Continuing Education Activity

Animal bites account for approximately one percent of all emergency visits in the U.S. yearly and can range from superficial injuries to disfiguring and even fatal wounds. Even relatively minor wounds have the capacity to become infected. Therefore, all bites should be evaluated carefully and thoroughly with an awareness of potential complications. Dog and cat bites are the most prevalent animal bites in the United States and account for over 95 percent of all bite wounds seen in the emergency department. This activity highlights the role of the interprofessional team in caring for patients with this condition.

Objectives:

• Describe the pathophysiology of animal bites.
• Review the evaluation of a patient with an animal bite.
• Outline the management options available for animal bites
• Summarize interprofessional team strategies for improving care coordination and communication to advance the treatment of animal bites and improve outcomes.

Introduction

Animal bites account for approximately one percent of all emergency department (ED) visits in the U.S. yearly and range from superficial injuries to disfiguring and even fatal wounds. Even relatively minor wounds can become infected, and therefore all bites should be evaluated carefully and thoroughly with a mind to potential complications.  This chapter will focus on dog and cat bites and the common sequelae as they are the most prevalent, and when considered with human bites (which will be a discussion topic in another chapter), account for over 95% of the total bite wounds seen in the ED.[1][2][3]

Etiology

Domesticated cats and dogs inflict practically all of the bites encountered in the ED in the United States. The most common complication is a local wound infection. Infections resulting from bites of all animal species are poly-microbial with aerobic and anaerobic bacteria; dogs and cats have an oral flora of Pasteurella, Staph, and Strep most commonly. In cat bites and scratches, Bartonella infections are an additional concern. Dog bites in immunocompromised individuals, especially asplenic patients, raise concern for a Capnocytophaga sepsis.[4]      

Epidemiology

Dog bites predominate (60 to 90%), followed by cat bites (5 to 20%). Children are more commonly bitten on the head, face, and neck due to their proportionately larger heads and shorter stature, while adult bites are more common on the hands and arms. Dog bites happen more in men and children. The patient usually knows the dogs, and the bites are less commonly provoked. Cat bites are more common in women and adults, and the bites more often result from provocation. In less traumatic bites, especially cat bites due to the puncturing nature of cat teeth, the patient will commonly only present after the infection has become apparent, and management has become more complicated.[5][1]

Pathophysiology

The initial injury is the result of the physical trauma of teeth puncturing and/or tearing soft tissue, and in the case of some dog bites, blunt force breaking bones. Dog bites are more commonly macerated due to the ripping and tearing forces involved. Cat bites are narrow and deep as the animal rarely pulls or shakes its head, simply biting and holding. Because the cat bite wound is deep and narrow, it is much more likely to seal itself relatively quickly, providing an anaerobic environment for the inoculated bacteria as well as initially appearing less consequential and prolonging time to seeking medical care.  

History and Physical

Focused H&P should determine the circumstances surrounding the bite, location of the bite, type of animal, time of occurrence, whether the patient has been febrile, local erythema, swelling, warmth, or purulent drainage.  If the patient is stable, the wound should be thoroughly explored after local or regional anesthesia to determine the potential for damage to underlying structures and foreign body inoculation. Local and distal neurovascular status should undergo assessment after anesthesia, as well as pain and apprehension, which may affect patient compliance with the exam.  Pertinent history includes any immunosuppression, be it iatrogenic (transplant, rheumatic disease treatment) or a disease process (diabetes, HIV/AIDS, sickle cell disease.)

Evaluation

As with all traumas, the initial evaluation is to ensure airway, breathing, and circulation is intact. Active venous bleeding should be controlled with direct pressure, while arterial bleeding will typically necessitate consult services. The examiner should explore the wound for foreign bodies such as broken teeth, claws, dirt, and plant material. When analyzing the wound, underlying structures require assessment for potential damage as well. During exploration, the patient should range the underlying structures through a full range of motion to ensure no injuries to those underlying structures.[2]

Treatment / Management

All wounds require extensive irrigation, and the patient’s tetanus status updated if necessary. Provide appropriate pain management before exploration, irrigation, or debridement of the wounds. The patient’s TDaP status should be updated if necessary. For uncomplicated dog bites, the patient should be educated on the risk/benefit of closure versus healing by secondary intention and the decision made with the provider. If the patient presents delayed from the initial bite, the risks of closing the wound almost certainly outweigh the cosmetic benefits of closure. If the wound is closed, the patient should be discharged with a week’s course of amoxicillin-clavulanate.

