PEDIATRIC. Mammalian bites are fairly common presentations in the emergency. Evidence-Based Management Of Mammalian Bite Wounds.

Transcription

1 PEDIATRIC Evidence-Based Management Of Mammalian Bite Wounds The emergency department is in chaos, and your chart rack is full. You pick up the next chart and are relieved to see the chief complaint: Scratches on hand and leg. However, your relief turns to dismay when you see a 15-year-old boy in the room with his very concerned mother and you hear the following history: The patient was carrying the family cat into the house when the pet became frightened by an unleashed dog. The cat bit the patient on the left hand before running into the bushes. The dog ran after the cat, with the patient in hot pursuit. As the patient retrieved his cat, the dog bit him on the right calf. The patient quickly sought out the dog s owner, a local homeless man. When approached by the patient, the man rudely denied responsibility for the dog s actions. Still a novice at conflict resolution skills, the patient argued with the dog s owner, eventually punching him in the face and sustaining a wound to his third MCP joint. The cat is healthy and has received all of its shots. The histories of the dog and the dog s owner, however, are unknown. The patient s mother just wants some antibiotics and a tetanus shot. How should each of the bites be treated? Is there concern for transmission of HIV from a potential human bite wound? Should the patient receive antibiotic prophylaxis, viral prophylaxis, or both? Your next patient is a healthy but upset 22-month-old child accompanied by his mother, who is clearly worried. The patient was playing with the family s new kitten, which became agitated and bit the toddler on the left forearm. The patient started running to his mother in the next room but tripped on the carpet and fell. As he landed, he accidentally bit himself on his right arm. How should each of these bites be treated? Mammalian bites are fairly common presentations in the emergency department (ED). In fact, half of all Americans will be AAP Sponsor Martin I. Herman, MD, FAAP, FACEP Professor of Pediatrics, UT College of Medicine, Assistant Director of Emergency Services, Lebonheur Children s Medical Center, Memphis, TN Editorial Board Jeffrey R. Avner, MD, FAAP Professor of Clinical Pediatrics and Chief of Pediatric Emergency Medicine, Albert Einstein College of Medicine, Children s Hospital at Montefiore, Bronx, NY T. Kent Denmark, MD, FAAP, FACEP Medical Director, Medical Simulation Center; Associate Professor of Emergency Medicine and Pediatrics, Loma Linda University Medical Center and Children s Hospital, Loma Linda, CA Michael J. Gerardi, MD, FAAP, FACEP Clinical Assistant Professor of Medicine, University of Medicine and Dentistry of New Jersey; Director, Pediatric Emergency Medicine, Children s Medical Center, Atlantic Health System; Department of Emergency Medicine, Morristown Memorial Hospital, Morristown, NJ Ran D. Goldman, MD Associate Professor, Department of Pediatrics, University of Toronto; Division of Pediatric Emergency Medicine and Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, ON Mark A. Hostetler, MD, MPH Assistant Professor, Department of Pediatrics; Chief, Section of Emergency Medicine; Medical Director, Pediatric Emergency Department, The University of Chicago, Pritzker School of Medicine, Chicago, IL Alson S. Inaba, MD, FAAP, PALS-NF Pediatric Emergency Medicine Attending Physician, Kapiolani Medical Center for Women & Children; Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, HI; Pediatric Advanced Life Support National Faculty Representative, American Heart Association, Hawaii and Pacific Island Region Andy Jagoda, MD, FACEP Professor and Vice-Chair of Academic Affairs, Department of Emergency Medicine, Mount Sinai School of Medicine; Medical Director, Emergency Medicine Department, Mount Sinai Hospital, New York, NY Tommy Y. Kim, MD, FAAP Assistant Professor of Emergency Medicine and Pediatrics, Loma Linda Medical Center and Children s Hospital, Loma Linda; Authors Attending Physician, Emergency Medicine Specialists of Orange County and Children s Hospital of Orange County, Orange, CA Brent R. King, MD, FACEP, FAAP, FAAEM Professor of Emergency Medicine and Pediatrics; Chairman, Department of Emergency Medicine, The University of Texas Houston Medical School, Houston, TX Robert Luten, MD Professor, Pediatrics and Emergency Medicine, University of Florida, Jacksonville, FL Ghazala Q. Sharieff, MD, FAAP, FACEP, FAAEM Associate Clinical Professor, Children s Hospital and Health Center/ University of California, San Diego; Director of Pediatric Emergency Medicine, California Emergency Physicians, San Diego, CA September 2009 Volume 6, Number 9 Brian Rempe, MD Associate Program Director, Emergency Medicine Residency Allegheny General Hospital, Pittsburgh, PA Mara Aloi, MD Program Director, Emergency Medicine Residency Allegheny General Hospital, Pittsburgh, PA Kara Iskyan, M.D. Resident Physician, Emergency Medicine/Internal Medicine Combined Residency Allegheny General Hospital, Pittsburgh, PA Peer Reviewers Steven A. Godwin, MD, FACEP Associate Professor And Program Director, Department Of Emergency Medicine, University Of Florida College Of Medicine Jacksonville, Jacksonville, FL Troy Turner, MD, FRCPC Assistant Professor, Department Of Pediatrics, University Of Alberta, Edmonton, AB, Canada CME Objectives Upon completion of this article, you should be able to: 1. Identify complications associated with bites. 2. Prescribe appropriate antibiotics for infection prophylaxis in bite wounds. 3. Determine when to suture wounds primarily and when to delay closure. 4. Identify bites associated with child abuse. Gary R. Strange, MD, MA, FACEP Professor and Head, Department of Emergency Medicine, University of Illinois, Chicago, IL Christopher Strother, MD Assistant Professor,Director, Undergraduate and Emergency Simulation, Mount Sinai School of Medicine, New York, NY Adam Vella, MD, FAAP Assistant Professor of Emergency Medicine, Pediatric EM Fellowship Director, Mount Sinai School of Medicine, New York, NY Michael Witt, MD, MPH, FACEP, FAAP Medical Director, Pediatric Emergency Medicine, Elliot Hospital Manchester, NH Research Editor Years Em e rg e n c y Medicine Practice Improving Patient Care An Evidence-Based Approach To PEDIATRIC Emergency Medicine s ebmedicine.net Date of original release: September 1, 2009 Date of most recent review: August 10, 2009 Termination date: September 1, 2012 Medium: Print and Online Method of participation: Print or online answer form and evaluation Prior to beginning this activity, see Physician CME Information on the back page. V. Matt Laurich, MD Fellow, Pediatric Emergency Medicine, Mt. Sinai School of Medicine, New York, NY Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Rempe, Dr. Aloi, Dr. Iskyan, Dr. Godwin, and Dr. Turner, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.

2 bitten by an animal or another human during their lifetime. 1,2 Not surprisingly, domestic cats and dogs are responsible for most bites. That said, emergency clinicians must be prepared to address bites from all types of animals, including exotic and wild species. Bite injuries can cause morbidity from pain, cosmetic disfigurement, poor functional outcome, and infectious complications. The emotional impact to patients and their families must also be managed. Closure techniques and the treatment of clinically apparent infections are relatively straightforward. The major controversies surrounding mammalian bites involve their initial management. Should patients with bite wounds be given antibiotics prophylactically at presentation? Should bite wounds be closed primarily, or does this procedure increase the risk of infection? Although the examples of mammalian bites given in the vignettes may appear extreme, emergency clinicians will likely be confronted with these types of treatment decisions multiple times during their career. This article reviews the available research on mammalian bite wounds in children to help the emergency clinician choose a strategy for managing the care of their pediatric patients. Critical Appraisal Of The Literature Ovid MEDLINE, CINAHL, and PubMed databases were searched for all articles on mammalian bites published between 1995 and Search terms included mammalian bites, animal bites, bite wounds, cat bites, bites, pediatric wounds, and bites and stings. A search of the Cochrane Database of Systematic Reviews produced a single review of 8 studies on mammalian bites that was updated in In addition, the clinical report and policy statement databases of the American College of Emergency Physicians and the American Academy of Pediatrics were reviewed, and one relevant report was found. A search of the Agency for Healthcare Research and Quality s online National Guideline Clearinghouse also yielded one relevant report. These articles served as the basis for further literature searches, which were performed manually. In all, approximately 500 articles were reviewed, and 122 are included here. Literature on the management of pediatric mammalian bites largely consists of case reports, retrospective reviews, and extrapolations from reviews of the adult population. Few reviews have focused on children. Studies containing adult data were included in this article if no comparable pediatric data were available or if the studies contained information on some pediatric patients. Case reports highlighting uncommon but clinically important complications were also included. The nature of this topic does not lend itself to randomized placebocontrolled clinical trials in the pediatric population. Epidemiology, Etiology, And Pathophysiology The true incidence of mammalian bites is unknown because many victims do not seek treatment for minor injuries and mandatory reporting is not in effect in all states. However, it is estimated that each year nearly 2 million bites result in medical treatment in the United States, with nearly half of these presenting in the ED. 4 In all, the evaluation and treatment of bite wounds account for about 1% of all visits to EDs. 2 This number is expected to rise as animals and humans increasingly share space. In most cases, animal bites are attributed to house pets. 2 In one study on animal aggression, 89% of attacks were caused by dogs, 8% by cats, and 3% by other species. 5 The study indicated that most injuries were single bites and that children younger than 15 years were 1.4 times more likely than other age groups to be attacked. Reports from the U.S. Department of Health and Human Services also indicate that male children are at greater risk of being bitten than female children. 6 In addition, children are more likely than adults to sustain head and neck wounds because of their smaller stature. The majority of fatalities due to bite wounds occur in children. 7 Traumatic encounters with mammals result in substantial economic impacts as well. Estimated costs of homeowners liability claims related to bites approach $1 billion annually in the United States, while ED care for dog and cat bites costs more than $850 million. 2,8 These figures do not include lost wages or added expenditures for worker s compensation claims. A review of the major categories of mammalian bites follows. Canine Bites The relationship between man and dog goes back 12,000 years. 9 According to the American Pet Product Association, Americans owned 73.9 million dogs in Given this number, it is not surprising that up to 4.5 million dog bites occur annually in the United States. 9 Nevertheless, only 1 in 20 dogs will bite a human. 1 The majority of dog bites are minor and do not lead to hospital visits, and those patients who do seek medical care usually have only minor injuries. 10 However, dog bites still account for 80% to 90% of all bite wounds in patients presenting for medical care, and some can be severe, with more than a dozen fatal dog bites reported annually in the United States. 11 Children warrant special consideration in the setting of dog bites. Research demonstrates that they are particularly susceptible to this type of injury, with the highest rate of dog bites occurring in children aged 5 to 9 years. 2 In a 2001 Centers for Disease Control and Prevention (CDC) report, the age group at highest risk was 0 to 9 years. 14 The incidence was Pediatric Emergency Medicine Practice EBMedicine.net September 2009

