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Basics

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Author:

Daniel T.Wu


Description!!navigator!!

Etiology!!navigator!!

Diagnosis

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Signs and Symptoms!!navigator!!

History

  • Time of injury
  • Patient allergies
  • Relevant medical history (immune status)
  • Last tetanus shot
  • HIV, hepatitis B status of person inflicting bite

Physical Exam

  • Record the location and extent of all injuries
  • Document any swelling, crush injuries, or devitalized tissue
  • Note the range of motion of affected areas
  • Note the status of tendon and nerve function
  • Document any signs of infection, including regional adenopathy
  • Document any joint or bone involvement

Essential Workup!!navigator!!

Careful physical exam for involvement of deep structures and foreign bodies

Diagnostic Tests & Interpretation!!navigator!!

Lab

  • Aerobic and anaerobic cultures from any infected bite wound
  • Cultures not indicated if wounds not clinically infected
  • CBC, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) if suspect infection
  • Electrolytes, glucose, BUN, and creatinine:
    • For diabetic patients or those with significant infections

Imaging

  • Generally not helpful
  • Plain radiograph indications:
    • Fracture
    • Suspect foreign body (e.g., tooth)
    • Baseline film if a bone or joint space has been violated in evaluating for osteomyelitis
    • For infection in proximity to a bone or joint space
  • Ultrasound can be useful in differentiating abscess from cellulitis

Differential Diagnosis!!navigator!!

Bite injuries from animals:

Other Considerations

  • In suspected sexual abuse:
    • Check for a central area of bruising or “hickey” from suction
  • Linear abrasions or bruises on both the dorsal and palmar/plantar surfaces of the hand or foot:
    • Highly suggestive of bite marks
    • Lesions on one extremity should prompt a search for lesions on the other extremities
  • An intercanine distance of >3 cm indicates permanent dentition (present only if the attacker is >8 yr)
  • If abuse suspected:
    • Rub a saline-moistened swab in the wound to collect any saliva and then place in a paper envelope for analysis
    • Obtain photographs
    • Notify authorities

Treatment

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Prehospital!!navigator!!

Control bleeding with direct pressure

Initial Stabilization/Therapy!!navigator!!

ABCs: Ensure patent airway and adequate peripheral tissue perfusion

ED Treatment/Procedures!!navigator!!

Medication!!navigator!!

First Line

Second Line

  • 2 drug therapy: 1 of the following below + anaerobic coverage:
    • Trimethoprim-sulfamethoxazole (Septra DS): 1 tablet q12h (peds: 8 mg/kg trimethoprim and 40 mg/kg sulfamethoxazole per day divided into 2 daily doses) PO
    • Penicillin (Penicillin VK): 500 mg (peds: 50 mg/kg/24 hr) PO q6h
    • Ciprofloxacin (Cipro): 500-750 mg q12h PO or 400 mg q12h IV
    • Doxycycline: 100 mg PO b.i.d
  • + (anaerobic coverage):
    • Clindamycin (Cleocin): 150-450 mg (peds: 8-20 mg/kg/24 hr) PO q6h or 600-900 mg (peds: 20-40 mg/kg/24 hr) IV q8h
    • Metronidazole (Flagyl): 500 mg PO t.i.d (peds: 10 mg/kg/dose t.i.d)

Follow-Up

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Disposition!!navigator!!

Admission Criteria

  • Infected wounds at presentation
  • Severe/advancing cellulitis/lymphangitis
  • Signs of systemic infection
  • Infected wounds that have failed to respond to outpatient (PO) antibiotics

Discharge Criteria

  • Healthy patient with localized wound infection:
    • Discharge on antibiotics with 24-hr follow-up
  • Noninfected wounds:
    • 48-hr follow-up
Geriatric Considerations
  • Human bite marks rarely occur accidentally; good indicators of inflicted injury
  • Consider elder abuse

Pediatric Considerations
  • Human bite marks rarely occur accidentally; good indicators of inflicted injury
  • If intercanine distance >3 cm, bite likely from an adult. Consider child abuse

Issues for Referral

Suspected child abuse

Follow-up Recommendations!!navigator!!

Pearls and Pitfalls

  • Examine the deepest part of clenched-fist bites while putting the fingers through full range of motion to check for extensor tendon lacerations and joint violation
  • Obtain hand consultation for operative irrigation for all patients with clenched-fist lacerations due to the high rate of infection
  • An intercanine distance of >3 cm indicates permanent dentition (present only if the attacker is >8 yr)

Additional Reading

See Also (Topic, Algorithm, Electronic Media Element)

Bite, Animal

Codes

ICD9

ICD10

SNOMED