Complicated dog bites should be stabilized and referred for the appropriate consultation service. Cat bites deeper than superficial need thorough irrigation under local anesthesia and the wound left open. The patient should be discharged with a week’s course of amoxicillin-clavulanate and given strict wound care precautions. All bites to the hands or feet, bites in immunocompromised individuals, bites that already show signs of infection, and bites with a puncture characteristic require treatment with amoxicillin-clavulanate. For patients with penicillin allergies, second-line therapy is doxycycline or TMP-SMX plus metronidazole or clindamycin. The appropriate consult service should see patients with extensive local infection; patients with evidence of disseminated infection should be treated with broad-spectrum IV antibiotics and admitted for further care.[6][7][8]

Differential Diagnosis

• Cellulitis

• Cervical spine fracture evaluation

• Emergency treatment of rabies

• Hand infections

• Human bites

• Neck trauma

• Osteomyelitis in emergency medicine

• Tetanus

Prognosis

The prognosis for most animal bites is excellent. However, it is essential to know that, on average, about 30 to 50 people die from dog bites each year.

Complications

• Cellulitis
• Tenosynovitis
• Endocarditis
• Osteomyelitis
• Abscess
• Meningitis
• Tendon rupture
• Nerve injury
• Post-traumatic stress disorder
• Rabies

Postoperative and Rehabilitation Care

Patients with animal bites need to be seen within 48 to 72 hours after the initial treatment to ensure that they are not developing an infection. The animal should be removed from the home and placed in a different location.

Deterrence and Patient Education

Patients should be encouraged to get an updated tetanus vaccination.

Pearls and Other Issues

1. Rabies is rarely a concern due to the broad vaccination program in domesticated animals and the fact that the patient usually knows the animal. Depending on the local prevalence of the disease, one may be able to defer rabies prophylaxis for dog and cat bites. 
2. If the status of the animal is unknown, rabies prophylaxis may be deferred if the animal is in custody and may be observed or has an evaluation for rabies.  Most commonly, rabies originates in bat and skunk populations. 
3. Any bite or suspected bite from a bat should require rabies prophylaxis.  Rabies prophylaxis initiation in the ED requires the rabies vaccine provided in a distant site from the injury with as much of the required rabies immune globulin being given local to the wound. 
4. Further rabies vaccine doses are necessary on days three, seven, and fourteen. 
5. Immunocompromised individuals with cat bites or scratches should be covered with TMP-SMX, ciprofloxacin, or rifampin as prophylaxis against cat-scratch disease.
6. Sepsis from Capnocytophaga is covered by standard prophylaxis in dog bites in immunocompromised individuals. 
7. Bites from K-9 officers should be treated similarly to the above with the additional documentation that the officers will require. 

Enhancing Healthcare Team Outcomes

About 300,000 people with dog bites visit the emergency room or the primary care provider each year—the earlier the treatment, the better the outcome. Managing animal bites requires an interprofessional approach as the bite may occur on any part of the body. There should be no hesitancy in consulting with the appropriate specialist if the bite is on the eyes, nose, hands, genitals, or the scalp. Several guidelines exist on managing specific animal bites like the dog, cat, snake, scorpion, bees, ants, or other wildlife. Healthcare workers who manage animal bites should be aware of the latest guidelines and be aware of the organisms and the antibiotics needed to manage such injuries. Since many animal bites present to the primary care provider or the emergency room, the first treatment is to ensure that the wound is irrigated and cleaned. Debridement of necrotic or dead tissue is the next step. If there is any doubt in the management, the injury is severe, or to the hand, it merits a consult with a specialist. for example, serious injury from dog bites always require management by an interprofessional group of healthcare professionals.[9][10] [Level 3]

Outcomes and Evidence

The majority of people with animal bites have an excellent outcome. However, injuries to the face, groin, and hands can lead to high morbidity. The available literature reveals conflicting opinions on management, and until evidence-based medical evidence is available, the treatment will remain empirical.[11] [Level 5]