3 especially high in young boys. The overall rate of ED presentation for dog bite wounds was 12.9 per 10,000 people. However, the rate for boys aged 5 to 9 years was nearly 5 times higher. Data from the CDC indicated that 369,245 bites were reported to U.S. EDs in The incidence was bites per 100,000 boys versus per 100,000 girls. However, this sex-related difference disappeared after age 14 years. The type of injury caused by dogs is related to the animal s anatomy. Canine teeth are not sharp and often cause tears and avulsions, although punctures can occur. Some large-breed dogs can inflict severe injury because of the tremendous crushing force of their bite. When biting, some dogs can exert between 200 and 450 psi, enough power to perforate sheet metal. 1 Pit bull bites can exceed 450 psi, and trained police dogs can exert a biting force of 1500 to 2000 psi. 12 Dog bites can break bones, including the skull, and penetrate body cavities. 13 Therefore, significant dog bites should be initially managed as multisystem trauma, especially when the patient is a small child. Because of the substantial biting force exerted by trained police dogs, injuries associated with these bites differ significantly from those observed in civilian dog bites. In a study of 705 dog bites sustained by jail ward patients in Los Angeles between 1988 and 1995, 19.3% involved complications. These included fractures and cortical penetration in 4%, vascular injuries in 7%, nerve injury in 1.9%, and infections in 5%, as well as tendon injuries, and joint disruption. 12 ED clinicians should be aware of the increased risk of these injuries in patients brought in with police dog bites. The anatomic location of dog bites in children is of particular concern. Whereas adults sustain bites to the extremities, children are more likely to sustain bites to the head or neck, which have greater cosmetic consequences. 9,15 Weiss et al reported in JAMA in 1998 that 73% of dog bites in patients aged 0 to 9 years were to the face versus only 30% of dog bites in the population as a whole. 9 Differences in bite location among age groups were also apparent in other reports. 1,14 According to the CDC, in the overall population, 71% of dog bites in 2001 were to an extremity, whereas 22% were to the head or neck. 14 However, for those 4 years and younger, 65% of dog bites were to the head or neck. In those 15 years and older, 86.2% were to an upper extremity. 14 (See Table 1.) As mentioned previously, dog attacks are occasionally fatal, and children younger than 10 years are grossly overrepresented in these cases. Sacks et al reported in Pediatrics that 109 dog bite-related deaths occurred in the United States between 1989 and 1994, and 56.9% were younger than The authors examined the breeds most frequently implicated in the fatalities. Pit bulls were responsible for 28.6% of fatal bites in which a breed could be identified. Rottweilers and German Shepherds are also associated with a high risk of fatal injuries. (See Table 2.) Notably, there was only one fatal bite from a police or guard dog during that time period. Prevention of these attacks is not simply an issue of keeping children away from strange dogs. In fact, the bite victim is familiar with the offending animal in 82% of cases. 4 Stray dogs are rarely implicated in fatal attacks. According to Sacks et al, among 82 bite cases where the location of the fatal attack was known, 63 bites occurred on the dog owner s property. 7 Among the 41 cases where the sex of the attacking dog was noted, 25 were males. Of the 20 dogs in the study whose neuter status was known, only 1 castrated male dog was responsible for a fatal bite. 7 Given these data, people should be encouraged to neuter dogs that are not used for breeding. As with bites from humans and other types of animal, dog bites carry the risk of infection. The average dog s mouth harbors more than 64 species of bacteria. 6,16 Not surprisingly, infections related to dog bites tend to be polymicrobial. 4,17 The reported rate of infection from dog bites varies from 1.4% to 30.0%,compared with an infection rate of 0.53% to 47.0% for all types of bites combined. 2,18 Of all bites, dog bites tend to represent the lowest infection risk, with rates similar to those of nonbite lacerations (ie, 3%-20%). 4 Feline Bites It is estimated that 5% to 15% of all bites are inflicted by cats. Assuming the incidence of all animal bites is 800 cases per 100,000 people per year, up to 300,000 Table 1. Incidence Of Dog Bites To The Face And Neck By Population Source Pediatric Patients All Patients Weiss et al 9 In patients 0-9 years, 73% of bites were to the face. Centers for Disease Control and Prevention 1,14 In patients < 4 years, 65% of bites were to the head or neck. 30% of bites were to the face. 22% of bites were to the head or neck. Table 2. Dog Breeds Associated With Fatal Bites From 1979 To Breed Pit bull 57 Rottweiler 19 German shepherd 17 Husky 12 Malamute Other (includes crossbreeds) Number Of Fatal Bites September 2009 EBMedicine.net 3 Pediatric Emergency Medicine Practice 2009

4 cat bites occur annually in the United States. 19 Feline attacks may be underreported because many people consider injuries from cats to be less serious than those caused by dogs and may not seek medical attention. In addition, patients may not be aware of the risks associated with cat bites and may not present until complications have already developed. This theory is supported by results from a recent Belgian study, which found that although 75% of dog-bite victims presented within 24 hours of the attack, all of the patients injured by cats presented relatively late, only after complications had developed. 21 Despite popular perception, cat bites result in clinical infection in 30% to 80% of cases, more than double the rate for dog bites. 1,2,20 The higher rate of infection may be due to the puncture injuries resulting from cats fanglike teeth, which are able to deliver inoculum deep into the tissue. The entry point seals off very quickly, hindering drainage and irrigation efforts. Even when these wounds are explored and drained early, they can reseal quickly, resulting in infection. These puncture wounds are present in 57% to 86% of cat bite injuries but in only 13% to 34% of dog bite wounds, which are more likely to entail longitudinal lacerations, crushed tissue, and avulsion of skin. 22 However, cats tend to exert less biting force than dogs, so significant trauma to the soft tissues is less common. The injury patterns observed with cat bites are similar in adult and pediatric populations, with most bites to an upper extremity rather than to the face. Up to 90% of cat bites are to the hand and arm. 23 Female patients are more likely to present with cat-related injuries because of the higher number of female cat owners. 24 Siamese cats are most often implicated in aggressive episodes, accounting for 43% of attacks in one study. 5 Most injuries occur when the victim attempts to intervene in a fight between animals or rescue or care for a sick or injured cat. 2 Big cat attacks, although infrequent, involve children more often than adults. 25 Children s smaller size makes them more attractive prey, particularly when no adults are present. Big cats such as cougars preferentially attack from behind and kill by shaking their victim. Children injured in this way are at risk for hyperextension injuries to the cervical spine in addition to the soft-tissue trauma incurred from the bite. A comprehensive evaluation of the cervical spine should always be included in the management of these types of injuries. The long front incisors of large cats can also easily inoculate the subarachnoid space, leading to central nervous system infection or abscess formation. The number of big cat attacks in the western United States has risen, particularly in California, which initiated a moratorium on the killing of cougars in The resultant rise in the cougar population and the increasing popularity of outdoor sports are bringing people in more frequent contact with these animals. Because cougars rarely attack groups of adults, adults should always supervise children in areas where the cats have been sighted. 25 Human Bites Human bites are thought to be rare, accounting for less than 0.01% of all visits to EDs. However, the true incidence of human bites is unknown, as patients suffering from this type of injury do not always seek medical attention Human bites can be categorized according to the circumstances precipitating them, as outlined by data from the New York City Department of Health in the late 1970s. About 75% of human bites result from aggression such as fighting and mugging. 31 These bites tend to occur during the summer months, when people are outside and wearing less clothing. Nearly 25% of human bites occur accidentally during sports, especially basketball and football, or roughhousing. 31 A small proportion of human bites are love nips (ie, acquired during sexual activities) or self-inflicted (eg, sustained during nail biting or thumb sucking). 32,33 The peak incidence of human bites occur in two age groups toddlers and early teenagers. 34 A retrospective analysis of visits to 3 urban pediatric EDs found that only 0.04% were for evaluation of human bites. Bites in the adolescent population were due to altercations and play in equal proportions. 35 However, in children aged 13 to 30 months, biting is associated with play; these toddlers lack the verbal skills to negotiate conflicts in a nonviolent way and may resort to biting to achieve their goals and get their point across. The majority of these wounds are minor and do not result in medical evaluation, according to one review of daycare center records. 36 The pathophysiology of human bites varies depending on whether the wound results from an occlusive bite or a fight bite. An occlusive bite is similar to an animal bite, with the human teeth closing over the skin with sufficient force to breach the tissue. 37 Human occlusive bites are usually elliptical or ovoid patterns of ecchymosis, abrasions, or lacerations. Ecchymosis is caused by positive pressure from the closing of teeth that disrupts small blood vessels and by negative pressure from suction and tongue thrusting. 38 Due to the morphology of the human incisors and canines, human bites generally compress tissue but rarely avulse it like animal bites. 34,38 In contrast, a fight bite occurs when a fist hits a tooth. Often dismissed by patients, fight bites can cause significant morbidity from infection. The injured tendon in the hand (most commonly over the third metacarpophalangeal joint) retracts as the fist is opened. The tendon retraction inoculates bacteria into the deep structures of the hand and conceals the penetration depth of the wound. 39,40 Patients with a human bite injury may seek treat- Pediatric Emergency Medicine Practice EBMedicine.net September 2009

