CHAPTER 46: Puncture Wounds and Bites

Question 1

A wound whose depth is greater than its width

Answer 1

Puncture wound

Question 2

TRUE or FALSE?

Puncture wounds are associated with lower incidence of infections and complications.

Answer 2

FALSE
Puncture wounds are problematic regardless of location and are independently associated with higher incidence of infections and complications compared to other wounds.

Question 3

The rate of infection from puncture wounds associated with dog bites is about —?—%

Answer 3

10% to 11%

Question 4

Organisms causing most of soft tissue infections from puncture wound

Answer 4

Gram-positive organisms

Staphylococcus aureus predominates

Question 5

Most frequent pathogen isolated from plantar puncture wound-related osteomyelitis particularly when the injury occurs through the rubber sole of an athletic shoe

Answer 5

Pseudomonas aeruginosa

Question 6

• Elderly
• Diabetes +/- microvascular complications
• Immunocompromised
• Peripheral vascular disease

Answer 6

Patient characteristics as Risk Factors for Puncture Wound Complications (Table 46-1 page 318)

Question 7

TRUE or FALSE?

Wounds >4 hours old with increasing pain and redness are likely infected.

Answer 7

FALSE

Wounds >6 HOURS old with increasing pain and redness are likely infected.

Question 8

TRUE or FALSE?

Probing the wound with a blunt instrument to assess depth and the presence of a foreign body is of unproven utility.

Answer 8

TRUE
Practice of probing the wound with a blunt instrument to assess depth and the presence of a foreign body is of unproven utility, but may improve the ability to cleanse wounds.

Question 9

Plain radiographs will detect >90% of radiopaque foreign bodies —?— mm in diameter

Answer 9

> 1 mm in diameter

Question 10

Foreign object that is difficult to visualize with any imaging modality

Answer 10

Rubber from athletic shoes

Question 11

TRUE or FALSE?

Traditional wound-cleaning techniques are largely ineffective in puncture wounds.

Answer 11

TRUE
Traditional wound-cleaning techniques are largely ineffective as a result of the small entrance wound that has often spontaneously sealed by the time of presentation.

Question 12

The hallmark of all infectious complications of puncture wound

Answer 12

Persistent pain

Question 13

Cellulitis usually presents within —?— days after injury

Answer 13

within 4 days after injury

Question 14

Complication of puncture wounds is usually associated with a retained foreign body

Answer 14

Localized abscess

Question 15

Complication of puncture wounds with key physical examination finding is tenderness, redness, or swelling remote from the puncture site

Answer 15

Deep soft tissue infection

Question 16

Is the most disastrous consequence of puncture wounds

Answer 16

Osteomyelitis

Question 17

Patients with osteomyelitis present often —?— days after injury

Answer 17

often >7 days after injury

Question 18

The imaging modality most helpful in the diagnosis of osteomyelitis

Answer 18

MRI

Question 19

Risk of infection in a nonimmune recipient after an inadvertent needlestick contaminated from an infectious source
Hep A: —?—
Hep B: —?—
Hep C: —?—
HIV: —?—

Answer 19

Hep A: negligible
Hep B: 37 to 62%
Hep C: 2%
HIV: 0.3%

Question 20

Risk of subsequent amputation in high-pressure injection injuries is reduced if surgical debridement is performed within —?— hours of the injury

Answer 20

within 6 hours of the injury

Question 21

The natural history of epinephrine autoinjector injury is spontaneous resolution from -?— hours

Answer 21

from 6 to 13 hours

Question 22

Is the one treatment consistently described that rapidly reverses digital ischemia from accidental epinephrine injection but is rarely indicated

Answer 22

Phentolamine
Dose: 1.5 to 3.0mg
0.5 mL phentolamine solution (5 mg/mL) + 0.5mL of 1% lidocaine
(1-mL total volume containing 2.5 milligrams of phentolamine that can be subcutaneously injected)

Question 23

Primarily closure of the bite wound with percutaneous sutures has a risk of postrepair wound infection of —?—

Answer 23

5% to 15%

Question 24

Dog bites in immunocompromised individuals most often due to this organism

Answer 24

Capnocytophaga canimorsus

Question 25

TRUE or FALSE?
Wound closure of bite wound is associated with a small increased risk of local wound infection and unlikely enhance the risk of serious systemic infection from Capnocytophaga.

Answer 25

TRUE
Wound closure of bite wound is associated with a small increased risk of local wound infection, but is unlikely to enhance the risk of serious systemic infection from Capnocytophaga, unless the patient is immunodeficient or the wound is at high risk of infection.

Question 26

TRUE or FALSE?

Primary wound closure should be avoided in patients with systemic immunodeficiencies

Answer 26

TRUE
The current practice is to avoid primary wound closure in patients with systemic immunodeficiencies and higherrisk wounds.

