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TRAUMATIC BITES SURGICAL APPROACH TO TRAUMATIC BITE INJURIES.

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Presentation on theme: "TRAUMATIC BITES SURGICAL APPROACH TO TRAUMATIC BITE INJURIES."— Presentation transcript:

1 TRAUMATIC BITES SURGICAL APPROACH TO TRAUMATIC BITE INJURIES

2 GOAL 28M presents with a laceration over his MCP joint incurred during an altercation 3 days prior. He has associated erythema, edema, purulent discharge and decreased ROM. What is your management plan? 35M presents 3 hours after an altercation with what is determined after your evaluation to be an uncomplicated closed fist injury, and you intend to discharge him home. Should you provide any prophylactic antibiotics, and if so, which one? What if the patient has a penicillin allergy? 45F presents 3 hours after a seizure with a mucocutaneous (through-and-through) lower lip laceration. Should this wound be closed? What is the infection rate of this wound without prophylactic antibiotics?

3 BACKGROUND 50% of Americans will be injured by the bite of an animal or human during their lifetime Bites account for 1% of all emergency department visits The highest incidence of bites occurs in boys 5 to 9 years of age Lack of well-designed, prospective studies Soft tissue infection is the most common complication Centers for Disease Control and Prevention. Nonfatal dog bite-related injuries treated in hospital emergency departments—United States, MMWR Morb Mortal Wkly Rep. 2003;52(26):605–610. Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA 1998;279:51-53 Griego RD, Rosen T, Orengo IF, et al. Dog, cat and human bites: a review. J Am Acad Dermatol 1995;33:1019.

4 BACKGROUND Soft tissue infection is the most common complication Factors determining risk of infection: Type of bite

5 BACKGROUND Soft tissue infection is the most common complication Factors determining risk of infection: Type of bite Site of bite

6 BACKGROUND Soft tissue infection is the most common complication Factors determining risk of infection: Type of bite Site of bite Time elapsed between bite and presentation

7 BACKGROUND Soft tissue infection is the most common complication Factors determining risk of infection: Type of bite Site of bite Time elapsed between bite and presentation Host factors: Oral flora

8 BACKGROUND Soft tissue infection is the most common complication Factors determining risk of infection: Type of bite Site of bite Time elapsed between bite and presentation Host factors: Oral flora Wound management

9 ANATOMY OF THE BITE Bite injuries reflect the dental anatomy and jaw strength of the biting animal DOG: large, broad, sharp teeth and powerful jaws Lacerations, Crush and avulsion injuries CAT: sharp, elongated needle-like teeth Puncture wounds HUMAN: more closely resemble dog bites than cat bites Abrasions and lacerations >> Punctures Tend to be more superficial than animal bites, but with higher infection rate

10 HUMAN BITES: CATEGORIES (NOT MUTUALLY EXCLUSIVE) Intentional bite Unintentional bite Occlusional bite/Simple Occlusional bite of the hand Clenched-fist bite

11 HUMAN BITES: 2 MAJOR CATEGORIES Occlusional Bite - teeth punctures the skin Carry same risk of infection as animal bites, except when they occur on the hand Most simple non-hand human bites are no more significant than ordinary lacerations Clenched-Fist Bite (“Fight Bite”) - hand is injured by contact with teeth Usually occurs during a fistfight or accidental sports injury Opponent’s tooth inoculates deeper tissue planes of fist with oral flora Typically occurs at the 3 rd MCP joint Associated with a high risk of infectious complications, significant morbidity Serious complications include septic arthritis, tenosynovitis, and osteomyelitis Surgical amputation may be required [74, 75] Rate of infectious complication in hand bites is estimated at 25 to 50% [88] Compartmentalized anatomy of the hand contributes to increased infection risk Requires prompt and appropriate identification and management

12 HUMAN BITES: MICROBIOLOGY Human mouth carries a high population of resident bacteria A larger number of bacteria is transferred to the victim compared to dog, cat bites Eikenella corrodens is characteristic of human bites (found in >30% of human bites) Pasteurella multicoda is absent in human bites Higher incidence of beta-lactamase producing organisms

13 CLASSIC SYSTEMIC INFECTIONS TRANSMITTED BY BITES Viral: Arbovirus (bat), B herpes virus (macaque), CMV (chimpanzee), hantavirus (rodent), HBV, HCV, HIV, rabies, Venezuelan equine encephalitis (bat) Bacterial: brucellosis (dog), cat-scratch disease (cat, dog, monkey), leptospirosis (dog, mouse, rat), plague (cat), rat-bite fever (dog, gerbil, mouse, rat, squirrel, weasel), syphilis, tetanus (dog), tularemia (cat, dog, other mammals) Mycobacterial: M. marinum (dolphin), tuberculosis (human) Fungal: blastomycosis (dog), sporotrichosis (cat) Parasitic: trypanosomiasis (bat)

14 RISK FACTORS FOR SOFT TISSUE INFECTION FROM ANIMAL OR HUMAN BITE Location on the hand, foot, or over a major joint Location on the scalp or the face of an infant Infection of cartilaginous (ear, nose) Puncture wound (often cat bites) Immunosuppression Chronic alcoholism Diabetes mellitus Corticosteroid use Delay in treatment lasting longer than 12 hours Preexisting edema in an affected extremity