5 ment due to concerns about wound care, tetanus immunization, infection, or permanent disfigurement; however, nearly 25% of them wait more than 12 hours to do so. 37,41 Late presenters are more likely to suffer from a fight bite and more likely to already have an active infection. These patients are also less likely to be honest about the circumstances of the injury because of embarrassment, concern about police intervention, and the involvement of alcohol. 28,37,43 Victims of human bites often sustain more than one wound, so a full skin examination is required in these patients. In most studies, more than 50% of human bites occur in the upper extremities. 41 The head and neck area (especially the ears, cheeks, and lips) is involved only slightly more often than the abdomen and thorax, except in children. Given the distribution of surface area in a child, human bites are more common on the head and neck. 35 Human bites on the lower extremities are uncommon. 29,44 Microbiology The most common organism isolated in the oral flora of cats and dogs (both domestic and wild) is Pasteurella, a facultative anaerobic coccobacillus. 42 A single animal can carry multiple strains of Pasteurella. Although the pathogenicity of these strains varies somewhat, there is no clinically significant difference in their antimicrobial susceptibility. 45 Infections involving Pasteurella, especially Pasteurella multocida, are associated with a rapid development and progression. 17 They can present as early as 12 to 24 hours after a bite, whereas infections due to other organisms typically do not present for 2 to 3 days. 17,46 Signs of Pasteurella infection include tenderness and erythema at the bite site along with local lymphadenopathy, fevers, and chills. Severe infections such as septic arthritis, osteomyelitis, meningitis, or sepsis can be seen in very young or immunocompromised patients. 47 A prospective case series of 107 patients presenting with strictly defined infected cat or dog bite wounds was conducted to delineate the organisms responsible for the infection. 17 Combined anaerobes and aerobes were isolated in 56% of the infected wounds, with an average of 5 organisms cultured per bite wound. The most common isolates from both cat and dog bites were Pasteurella species, with Pasteurella canis predominating in dog bite wounds and P multocida more common in cat bite wounds. A common misconception is that Pasteurella is an unusual pathogen in dog bites. However, in this study, the organism was present in nearly 50% of cases. Streptococci, staphylococci, Moraxella, and Neisseria were common aerobic isolates. Anaerobic isolates, which included Fusobacterium, Bacteroides, Porphyromonas, and Prevotella, were more often isolated from abscesses and were more often part of a mixed infection. Purely anaerobic organisms were present in only 1% of cases. 17 In a smaller study of 39 mammalian bite wounds in pediatric patients, 74% of infections were attributed to mixed aerobic and anaerobic pathogens. 48 P multocida and Pseudomonas fluorescens were present only in animal bites. Group A Streptococcus was found only in the human bite wounds. Cultures of infected human bite wounds grow anaerobic organisms in 50% of cases. 49,50 The most common organisms found in human bites are also frequently found in cat and dog bites, with the exception of viridans streptococci and Eikenella corrodens. The latter may spread hematogenously from a human bite and result in endocarditis or bacteremia with sepsis. 51 (See Table 3.) Although usually self-limited, scratches or bites from cats (and rarely dogs or monkeys) can result in cat-scratch disease. This infection is due to Bartonella henselae, a gram-negative rod, and is characterized by an erythematous papule at the site of inoculation, with the development of regional adenitis and fever several days later. Many studies have found a high prevalence of infection in stray cats or adopted cats of stray origin, especially in younger animals. 52 Capnocytophaga canimorsus is found frequently in wound cultures, but it seldom leads to clinical infection because of its low virulence. The bacterium can lead to sepsis and death in certain patients, however. Risk factors for severe infection include asplenia, alcohol abuse, corticosteroid therapy, or other immunocompromised states. 4,53 Fortunately, the organism is susceptible to most antibiotics used for prophylaxis. 4,54 ED clinicians should be aware of this organism, as special culture techniques may be needed to diagnosis the infection. 54 Although very rare, 5 cases of C canimorsus septicemia resulting from cat bites have been reported. 53 Differential Diagnosis The chief concerns in the differential diagnosis of bite wounds are those related to wound severity or potential exposure to infectious disease. Cases of hu- Table 3. Common Bacteria In Human Bite Wounds 36,70 Campylobacter sp Corynebacterium sp Eikenella corrodens Fusobacterium sp Haemophilus sp Peptostreptococcus sp Prevotella sp Staphylococcus sp Streptococcus sp Veillonella sp September 2009 EBMedicine.net 5 Pediatric Emergency Medicine Practice 2009

6 man bites also bring the possibility of child abuse to the clinical situation. (See Table 4.) Prehospital Care Prehospital care providers must be aware that dog bites have the rare but serious potential to threaten life or limb and that patients may require triage to a trauma center. Although no data exist to support one method of prehospital care over another, it has been suggested that if ED care is likely to be delayed for more than 1 hour, wounds should be cleaned at the scene and covered with sterile dressings. Hands and feet should be immobilized if injured. 6 Emergency Department Evaluation History A thorough patient history should be obtained, including the following information about the bite wound: Animal characteristics: The species of animal that bit the patient may give clues about the expected injury pattern. The immunization status of the animal should be determined. Unprovoked attacks or attacks by animals that cannot be located or captured may necessitate rabies immunoprophylaxis. Unfortunately, the term provoked attack is not clearly defined. Dogs naturally will exhibit territorial behavior and attack anyone who intrudes into their territory, even without overt action by the intruder. History may be most important in human bite cases, when the circumstances surrounding the bite can provide a wealth of information. Patient characteristics: An immunocompromised state predisposes the patient to the development of an infection and contributes to disposition considerations. Any antibiotic allergies should be identified, and the patient s tetanus and hepatitis immunization status should be determined. Timing of injury: As mentioned previously, a delay in presentation leads to a higher rate of Table 4. Chief Concerns In The Differential Diagnosis Of Bites Wounds Cortical penetration or bony fracture Tendon injury Vascular injury Nerve injury Joint space penetration Foreign body Rabies exposure Human pathogen exposure Child abuse Envenomation infection. Risk of human immunodeficiency virus (HIV) transmission: In cases of human bites, this risk should be assessed to determine the need for antiviral prophylaxis. Questions should focus on HIV risk factors of the alleged perpetrator and any known diagnoses such as hepatitis C. Physical Examination Bites vary in severity from minor to limb or life threatening. The emergency clinician should perform a complete trauma evaluation on a child who is bitten if the situation calls for it. All children who are victims of an animal attack should be evaluated from head to toe to identify signs of both penetrating and blunt trauma. Wounds should be assessed for location, depth of penetration, amount of devitalized tissue, and the presence of any foreign material. Assessments of neurovascular function and tendon and joint function are also required, especially for bite wounds to the digits. Obvious foreign material and the involvement of deep structures such as tendons and joints in a severe wound increase the chances of future infection. Evaluation of hand wounds complicated by infection should also include an assessment for flexor tenosynovitis. The four signs of flexor tenosynovitis as described by Kanavel are fusiform swelling of the digit, the digit being held in a partially flexed posture, pain with passive extension of the involved finger, and tenderness along the tendon sheath. Diagnostic Studies The physical examination is the most important aspect of the initial evaluation of bite wounds. Few diagnostic studies will affect initial treatment. Unless clinically indicated for excessive blood loss, a complete blood cell count is rarely useful. Even in the presence of infection, the white blood cell count is rarely elevated. 55 Some controversy exists regarding the necessity of obtaining routine wound cultures on fresh, noninfected bite wounds because the results do not reliably predict which wounds will become infected. 56 However, cultures in grossly infected wounds may guide therapy. Both aerobic and anaerobic cultures should be obtained, and the microbiologist should be informed of the animal responsible for the wound so that a diagnosis of Pasteurella infection can be considered if needed. Some pathogens are slow growing, so cultures should be held for 7 to 10 days. Erythrocyte sedimentation rate and C-reactive protein level are elevated in the majority of clinically evident infections. In the case of possible infection with C canimorsus, diagnosis can be confirmed with a peripheral blood film, which will demonstrate intracellular gram-negative rods. 46 Pediatric Emergency Medicine Practice EBMedicine.net September 2009

7 Radiography should be used liberally, especially for dog bites in small children. The force produced by the bite of a large dog is more than sufficient to fracture bone. Since open fractures require specialty consultation and possible operative management, these injuries should be identified early. In addition, bite wounds over joints, such as fight bites, necessitate radiographs to detect the presence of air, which may suggest joint penetration. 57 Up to 70% of radiographs taken to evaluate fight bites show foreign bodies, fractures or bony fragments, narrowing of joint space, and air. However, despite negative results on physical examination and initial plain radiographs (including arthrograms), 16.5% of fight bites still have joint penetration. 40 Radiographs may be useful if foreign bodies are suspected. Diagnostic imaging, including radiographs and ultrasound, has a more important role in the evaluation of late complications of a bite wound, such as osteomyelitis, septic arthritis, and tenosynovitis. Treatment As mentioned previously, most bites are not life threatening. However, these injuries can be a source of stress for the emergency clinician, particularly when they occur in children. Some controversy surrounds the management of simple bites as well as life-threatening wounds. Treatment of bites should include consideration of analgesia, local wound management, infection prevention, and management of complications (as described in the Complications section). Analgesia is often achieved locally during acute treatment, but patients may require systemic medications depending on the severity of the injury. Younger children in particular may require procedural sedation for the management of wounds. As with other traumatic injuries, immobilization and elevation of the bite wound promote analgesia. Local wound management consists of wound exploration, thorough irrigation, debridement of necrotic tissue, and closure (if appropriate; see discussion that follows). Infection prevention in bite wounds requires attention to both viral and bacterial agents. Viral prophylaxis depends on the species of the assailant. B virus, or Cercopithecine herpesvirus, transmission from a monkey to a human can cause fatal encephalomyelitis. Animal bites also raise concerns of rabies and tetanus, whereas human bites require consideration of the transmission of viruses such as hepatitis and HIV. If the human bite is deemed to be high risk, laboratory studies such as rapid plasma regain (RPR), hepatitis B surface antigen, hepatitis C antibody, and HIV-1 and HIV-2 tests are indicated, with appropriate follow-up for the results and future testing. 37 Empiric Antibiotics One decision the emergency clinician must make is whether to prescribe antibiotics to bite victims without obvious infection on initial presentation. This question was addressed in numerous small studies Cummings reviewed 8 randomized trials on this topic in a 1994 meta-analysis reported in the Annals of Emergency Medicine. 63 The author reported a significant decrease in infection rates when antibiotics were given prophylactically to patients with dog bites, and the study demonstrated a relative risk of infection of ,63 (Although the term prophylactically is used widely in the literature, the administration of antibiotics to prevent an infection after a bite wound is actually therapeutic because injury and inoculation have already occurred.) However, an analysis of the use of prophylactic antibiotics for bite wounds by Turner did not support the routine use of antibiotics for dog or cat bites to areas other than the hand, although the author cautioned that the sample size was small. 64 In addition, the studies analyzed by Turner used inappropriate antibiotics, as the microbiological analysis published in 1999 by Talan et al was not yet well-known. Turner did report a reduction of infections in human bites and bites to the hand. 64 Based on this analysis, empiric coverage against Staphylococcus, Streptococcus, and Pasteurella is indicated in hand wounds, especially. Other wounds requiring prophylaxis include deep puncture wounds, wounds with extensive tissue trauma requiring debridement, and wounds in elderly patients, the immunocompromised, or those with poor circulation to the involved area. 54 (See Table 5.) Amoxicillin-clavulanate is commonly recommended as a first-line agent for the prevention and treatment of infection after animal bites because it offers excellent coverage against all common bite wound pathogens. 13,18 The recommended dosage for outpatient prophylactic therapy with this agent is 45 mg/kg per day divided into 2 doses or 40 mg/ kg per day divided into 3 doses for 3 to 5 days. For Table 5. Indications For The Use Prophylactic Antibiotics In Mammalian Bite Wound Management 41,54 Age greater than 50 years Asplenia Chronic alcohol use Diabetes mellitus Immunocompromised state Preexisting edema in affected area Vascular disease Wound characteristics (eg, depth of the bite) Severity of the bite Location of the bite (hand, foot, joint) Time lapse since bite (more than 12 hours prior to evaluation) September 2009 EBMedicine.net 7 Pediatric Emergency Medicine Practice 2009

