Fingernail/Nailbed Wounds Animal Bites

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Julia Lang
8 years ago
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1 Fingernail/Nailbed Wounds Animal Bites Fingernail & Nailbed Injury Kent Benedict, MD, FACEP Clinical Associate Professor of Medicine Stanford University Crush Injury to Finger Crushed Finger X-Ray Anatomy Nail arises from germinal matrix and is loosely attached Nail is firmly attached to the nail bed(sterile matrix) 1

University Crush Injury to Finger Crushed Finger X-Ray Anatomy Nail arises from

2 Approximate skin fold and germinal matrix First - completely remove nail Second - fine(6-0) absorbable sutures repair nailbed Third - replace nail by suturing or place gauze pack between germinal matrix and eponychium The avulsed nail or gauze pack remains in place for 2-3 weeks to prevent scar formation A large hole in nail is drilled to allow drainage The old nail is pushed out by new one Three Most Common Animal Bites - Dog, Cat, Human 1% of ER visits Annual health care cost $30 million Dog Bites Dog bites are 80-90% of all reported animal bite cases Most common breeds - German shephards, Rottweilers, Dobermans, pit bulls Children more common than adults Dog Bites 4.5 million dog bites annually 765,000 seek medical care 44,000 child face bites a year 16,000 require plastic surgery 20 deaths 2

Three Most Common Animal Bites - Dog, Cat, Human 1% of ER visits Annual health care cost $30 million Dog Bites Dog bites are 80-90% of all reported animal bite cases Most common breeds - German

3 Dog Bites - Polymicrobial Dog Bites - Management Common Pasteurella( canis & multocida) 50% Staph aureus Streptococcus Rare Rabies Leptospirosis Complication rate - 10% Irrigation Debridement Delayed closure Antibiotics Dog Bites - Antibiotics Augmentin is the reasonable first choice(875mg bid or 500mg tid) If penicillin allergic - adults: clindamycin 300mg po qid + ciprofloxacin 500mg bid If penicillin allergic - children: clindamycin + bactrim Cat Bite Rapid inflammatory response (< 24 hours) Cat Bites More frequently lead to infection, deeper penetration > 50 % Pasteurella multocida Rapid inflammatory response(within 24 hours) Antibiotics and surgical drainage Augmentin is good first choice A 50 year-old man presented to the ED after having sustained several cat bites and scratches to his left hand three hours prior to arrival while separating his fighting pets 3

penicillin allergic - children: clindamycin + bactrim Cat Bite Rapid inflammatory response (< 24 hours) Cat Bites More frequently lead to infection, deeper penetration > 50 % Pasteurella multocida

4 The patient was a known Type II diabetic and also allergic to penicillin (manifested by immediate hives). The patient was afebrile and exhibited several cat bite punctures on the dorsum of his hand, in addition to several other scratches This infected cat bite is notable for 1) The aggressive nature of the infection 2) The finding of subcutaneous air Pasteurella multocida 1) More than 50% of cat bite wounds become infected and P. multocida is found as a pathogen over 75% of the time 2) Local pain and inflammation often occur within 4 to 6 hours of the injury and almost always within 24 hours The finding of air in the soft tissues along the dorsum of the hand on the lateral X-ray of the hand (Left Photo) Pasteurella multocida(aerobic, Gram-negative rods). (Right Photo) Beta hemolytic streptococcus(aerobic, Gram-positive cocci). Beta hemolytic streptococcus A common cause of cat bite infections and also is known to be associated with a rapid onset of infection. The air in the soft tissues suggests streptococcal infection, but it is by no means pathognomonic. 4

the infection 2) The finding of subcutaneous air Pasteurella multocida 1) More than 50% of cat bite wounds become infected and P.

5 Treatment Cat Bite - Surgical Augmentin would have been chosen to treat this patient if not for his penicillin allergy This patient was started on intravenous doxycycline (coverage against P. Multocida) and clindamycin (excellent streptococcal coverage) If there was no improvement, to have him undergo surgical incision and drainage Cat Bite - Surgical Human Bites Fist fights cause 60-80% of human bites May not give accurate history Often delayed presentation Human Bites - Bacteria Human Bites - Treatment Debride, explore, look for MCPJ involvement Augmentin is a good first choice Staph aureus Beta hemolytic strep Eikenella corrodens 5

Multocida) and clindamycin (excellent streptococcal coverage) If there was no improvement, to have him undergo surgical incision and drainage Cat Bite -

Taking the Bite out of Dog ma

Taking the Bite out of Dog ma Dr. Michael Woo MD, CCFP(EM), RDMS Director, Emergency Medicine Ultrasonography Associate Professor, Department of Emergency Medicine Ultrasound uottawa DEM 25 May 2013 ACKNOWLEDGEMENTS