15 AMONG THOSE WHO SEEK MEDICAL ATTENTION FOR BITE INJURY Infection rates Dog: 2 to 20% Cat: 30 to 50% Human: 10 to 50% Bite Type Dog: 80 to 90% Cat: 3 to 15% Nondomestic animals: 1 to 2%

16 ORGANISMS MOST FREQUENTLY ISOLATED FROM DOG AND CAT BITE WOUNDS Bite wounds are grossly contaminated Polymicrobial (mix of aerobes and anaerobes) Aerobes: Pasteurella multocida (50 to 80% of cat bites, 25% of dog bites) Corynebacterium spp, Staph, Strep and (rare) Capnocytophaga canimorsus Anaerobes: Bacteroides spp, B. fragilis, Prevotella, Porphyromonas, Peptostreptococci, Fusobacterium, Veillonella parvula

17 PASTEURELLA MULTOCIDA - MOST COMMON DOMESTIC ANIMAL BITE PATHOGEN Gram negative, facultative anaerobe, zoonotic pathogen Most common pathogen isolated from domestic animal bite 50 to 80% of cat bites, 25% of dog bites Symptoms classically arise within first 24 hours of bite Erythema, edema, tenderness, bloody drainage Typically, localized cellulitis and abscesses Complications: direct extension, lymphangitis, LAD, bacteremia, OM, arthritis, tenosynovitis, sepsis, meningitis, brain abscess, pneumonia, endocarditis Risk factors for complicated infection: DM, cirrhosis, rheumatoid arthritis, neoplasms, immunosuppression Bite wound infection developing after >24hr, less likely Pasteurella

18 ANTIBIOTICS – FOR HIGH RISK ANIMAL BITES Select a broad-spectrum antibiotic with anaerobic and aerobic coverage Augmentin (amoxicillin-clavulanate) is gold standard Bactrim (trimethoprim-sulfamethoxazole), Doxycycline, Ciprofloxacin

19 PATHOGENS OF HUMAN BITES Also polymicrobial, but usually higher # of isolated organisms compared to animal bites Average 5 organisms per bite wound The concentration of bacteria in the human oral cavity is higher compared to animals Anaerobes: Similar distribution of anaerobes as in animal bites. Bacteroides spp are more common than animals -However in human bites these pathogens often produce Beta-lactamases Aerobes: Different distribution. Most common Staph aureus, Staph epidermidis, alpha and beta hemolytic strep, Corynebacterium, and E. corrodens Viral exposures: Hepatitis B or C, HIV

20 EIKENELLA CORRODENS - COMMON HUMAN BITE PATHOGEN Gram negative rod, facultative anaerobe Normal human oropharyngeal flora Often causes serious, chronic infections [you may remember it as implicated in culture-negative endocarditis “HACEK” and Needle-licker’s osteomyelitis] Typically indolent infections, requiring incubation period of 1 week or more Foul-smelling Common isolate of human bite infections Especially in Clenched-Fist injuries (25%) Augmentin or Unasyn are first-line due to broad coverage and E. corrodens sensitivity

21 MANAGEMENT OF BITE WOUNDS ABCs. History. Neurovascular assessment (distal pulses, sensory/motor exam, ROM) Evaluate for signs of infection and involvement of deeper structures (joint, tendon, bone) Gram stain and culture (aerobic and anaerobic) wounds that appear infected * Meticulous wound care is of utmost importance * High-pressure irrigation Debridement Always leave HUMAN BITE wounds OPEN Immobilize and elevate injured extremities Determine tetanus status and vaccinate prn

22 MANAGEMENT OF BITE WOUNDS X-rays may be indicated to rule out osseous injury, gas formation, foreign bodies CT, MRI or even open exploration/surgical debridement may be indicated in rare instances Antimicrobial therapy? Empiric treatment if evidence of wound infection. Or consider prophylaxis for wounds without evidence of infection. Critical attacks may require collaboration of multiple services: Plastics, Vascular, Ortho, etc. The majority of cases can be treated as outpatient With oral antibiotics and site elevation at home

23 WOUND MANAGEMENT: TO CLOSE OR NOT TO CLOSE Controversial topic Options for closure include primary closure, healing by secondary intention, delayed direct closure, skin grafts, composite grafts, and local flaps When to close:All CLOSED wounds require prophylactic abx DOG BITE If seen early (<12h) and not involving the handAvoid any buried sutures or layered closures Many facial bite woundsGoal: approximate edges yet allow for drainage When to leave open: Most DOG BITES After 12h ALL CAT BITES ALL HUMAN BITES ALL bites involving the victim’s HAND Most puncture wounds Infected wounds