8 Clinical Pathway For The Treatment Of Mammalian Bites Perform wound care. Irrigate. Debride if indicated. Perform incision and drainage if an abscess is present. Consider wound closure in cosmetically important areas. Elevateand immobilize if wound is on extremity. Gather the history of the injury. Obtain patient information including past medical history, medica- tions, drug allergies, tetanus immunization status, and social factors. Obtain animal information including rabies immunization status, animal s health, and location of animal. Obtain information regarding the injury including provoked vs un- provoked injuries, timing, and delay in seeking medical treatment. High risk injury? (including those with delayed presentation, bites to the hand, and immunocompromised patients) Lower risk injury? (including those to young, otherwise healthy patients who were not bitten on their hand) Consider a consultation and prescribing antibiotics. Perform physical examination. Note the location of wound. Note the depth and type of wound (eg, avulsion, puncture, crush). Assess function if an extremity is involved. Perform a neurovascular examination. Assess patient for signs of infection if delayed presentation. Order diagnostic studies. Order radiographs if bony injury, violation of joint, or foreign body is suspected. Order a wound culture and Gram stain for infected wounds. Order additional studies if bacteremia/sepsis is present including a complete blood cell count, blood culture, coagulation studies, and liver panel. If the injury is complicated: (involves tendons, joints, bones, and/or nerves, or sepsis is evident) If the injury is uncomplicated, ask: Is it a puncture wound? Yes NO Is it a laceration? Yes Consider a consult and possible admission. Cleanse and dress the wound. Consider antibiotics. Is the laceration of cosmetic concern? Yes NO Suture the laceration. Consider suturing the wound if needed. Pediatric Emergency Medicine Practice EBMedicine.net September 2009

9 inpatient therapy of infected wounds, the parenteral form of this combination drug should be given. The recommended dosage of ampicillin-sulbactam is 100 to 150 mg/kg per day in divided doses every 6 hours, given for 10 to 14 days depending on the severity of the infection. (See Table 6.) For patients who are allergic to penicillin and the cephalosporins, clindamycin plus trimethoprim-sulfamethoxazole can be used. 13,54 On the basis of in vitro data and case reports, penicillin is still the drug of choice for treating solitary Pasteurella infection. This research also showed positive results for tetracycline, fluoroquinolones, and chloramphenicol, all of which can be used in the penicillin-allergic adult patient but are not recommended for use in children. 47,65,66 However, because culture results for Pasteurella are not available initially and polymicrobial infections are so common, starting penicillin as monotherapy is not recommended. High rates of resistance were found with clindamycin and erythromycin. In addition, monotherapy with these agents is not recommended for the treatment of cat bites. 66 Azithromycin was also studied in vitro with positive results. 67 Although no clinical trials have been conducted, there is one case report of azithromycin being used successfully in combination with clindamycin in a patient who had multiple drug allergies. 68 No human trials exist to support monotherapy with azithromycin for the treatment of Pasteurella infections. A report on the use of ceftriaxone for infected cat and dog bites determined that this agent was a convenient alternative to inpatient intravenous (IV) therapy. 69 However, this study was based on only 23 patients, and cotherapy with other antimicrobial agents was not standardized. In addition, the protocol described in this study required daily follow-up in a cellulitis clinic, which is not available to all emergency clinicians. Thus, outpatient monotherapy with ceftriaxone cannot be recommended at this time. Antibiotics For Human Bite Wounds Given the high infection rate with human bite wounds, antibiotic prophylaxis for an uninfected wound is usually considered but remains controversial. The evidence for antibiotic prophylaxis is poor. For example, Broder et al compared the use of placebo for the treatment of low-risk human bite wounds (defined as penetration through the epidermis only and not involving hands, feet, overlying joints, or cartilaginous structures) versus use of a cephalexin-penicillin combination. 34 As only 1 of 62 patients receiving placebo developed an infection (compared with 0 of 63 patients receiving cephalexin-penicillin), the statistical significance of the study must be questioned. Despite the lack of clear evidence supporting prophylactic antibiotics in the management of human bite wounds, their use is Table 6. Recommendations For Empiric Antibiotic Therapy In Bite Wounds in 13, 71 Pediatric Patients Antibiotic Dosage Additional Information encouraged because these injuries carry both aerobic and anaerobic organisms. 50,70 The antibiotic choice for human bite wound prophylaxis and treatment of wound infection can be difficult but must account for both the pathogenic organisms (see Table 3, page 5) and the characteristics of the antibiotic. With four isolates per wound, the organisms may be unique to human mouth flora. 50 For instance, the slow-growing gram-negative E corrodens originates from gingival plaque and is significant due to its resistance to penicillin. 42 The most common oral antibiotic used for human bite prophylaxis is amoxicillin-clavulanate. Goldstein et al advocated the use of amoxicillin-clavulanate for human bites in the 1980s despite criticism of their study. 71 (The criticism included sponsorship by a drug company, poor protocol, and unclear superiority of amoxicillin-clavulanate. 72 ) An alternative to amoxicillin-clavulanate for human bite prophylaxis is penicillin and dicloxacillin; however, both drugs are required, as penicillin has poor Staphylococcus aureus coverage and dicloxacillin has poor E corrodens coverage. 71,73 Both prophylactic options are safe for children, who are more likely to receive antibiotics. 35 The utility of viral prophylaxis after a human bite remains unclear due to the lack of evidence. Only a few case reports of hepatitis B, hepatitis C, and HIV transmission through human bites have been reported Key factors when considering viral prophylaxis include the assailant s viral status (if known) and the integrity and gross contamination of the wound. 37,74 A bite sustained in a work environ- Amoxicillinclavulanate Ampicillinsulbactam Clindamycin plus trimethoprim-sulfamethoxazole Penicillin plus dicloxacillin 45 mg/kg/d divided into 2 doses 40 mg/kg/d divided into 3 doses mg/kg/d in divided doses every 6 hours 8-16 mg/kg/d divided into 3 doses 8 mg trimethoprim/40 mg sulfa/ kg/d divided into 2 doses mg/kg/d in divided doses every 6-8 hours mg/kg/d in divided doses every 6 hours (maximum, 1g/d) 3-5 days for outpatient days depending on the severity of the infection For use in patients who are allergic to penicillin Alternative for human bite prophylaxis September 2009 EBMedicine.net 9 Pediatric Emergency Medicine Practice 2009

10 ment such as health care or law enforcement presents an added risk for viral transmission. 37 In addition to baseline blood work (RPR, hepatitis B surface antigen, hepatitis C antibody, and HIV-1 and HIV-2 tests) and follow-up blood work, the patient may be offered hepatitis B immunoglobulin, hepatitis B vaccination, and antiviral medications to prevent HIV. Treatment for fight bites is more aggressive because of the difficulty in determining deep structure involvement, the increased risk of infection, and the morbidity from established infection. As a result, the decision to treat these wounds in the ED versus the operating room (OR) is sometimes a matter of debate. For example, fight bites often involve underlying damage not recognized on ED evaluation. In a study by Phair and Quinton of 29 fight bites, nearly 60% had deep structure involvement. 78 Damage to the tendon also indicated likely damage to the bone and capsule. In addition, the bacterial inoculation of deep hand structures observed in many fight bites increases the risk of infection. According to the results of one randomized placebo-controlled study, local wound care alone is not adequate for managing these injuries. 79 In addition to irrigation of the wound in the ED or the OR, depending on the extent of the injury, antibiotics must be used to either prevent or treat an active infection. For the recent, uninfected fight bite, prophylactic antibiotics (administered orally or intravenously) are also indicated. 79 Moreover, fight bites are more likely than other human bites to harbor an active infection because of the age of the wound at presentation, 39 increasing the risk of morbidity. Wound Management The goal of wound management is to achieve optimal cosmesis and maintain optimal function while preventing secondary infection. The decision to suture a wound is based on several considerations including its location, host immunity, time of injury, presence of contaminants, and amount of devitalized, crushed tissue, all of which contribute to the risk of infection. Copious irrigation with saline or sterile water prior to wound closure is recommended. 54,80 Similar to the treatment of lacerations, treatment of bite wounds with pressure irrigation is thought to decrease the amount of potentially pathogenic microbes that may colonize the wound and ultimately result in infection. Tap water is also a consideration, but a 2002 study comparing sterile saline with tap water wound preparations notably excluded bite wounds. 81 Debridement is recommended to remove any devitalized tissue, which contributes to the rate of infection and poor cosmetic outcome. In one study, debridement of dog bite wounds resulted in a 30-fold reduction in the rate of infection. 82 The location of the bite may predict the risk of wound infection. In general, facial wounds have a low risk of infection due to the excellent vascularity of the facial tissues. A small study by Donkor and Bankas involving 30 patients who underwent primary closure of a human bite wound to the face confirmed the finding that primary repair of facial bites is safe, but wound closure did not elucidate clear superiority in preventing infections. 83 In contrast, injuries to the hands and feet result in more frequent infections. Numerous small compartments in the hand and the absence of significant soft tissue separating the skin from deeper structures such as bone and joints make it more prone to infection. In one study of bite wounds to the hand, 18.8% of wounds became infected. If these wounds were closed primarily, the infection rate rose to 25%. In addition, the bite wounds of patients who presented more than 2 hours after injury were more likely to become infected. 84 Infections of the hand can result in permanent loss of function, so these wounds should be treated aggressively with irrigation and debridement if needed. The bite wounds should be left open with the hand immobilized. 85 Some large dog bites have cosmetic significance, and the patient may expect these wounds to be sutured. However, this may not always be the case. It has been reported that just 12% of dog bites in the ED are closed primarily. 18,86 In 1988, a prospective controlled trial was conducted among 96 patients with 169 lacerations related to dog bites. 87 Of these, 92 were sutured and 77 were left open. Thirteen wound infections were subsequently noted, with an overall infection rate of 7.7%. The difference in rate of infection between wounds that were sutured and those left open was not significant. The issue of primarily closing dog bite wounds was again discussed in a 2000 article presented in Academic Emergency Medicine. 88 In this study, 88 of the 145 patients included had sustained dog bites. These wounds were closed primarily. Five of the 88 dog bites became infected, representing an infection rate of 5.7%. The infection rate for nonbite lacerations at the same hospital at that time was 3.4%. Although 81 of the 145 patients received antibiotics, their use was not controlled for in the study, clouding the picture. Nevertheless, the results indicate that dog bites may be closed, particularly in the setting of cosmetically important wounds. Other authors have concluded that suturing of puncture wounds should be avoided, that high-risk wounds to the hand should be closed only under special consideration, and that the risks and benefits of wound closure should be discussed with the patient prior to closure. 13 Physicians may also choose delayed primary closure, in which wounds are left open by the ED clinician and then repaired a few days later after careful cleansing. 13 Human bites are more likely than animal bites to become infected, although the infection rate var- Pediatric Emergency Medicine Practice EBMedicine.net September 2009

