The physician's first priority is to protect the victim from infection. Proper wound management is required to reduce the risk of developing wound infection, sepsis, osteomyelitis, tenosynovitis, and septic arthritis. The wound is cleaned carefully. After cleaning, it is irrigated with normal saline under pressure using a 19-gauge needle and large syringe. A 20-gauge angiographic catheter often is attached and introduced into puncture wounds to facilitate irrigation. Victims frequently state that this is the most painful part of treatment.
It is important to find out when and if the victim had a tetanus shot. Such a shot may be administered if required or the date of the last shot cannot be determined. The dog may be known to be rabid. If so, the victim is treated preventatively for rabies. (Blackman JR. Animal bites. In: Rakel RE, Pedersen D, editor. Saunders Manual of Medical Practice. Philadelphia: WB Saunders, 1996; Wiley JF 2nd. Mammalian bites. Review of evaluation and management. Clin Pediatr Phila 1990; 29:283-7.)
Cultures and Gram stain are useless on a fresh wound, but they should be obtained for obviously infected wounds and victims who are already febrile or immunocompromised. [Kelleher AT, Gordon SM. Management of bite wounds and infection in primary care. Cleve Clin J Med 1997;64:137-41.]
Because dogs can develop a tremendous force when biting, x-ray studies might be necessary to determine underlying bone and joint injury. Fractured bones must be set. Nerve injuries must be repaired.
Dog bites to the neck and face require special considerations. Most occur in children younger than 10 years, and severe brain injury and death are most common in this age group. Most deaths occur from hemorrhage from the great vessels of the neck.
The nose, mouth, and parotid region is a primary target area for dog bites. [Morgan JP 3rd, Haug RH, Murphy MT. Management of facial dog bite injuries. J Oral Maxillofac Surg 1995;53:435-41.] Carotid artery injury with delayed cerebral infarction has been reported. [Meuli M, Glarner H. Delayed cerebral infarction after dog bites: case report. J Trauma 1994;37:848-9.] After a detailed exploration looking for damaged tissue (salivary duct, facial nerve, blood vessels), many wounds may be closed primarily. [Morgan JP 3rd, Haug RH, Murphy MT. Management of facial dog bite injuries. J Oral Maxillofac Surg 1995;53:435-41.]
Depending on the type of bite, the wounds may be closed. If the damage is not extensive, the wounds may be closed with tape or sutures. High-risk wounds should not be sutured but should receive antibiotic treatment. Low-risk wounds may be sutured and do not require antibiotic treatment unless infected. High-risk wounds include all human and cat bites; hand and foot wounds; wounds surgically debrided; puncture wounds; wounds involving joints, ligaments, tendons, and bones; bites with treatment delay exceeding 12 hours; and bites in immunocompromised patients. Low-risk wounds include bites involving the extremities, face, and body. (Blackman JR, "Man's Best Friend?", J Am Board Fam Pract 11(2):167-169, 1998.)
Heavily damaged tissue may have to be debrided -- cut away. Sometimes it can be reattached by grafting; other times it is replaced with skin from another area of the victim's body. More than one type of surgery may be required:
- Plastic/reconstructive surgery
- Orthopedic surgery