First of all, from Plastic Surgery perspective, I disagree with many online recommendations for treating dog and animal bites. There is no question that most dog bites heal reasonably well, but is reasonably well good enough if it is your face, or your child? When I started doing things a little differently, initially my colleagues were a bit skeptical. 6 month later I was getting calls for most of their family members’ dog bite injuries.
The secret is antibiotics, meticulous attention to anatomy, gentle tissue handling, no aggressive debridement, early mini-drainage, regular soapy water washing of bite sites and staged closure approach.
Did you know that there are almost 70 million pet dogs and 74 million pet cats in the United States? CDC report estimates about 4.5 million dog bites each year in the US. About 900,000 patients seek medical attention every year due to dog bite injuries. However, many dog owners do not report the bites and do not seek medical attention for every bite. Based on my personal experience with my own dog, and I have one mean Chihuahua, I would estimate that the number of total bite events is at least 3 to 4 times greater if not more.
The risk of being bitten by a dog increases if there is a dog in the household. Men are bitten more often than women, and women on the other hand are more commonly bitten by cats. Children between the ages of 5 and 9 years old are more common victims of pediatric dog bites. Children are also more likely to be treated for dog bites than adults.
WHAT TO DO IF BITTEN BY THE DOG?
Place victim in safe location
Remove the assailant dog to prevent additional injury
Evaluate Airway, Breathing and Circulation – CPR basics
Call 911 and request ambulance if indicated
Control bleeding with gentle pressure and proceed to the closest Emergency Room or Urgent Care facility
Elevate bite area
Wash the injured area with sterile, or clean water, or cooled down previously boiled water or mild soap solution. Make sure to wash inside the wound. Using clean toy spray bottle, or shower head or tap water, let run into the wound can help in decreasing risk of infection. Cleaning should take at least 10-20 minutes, not 5. You might be surprised how long 15 minutes can be if you actually watch the clock.
Apply sterile dressing
Caregiver must wear protective gloves.
Despite popular belief and recommendation on some web sites, antibiotic ointments are not very effective in preventing infections, I personally feel that they create more problems than the solve first week. Use of alcohol and peroxide on the open bite wounds is not recommended because they can create chemical damage to open wound tissues on top of potential infection. The idea or use of peroxide is for bubbles of oxygen to clean the dirt out of tissues. If you are determined to use it, to decrease toxic effect, I suggest diluting commercially available Peroxide solution at least 5 times with saline or water solution.
Obtain Information from owner on animals immunization status if available as this information will be needed in the medical facility to determine in rabies prophylaxis is needed. If dog is unknown, wild or immunization status is unclear, rabies immunization must be started as soon as possible. Please remember that if rabies treatment is started early, rabies can be prevented, if the patient ignores medical care and presents to medical facility with clinical signs of rabies, the disease almost always lethal, or lead to death.
Obtain information on tetanus immunization of the victim.
WHAT NEEDS TO BE TREATED?
When treating animal bites victims, the care is focused on 3 objectives – repair skin, repair underlying structures (bones, tendons, nerves, vessels, muscles, joints, ets and prevent infection.
The amount of skin damage may or may not reflect the extent and complexity of deep structure injury. Especially in the extremities, hands, feet, or face,the density of the various anatomic structures is very high and victim of animal bite might have extensive injuries to multiple important anatomic structures with fairly small but deep external wounds. That is why it is very important that the treating physician is intimately familiar with regional anatomy and with the ways to properly test all anatomic structures in the zone of injury.
It is estimated that 64 different species of bacteria are found in the canine mouth, and the most common are Staphylococcus, Streptococcus, Eikenella, Pasteurella, Proteus, Klebsiella, Haemophilus, Enterobacter, Bacteroides, Moraxella species , Corynebacterium, Neisseria, Fusobacterium, Prevotella , Porphyromonas and others. The medical studies report that 25-75% of animal bites can become infected. However, in my book 100% of them are severely contaminated. Even if there is no clinical infection, the cosmetic deformity can be very significant. I surgically close dog bite wounds ONLY if I am able to fully remove injured area. If not, I repair deep structures injured during the bite but close skin loosely to allow drainage. Also I use micro-drains to further improve the result.
This part is, perhaps, the most important to create better result. I believe that despite most careful and diligent washing and cleaning, it is impossible to fully remove contamination from the tissues. With antibiotics full blown infection may not occur but what I used to see is subclinical infection. It presents as prolonged inflammation, redness, tenderness, but no fever, chills, or pus. Some surgeons believe that this is normal part of healing for bite wound and I used to think the same. However, now I believe that after bite injury subcutaneous fatty tissues under the skin are subjected to stress from mechanical effect of injury, surgery, and low grade infection. Some of them could survive if they were not exposed to low level of bacterial contamination that tips them over to not surviving. As the result, patient lose pockets of fatty tissue under the skin and it created unsightly indentations, commonly visible in kids. My solution is to use micro-drains for the first week. That allows toxic substances to escape the wound site and allows more tissues to survive. Results are better because of less scar tissue formation, loss indentations and overall more natural result. Some of my colleagues may feel that I am over complicating things but I like my results better and my patients are happier, so I think it is a right thing to do.
Most common antibiotic used is for treatment of bites is Augmentin. The first dose can be usually given IV and the rest as pills at home twice a day. It is important to take it with food and add probiotic to the regimen as the most common problem with Augmentin is gastrointestinal complications.
For patients allergic to Penicillins, I recommend Clindamycin, Doxycycline, and combination with Bactrim.
Taking antibiotics is not a substitute for proper local wound care with soap and water. I do not recommend use of antibiotic ointments earlier than 5-7 days after bite injury. Obviously, there is a reason for that also.
WHEN TO SEEK MEDICAL CARE
The patient or parent commonly have to make a decision if they need to be seen in the hospital or other medical facility. Here are more common reasons to seek medical care:
dog is unknown
dogs immunization status is unknown
patient is a minor
bites are deep,
persistent bleeding from bite site
changes in function or sensation of the injured area
patients with weakened immune system, such as on steroids, on immunosuppressants, transplant patients, HIV, elderly, malnourished, patients with diabetes, liver disease, kidney disease, on dialysis, with cancer, etc
Bites around the face, neck or/and extremities
Wound is larger than 1-2 cm
HOW IS RABIES PROPHYLAXIS DONE
Rabies vaccination involves 3 shots, first dose right away after the bite, second dose 1 week later and the third one 3-4 weeks after the second dose.
Healing will take several weeks but final healing of skin and deep tissues may take as long as 9-12 month. Some patients may experience chronic pains and discomfort at the bite sites for several years especially if patients are older and / or injuries involved deeper structures, like tendons, nerves, joints.
LONG-TERM RECONSTRUCTION AFTER DOG BITES
Some patients present to our office after being treated at other locations complaining about the very deformities I am trying to avoid from the start. The reconstruction of deformities may require deep tissue rotation to improve shape, fat or fascia grafting to correct indentations and / or scar revisions.
In many cases these reconstructive surgeries can be covered by insurance, especially in children.