11 ies. Lindsey et al described the natural history of 434 human bite wounds sustained by residents in a long-term care facility, using 803 lacerations for comparison. 30 The 434 human bite wounds had a 17.7% infection rate without any serious complications. Factors that increase the possibility of infection include location of the bite (hand, foot, and joint), depth of the bite (bone or joint involvement and puncture or crush injury), vascular supply to the site (peripheral vascular disease, peripheral edema), immune status of the patient (age greater than 50 years, immunosuppression, diabetes mellitus, chronic alcohol use), and timing of treatment. 41 (See Table 6, page 9.) Thus, prevention of infection drives decisions in the treatment of human bite wounds. On the basis of the data presented previously, primary repair of bite wounds is not recommended in the following cases because of the high risk of infection: bite wounds to the hand, human bites and cat bites to areas other than the face, and injuries in immunocompromised patients. If there has been a delay of greater than 6 hours in presentation for facial and scalp bites or greater than 12 hours for bites in other locations, the risks of infection versus the cosmetic benefits of primary wound closure should be weighed when deciding on management, although the cutoff of 12 hours has not been well studied. Wounds that are not sutured should be irrigated and dressed. Injured extremities should be immobilized, and all patients should be instructed to have their wounds reevaluated within 24 to 48 hours. Tetanus Bite wounds present a high risk of transmission of Clostridium tetani, which is present in the teeth and saliva of animals. For any breach in skin integrity, tetanus immunization is required. If the wound is clean with little devitalized or crushed tissue, tetanus immunization within the past 10 years is adequate. Patients with wounds that are contaminated or that involve crushed tissue or punctures require immunization within the past 5 years. If immunization status is unknown, both tetanus immune globulin and the diphtheria and tetanus toxoids booster vaccine should be administered. Rabies Immunoprophylaxis More than 85% of reported rabies cases result from injuries caused by wild animals, 89 with raccoons, skunks, bats, and foxes currently the main source of human rabies infection. However, oral vaccineimpregnated bait is being used in an attempt to decrease rabies in the wild animal reservoir, particularly among raccoons. 93 Only 7.9% of all rabid animals reported in the United States are domesticated, 90 with cats the most commonly reported domestic animal with rabies in the last decade. 91 According to the CDC, although there were 79 cases of rabies in U.S. dogs in 2006, only one case of human rabies infection was attributed to a dog bite. 92 (This occurred in the Philippines, with the infected individual later returning to the United States.) The rate of transmission from domestic animals remains low because of current aggressive rabies vaccination programs 89 that have greatly reduced the incidence of canine-variant rabies. The CDC still recommends rabies treatment in the setting of a suspicious dog bite. Bites that pose a risk of rabies should be washed with copious amounts of a virucidal solution such as povidoneiodine, as this agent has been shown to decrease the rate of rabies infection. 89 However, the agency recommends no additional treatment as long as the dog appears healthy and can be observed for a 10-day period. 92 Lagomorphs are thought to present a low risk of rabies transmission. Despite case reports of rabies in guinea pigs and rabbits, no reports of human rabies have resulted from these exposures. 94 Therefore, routine postexposure rabies prophylaxis for children injured by these animals is not indicated. Prevention Animal bite prevention is important in the pediatric group. Certain predictable behaviors observed in both humans and animals typically result in injury. Bites can result when a child tries to remove a pet from a fight with another animal. Although avoidance of this rescue attempt is most prudent, if a child insists on intervening in an animal fight, he or she should grab the pet s hind legs and pull it away rather than trying to pry the animals apart at the head and mouth. 2 Interacting with an animal during feeding times can also be potentially dangerous, as the animal s natural instinct is to protect its meal. Education on how to interact with dogs may be helpful in preventing dog bites. An Australian study indicates that after only 30 minutes of instruction, children were much less likely than members of a control group to exhibit potentially dangerous behavior around a dog. 42 The study involved 7- to 8-year-old children who were taught how to approach dogs, how to recognize angry or frightened dogs, and how to respond when pushed down or approached by a dog. Parents should also be advised on preventive techniques. If the animal responsible for a bite is a family pet, a discussion should take place on the risks of keeping the pet in the home. An audit of dog bite referrals in one plastic surgery department found that of 17 pet dogs that attacked a child, 12 remained in the home afterward. 95 Six of the 17 children had been bitten before, 3 by the same dog. The general public should also be taught the importance of seeking prompt medical care after injury September 2009 EBMedicine.net 11 Pediatric Emergency Medicine Practice 2009

12 by any animal, as this precaution may reduce the frequency of negative outcomes. Complications Complications from bite wounds vary but center around infection. In one retrospective review, the most common serious development from animal bites was osteomyelitis, which was seen in 10% of patients. 96 Insufficient data were presented to determine which types of wounds were associated with this complication. Some bites in children may be trivial and missed on initial examination, but these have the potential for negative outcomes. There are at least 3 reports of brain abscesses with neurologic compromise as a result of dog-inflicted head wounds that were missed or presumed to be minor. Initial assessment of bites to the head in children, especially when the child is attacked by a large animal, should involve meticulous wound care and an assessment to determine whether the skull has been punctured Noninfectious complications such as arthritis or disfigurement may require outpatient treatment by a specialist. Endocarditis is a rare complication of mammalian bites in children with congenital heart disease who have undergone surgical correction. 101 When patients in this subset present with fever after a bite, multiple blood cultures may be useful. Even if the wound is identified as the source of the fever, bacteremia and subsequent seeding of the valvular tissue may have occurred. Possible emotional effects in children following a dog bite deserve mention as well. One study found evidence of posttraumatic stress disorder (PTSD) in 12 of 22 pediatric patients 2 to 9 months after a bite. However, these children were usually bitten by dogs unknown to them, and those diagnosed with full PTSD had suffered severe or multiple bites. 14 This possibility should be considered when discussing follow-up with patients and their parents. If a child is suffering from nightmares or is exhibiting excessive fear of animals after the event, psychological counseling should be recommended. 102 Special Circumstances Bite Wounds To The Genitalia The occurrence of bites to the genitalia is underreported, possibly because of self-treatment and embarrassment. Injuries to this area of the body are prone to complications because of delayed presentation. In addition, the nature and location of the genital tissues are conducive to the development of infection. In particular, the copious loose subcutaneous tissue of the penis allows bacteria to spread, causing infections such as E corrodens, Fournier gangrene, or a penile abscess. 46, The literature on the management of these injuries is limited. One case series indicated that the majority of human bites to the genitalia presented as ulcers, while dog bite wounds had presentations ranging from small abrasions to amputation wounds. 106 Wild Animals A complete discussion of wild animal bites is beyond the scope of this article. With the expansion of urban living areas into the wilderness, wild animal attacks on people are becoming more frequent. Episodes most often involve children attacked by cougars or coyotes. 107 Bite wounds by large cat species are almost always deep puncture wounds because of the animal s substantial front incisors and their propensity for biting into the neck and abdomen, which have no bony protective covering. Pasteurella is among the normal oral flora in these larger cats, just as it is in their smaller, domestic counterparts. Mouth cultures of black bears have yielded results similar to those from cultures of domestic dogs. 108 Treatment of coyote and bear bites is similar to the management of domestic dog bites. Envenomation Although the management of envenomation resulting from a bite is beyond the scope of this article, it should be remembered that the bites of certain mammals such as the platypus, slow loris, and shorttailed shrew involve venom transfer. Rodent Bites The oral flora of rodents is similar to that of other species. Rat bites occur most often in children younger than 5 years and in those from lower socioeconomic levels. Depending on the age of the child (ie, the ability to flee or fend off attacks), some bites may be fatal. Reports of hypovolemic shock in infants with multiple bites have been published. 109 Rodent bites present a low risk of rabies transmission because the virus is not secreted in the saliva of infected animals. There have been case reports of hamster bite peritonitis in patients on peritoneal dialysis whose catheters were chewed by their pet rodents, resulting in inoculation and eventual infection of the peritoneal dialysate. In these cases, Pasteurella species were isolated. 110 Rarely, animal care workers and pet owners with repeated low-level exposure to rodent allergens may have allergic reactions to saliva when bitten by a rodent. 111 Case reports of hamster bites have also been noted. Patients with household dust mite allergies are more susceptible to this type of reaction because of some cross-reactivity between dust mite allergens and hamster allergens. 112 A potential contaminant involved in rodent bite wounds is Streptobacillus moniliformis, which can cause rat-bite, or Haverhill, fever. Infection with this agent presents weeks after the initial bite with a Pediatric Emergency Medicine Practice EBMedicine.net September 2009

13 viral-like illness, regional lymphadenopathy, arthralgia, and a maculopapular, urticarial, or vasculitic rash. 113 Penicillin G can be used to treat this infection. The recommended dosage is 25,000 to 50,000 U/kg daily, divided into 4 doses, for 7 days. 114 Alternatives for the penicillin-allergic patient include streptomycin (20-40 mg/kg, up to a maximum of 1g daily), erythromycin (30-50 mg/kg per day divided into 2-4 doses), and tetracycline (only for children older than 8 years; mg/kg per day divided into 2-4 doses). Forensic Considerations In some cases of mammalian bites, forensic evidence may be required by law enforcement officials. If a fatality has been attributed to an animal attack, all wounds should be carefully documented. Photographs may also be helpful, especially when the injuries are extensive. An attempt should be made to correlate the bite with the species implicated. Humans have 4 incisors and short canines, and human bite wounds are typically elliptical or ovoid. 115,116 Dogs have 6 incisors and 2 very large canines, which can result in deep punctures with torn tissue. Dog bite wounds are not oval. Although the majority of human bites to younger children result from frustration, the emergency clinician should be aware that human bites may involve potential child abuse. If the intercanine distance (the linear distance between the central points of the cuspid tips of the wound) is greater than 3 cm, the bite was likely inflicted by an adult. A forensic odontologist, a forensic pathologist, or a health care worker experienced in patterns of child abuse should be consulted for the collection of evidence such as photographs, dental casts, and saliva samples. 38 In one case series, the forensic dentist was able to positively identify the adult perpetrator in 46% of cases. 117 If a bite has resulted in significant disfigurement or if there is a risk of litigation, photodocumentation may also be warranted. Monkey Bites Monkey bites are rare, with only about 130 reported per year in the U.S.. Most of these bites are to pet owners or researchers. 118 Monkey bites are similar to human bites, with the important exception of Cercopithecine herpesvirus, or the B virus. Native to wild Old World monkeys of North Africa and Asia (eg, rhesus and other macaque monkeys), the B virus causes little morbidity in the natural host. 118 However, untreated B virus in humans has a 70% fatality rate from rapidly ascending encephalomyelitis. Although still uncommon, the B virus is gaining momentum as captive monkeys harboring latent infections are increasingly used for research. Standard Risk Management Pitfalls For Mammalian Bites 1. The wound on the patient s arm looked like a bite, but he said he cut it on a dresser. Always delve into the history of a wound that looks like a bite (especially a human bite). Patients may provide an accurate bite history on further questioning. 2. That cut on the patient s knuckle after he punched someone didn t look like much. I just had the nurse put a bandage on it. Avoid treating fight bites like other bites. Fight bites require careful evaluation for deep structure involvement as well as copious irrigation, antibiotics, and possibly a consultation with a hand surgeon. 3. I treated the patient for a human bite wound, and she came back with hepatitis. Failure to evaluate for HIV, hepatitis, and syphilis and discuss their prevention and treatment can put victims of human bites at risk. 4. I thought I cleaned that puncture out pretty well, but the surgeon called and said he found a piece of cat tooth during the irrigation and debridement. Failure to recognize the presence of a foreign body is the most common reason for wound care related lawsuits. 121,122 The small pointed teeth of some mammals can break off and enter wounds. 5. The police were in a hurry, and the patient s elbow laceration seemed pretty small. Failure to appropriately determine the presence of joint space invasion is another common cause of wound care related litigation. 121,122 Joint space involvement is of particular concern in the setting of police dog bites. 6. The patient didn t tell me his injured finger was numb. Unrecognized nerve and tendon injuries are also a source of wound care related lawsuits. 123,124 A careful neurovascular examination helps to catch these injuries. September 2009 EBMedicine.net 13 Pediatric Emergency Medicine Practice 2009