Question 27

Only approximately —?—% of dog bites will become infected

Answer 27

approximately 5%

Question 28

Up to —?—% of cat bites that present for care will become infected if untreated

Answer 28

Up to 50%

Question 29

Common organisms obtained from this animal bite:
Pasteurella multocida
Bartonella henselae

Answer 29

Cat
Tx: Amoxicillin-clavulanate; Azithromycin
Common Bites and First-Line Treatment (Table 46-4 page 322)

Question 30

Common organisms obtained from this animal bite:
Pasteurella
Streptococci
Staphylococci
Capnocytophaga canimorsus

Answer 30

Dog
Tx: Amoxicillin-clavulanate
Common Bites and First-Line Treatment (Table 46-4 page 322)

Question 31

Common organisms obtained from this animal bite:
Eikenella
Staphylococci
Streptococci
Herpes simplex (herpetic whitlow)

Answer 31

Human
Tx: Amoxicillin-clavulanate; Cephalexin; Acyclovir or valacyclovir
Common Bites and First-Line Treatment (Table 46-4 page 322)

Question 32

Common organisms obtained from this animal bite:
Streptobacillus moniliformis (North America) or Spirillum minus/minor (Asia)

Answer 32

Rats, mice, squirrels, gerbils
Tx: Amoxicillin-clavulanate
Common Bites and First-Line Treatment (Table 46-4 page 322)

Question 33

Common organisms obtained from this animal bite:
Multiple organisms
Brucella
Leptospira
Francisella tularensis

Answer 33

Livestock, large game animals
Tx: Amoxicillin-clavulanate or specific agent for disease
Common Bites and First-Line Treatment (Table 46-4 page 322)

Question 34

Common organisms obtained from this animal bite:

Rabies

Answer 34

Bats, monkeys, dogs, skunks, raccoons, foxes (all carnivores and omnivores)
Tx: Rabies immune globulin, rabies vaccine
Common Bites and First-Line Treatment (Table 46-4 page 322)

Question 35

Common organisms obtained from this animal bite:

Herpes B virus (Cercopithecine herpesvirus)

Answer 35

Monkeys
Tx: Acyclovir or valacyclovir
Common Bites and First-Line Treatment (Table 46-4 page 322)

Question 36

Common organisms obtained from this animal bite:
Aeromonas spp.
Staphylococci
Streptococci

Answer 36

Freshwater
Tx: Fluoroquinolone or TMP-SMX
Common Bites and First-Line Treatment (Table 46-4 page 322)

Question 37

Common organisms obtained from this animal bite:
Vibrio
Staphylococci
Streptococci

Answer 37

Saltwater
Tx: Fluoroquinolone; Doxycycline
Common Bites and First-Line Treatment (Table 46-4 page 322)

Question 38

Is the antibiotic most commonly recommended for prophylaxis of uninfected wounds and for treatment of local infections following dog, cat, or human bites.

Answer 38

Amoxicillin-clavulanate

Question 39

Antibiotic adequate for Pasteurella multocida

Answer 39

Penicillin V OR Ampicillin

Question 40

Alternative antibiotic for patients with CAT bites who has penicillin allergy

Answer 40

Doxycycline OR Cefuroxime

Question 41

Alternative antibiotic for patients with DOG bites who has penicillin allergy

Answer 41

Clindamycin PLUS Fluoroquinolone

Question 42

Antibiotics that should not be used alone for dog or cat bites

Answer 42

Cephalexin
Dicloxacillin
Erythromycin
Clindamycin

Question 43

Capnocytophaga canimorsus produces a rare but fulminant bacteremic illness after a dog bite, with fatal multiorgan failure, particularly in patients with these conditions with:

Answer 43

Splenectomy
Alcoholism
Immunosuppressive disorders

Question 44

Is a clinical syndrome of regional lymphadenopathy developing 7 to 12 days after a cat bite or scratch

Answer 44

Cat-scratch disease

caused by Bartonella henselae

Question 45

Most cases of Cat-scratch Disease with only lymph node involvement resolve in —?— months

Answer 45

2 to 5 months

Question 46

TRUE or FALSE?

Human bites are treated as non-contaminated wounds.

Answer 46

FALSE

All human bites should be treated as contaminated wounds.

Question 47

Is a common human bite injury incurred when a flexed knuckle strikes a human tooth in the course of an altercation

Answer 47

Closed-fist injury

Question 48

Primary closure of human bite wounds to the face is associated with a postrepair wound infection rate of approximately —?—%

Answer 48

approximately 10%

Question 49

Is cost effective and adequate as an initial agent in human bite injuries

Answer 49

Cephalexin

Question 50

Is a local infection caused by HSV after a human bite or contact with infected saliva

Answer 50

Herpetic whitlow

Tx: oral acyclovir (7 to 10 days) OR topical acyclovir ointment (7 to 14 days)

Question 51

Consists of two similar febrile illnesses occurring after a small percentage of bites from rats, mice, squirrels, or gerbils

Answer 51

Rat-bite fever
(caused either by either Streptobacillus moniliformis (North America) or Spirillum minus/minor (Asia))
Tx: IV penicillin (5 to 7 days) followed by oral penicillin (addt’l 7 days)

Question 52

Disseminated viral illnesses resulting from mammalian bites

Answer 52

Rabies
Hepatitis
Herpes B virus
HIV

Question 53

Human infection with B virus (Herpes B/Macacine herpesvirus 1) these complications

Answer 53

Myelitis & Hemorrhagic encephalitis

case fatality rate of 70%

Question 54

TRUE or FALSE?

Viral hepatitis and HIV can both be transmitted by a human bite.

Answer 54

TRUE
Viral hepatitis and HIV can both be transmitted by a human bite, although HIV viral concentration in nonbloody saliva is thought to be relatively low.