Education and follow-up/referral

The patient and family need to be educated on wound care at home. To help reduce pain and swelling, apply ice to the affected area for 15 minutes every hour for the first 24 hours. Keep the wound elevated and immobilized for 48 hours.15 Wash the wound with soap and water and pat dry. Do not soak the wound. Instruct patients given antibiotics to take all the medication as prescribed without skipping or doubling doses. Tell the patient and family to return to the clinic if any signs or symptoms of infection emerge or if severe pain continues beyond 24 hours. Otherwise, patients should follow up with a primary-care provider within 48 hours. Referral to multidisciplinary services, such as plastic surgery, orthopedics, and wound-care specialists, should be made as indicated. Finally, report the incident to animal control as required by local and state law. 

Provide information on dog-bite prevention. This is available from both the American Veterinary Medical Association and the CDC.17,18 It is important to teach young children about safety around dogs and review the information with them regularly in an age-appropriate manner. Families considering adding a dog to the home should be encouraged to speak first with their primary-care provider and veterinarian. It is important to match the temperament of the dog to the age and activity levels of all family members. Unfortunately for many victims, most people do not receive prevention information until the first incident occurs. After a dog bite, all patients and families need to be educated on how to prevent future accidents.


Continue Reading

Dog-bite protocol algorithm

A methodical approach is essential to effectively treat dog bites and help provide the best possible outcomes. An algorithm for use as a tool for the systematic assessment and management appears in Figure 2. The versatility of the algorithm can aid practitioners in multiple settings from primary care and urgent-care clinics to EDs. Even with the algorithm, the practitioner must use reasonable judgment, and treatment may need to be adjusted for special situations.

Conclusion

The best dog bite is one that is prevented. Anyone can learn to reduce his or her chances of being bitten. Education alleviates patient and family suffering and eases the burden on the health-care community. Research shows that proper initial management can reduce adverse sequelae related to dog bites as well as cut health-care costs for repeat treatment. Finally, prompt wound management and judicious use of antibiotics decrease antimicrobial resistance and infection incidence.19

Ms. Rizzo is a family nurse practitioner at Metropolitan Methodist Hospital in San Antonio. Ms. Lefner is a family nurse practitioner in private practice in San Antonio. Dr. Gerardi is assistant professor in the Department of Family Nursing Care at The University of Texas Health Science Center at San Antonio.

References
1. Centers for Disease Control and Prevention (CDC). Nonfatal dog bite-related injuries treated in hospital emergency departments—United States, 2001. MMWR Morb Mortal Wkly Rep. 2003;52:605-610. Available at www.cdc.gov/mmwr/preview/mmwrhtml/mm5226a1.htm. Accessed September 2, 2008.
2. Stump JL. Bites, animal. Available at www.emedicine.com/emerg/topic60.htm. Accessed September 2, 2008.
3. Centers for Disease Control and Prevention. Hospitalizations for dog bite injuries. Available at www.cdc.gov/ncipc/duip/hospital.htm. Accessed September 2, 2008.
4. Morgan M, Palmer J. Dog bites. BMJ. 2007;334:413-417.
5. Kravetz JD, Federman DG. Mammalian bites. Available at pier.acponline.org/physicians/public/d987/d987.html. Accessed September 2, 2008.
6. Lewis KT, Stiles M. Management of cat and dog bites. Am Fam Physician. 1995;52:479-485, 489-490.
7. Bower MG. Managing dog, cat, and human bite wounds. Nurse Pract. 2001;26:36-38.
8. Centers for Disease Control and Prevention. Emergency wound management for healthcare professionals. Available at www.bt.cdc.gov/disasters/emergwoundhcp.asp. Accessed September 2, 2008.
9. Callaham M. Prophylactic antibiotics in dog bite wounds: nipping at the heels of progress. Ann Emerg Med. 1994;23:577-579.
10. Smith MR, Walker A, Brenchley J. Barking up the wrong tree? A survey of dog bite wound management. Emerg Med J. 2003;3:253-255.
11. Villani NM. Treating dog and cat bites. Adv Nurse Pract. 2006;14:44-45.
12. Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database Syst Rev. 2001;(2):CD001738.
13. American Academy of Pediatrics (2000). Red Book: Report of the committee on infectious diseases (25th ed.). Elk Grove Village, Ill.: American Academy of Pediatrics.
14. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41:1373-1406. Available at www.journals.uchicago.edu/doi/pdf/10.1086/497143. Errata in Clin Infect Dis. 2005;41:1830 (available at www.journals.uchicago.edu/doi/pdf/10.1086/499250) and Clin Infect Dis. 2006;42:1219, dosage error in text (available at www.journals.uchicago.edu/doi/pdf/10.1086/503575). All electronic documents accessed September 2, 2008.
15. Presutti RJ. Prevention and treatment of dog bites. Am Fam Physician. 2001;63:1567-1572. Available at www.aafp.org/afp/20010415/1567.html. Accessed September 2, 2008.
16. Kretsinger K, Broder KR, Cortese MM, et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep. 2006;55(RR-17):1-37. Available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm. Accessed September 2, 2008.
17. Manning SE, Rupprecht CE, Fishbein D, et al. Human rabies prevention—United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2008;57(RR-3):1-28. Available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5703a1.htm. Accessed September 2, 2008.
18. American Veterinary Medical Association Task Force on Canine Aggression and Human-Canine Interactions. A community approach to dog bite prevention. J Am Vet Med Assoc. 2001;218:1732-1749.
19. World Health Organization. WHO Global Strategy for Containment of Antimicrobial Resistance. Available at www.who.int/drugresistance/WHO_Global_Strategy_English.pdf. Accessed September 2, 2008.