14 precautions when dealing with monkeys may prevent B virus transmission. Once a worker is exposed to the B virus, research facilities follow detailed protocols including copious irrigation and scrubbing of the wound, evaluation of the monkey, contact with a veterinarian or the CDC, and possible empiric treatment with acyclovir. 119 After this aggressive care, a monkey bite may still present to the ED for further treatment or with subsequent complications. Cost-Effective Strategies 1. Limit wound cultures to clinically infected wounds. Culturing noninfected wounds does not help direct care. 2. Provide antibiotics only to patients with higher risk wounds. Risk management caveat: careful and complete discharge instructions on early recognition of infection will improve patient satisfaction and limit clinician liability if an infection does develop. Disposition Disposition of a human bite wound depends on the location and depth of the bite, the active signs of infection, and any comorbid conditions. Although most human bite wounds can be managed in the ED with local wound care and oral antibiotics, the admission rate after these injuries varies greatly in the literature. Because human bite wound studies are very diverse, admission rates vary from 10% to 50%. 29,37,50,120 Admission of children, however, is rare. 35 Risk factors that increase the likelihood of admission include a bite sustained during an altercation, a bite to the hands or fingers (including fight bites), presentation for medical attention more than 24 hours after the bite, and active infection. 120 Most fight bites do require admission, but about 10% of patients leave against medical advice. 39 Indications for hospitalization include the following factors: 1,82 Systemic manifestation of infection Failure of outpatient therapy Infected human bite to the hand Immunocompromised patient Bite wound requiring reconstructive surgery Involvement of joints or tendons Evidence of multisystem trauma Poor social situation Summary Mammalian bites in children may result in wound infection, poor cosmetic outcome, and emotional stress. A meticulous physical examination should be performed on all pediatric patients in order to identify wounds that may later result in serious infections. Appropriate selection of wounds for primary closure or treatment with prophylactic antibiotics should lower the risk of wound infection. Preventive measures should be aimed at teaching parents and children appropriate behavior around animals. This may include limiting contact with pets while they are eating, avoidance of strange animals, and proper supervision of children around animals. In addition, children with certain medical conditions, such as congenital heart disease or an immunocompromised state, should be brought for immediate evaluation after any injury by an animal. Case Conclusion The patient is uncomfortable and is given analgesics. The cat and dog bites are superficial and require only exploration and irrigation. A small open wound without any bleeding is visible on the patient s right third MCP joint, but the finger s range of motion is significantly limited by pain. A radiograph of the hand reveals a foreign body in the wound, so the hand surgeon takes the patient to the OR for exploration and irrigation of the wound. Part of a tooth and a few small, loose cartilaginous bone fragments are extracted from the fight bite wound, and it is then primarily repaired. The patient receives 4 days of IV ampicillin-sulbactam and is discharged with 7 days of amoxicillin-clavulanate. The patient s mother declines HIV prophylaxis, but the patient does receive vaccines for hepatitis B, tetanus, and rabies. The patient s initial and follow-up tests are negative for syphilis, hepatitis B and C, and HIV. Animal control is contacted and watches the dog for 10 days. The patient recovers fully, with mild arthritis around his third MCP joint. For the second patient, topical LET (lidocaine-epinephrine-tetracaine) is placed on the bites. After the patient calms down and anesthesia is adequate, the wounds are irrigated and explored. An examination of the cat bite on the left forearm reveals only puncture marks without any bleeding or surrounding erythema. The human bite on the right forearm is a superficial laceration requiring two Steri-Strips (3M, St Paul, Minnesota). After a long discussion with the patient s mother about the risk of infection and potential consequences, antibiotics are declined, but follow-up with the patient s pediatrician is scheduled in 2 days. The kitten is a house pet and has not shown any erratic, aggressive behavior. The animal has received appropriate immunization and will be monitored at home for 10 days. The patient leaves happily with a Popsicle. References Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are Pediatric Emergency Medicine Practice EBMedicine.net September 2009

15 equally robust. The findings of a large, prospective, random ized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. 1. Griego RD, Rosen T, Orengo IF, Wolf JE. Dog, cat and human bites: a review. J Am Acad Dermatol. 1995;33(6): Benson LS, Edwards SL, Schiff AP, Williams CS, Visotsky JL. J Hand Surg Am. Dog and cat bites to the hand: treatment and cost assessment. 2006;31(3): Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database Syst Rev. 2001;(2):CD Ball V, Younggren BN. Emergency management of difficult wounds: part 1. Emerg Med Clin North Am. 2007;25(1): (Review) 5. Palacio J, León-Artozqui M, Pastor-Villalba E, Carrera- Martín F, García-Belenguer S. Incidence of and risk factors for cat bites: a first step in prevention and treatment of feline aggression. J Feline Med Surg. 2007;9(3): Freer L. North American wild mammalian injuries. Emerg Med Clin North Am. 2004;22(2): (Review) 7. Sacks JJ, Lockwood R, Hornreich J, Sattin RW. Fatal dog attacks, Pediatrics. 1996;97(6, pt 1): Drobatz KJ, Smith G. Evaluation of risk factors for bite wounds inflicted on caregivers by dogs and cats in a veterinary teaching hospital. J Am Vet Med Assoc. 2003;223(3): Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA. 1998;279(1): Marcy SM. Infections due to dog and cat bites. Pediatr Infect Dis. 1982;1(5): Presutti RJ. Prevention and treatment of dog bites. Am Fam Physician. 2001;63(8): (Review) 12. Hutson HR, Anglin D, Pineda GV, Flynn CJ, Russell MA, McKeith JJ. Law enforcement K-9 dog bites: injuries, complications, and trends. Ann Emerg Med. 1997;29(5): Moran GJ, Talan DA, Abrahamian FM. Antimicrobial prophylaxis for wounds and procedures in the emergency department. Infect Dis Clin North Am. 2008;22(1): , vii. (Review) 14. 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): Schalamon J, Ainoedhofer H, Singer G, Petnehazy, Mayr J, Kiss K, Höllwarth ME. Analysis of dog bites in children who are younger than 17 years. Pediatrics. 2006;117(3):e374-e Moreira ME, Markovchick VJ. Wound management. Emerg Med Clin North Am. 2007;25(3): , xi. 17. Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ. Bacteriologic analysis of infected dog and cat bites. N Engl J Med. 1999;340(2): Capellan O, Hollander JE. Management of lacerations in the emergency department. Emerg Med Clin North Am. 2003;21(1): Elenbaas RM, McNabney WK, Robinson WA. Evaluation of prophylactic oxacillin in cat bite wounds. Ann Emerg Med. 1984;13(3): Correira K. Managing dog, cat, and human bite wounds. JAAPA. 2003;16(4):28-32, 34, Philipsen TE, Molderez C, Gys T. Cat and dog bites: what to do? Guidelines for the treatment of cat and dog bites in humans. Acta Chir Belg. 2006;106(6): Dire DJ. Emergency management of dog and cat bite wounds. Emerg Med Clin North Am.1992;10(4): Westling K, Farra A, Cars B, et al. Cat bite wound infections: a prospective clinical and microbiological study at three emergency wards in Stockholm, Swedem. J Infect. 2006;53(6): Hemmo-Lotem M, Barnea Y, Jinich-Aronowitz C, et al. Epidemiology of pediatric bite/sting injuries: one-year study of a pediatric emergency department in Israel. ScientificWorld- Journal. 2006;6: Kizer KW. Pasteurella multocida infection from a cougar bite: a review of cougar attacks. West J Med. 1989;150(1): Wiens MB, Harrison PB. Big cat attack: a case study. J Trauma. 1996;40(5): Pretty IA, Anderson GS, Sweet DJ. Human bites and the risk of human immunodeficiency virus transmission. Am J Forensic Med Pathol. 1999;20(3): (Review) 28. Wallace CG, Robertson CE. Prospective audit of 106 consecutive human bite injuries: the importance of history taking. Emerg Med J. 2005;22(12): (Prospective; 100 patients) 29. MacBean CE, Taylor DM, Ashby K. Animal and human bite injuries in Victoria, Med J Aust. 2007;186(1): (Retrospective; 12,982 injuries) 30. Lindsey D, Christopher M, Hollenbach J, Boyd JH, Lindsey WE. Natural course of the human bite wound: incidence of infection and complications in 434 bites and 803 lacerations in the same group of patients. J Trauma. 1987;27(1): (Retrospective; 1237 injuries) 31. Marr JS, Beck AM, Lugo JA Jr. An epidemiologic study of human bites. Public Health Rep. 1979;94(6): (Retrospective; 892 injuries) 32. Kelleher AT, Gordon SM. Management of bite wounds and infection in primary care. Cleve Clin J Med. 1997;64(3): (Review) 33. Leung AK, Robson WL. Human bites in children. Pediatr Emerg Care. 1992;8(5): Broder J, Jerrard D, Olshaker J, Witting M. Low risk of infection in selected human bites treated without antibiotics. Am J Emerg Med. 2004;22(1): (Prospective, 125 patients) 35. Merchant RC, Fuerch J, Becker BM, Mayer KH. Comparison of the epidemiology of human bites evaluated at three US pediatric emergency departments. Pediatr Emerg Care. 2005;21(12): (Retrospective; 115 visits) 36. Solomons HC, Elardo R. Biting in day care centers: incidence, prevention, and intervention. J Pediatr Health Care. 1991;5(4): Henry FP, Purcell EM, Eadie PA. The human bite injury: a clinical audit and discussion regarding the management of this alcohol fuelled phenomenon. Emerg Med J. 2007;24(7): (Retrospective; 92 patients) 38. Kellogg, N; American Academy of Pediatrics Committee on Child Abuse and Neglect. Oral and dental aspects of child abuse and neglect. Pediatrics. 2005;116(6): (Report) 39. Tonta K, Kimble FW. Human bites of the hand: the Tasmanian experience. ANZ J Surg. 2001;71(8): (Retrospective; 35 patients) 40. Patzakis MJ, Wilkins J, Bassett RL. Surgical findings in clenched-fist injuries. Clin Orthop Relat Res. 1987;220: (Prospective; 191 patients) 41. Smith PF, Meadowcroft AM, May DB. Treating mammalian bite wounds. J Clin Pharm Ther. 2000;25(2): (Review) 42. Chapman S, Cornwall J, Righetti J, Sung L. Preventing dog bites in children: randomised controlled trial of an educational intervention. BMJ. 2000;320(7248): Lewis JA, Miller DR, Davies SG. Osteomyelitis complicating three types of traumatic hand wound. J Wound Care. 2004;13(7): (Case series; 3 patients) 44. Merchant RC, Nam DW, Becker BM, Mayer KH. Who gets bitten, why, and where? An updated assessment of human September 2009 EBMedicine.net 15 Pediatric Emergency Medicine Practice 2009

