Dog bite

Question 1

A 60 year old lady has been bitten by a dog on the hand 4 days ago. on exam she has a swollen hand and is unable to make a fist. How will you assess and manage this patient?

Answer 1

Impression
With dog bite and hand swelling + limited ROM, I am concerned about a complication with cellulitis or erysipelas.

Other DDX
- MSK: tenosynovitis, tendon rupture, fractures, other soft tissue injury leading to swelling

GOals

• targeted Hx/Ex/Ix, rule out systemic infection
• likely begin IV antibiotic therapy, and involve ortho for ?washout/debridemount for definitive mx

Question 2

Dog bite - History

Answer 2

History

• PC: pain (SOCRATES), onset, timing, progression of pain/swelling/limited ROM
• HPI: how has patient been managing wound since? betadine/other dressings
• REDs: fevers, chills, rigors, hypotension, loc/drowsiness
• when was last tetanus booster
• RISKS: immunocompromised, diabetes, steroids
• PMHx, meds, allergies
• Social: what patient does for work, functional impairment
• SNAP

Question 3

Dog bite - Examination

Answer 3

Examination

• general appearance + vitals
• Hand exam: inspection (erythema, swelling), active ROM, passive ROM, inspect wounds for signs of infection
• systems review for systemic infection

Question 4

Dog bite - Investigations

Answer 4

Investigations
Key:
- Swab of wounds for MCS
- Septic screen if indicated on h/e
- X-ray for bony injuries

Other
- bloods: FBC, CRP, UEC, VBG

Question 5

Dog bite - Management

Answer 5

Management

Definitive;
- Presumptive therapy if no infection but risk factors (hand, face, feet, immunocompromised, presentation delayed > 8 hrs, puncture wound, etc)
o amoxicillin + clavulanate PO
- Empirical therapy if evidence of infection
o Augmentin PO or IV
- Empirical therapy if systemic signs of illness
o Augmentin IV
o Vancomycin if MRSA risk
change agents according to eTG if hypersensitivity to penicillins
- ortho referral for debridement and washout in theatres

Supportive

• wound care
• GP follow-up
• stitching for primary closure of any wounds
• analgesia, antipyretics
• fluids if hospital stay for IV
• NBM for theatres