Rosen & Barkin's 5-Minute Emergency Medicine Consult (105 page)

• In suspected sexual abuse:
  
  • Check for a central area of bruising or “hickey” from suction
    
• Linear abrasions or bruises on both the dorsal and palmar/plantar surfaces of the hand or foot:
  
  • Highly suggestive of bite marks
    
  • Lesions on one extremity should prompt a search for lesions on the other extremities.
    
• An intercanine distance of >3 cm indicates permanent dentition (present only if the attacker is >8 yr)
  
• If abuse suspected:
  
  • Rub a saline-moistened swab in the wound to collect any saliva and then place in a paper envelope for analysis.
    
  • Obtain photographs.
    
  • Notify authorities.
    

TREATMENT

Control bleeding with direct pressure.

ABCs: Ensure patent airway and adequate peripheral tissue perfusion

• Wound irrigation:
  
  • Copious volumes of normal saline irrigation with an 18G needle or plastic catheter tip aimed in the direction of the puncture
    
  • Care should be taken not to inject fluid into the tissues.
    
• Débridement:
  
  • Remove any foreign material, necrotic skin tags, or devitalized tissues.
    
  • Do not débride puncture wounds.
    
  • Remove any eschar present so that underlying pus may be expressed and irrigated.
    
• Clenched-fist injuries:
  
  • Immobilize
    
  • Splint in a position of function that maintains the maximal length of ligaments and intrinsic muscles.
    
  • Use a bulky hand dressing
    
  • Consultation with hand surgeon regarding operative irrigation/exploration of wound
    
  • Elevation for several days until any edema resolved
    
  • Sling for outpatients
    
  • Place the hand in a tubular stockinette attached to an IV pole for inpatients.
    
  • Administer antibiotics
    
• Do not perform primary repair of avulsion wounds.
  
• Wound closure:
  
  • Closing wounds increases risk of infection and must be balanced with scar formation and effect of leaving wound open to heal secondarily.
    
  • Do not suture infected wounds or wounds >24 hr after injury.
    
  • Repair of wounds >8 hr after bite: Controversial.
    
  • Close facial wounds up to 24 hr after bite (warn patient of high risk of infection).
    
  • Infected wounds and those presenting >24 hr should be left open.
    
  • May approximate the wound edges with Steri-Strips and perform a delayed primary closure.
    
  • Do not suture CFIs.
    
• Prophylactic antibiotics controversial for low-risk bites
  
• Antibiotics for outpatients with:
  
  • Moderate to severe injuries with crush injury or edema
    
  • Involvement of the bone or a joint
    
  • Hand bites
    
  • Wounds near a prosthetic joint
    
  • Underlying disease (diabetes, prior splenectomy, or immunosuppression) that increases the risk of developing a more serious infection
    
• Tetanus prophylaxis
  
• Refer for possible testing/surveillance for HIV infection.
  

• Amoxicillin/clavulanic acid (Augmentin): 500/125 mg (peds: 40 mg/kg/24h) q8h PO
  
• Ampicillin–sulbactam (Unasyn): 3 g q6h IV
  
• Piperacillin–Tazobactam (Zosyn): 4.5 g q8h IV
  
• Ticarcillin–clavulanate (Timentin): 3.1 g q4h IV
  
• Ceftriaxone (Rocephin): 1 g/d plus Metronidazole (Flagyl): 500 mg q8h
  

• 2 drug therapy: 1 of the following below + anaerobic coverage:
  
  • Trimethoprim–sulfamethoxazole (Septra DS): 1 tablet q12h (peds: 8 mg/kg trimethoprim and 40 mg/kg sulfamethoxazole per day divided into 2 daily doses) PO
    
  • Penicillin (Penicillin VK): 500 mg (peds: 50 mg/kg/24h) PO q6h
    
  • Ciprofloxacin (Cipro): 500–750 mg q12h PO or 400 mg q12h IV
    
  • Doxycycline: 100 mg PO BID
    
• + (anaerobic coverage):
  
  • Clindamycin (Cleocin): 150–450 mg (peds: 8–20 mg/kg/24h) PO q6h or 600–900 mg (peds: 20–40 mg/kg/24h) IV q8h
    
  • Metronidazole (Flagyl): 500 mg PO TID (peds: 10 mg/kg/dose TID)
    

FOLLOW-UP

• Infected wounds at presentation
  
• Severe/advancing cellulitis/lymphangitis
  
• Signs of systemic infection
  
• Infected wounds that have failed to respond to outpatient (PO) antibiotics
  

• Healthy patient with localized wound infection:
  
  • Discharge on antibiotics with 24-hr follow-up.
    