16 bites. Ann Emerg Med. 2002:40(4, pt 2):S41. (Retrospective; 172 patients) 45. Ganiere JP, Escande F, Andre G, Larrat M. Characterization of Pasteurella from ginigival scrapings of dogs and cats. Comp Immunol Microbiol Infect Dis. 1993;16(1): Morgan M. Hospital management of animal and human bites. J Hosp Infect. 2005;61(1):1-10. (Review) 47. Layton CT. Pasteurella multocida meningitis and septic arthritis secondary to a cat bite. J Emerg Med. 1999;17(3): (Case report and review of literature) 48. Brook I. Microbiology and management of human and animal bite wound infections. Prim Care. 2003;30(1):25-39, v. 49. Rayan GM, Downard D, Cahill S, Flournoy DJ. A comparison of human and animal mouth flora. J Okla State Med Assoc. 1991;84(10): (Retrospective; 15 subjects) 50. Talan DA, Abrahamian FM, Moran GJ, Citron DM, Tan JO, Goldstein EJ; Emergency Medicine Human Bite Infection Study Group. Clinical presentation and bacteriologic analysis of infected human bites in patients presenting to emergency departments. Clin Infect Dis. 2003;37(11): (Prospective; 50 patients) 51. Taplitz R. Managing bite wounds: currently recommended antibiotics for treatment and prophylaxis. Postgrad Med. 2004;116(2):49-52, 55-56, Fabbi M, De Guili L, Tranquillo M, Bragoni R, Casiraghi M, Genchi C. Prevalence of Bartonella henselae in Italian stray cats: evaluation of serology to assess the risk of transmission of Bartonella to humans. J Clin Microbiol. 2004;42(1): Valtonen M, Lauhio A, Carlson P, et al. Capnocytophaga canimorsus septicemia: fifth report of a cat-associated infection and five other cases. Eur J Clin Microbiol Infect Dis. 1995;14(6): Nakamura Y, Daya M. Use of appropriate antimicrobials in wound management. Emerg Med Clin North Am. 2007;25(1): (Review) 55. Mitnovetski S, Kimble F. Cat bites to the hand. ANZ J Surg. 2004;74(10): Fleisher GR. The management of bite wounds. N Engl J Med. 1999;340(2): Jackimczyk K, Pollack ES. Management of pediatric wounds. Pediatr Ann. 1996;25(8): Dire DJ, Hogan DE, Walker JS. Prophylactic oral antibiotics for low-risk dog bite wounds. Pediatr Emerg Care. 1992;8(4): Jones DA, Stanbridge TN. A clinical trial using co-trimoxazole in an attempt to reduce wound infection rates in dog bite wounds. Postgrad Med J. 1985;61(717): Rosen RA. The use of antibiotics in the initial management of recent dog-bite wounds. Am J Emerg Med. 1985;3(1): Elenbaas RM, McNabney WK, Robinson WA. Prophylactic oxacillin in dog bite wounds. Ann Emerg Med. 1982;11(5): Callaham M. Prophylactic antibiotics in common dog bite wounds: a controlled study. Ann Emerg Med. 1980;9(8): Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med. 1994;23(3): Turner, TWS. Evidence-based emergency medicine/systematic review abstract: do mammalian bites require antibiotic prophylaxis. Ann Emerg Med. 2004;44(3): Noel G, Teele DW. In vitro activities of selected new and long-acting cephalosporins against Pasteurella multocida. Antimicrob Agents Chemother. 1986;29(2): Levin JM, Talan DA. Erythromycin failure with subsequent Pasteurella multocida meningitis and septic arthritis in a catbite victim. Ann Emerg Med. 1990;19(12): Goldstein EJ, Citron DM, Hunt Gerardo S, Husdpeth M, Merriam CV. Activities of HMR 3004 (RU 64004) and HMR 3647 (RU 66647) compared to those of erythromycin, azithromycin, clarithromycin, roxithromycin, and eight other antimicrobial agents against unusual aerobic and anaerobic human and animal bite pathogens isolated from skin and soft tissue infections in humans. Antimicrob Agents Chemother. 1998;42(5): Wagner BK, Martone JD, Conte HA, Hill M, Kusan K. Complications of a cat bite. J Am Podiatr Med Assoc. 2006;96(5): Pennie R, Szakacs TA, Smaill FM, et al. Short report: ceftriaxone for cat and dog bites: simply outpatient treatment. Can Fam Physician. 2004;50: Merriam CV, Fernandez HT, Citron DM, Tyrrell KL, Warren YA, Goldstein EJ. Bacteriology of human bite wound infections. Anaerobe. 2003;9(2): (Retrospective; 57 patients) 71. Goldstein EJ, Reinhardt JF, Murray PM. Animal and human bite wounds: a comparative study, augmentin vs penicillin ± dicloxacillin. Postgrad Med J. 1984;60(suppl): Callahan M. Controversies in antibiotic choices for bite wounds. Ann Emerg Med. 1988;17(12): (Review) 73. Goldstein EJ, Citron DM, Vagvolgyi AE, Finegold SM. Susceptibility of bite wound bacteria to seven oral antimicrobial agents, including RU-985, a new erythromycin: considerations in choosing empiric therapy. Antimicrob Agents Chemother. 1986;29(4): (Basic science) 74. Bartholomew CF, Jones AM. Human bites: a rare risk factor for HIV transmission. AIDS. 2006;20(4): (Case series; 6 patients) 75. Andreo SM, Barra LA, Costa LJ, Sucupira MC, Souza IE, Diaz RS. HIV type 1 transmission by human bite. AIDS Res Hum Retroviruses. 2004;20(4): (Case report) 76. Hui AY, Hung LC, Tse PC, Leung WK, Chan PK, Chan HL. Transmission of hepatitis B by human bite confirmation by detection of virus in saliva and full genome sequencing. J Clin Virol. 2005;33(3): (Case report) 77. Fiumara NJ, Exner JH. Primary syphilis after human bite. Sex Transm Dis. 1981;8(1): (Case report) 78. Phair IC, Quinton DN. Clenched fist human bite injuries. J Hand Surg Br. 1989;14(1): (Prospective; 29 patients) 79. Zubowicz VN, Gravier M. Management of early human bites of the hand: a prospective randomized study. Plast Reconst Surg. 1991;88(1): (Prospective; 48 patients) 80. Brancato JC. Minor wound preparation and irrigation (Version 16.2). UpToDate Web site. home/index.html. Updated May (Systematic review) 81. Bansal BC, Wiebe RA, Perkins SD, Abramo TJ. Tap water for irrigation of lacerations. Am J Emerg Med. 2002;20(5): Stefanopoulos P, Karabouta Z, Bisbinas I, Georgiannos D, Karabouta I. Animal and human bites: evaluation and management. Acta Orthop Belg. 2004;70(1): Donkor P, Bankas DO. A study of primary closure of human bite injuries to the face. J Oral Maxillofac Surg. 1997;55(5): (Prospective; 30 patients) 84. Aigner N, König S, Fritz A. Bite wounds and their characteristic position in trauma surgery management. Unfallchirurg. 1996:99(5): Wiggins ME, Akelman E, Weiss AP. The management of dog bites and dog bite infections to the hand. Orthopedics. 1994;17(7): Garbutt F, Jenner R. Wound closure in animal bites. Emerg Med J. 2004;21(5): Maimaris C, Quinton DN. Dog-bite lacerations: a controlled trial of primary wound closure. Arch Emerg Med. 1988;5(3): Chen E, Hornig S, Shepherd SM, Hollander JE. Primary closure of mammalian bites. Acad Emerg Med. 2000;7(2): Human rabies prevention United States, 1999: recommendations of the Advisory Committee on Immunizaton Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2000;49(32): MMWR Morb Mortal Wkly Rep. Summary of Notifiable Diseases --- United States, 56(51); Pediatric Emergency Medicine Practice EBMedicine.net September 2009

