<\/p>\n
<\/p>\n
Chronic illnesses<\/p>\n
\u0095 Cirrhosis<\/p>\n
\u0095 Renal failure<\/p>\n
\u0095 Systemic lupus erythematosus and other immune disorders<\/p>\n
\u0095 Diabetes mellitus<\/p>\n
\u0095 Raynaud’s<\/p>\n
Medications<\/p>\n
\u0095 Corticosteroids<\/p>\n
\u0095 Methotrexate and other immunosuppressives<\/p>\n
Alcoholism<\/p>\n
Asplenia<\/p>\n
Peripheral vascular disease<\/p>\n
HIV<\/p>\n
Conditions causing chronic edema of the bitten part<\/p>\n
\u0095 Mastectomy<\/p>\n
\u0095 Congestive heart failure with pedal edema<\/p>\n
<\/p>\n
If you are going to give proph abx, give 3-5 days of:<\/p>\n
\u0095 Amoxicillin\/clavulanate (relatively expensive withfrequent gastrointestinal side effects)<\/p>\n
\u0095 A second-generation cephalosporin with anaerobic activity (e.g., cefuroxime) (also expensive)<\/p>\n
\u0095 Penicillin plus a first-generation cephalosporin (cheap, but requires frequent dosing of two medications)<\/p>\n
\u0095 Clindamycin plus a fluoroquinolone or trimethoprimsulfamethoxazole (good options for those who are penicillin-allergic)<\/p>\n
For human bites, you can use the above except for number 3, instead give PCN and Diclox (EM Practice)<\/p>\n
Capnocytophaga Canimorsus (most virulent)-can result in rapid and deadly sepsis.\u00a0 Usually presents in 4 days but can take as long as 4 weeks to manifest.\u00a0 Can cause renal failure, DIC, endocarditis, and meningitis.\u00a0 May not have infection present at bite site.<\/p>\n
Staph Intermedius<\/p>\n
CDC NO-1<\/p>\n
Pasteurella Multicoda-rapid, and virulent (patients have pain disproportional to injury and minimal lymphadenitis)<\/p>\n
Presents early, while staph and strep present >24 hrs after bite.\u00a0 Pasteurella is the most common (EM Practice) followed by Staph and Strep.<\/p>\n
Reasons dogs bite:<\/strong> pain response; territorial protection of home, environment, property; assertion and dominance; fear; some breeds unpredictable<\/p>\n Bite characteristics:<\/strong> combination penetrating-crushing injury; bite pressure 200 lb\/in2 with average small- to medium- sized dog, up to 1800 lb\/in2 in pit bull (can easily fracture adult male femur)<\/p>\n Canine pack behavior:<\/strong> social hierarchy consists of dominant male, dominant female, and subordinates; dogs protect pack, defend territory, defend food; humans part of pack<\/p>\n Wound care:<\/strong> vigorous saline irrigation (speaker does not recommend using Betadine [povidone\u0096iodine] or hydrogen peroxide); d\u00e9bride necrotic tissue, consider wound closure<\/p>\n Facial injuries:<\/strong> seen mainly in 3-5 yr age group; dogs\u0092 natural reaction to nuzzling within their own pack is to bite other dog\u0092s muzzle<\/p>\n Severe attacks:<\/strong> characterized by repeated biting, violent shaking of victim; difficult to end attack (must sometimes use deadly force); pack of dogs extremely dangerous; fatal attacks increasing; pit bull most common breed involved in fatal attacks, however, rottweilers most likely to bite<\/p>\n Fatal attacks:<\/strong> major problem bringing newborn into home with dog that has been in family for years; must acclimate child and dog to each other; never leave neonate alone with dog; 50% of all deaths occur in children <10 yr of age; 45% of 1- to 9-yr-old victims killed by loose dog on owner\u0092s property (child invades owner\u0092s yard, dog protects property), 29% by chained dog on owner\u0092s property; 26% killed by loose dog roaming<\/p>\n Pit bull:<\/strong> repeat biter; grinding, holding bite; no threatening gestures; dogs assume wide stance, attack at great speed; call local police if pit bull seen running loose, stay away from animal; unprovoked attacks 42% for all breeds combined, 94% for pit bulls alone<\/p>\n Prevention:<\/strong> choose calm animal; educate children; modify dog\u0092s behavior; neuter animal; monitor interaction; do not enforce behavior of play-biting, roughhousing, tug-of-war; newborns can be threatening to dog; behaviors to avoid include hugging and kissing dog (face to muzzle), roughhousing, startling sleeping dog, invading dog\u0092s territory, interrupting feeding; dog does not recognize when child going to be aggressive and vice versa; teach children not to escalate level of activity, eg,<\/em> by running away from dog; do not approach dog in hand-on-dog\u0092s-head position (dominant gesture); do not run up to or away from animal; allow dog to smell hand before petting dog under muzzle; suppress behavior of nipping, chewing, mouthing hand, growling, barking, guarding food, stealing food, tug-of-war<\/p>\n Choosing a dog:<\/strong> avoid anthropomorphism (\u0093don\u0092t make the dog a human in your family\u0094); assume dominant role (even smallest child needs to be dominant); adopt dog at 6-7 wk of age, socialize until 13 wk of age; be consistent; make certain when you walk up to dog that dog submissive (lying down with stomach exposed); choose dog that looks best for you, then pick up and hold dog by nape of neck; if dog struggles or tries to bite, dog may be aggressive when older; also, if dog does not struggle too often when turned on back or try to nip, \u0093that\u0092s a dog you may want to have\u0094; speaker does not recommend getting 1- to 2 yr-old dog from pound if children in home<\/p>\n Preventing attack:<\/strong> never scream or run; avoid direct eye contact; stand motionless; if knocked down, stay in fetal position and try not to fight off animal; most dogs (but not pit bulls or rottweilers) stop biting if they get victim on ground and victim stops moving; stand as still as possible and present least amount of body as possible (Audiodigest-James Betts, MD)<\/p>\n Suture Everything Closed<\/p>\n Management of dog bites still exhibits significant variability. \u00a0Antibiotics, traditionally generally prescribed, are only selectively necessary. \u00a0Another element of mythology, primary closure of wounds for optimal cosmesis, is the subject of this trial.<\/p>\n These Greek authors randomized 182 patients to either primary suturing or non-suturing of traumatic bite lacerations. \u00a0Obviously, the lacerations receiving primary closure had much improved cosmetic outcome. \u00a0The infection rate of suturing was 9.7% vs. 6.9% without, and this study was underpowered to confirm whether this small difference occurred by chance alone. \u00a0The main predictor of subsequent infection was treatment >8 hours after injury. \u00a0All patients, unfortunately, received local scrubbing with povidone-iodine and were prescribed amoxicillin\/clavulanic acid, neither of which were likely helpful.<\/p>\n I think it’s absolutely reasonable to approximate wound edges for dog bite lacerations after gentle and thorough cleansing. \u00a0This study doesn’t provide any truly conclusive guidance for wounds >8 hours old \u2013 as they had similarly poor outcomes, regardless \u2013 other than to offer information to patients on their sub-optimal prognosis.<\/p>\n<\/span>From EM Lit of Note<\/span><\/h3>\n