Mammalian bite injuries to the hand and their management

[Management of bite injuries]

Bite injuries cause contaminated wounds with a high risk of infection. It is a progressive process. The prognosis depends less on the extent of the surface area but more on the depth of penetration. Due to the close spatial relationships the structures in the hand are particularly at risk from bite injuries. This study evaluated the dynamics of the disease progression based on the extent of injury and the timing of treatment initiation. A total of 332 bite injuries were treated and retrospectively analyzed. The severity of injuries was classified into five grades based on the affected compartments. The evaluation of the treatment was conducted according to the timing in four groups. The infection rates increased with the severity of the injury and the elapsed time. On the day of the accident 11% of patients showed signs of infection, rising to 72% the following day under conservative treatment, and 93% if no treatment was initiated by then. Patients treated conservatively elsewhere also showed similar levels. The average number of interventions also increased with the interval between the bite and the start of treatment. Not all bites are equal. The extent matters. Cutaneous injuries show signs of infection in 23% of cases but can mostly be treated conservatively. All deeper injuries require surgical treatment with debridement, immobilization and antibiotics. After immediate surgical treatment revision was necessary in 4% of cases.

Ambulatory Management of Bite Injuries to the Hand: A Safe and Cost-Effective Option

Introduction Animal or human hand bites are a common presentation to the emergency department. If hand bites are not treated adequately, they can give rise to significant local and systemic complications, potentially leading to functional deficits that impact patients' lives. Traditionally, hand bites require hospital admission for the administration of intravenous antibiotics and, in some cases, surgical intervention. A combination of the increasing incidence, hospital admission rates, and in-patient bed pressures prompted a change in our bite management protocol and a move toward ambulatory management of bite injuries. We found this new protocol to be safe, efficient, and cost-effective with a scope for wider implementation. Aim The primary outcome is to assess the feasibility of safely managing hand bites on an outpatient basis, by reviewing the local data before and after the change in practice. The secondary outcome is to compare the financial implications of treating hand bites with an outpatient approach. Material and methods All first-presentation adult consultations referred to Trauma and Orthopaedics from the emergency department over a three-month snapshot period were reviewed in 2017. This was repeated after the implementation of the updated handbite guidelines in 2023. Initial admission documentation as well as operation notes and clinic follow-up letters were each reviewed retrospectively.  Results  In 2017, 36 patients were identified over three months. The average time to surgery was 1.19 days with an average inpatient stay of 2.36 days. There were two re-operations and follow-up of two cases of osteomyelitis.  In 2023, 63 patients were identified over three months. The average time to surgery was 1.03 days with an average inpatient stay of 0.56 days. Thirty-seven surgeries were performed for 33 patients with 32% (20/63) of patients admitted directly from the emergency department. There were no documented cases of osteomyelitis on follow-up. The cost per patient episode decreased by 40% from 2017 to 2023, without accounting for inflation. Conclusions With the implementation of the new departmental guidelines, there has been a reduced average inpatient stay and reduced time to surgery without an increase in documented osteomyelitis. There is also a significant decrease in the average patient cost. This data suggests that without compromising patient safety it is possible to cost-effectively manage hand bites without the need for long inpatient stays.  However, it is imperative that there is close patient follow-up as well as prompt time to surgery to ensure patient safety. Our findings suggest a need for further research to strengthen the evidence supporting our conclusions.

Injuries related to pets, exotic animals, and falconry in Qatar

INTRODUCTION

Pets and exotic animals are increasingly popular all over the world. Some of these animals may cause injuries to their owners or other people during interactions. Both injuries and systemic infections always present diagnosis and treatment challenges. Emergency physicians´ clinical experience in managing patients with injuries caused by pets and exotic animals, in particular, is limited; hence, we believe that it is a domain to explore in a Middle Eastern country to help raise awareness and provide reminders as to the best evidence-based medical practice.

METHODS

Hamad Medical Corporation's hospital records of patients treated between 2015 and 2022 were analyzed retrospectively. Cases whose diagnosis was recorded as injuries caused by animals kept as pets were included in the study. Patients were evaluated in terms of demographic characteristics, type of injury, injury locations, injury severity, treatments applied, and complications. Descriptive statistics were carried out, and findings were expressed as percentages in a frequency table.