• Noninfected wounds
  
  • 48-hr follow-up
    

• Human bite marks rarely occur accidentally; good indicators of inflicted injury.
  
• Consider elder abuse.
  

• Human bite marks rarely occur accidentally; good indicators of inflicted injury.
  
• If intercanine distance >3 cm, bite likely from an adult. Consider child abuse.
  

Suspected child abuse

• Hand specialist referral/follow-up for infected hand wounds
  
• Healthy patient with localized wound infection: Discharge on antibiotics with 24-hr follow-up.
  
• 48-hr follow-up for noninfected wounds
  

• Examine the deepest part of clenched-fist bites while putting the fingers through full range of motion to check for extensor tendon lacerations and joint violation.
  
• Obtain hand consultation for operative irrigation for all patients with clenched-fist lacerations due to the high rate of infection.
  
• An intercanine distance of >3 cm indicates permanent dentition (present only if the attacker is >8 yr).
  

• Broder J, Jerrard D, Olshaker J, et al. Low risk of infection in selected human bites treated without antibiotics.
  Amer J Emerg Med
  . 2004;22(1):10–13.
  
• Brook I. Microbiology and management of human and animal bite wound infections.
  Prim Care.
  2003;30(1):25–39.
  
• Endom E. Initial management of animal and Human Bites.
  UpToDate
  , Oct 25, 2012.
  
• Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites.
  Cochrane Database Syst Rev
  . 2001;(2):CD001738.
  
• Pickering L.
  Red book: 2003 Report of the Committee on Infectious Diseases
  . 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003.
  
• Smith PF, Meadowcroft AM, May DB. Treating mammalian bite wounds.
  J Clin Pharm Ther
  . 2000;25:85–99.
  

See Also (Topic, Algorithm, Electronic Media Element)

Bite, Mammal

CODES

• 879.8 Open wound(s) (multiple) of unspecified site(s), without mention of complication
  
• 882.0 Open wound of hand except finger(s) alone, without mention of complication
  
• 882.1 Open wound of hand except finger(s) alone, complicated
  

BASICS

• Blunt trauma is the most common mechanism.
  
• 10% of pelvic fractures have serious bladder injury.
  
• 80–90% of bladder ruptures have pelvic fracture.
  
• Mortality: 17–22% overall; 60% if combined intraperitoneal/extraperitoneal rupture
  

• Mechanism:
  
  • Trauma, 82%
    
  • Blunt trauma: Motor vehicle accident (MVA; 87%), falls (7%), assault (6%)
    
  • Penetrating: Gunshot wound (GSW) (85%), stabbings (15%)
    
  • Iatrogenic 14%: TURP and urologic procedures, gynecologic procedures, obstetric procedures, abdominal procedures, hernia repair, intrauterine device (IUD), orthopedic hip procedures, biopsies, indwelling Foley
    
  • Intoxication 2.9%
    
  • Spontaneous <1%
    
• Classification:
  
  • Extraperitoneal bladder rupture (62%):
    
    • Associated with pelvic fractures
      
    • Caused by blunt force or fracture fragments
      
  • Intraperitoneal bladder rupture (25%):
    
    • Direct compression of distended bladder
      
    • Caused by rupture of the dome of the bladder
      
  • Combined extraperitoneal and intraperitoneal rupture (12%):
    
    • Highest mortality owing to associated injuries
      
  • Bladder contusion:
    
    • Damage to endothelial lining or muscularis layer with intact bladder wall
      
    • Gross hematuria after extreme physical activity (long-distance running)
      
    • Gross hematuria with normal imaging
      
    • Usually resolves without intervention