First of all, from a plastic surgery perspective, I disagree with many online recommendations for treating dog and animal bites. There is no question that most dog bites heal reasonably well, but is reasonably well good enough if it is your face, or your child? When I started doing things a little differently, initially my colleagues were a bit skeptical. Six months later I was getting calls for most of their family members’ dog bite injuries.
What’s my secret? Antibiotics, meticulous attention to anatomy, gentle tissue handling, no aggressive debridement, early mini-drainage, regular soapy water washing of bite sites and a staged closure approach.
Did you know that there are almost 70 million pet dogs and 74 million pet cats in the United States? The CDC report estimates about 4.5 million dog bites each year in the US. About 900,000 patients seek medical attention every year due to dog bite injuries. However, many dog owners do not report the bites and do not seek medical attention for every bite. Based on my personal experience with my own dog, and I have one mean Chihuahua, I would estimate that the number of total bite events is at least 3 to 4 times greater than the CDC estimates if not more.
The risk of being bitten by a dog increases if there is a dog in the household. Men are bitten more often than women, and women on the other hand are more commonly bitten by cats. Children between the ages of 5 and 9 years old are more common victims of pediatric dog bites. Children are also more likely to be treated for dog bites than adults.
WHAT TO DO IF BITTEN BY A DOG OR ANIMAL:
Place victim in safe location
Remove the assailant (dog other animal) to prevent additional injury
Evaluate Airway, Breathing and Circulation – CPR basics
Call 911 and request ambulance if indicated
Caregiver must wear protective gloves.
Control bleeding with gentle pressure and proceed to the closest Emergency Room or Urgent Care facility, or wait for medical assistance to arrive after dialing 911.
Elevate bite area
Wash the injured area with sterile, or clean water, or cooled down previously boiled water or mild soap solution. Make sure to wash inside the wound. Using a clean spray bottle, shower head, or tap water spray nozzle, washing the wound can help in decreasing risk of infection. Cleaning should take at least 10-20 minutes, not 5. You might be surprised how long 15 minutes can be if you actually watch the clock.
Apply sterile dressing
Despite popular belief and recommendation on some web sites, antibiotic ointments are not very effective in preventing infections, I personally feel that they create more problems than they solve during first week. I do not recommend the use of alcohol and peroxide on the open bite wounds since they can create chemical damage to open wound tissues on top of potential infection. The idea behind the use of peroxide is for bubbles of oxygen to clean the dirt out of tissues. If you are determined to use it, I suggest diluting commercially available Peroxide solution at least 5 times with saline or water solution to decrease the toxic effect.
If possible, obtain information from owner on animals immunization status as this information will be needed in the medical facility to determine in rabies prophylaxis is needed. If dog is unknown, wild or immunization status is unclear, rabies immunization must be started as soon as possible. Please remember that if rabies treatment is started early, rabies can be prevented, if the patient ignores medical care and presents to medical facility with clinical signs of rabies, the disease almost always lethal, or leads to death.
Obtain information on tetanus immunization of the victim.
What needs to be treated when a dog or animal bite occurs?
When treating animal bite victims, the care is focused on three objectives – repair skin, repair underlying structures (bones, tendons, nerves, vessels, muscles, joints, etc.) and prevent infection.
The amount of skin damage may or may not reflect the extent and complexity of the deep structure injury. The anatomic structures of the extremities, hands, feet, or face are very dense and the victim might have extensive injuries to multiple important anatomic structures with fairly small but deep external wounds. This is why it is very important that the treating physician is intimately familiar with regional anatomy and with the expertise to properly test all anatomic structures in the zone of injury.
It is estimated that 64 different species of bacteria are found in the canine mouth, and the most common are Staphylococcus, Streptococcus, Eikenella, Pasteurella, Proteus, Klebsiella, Haemophilus, Enterobacter, Bacteroides, Moraxella species , Corynebacterium, Neisseria, Fusobacterium, Prevotella , Porphyromonas, and many others. A medical study reports that 25-75% of animal bites can become infected. However, in my book 100% of them are severely contaminated. Even if there is no clinical infection, the cosmetic deformity can be very significant. I surgically close dog bite wounds ONLY if I am able to fully remove injured area. If not, I repair deep structures injured during the bite and close skin loosely to allow drainage. Also I use micro-drains to further improve the result.
This part is, perhaps, the most important to create better results. I believe that in spite of the most careful and diligent washing and cleaning, it is impossible to fully remove contamination from the tissues. With antibiotics, a full blown infection may not occur, however what I used to see is a sub-clinical infection. It presents as prolonged inflammation, redness, tenderness, but without fever, chills, or pus. Some surgeons believe that this is the normal part of healing for bite wounds... and I used to agree. However, now I believe that after a bite injury, the subcutaneous fatty tissues under the skin are subjected to stress from the mechanical effect of the injury, surgery, and low grade infection. Some of the tissues could survive if not exposed to low levels of bacterial contamination which tips them over to not surviving. As the result, patients lose pockets of fatty tissue under the skin and it creates unsightly indentations, commonly visible in kids. My solution is to use micro-drains for the first week. This allows the toxic substances to escape the wound site and allows more tissues to survive. The results are better because of less scar tissue formation, less indentations and overall a more natural result. Some of my colleagues may feel that I am over complicating things but I like my results better and my patients are happier, so I think my way is successful.
The most common antibiotic used for treatment of bites is Augmentin. The first dose can usually be given intravenously in the hopsital and the rest as pills at home twice a day. It is important to take antibiotics with food and add a probiotic to the regimen. Tthe most common problem with Augmentin is gastrointestinal complications.
For patients allergic to Penicillins, I recommend Clindamycin, Doxycycline, combined with Bactrim.
Taking antibiotics is not a substitute for proper local wound care with soap and water. I do not recommend use of antibiotic ointments earlier than 5-7 days after bite injury. Obviously, there is a reason for that also.
When to seek medical care for a dog or animal bite:
The patient or parent commonly have to make a decision if they need to be seen in the hospital or other medical facility. Here are more common reasons to seek medical care:
Dog is unknown
Immunization status is unknown
Patient is a minor
Bites are deep,
Persistent bleeding from bite site
Changes in function or sensation of the injured area
Infection or signs of infection
Patients with a weakened immune system, such as on steroids, on immuno-suppressants, transplant patients, HIV, elderly, malnourished, patients with diabetes, liver disease, kidney disease, on dialysis, with cancer, etc
Bites around the face, neck or/and extremities
Wound is larger than 1-2 cm
What is the rabies prophylaxis for a dog or animal bite?
A rabies vaccination involves 3 shots, first dose right away after the bite, second dose 1 week later and the third one 3-4 weeks after the second dose.
What is the healing time after a dog or animal bite?
The initial healing will take several weeks but final healing of the skin and deep tissues may take as long as 9-12 months. Some patients may experience chronic pains and discomfort at the bite sites for several years especially if patients are older and / or injuries involved deeper structures, such as tendons, nerves and joints.
Long term reconstruction after dog or animal bites
Some patients present to our office after being treated at other locations complaining about the very deformities I am trying to avoid from the start. The reconstruction of deformities may require a deep tissue rotation to improve the shape, fat or fascia grafting to correct indentations, and / or scar revisions.
In many cases these reconstructive surgeries are covered by insurance, especially in children.
If you or your loved one has endured a dog or animal bite, and you would like our board certified plastic surgeon, Dr. Boris Volshteyn, to evaluate and treat the wound, please have your emergency treating physician, or yourself call our office as soon as possible 732-641-3350 and follow the prompts to reach Dr. Volshteyn directly.