RESULTS

Following a search of the electronic patient records during the period of interest, 43 patients were found to have sought treatment following an injury caused by a pet or domestic exotic animal. The mean age of the patients was 23.5 years; about three-quarters were male, and approximately half were children. All injuries were minor, and 74.4% were skin abrasions. The most commonly injured body parts were the hand, the leg, and facial injuries. It was observed that cats caused 53.5% of the injuries, whereas falcons were involved in 11.6% of the cases. All patients were prescribed prophylactic antibiotics, and 60.5% were administered a tetanus injection.

CONCLUSION

Despite our study spanning over seven years, a relatively low number of patients reported to the government hospitals´ emergency departments. The injuries are most commonly caused by cats and often involve children and animal bites to hands. The key recommendations are for parents or childminders to always supervise children when interacting with animals, be particularly cautious, and wear some form of protection when handling pets and domestic, exotic animals. Whether it is a bite or a scratch, healthcare professionals should always anticipate the potential risk of infection, treat the patient accordingly, and prescribe prophylactic antibiotics.

[Infections of the Hand after Bite Injuries]

Bite injuries are common. Along with the resulting complications, they represent approximately 1-2 % of all emergency department visits. In over 75 %, the hands are affected. In Northern Europe, bites and subsequent infections are mainly caused by dogs and cats but also by humans.Up to 40 % of all hand infections are caused to bite injuries. Due to the multiple and complex compartments as well as the low soft tissue coverage of functionally relevant structures, even the smallest and most superficial bite injuries of the hand lead to infections. Any bite injury to the hand may subsequently may result in a fulminant infection and, rarely, even death.The spectrum of pathogens from the oral flora of the biting animal or person is diverse and includes aerobic and anaerobic bacterial strains. Bite injuries represent a major challenge for both the injured person and the attending physician. The rate of complications has been shown to increase with delayed medical consultation, lack of medical care and inadequate wound care. In this review, we discuss the types and complications of bite wounds, their potential risk of infection, their pathogen spectrum and appearance, and their effective treatment.

Diagnosis and Management of Common Hand Infections

While many hand infections are superficial, diligent evaluation, diagnosis, and treatment of these infections are central for preventing disability and morbidity. Maintaining a wide differential diagnosis is important as some hand infections may mimic others. In geographic areas with more than a 10% to 15% prevalence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) hand infections, empiric antibiotics should adequately cover MRSA. Once culture results are available, antibiotic regimens should be narrowed to reduce the development of resistant pathogens.

Seal bites at sub-Antarctic Marion Island: Incidence, outcomes and treatment recommendations

Seal biologists at Marion Island (Southern Ocean) are in frequent contact with seals. During research activities, biologists may be bitten by seals, yet no standardised protocol for treating such bites is in place. Information on 22 seal bite cases at Marion Island was collected. Treatment of these bites varied, reflecting a need for standardised protocols for the treatment of bites. Recommendations for the in-field treatment of bites are presented. Five of the 22 cases had some symptoms which resembled ‘seal finger’ – a zoonotic infection, usually of the hands, that is contracted after a person comes into contact with tissues of seals or is bitten by one. However, in four of these cases, symptoms subsided within 4 days without antibiotic treatment; in the fifth case antibiotics were administered and symptoms subsided in 4 days. There is little evidence of the occurrence of seal finger at Marion Island, but this deserves further investigation.

[Surgical treatment of bites]

OBJECTIVE

Thorough and profound debridement for acute bite injuries while sparing nerves, vessels and tendons.

INDICATIONS

Acute traumatic and late presented bite injuries.

CONTRAINDICATIONS

General contraindication for anesthesia or surgery.

SURGICAL TECHNIQUE

Extensive flabellate local anesthesia/general anesthesia, wound irrigation using 0.9% NaCl or antiseptic solutions, removal of avital tissues, wound debridement, wound edge excision, anew extensive irrigation, drainage if necessary, wound closure where applicable (except older or punctual deep injuries), bandage, elastic wrapping and immobilization. If necessary, plastic surgery with coverage of remaining defects.