24 SPECIAL CONSIDERATIONS IN CLENCHED-FIST BITE MANAGEMENT Important to recognize the potential severity of the injury in a clenched-fist bite The compartmentalized anatomy of the hand can contribute to the development of an infection. If an infection is not appropriately diagnosed and treated, significant morbidity can result. Often delay in seeking care, late presentation Classically a small 3 to 5mm laceration on the dorsum of the hand, overlying an MCP joint Must assess extensor tendon function in clenched-fist injuries Puncture wounds should be extended proximally & distally while looking for extensor tendon injury Early surgical intervention may be warranted, especially in setting of risk factors/comorbidities (DM, PVD, immune compr) Some MDs believe that all CFIs warrant inpatient admission and surgical consultation

25 OTHER SPECIAL CONSIDERATIONS For infants and small children (up to 2 years old) who sustain substantial bite wounds to the scalp, should obtain skull films or CT. Evidence of skull perforation  neurosurgical c/s and admit patient Facial bite wounds: infectious complications create challenges in restoring esthetic appearance Care of avulsed body parts: Wrap in sterile gauze soaked with normal saline and place in plastic bag Place that bag in a container of ice water For bites violating cartilaginous tissue, should consult plastics and/or ENT Inform your patients and involve them in decisions

26 SPECIAL CONSIDERATIONS FOR ANIMAL BITES In most states, physicians are required by law to report animal bites Address potential need for Rabies prophylaxis Immune-globulin on day of presentation. Vaccination on days 0, 3, 7, 14

27 MANAGEMENT OF EARLY HUMAN BITES OF THE HAND: A PROSPECTIVE RANDOMIZED STUDY Zubowicz VN, Gravier M. Plast Reconstr Surg. 1991;88:111–4 N=45 bite wounds to the hand All seen within 24 hours All without e/o infection, tendon injury or joint capsule penetration Of those subjects who did NOT receive antibiotics, 47% developed an infection Of those subjects who Did receive prophylactic antibiotics, 0% developed an infection Study was terminated early d/t high infection rate in control group CONCLUSION: ALL hand bites should be managed with ppx antibiotics Zubowicz VN, Gravier M. Management of early human bites of the hand: a prospective randomized study. Plast Reconstr Surg. 1991;88:111–4

28 ANTIMICROBIAL THERAPY Prophylaxis is still controversial. Should at least be considered with every bite wound. Generally 5 to 7 days of oral broad-coverage antibiotic: Augmentin is first-line Prophylactic abx for all bite wounds that are closed to heal by primary intention Empiric therapy with broad coverage for infected wounds Narrow to culture/sensitivities Lack of well-designed, prospective, randomized controlled studies A meta-analysis of randomized trials found that prophylactic antibiotics reduced the rate of infection in dog bite wounds A Cochrane review found there is evidence that the use of ppx abx reduced infection rates in bites of the hand, and that there is no evidence for ppx abx in dog and cat bites

29 INDICATIONS FOR INTRAVENOUS ANTIBIOTICS Patients with systemic signs/symptoms of infection Severe or extensive cellulitis Compromised immune status Diabetics Significant bites to the hand Joint, nerve, bone or tendon involvement Infection refractory to oral antibiotic therapy

30 (DEBATABLE) INDICATIONS FOR PROPHYLACTIC ANTIBIOTICS All hand bites Dog bites more than 8-12 hours old Moderate to severe dog bites less than 8-12 hours (edema, crush injuries) Puncture wounds, particularly if bone or joints were penetrated Severe facial wounds Wounds in the genital area Wounds in immunocompromised or asplenic patients Moderate to severe cat or human bites

31 HUMAN BITE WOUNDS TO THE HAND = Indication for antibacterial therapy Broad spectrum ie Augmentin recommended COURSE? For Penicillin allergy, Clindamycin + CIPRO or BACTRIM or DOXYCYCLINE For prophylaxis: 5 to 7 day course Longer course for infected wounds [44]

32 REFERENCES Agency for Healthcare Research and Quality National Guideline Clearinghouse. Management of human bite wounds. Available at: Dellinger EP, Wertz MJ, Miller SD, Coyle MB. Hand infections. Bacteriology and treatment: a prospective study. Arch Surg. 1988;123:745–50. Goldstein EJC. Bite wounds and infections. Clin Infect Dis 1992;14:633. Griego RD, Rosen T, Orengo IF, et al. Dog, cat and human bites: a review. J Am Acad Dermatol 1995;33:1019. Gurunluoglu R 1, Glasgow M, Arton J, Bronsert M. Trauma Acute Care Surg May;76(5): Retrospective analysis of facial dog bite injuries at a Level I trauma center in the Denver metro area. Patzakis MJ, Wilkins J, Bassett RL. Surgical findings in clenched-fist injuries. Clin Orthop. 1987;220:237–40. Presutti RJ. Bite wounds: early treatment and prophylaxis against infectious complications. Postgrad Med 1997;101:243. Smith PF, Meadowcroft AM, May DB. Treating mammalian bite wounds. J Clin Pharm Ther 2000;25:85- Tan JS. Human zoonotic infections transmitted by dogs and cats. Arch Intern Med 1997;157:1933. Weber DJ, Hansen AR. Infections resulting from animal bites. Infect Dis Clin North Am 1991;5:663. Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA 1998;279:51-53 Zubowicz VN, Gravier M. Management of early human bites of the hand: a prospective randomized study. Plast Reconstr Surg. 1991;88:111–4


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