17 91. McNabb SJ, Jajosky RA, Hall-Baker PA, et al. Summary of notifiable diseases United States, MMWR Morb Mortal Wkly Rep. 2008;55(53); Centers for Disease Control and Prevention. Human rabies prevention United States: 2008 recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2008;57(RR03):1-26, Krebs JW, Mandel EJ, Swerdlow DL, Rupprecht CE. Rabies surveillance in the United States during J Am Vet Med Assoc. 2005;227(12): Eidson M, Matthews SD, Willsey AL, Cherry B, Rudd RJ, Trimarchi CV. Rabies virus infection in a pet guinea pig and seven pet rabbits. J Am Vet Med Assoc. 2005;227(6): O Brien CM, Richards B. A surgeon s duty in dog bite prevention in children. Ann Plastic Surg. 2006;56(1): (Letter to the editor: retrospective review of 28 children referred for plastic surgery after dog bites) 96. Feder HM Jr, Shanley JD, Barbera JA. Review of 59 patients hospitalized with animal bites. Pediatr Infect Dis J. 1987;6(1): Sutton LN, Alpert G. Brain abscess following cranial dog bite. Clin Pediatr (Phila). 1984;23(10): Jones N, Khoosal M. Infected dog and cat bites. N Engl J Med. 1999;340(23): Klein DM, Cohen ME. Pasteurella multocida brain abscess following perforating cranial dog bite. J Pediatr. 1978;92(4): Pinckney LE, Kennedy LA. Fractures of the infant skull caused by animal bites. AJR Am J Roentgenol. 1980;135(1): Ashrafian H, Grisell M, Rubens MB, Mullen MJ, Sethia B. Pulmonary homograft endocarditis 19 years after a Ross procedure. Thorac Cardiovasc Surg. 2007;55(1): Villani NM. Treating dog and cat bites. Adv Nurse Pract. 2006;14(7): Rosen T. Penile ulcer from traumatic orogenital contact. Dermatol Online J. 2005;11(2):18. (Case report) 104. Wolf JS Jr, Gomez R, McAninch JW. Human bites to the penis. J Urol. 1992;147(5) (Retrospective; 5 patients) 105. Sikora CA, Spielman J, Macdonald K, Tyrrell GJ, Embil JM. Necrotizing fasciitis resulting from human bites: a report of two cases of disease caused by group A Streptococcus. Can J Infect Dis Med Microbiol. 2005;16(4): (Case reports) 106. Nabi G, Mishriki SF. Bite wounds to the genitalia: clinical presentation and management. Hosp Med. 2005;66(2): Jaffe AC. Animal bites. Pediatr Clin North Am. 1983;30(2): Floyd T, Manville AM, French SP. Normal oral flora in black bears: guidelines for antimicrobial prophylaxis following bear attacks. J Wilderness Med. 1990;1(1): Donoso A, León J, Rojas G, Ramírez M, Oberpaur B. Hypovolaemic shock by rat bites: a paradigmatic case of social deprivation. Emerg Med J. 2004;21(5): Freeman AF, Zheng XT, Lane JC, Shulman ST. Pasteurella aerogenes hamster bite peritonitis. Pediatr Infect Dis J. 2004;23(4): Trummer M, Komericki P, Kränke B, Aberer W. Anaphylaxis after a Mongolian gerbil bite. J Eur Acad Dermatol Venereol. 2004;18(5): Lim DL, Chan RM, Wen H, Van Bever HP, Chua KY. Anaphylaxis after hamster bites identification of a novel allergen. Clin Exp Allergy. 2004;34(7): Managing bites from humans and other mammals. Drug Ther Bull. 2004;42(9): American Academy of Pediatrics. Bite wounds. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove, IL: American Academy of Pediatrics; 2006:191. (Practice guideline) 115. Murmann DC, Brumit PC, Schrader BA, Senn DR. A com- parison of animal jaws and bite mark patterns. J Forensic Sci. 2006;51(4): Fischer H, Hammel PW, Dragovic LJ. Images in clinical medicine: human bites vs dog bites. N Engl J Med. 2003;349(11):e Whitaker DK, Aitken M, Burfitt E, Sibert JR. Assessing bite marks in children: working with a forensic dentist. Ambulatory Child Health. 1997;3(3): Goldstein EJ, Pryor EP III, Citron DM. Simian bites and bacterial infection. Clin Infect Dis. 1995;20(6): (Case series and review) 119. Holmes GP, Chapman LE, Stewart JA, Straus SE, Hilliard JK, Davenport DS. Guidelines for the prevention and treatment of B-virus infections in exposed persons. The B virus Working Group. Clin Infect Dis. 1995;20(2): (Guidelines) 120. Merchant RC, Zabbo CP, Mayer KH, Becker BM. Factors associated with delay to emergency department presentation, antibiotic usage, and admission for human bite injuries. CJEM. 2007;9(6): (Retrospective; 388 adults) 121. Wareham DW, Michael JS, Warwick S, Whitlock P, Wood A, Das SS. The dangers of dog bites. J Clin Pathol. 2007;60(3): Pfaff JA, Moore GP. Reducing risk in emergency department wound management. Emerg Med Clin North Am. 2007;25(1): CME Questions Take This Test Online! Physician subscribers receive CME credit absolutely free by completing the following test. Monthly online testing is now available for current and archived issues. Visit Take This Test Online! today to receive your free CME credits. Each issue includes 4 AMA PRA Category 1 Credits TM or 4 ACEP Category 1, AAP Prescribed credits. 1. Which statement is true? a. Cat bites avulse tissue. b. Human bites are the most common type of bites. c. Monkey bites carry little risk. d. Rabies is common among dogs. e. Most patients who sustain bites do not seek professional medical care. 2. Where are human bite wounds most commonly found on adults? a. Genitals b. Head and neck c. Lower extremities d. Thorax and abdomen e. Upper extremities 3. Fight bites require which of the following treatments? September 2009 EBMedicine.net 17 Pediatric Emergency Medicine Practice 2009

18 a. Automatic inpatient admission b. Antibiotics only if there is an active infection c. Primary closure d. Radiographs 4. Which statement about human bites in 13 to 30 month old children is true? a. They require admission more frequently than human bites in adults. b. They usually are acquired during altercations. c. They should be considered child abuse until proven otherwise. d. Biting is associated with play. e. None of the above 5. Which antibiotic is not optimal for human bite prophylaxis? a. Amoxicillin-clavulanate b. Doxycycline c. Moxifloxacin d. Penicillin alone e. Penicillin and dicloxacil Physician CME Information Date of Original Release: September 1, Date of most recent review: August 10, Termination date: September 1, Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Credit Designation: EB Medicine designates this educational activity for a maximum of 48 AMA PRA Category 1 Credits TM per year. Physicians should only claim credit commensurate with the extent of their participation in the activity. ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category 1 credit per annual subscription. AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics. Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians. Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents. Goals & Objectives: Upon reading Pediatric Emergency Medicine Practice, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered. Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product. Disclosure of Off-Label Usage: This issue of Pediatric Emergency Medicine Practice discusses no off-label use of any pharmaceutical product. Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Rempe, Dr. Aloi, Dr. Iskyan, Dr. Godwin, and Dr. Turner report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Method of Participation: Print Subscription Semester Program: Paid subscribers who read all CME articles during each Pediatric Emergency Medicine Practice six-month testing period, complete the post-test and the CME Evaluation Form distributed with the June and December issues, and return it according to the published instructions are eligible for up to 4 hours of CME credit for each issue. You must complete both the post test and CME Evaluation Form to receive credit. Results will be kept confidential. CME certificates will be delivered to each participant scoring higher than 70%. Online Single-Issue Program: Current, paid subscribers who read this Pediatric Emergency Medicine Practice CME article and complete the online post-test and CME Evaluation Form at EBMedicine.net are eligible for up to 4 hours of Category 1 credit toward the AMA Physician s Recognition Award (PRA). You must complete both the post-test and CME Evaluation Form to receive credit. Results will be kept confidential. CME certificates may be printed directly from the website to each participant scoring higher than 70%. Hardware/Software Requirements: You will need a Macintosh or PC with internet capabilities to access the website. Adobe Reader is required to download archived articles. CEO: Robert Williford President & Publisher: Stephanie Ivy Director of Member Services: Liz Alvarez Associate Editor & CME Director: Jennifer Pai Associate Editor: Dorothy Whisenhunt Marketing & Customer Service Coordinator: Robin Williford Direct all questions to: EB Medicine Outside the U.S.: Fax: Triangle Parkway, Suite 150 Norcross, GA ebm@ebmedicine.net Web Site: EBMedicine.net To write a letter to the editor, JagodaMD@ebmedicine.net Subscription Information: 48 AMA PRA Category 1 Credits TM or 48 ACEP Category 1, AAP Prescribed CME credits, and full online access to searchable archives and additional CME: $299 Individual issues, including 4 CME credits: $30 (Call or go to to order) Pediatric Emergency Medicine Practice (ISSN Print: , ISSN Online: ) is published monthly (12 times per year) by EB Practice, LLC Triangle Parkway, Suite 150, Norcross, GA Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Pediatric Emergency Medicine Practice is a trademark of EB Practice, LLC. Copyright 2009 EB Practice, LLC. All rights reserved. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC. This publication is intended for the use of the individual subscriber only, and may not be copied in whole or in part or redistributed in any way without the publisher s prior written permission including reproduction for educational purposes or for internal distribution within a hospital, library, group practice, or other entity. Pediatric Emergency Medicine Practice EBMedicine.net September 2009

19 Lock in your current low rate for up to three additional years. Renew today to save at least $100 and avoid future price increases! Take advantage of this limited-time opportunity to renew your Pediatric Emergency Medicine Practice subscription at your current low price. When you renew today, you pay just $199 a $100 savings off the regular price! Even better, you can save $220 when you renew for two years. Or, take advantage of our best offer by renewing for three years and saving $360! Now is the time to lock in your current low rate! Don t miss out on this exclusive opportunity renew today! Continue receiving diagnosis and treatment recommendations solidly based in the current literature and all the CME you need. To renew, call , ebm@ebmedicine.net, or visit Don t miss out lock in your low rate today!

20 Binders Pediatric Emergency Medicine Practice has sturdy binders that are great for storing all your issues. To order your binder for just $15, please call , or go to scroll down, and click Binders on the left side of the page. If you have any questions or comments, please call or us. Thank you! Group subscriptions are available offering substantial discounts off the regular price. Please contact Robert Williford, Director of Group Sales, at or for more information. Coming In Future Issues Metabolic Emergencies PALS Retained Foreign Bodies Pediatric Emergency Medicine Practice subscribers: Your subscription includes FREE CME: up to 48 AMA PRA Category 1 Credits TM or 48 ACEP Category 1, AAP Prescribed credits per year from current issues, plus an additional 144 credits online. To receive your free credits, simply mail or fax the 6-month print answer form to EB Medicine or log in to your free online account at Call if you have any questions or comments. Are you prepared for the ABEM LLSA Exam? EB Medicine s LLSA Study Guide is the definitive resource to prepare for the annual ABEM LLSA exam. With it, you receive full article reprints, summaries and discussions of each article, sample questions with answers and explanations, and 35 AMA/ACEP Category 1 CME credits. Order yours today by calling or visiting Do you like what you re reading? Then pass along this issue so a colleague can become a subscriber too at this special introductory rate: just $199 for a full year (12 issues) of Pediatric Emergency Medicine Practice. Plus, you receive 3 free issues for each colleague you refer. Bill me Check enclosed (payable to EB Medicine) Charge my: Visa MC AmEx Credit card number: Expiration date: Signature: Promotion Code: ISSUEP Name of new subscriber: Address: City, State, Zip: Colleague s name who referred you: Send to: EB Medicine / 5550 Triangle Pkwy, Ste 150 / Norcross, GA Or fax to: Or visit: and enter Promo Code ISSUEP. Or call: or EBMedicine.net September Pediatric Emergency Medicine Practice 2009