POSTOPERATIVE MANAGEMENT

Immobilization with initially daily wound evaluation, removal of drainage/loop on postoperative day 2; if necessary, antibiotic therapy with amoxicillin and clavulanic acid in high-risk wounds (e.g., puncture wounds, joint or bone involvement, extensive soft tissue squeezing), suture removal on day 10-12 after surgery.

RESULTS

Of 142 bite injuries that were treated and retrospectively evaluated, 46% were caused by dogs and 32% by cats. Patients were on average 44 years old; 55% of all dog bites affected women, but 67% of all cat bites. In 48% of the cases, general anesthesia was necessary. The postoperative infection rate was 6.3%.

Epidemiology of Animal Bites and Factors Associated With Delays in Initiating Post-exposure Prophylaxis for Rabies Prevention Among Animal Bite Cases: A Population-based Study

Objectives

One way to prevent deaths due to rabies is the timely utilization of post-exposure prophylaxis (PEP). Therefore, in addition to an understanding of the epidemiological distribution of animal bites, it is necessary to explore the factors leading to delays in PEP initiation.

Methods

This cross-sectional study was conducted in Iran in 2011, and included 7097 cases of animal bites recorded at the Rabies Treatment Center of the Shiraz University of Medical Sciences using the census method. Logistic regression was used to identify factors associated with delays in PEP.

Results

Among the patients studied, 5387 (75.9%) were males. The prevalence of animal bites in Fars province was 154.4 per 100 000 people. Dogs were the most frequent source of exposure (67.1%), and the most common bitten part of the body was the hands (45.5%). A delay in the initiation of PEP was found among 6.8% of the studied subjects. This delay was more likely in housewives (odds ratio [OR], 4.66; 95% confidence interval [CI], 2.12 to 10.23) and less likely in people with deep wounds (OR, 0.65; 95% CI, 0.43 to 0.97).

Conclusions

Although all animal bite victims received complete PEP, in some cases, there were delays. Further, the type of animal involved, the depth of the bite, and the patient’s occupation were the major factors associated with a delay in the initiation of PEP for rabies prevention.

Survey of practitioners handling slow lorises (Primates: Nycticebus): an assessment of the harmful effects of slow loris bites

Slow lorises (Nycticebus spp.) are one of six venomous mammals, and the only known venomous primate. In the wild envenomation occurs mainly during conspecific competition for mates and territory, but may also be used as an application against parasites or for predator defense. Envenomation in humans is documented, with the most extreme accounts detailing near-fatal anaphylactic shock. From September 2016 - August 2017, we received questionnaire responses from 80 wild animal practitioners working with Nycticebus spp. in zoos, rescue centres and in the wild. We identified 54 practitioners who had experience of being bitten or were otherwise affected by slow loris venom, and an additional 26 incomplete entries. No fatalities were reported. Fifteen respondents noted that medical intervention was required, 12 respondents indicated no reaction to being bitten (9 of these indicated they were wearing gloves). Symptoms for those affected included: anaphylactic shock, paraesthesia, haematuria, dyspnoea, extreme pain, infection and general malaise. Impact of slow loris bites ranged from instantaneous to long-persisting complications, and healing time ranged from 1 day to >8 months. Extremities, including hands and arms, were mostly affected from the bites. Six of nine species of slow loris were reported to bite, with N. pygmaeus being the most common in our sample. We make suggestions regarding the use of these highly threatened yet dangerous primates as unsuitable tourist photo props and zoo animal ambassadors. We discuss the medical complications experienced in relation to protein sensitisation, and bacterial pathogenesis. We recommend future work to ascertain the protein content of slow loris venom to aid in enabling mitigation of risks posed.

Development of a clinical path for the emergency care of hand bite injuries without signs of infection

HYPOTHESIS

The care of bite injuries has not currently reached a consensus, including in our department. The goal of this study was to evaluate our current care of bite injuries by an assessment of professional practices (APP), then formulate and validate a flowchart to standardize our practices.

