepatitis C
10. Prevention
11. Complications
12. Special Circumstances
    1. Bite Wounds to the Genitalia
    2. Wild Animal Bites
    3. Envenomation
    4. Rodent Bites
    5. Monkey Bites
    6. Forensic Considerations
13. Time- and Cost-Effective Strategies
14. Disposition
15. Summary
16. Risk Management Pitfalls in Emergency Department Management of Mammalian Bites
17. Case Conclusions
18. Clinical Pathway for Repair and Antibiotic Treatment of Mammalian-Bite Wounds in the Emergency Department
19. Tables
20. References

Abstract

Mammalian bites in children carry risk for infection, adverse cosmetic outcomes, and emotional distress. Emergency clinicians must carefully assess bite wounds and consider any risk factors for serious infection or other complications in order to make appropriate treatment decisions. This review provides evidence-based recommendations for the evaluation and treatment of mammalian bite wounds in children in the emergency department, including guidelines for empiric antibiotic therapy, wound management, and prophylaxis for infectious disease and bloodborne pathogens. The unique considerations in the management of human bite wounds are also discussed.

Case Presentations

A 15-year-old boy arrives in the ED with his mother for treatment of animal bites on his hands and leg…

• The boy was carrying the family cat into the house when it became frightened by an unleashed dog. The cat bit the boy on the left hand before running into the bushes. The dog ran after the cat and the boy followed them. As the patient retrieved his cat, the dog bit him on the right calf.
• The dog’s owner, an unhoused man who was often in the neighborhood, was nearby. The patient confronted the man right after being bitten by the dog; during this confrontation, the boy punched the man in the face and sustained a bite wound to the third MCP joint on his right hand.
• The patient’s mother reports that the cat is healthy and up to date on vaccinations. The histories of the dog and the dog’s owner, however, are unknown.
• On examination, you determine that the cat and dog bites are superficial and require only exploration and irrigation. A small, open wound without any bleeding is visible on the patient’s right third MCP joint, but the finger’s range of motion is significantly limited by pain.
• The mother requests “some antibiotics and a tetanus shot.”
• You order analgesics and wonder whether the patient needs antibiotic prophylaxis, viral prophylaxis, or both…

A 22-month-old girl with bites on each arm is brought to the ED by her father…

• The father reports that the toddler was playing with the family’s new kitten, which became agitated and bit the toddler on the left forearm.
• Following the bite, the patient ran across the room toward her parents but tripped on the carpet and fell. As she landed, she accidentally bit herself on her right forearm.
• The patient is tearful and does not want to allow you or the nurse to examine the bites. She is keeping both arms behind her back.
• You wonder how you’re going to examine these bites on a stubborn toddler, and how each wound should be treated…

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Repair and Antibiotic Treatment of Mammalian-Bite Wounds in the Emergency Department

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Tables

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

3. * Ball V, Younggren BN. Emergency management of difficult wounds: part I. Emerg Med Clin North Am. 2007;25(1):101-121. (Review) DOI: 10.1016/j.emc.2007.01.003

9. American Pet Products Association. Pet industry market size, trends & ownership statistics. Accessed August 10, 2023. (Industry data)

25. * Moran GJ, Talan DA, Abrahamian FM. Antimicrobial prophylaxis for wounds and procedures in the emergency department. Infect Dis Clin North Am. 2008;22(1):117-143. (Review) DOI: 10.1016/j.idc.2007.12.002

30. * Talan DA, Citron DM, Abrahamian FM, et al. Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med. 1999;340(2):85-92. (Prospective; 107 patients) DOI: 10.1056/NEJM199901143400202

72. * Nakamura Y, Daya M. Use of appropriate antimicrobials in wound management. Emerg Med Clin North Am. 2007;25(1):159-176. (Review) DOI: 10.1016/j.emc.2007.01.007

88. * Turner TW. Evidence-based emergency medicine/systematic review abstract. Do mammalian bites require antibiotic prophylaxis? Ann Emerg Med. 2004;44(3):274-276. (Systematic review; 8 studies)

100. *Bhaumik S, Kirubakaran R, Chaudhuri S. Primary closure versus delayed or no closure for traumatic wounds due to mammalian bite. Cochrane Database Syst Rev. 2019;12(12):Cd011822. (Meta-analysis; 4 studies, 998 patients) DOI: 10.1002/14651858.CD011822.pub2

105. *Kay HF, Kang HP, Fisch R, et al. The management of clenched fist injuries with local anaesthesia and field sterility. J Hand Surg Eur Vol. 2021;46(4):411-415. (Randomized controlled trial; 442 patients) DOI: 10.1177/1753193420960588

113. US Centers for Disease Control and Prevention. Tetanus: for clinicians. Reviewed August 29, 2022. Accessed August 10, 2023. (CDC recommendations)

117. US Centers for Disease Control and Prevention. Rabies in the U.S.: public health importance of rabies. Reviewed April 6, 2020. Accessed August 10, 2023. (CDC website)

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Keywords: mammalian bites, dog bites, cat bites, human bites, rodent bites, monkey bites, fight bites, primary repair, puncture wound, Pasteurella, rabies, tetanus, PEP, post exposure prophylaxis, hepatitis, HIV