Plastic Surgery/Wound Repair

19.1 Bites

Curr Clin Top Infect Dis 1999;19:99; Nejm 1999;340:138

Cause: Human, domestic or wild animal bite, or awakening in a room/tent with a bat as additional occupant (Wis Med J 1996;95:242).

Epidem: Pastuerella multocida is in > 50% of animal bite and cat scratch infections; polymicrobial infections in human and mammalian bite wounds (Nejm 1999;340:85); Higher risk in animal control officers (Am J Public Hlth 1984;74:255).

Pathophys: Inoculation of bacteria—cat bites frequently become infected because of deep inoculation; possible rabies virus in unvaccinated or wild animal saliva; envenomations (see p 87).

Sx: Obvious wound; may lack obvious wound for those with bat bites.

Si: Wound—note tenderness, erythema pattern, adenopathy, depth, and discharge; evaluate distal neurovascular status, check for tendon injury.

Crs: Varies with potential need for rabies prophylaxis.

Cmplc: Cellulitis, lymphangitis, tenosynovitis, or osteomyelitis (Arch EM 1992;9:299); rabies; sepsis—infections more common in those who are immunosuppressed such as those with DM.

Lab: Uncomplicated bites without specific lab evaluation; consider CBC with diff, ESR, wound gram stain, and culture for those with more significant infections.

For assailant in human bites, obtain HIV, Hep B, and Hep C, if possible.

X-ray: Consider for osteomyelitis, look for periosteal reaction—not seen acutely.

Emergency Management:

Clean wound, soap, and water as good as anything else.
Update/initiate Tetanus if needed (see p218).
Treat for rabies if mammalian bite from unvaccinated animal such as dog, cat, bat, fox, raccoon, or skunk, with no quarantine ability of attacking animal, or if awakened with bat in the same room (see p208). Not usually seen in mice, squirrels, or other rodents, nor rabbits.
For envenomations, see p87.
Do not close wounds if possible, although those on the head and neck may be closed if repaired within 12 hr (Ear Nose Throat J 1998;77:216). If closing on other areas of the body, consider placing a drain and do not use tissue adhesives for any bite wound closures. Debride all devitalized tissue, surgical consult if this extends beyond the myofascial plane or into tendons, ligaments, joint spaces, or bone.
Splint and elevate the injured area.
Consider oral prophylactic antibiotics for human bites (Plast Reconstr Surg 1975;56:538), especially to any part of the hand, and all animal bites (Arch EM 1989;6:251). Human and Animal bites—first choice is amoxicillin/clavulanate 875 mg bid for 3-5 d, or clindamycin 300 mg qid combined with ciprofloxacin 500 mg bid or TMP/SMX DS 1 pill bid; second choices include doxycycline 100 mg po bid or cefuroxime 500 mg bid.
If antibiotics for rx of minor infection, such as cellulitis or minimal lymphangitis (no adenopathy) in an otherwise healthy person, first dose iv, such as ampicillin/sulbactam 1.5-3 gm, home with amoxicillin/clavulanate 875 mg po bid or one of the previous choices under prophylaxis, but treat for 10 d, and have next day follow-up—probably in the ER.
For more serious infections, iv antibiotic as above, and ortho/plastics/general surgery consult (one of these) for admission.

19.2 Topical and Local Anesthesia

Selection and site of appropriate anesthesia is important for surgical procedures. All infiltration should be done through the cleanest field possible, and nerve blocks should have sterile prep performed.

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