MATERIAL AND METHODS

During a first round of file reviewing, 30 files were randomly selected and then evaluated using a 15 item auditing form (group 1). A flowchart was then designed to standardize the care of hand bite injuries and released in our department. Six months later, 30 new files were randomly selected and evaluated using the same auditing form (group 2).

RESULTS

When comparing the results of the 15 items before and after the release of the flowchart, 7 items reached 100% in group 2. The wounds were described more precisely, signs of severity were systematically researched and the antibiotic treatment was standardized. Two items decreased but did not reach 0%: systematic prescription of bacteriologic swabs and X-rays. Using these results the flowchart was improved.

DISCUSSION AND CONCLUSION

Our results showed an improvement of the care of hand bites for 11 items, including 5 that were statistically significant. This flowchart enabled to standardize our practices and could be used in other emergency departments.

Predictive Factors of Neurovascular and Tendon Injuries Following Dog Bites to the Upper Extremity

Background: Dog bite injuries to the upper extremity can result in traumatic neurovascular and musculotendinous damage. Currently, there are no clear guidelines dictating which patients may benefit from early operative exploration. The purpose of this study was to identify clinical variables that were predictive of abnormal intraoperative findings in patients who sustained an upper extremity dog bite injury. Methods: All patients who presented to a level I trauma center between 2007 and 2015 with an upper extremity dog bite injury who underwent subsequent surgical exploration were retrospectively screened for inclusion in our study. Patients with inadequate documentation or preexisting neurovascular or motor deficits were excluded. Abnormalities on physical exam and injuries encountered during surgical exploration were recorded for each patient. Contingency tables were constructed comparing normal and abnormal nerve, tendon, and vascular physical exam findings with intact or disrupted neurovascular and musculotendinous structures identified during surgical exploration. Results: Between 2007 and 2014, 117 patients sustained a dog bite injury to the upper extremity, of which 39 underwent subsequent surgical exploration and were included in our analysis. Sixty-nine percent of patients with neuropraxia on exam had intraoperative nerve damage. Seventy-seven percent of patients with an abnormal tendon exam had intraoperative musculotendinous damage. One hundred percent of patients with an abnormal vascular physical exam had intraoperative arterial injury. Conclusions: To date, there are no clear guidelines on what clinical criteria indicate the need for operative exploration and possible repair of neurovascular structures in upper extremity dog bite injuries. In our study, nerve, tendon, and vascular abnormalities noted on physical exam were strongly predictive of discovering neurovascular and musculotendinous damage during surgical exploration.

A Three-year (2011-2013) Surveillance on Animal Bites and Victims Vaccination in the South of Khorasan-e-Razavi Province, Iran

INTRODUCTION

Rabies is acute encephalitis caused by rabies virus and is transmissible between humans and warm blooded animals. The virus is belong to the family of Rabdoviridae and, of Lissavirus genus.

AIM

To find out the success of rabies surveillance system to prevent victims of this deadly disease and to identify its risk factors in the community.

MATERIALS AND METHODS

This research is a cross-sectional analysis and the information pertaining to bite incidents was obtained from documents of the Centers for Disease Control of Rabies from 2011 to 2013. A questionnaire was used which included questions on demographics information (sex and age) of the victims, and the others.

RESULTS

A total of 616 cases (animal rabies) were brought to rabies treatment center during 2011- 2013 of which 81.2% of the cases were males and 18.8% were females. Most animal bites (37.5%) reported in 2011. The difference between the months and the number of biting were statistically significant (p = 0.001). Animal biting was more frequent among people of age group 21-30 years than other age groups which constituted roughly 27.2% of the cases. There was no significant relationship between the variables of gender and site of the bites victims, (p> 0.05). Domestic dog bite was most frequent, found in 66.7% cases. 83.9% victims had been uncompleted vaccinated and 16.1% were completed.

CONCLUSION

Since, the cost of conservation was high for the health system after biting, preventive programs should be concentrated on public health instructions, particularly in villagers, free occupation and emphasis to ranchers that have collar dogs during the day.