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Medical Author:

Scott D Fell, DO, FAAEM

Medical Editor:

Jerry R. Balentine, DO, FACEP

Jerry R. Balentine, DO, FACEP

Dr. Balentine received his undergraduate degree from McDaniel College in Westminster, Maryland. He attended medical school at the Philadelphia College of Osteopathic Medicine graduating in1983. He completed his internship at St. Joseph's Hospital in Philadelphia and his Emergency Medicine residency at Lincoln Medical and Mental Health Center in the Bronx, where he served as chief resident.

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The doctor will assess the risk of infection, look for other injuries, and try to minimize any scarring or deformity from an animal bite. Additional questions will help clarify if the patient needs tetanus vaccination, and if there is a risk of rabies exposure.

Inspection: The wound will be thoroughly examined to look for any debris such as dirt, grass, teeth, clothing, or other objects that may have become embedded into the bite area. Leaving behind any of these would increase the risk for infections significantly. Sometimes the wound will be numbed with lidocaine to decrease pain while the doctor makes a complete inspection of the area. This is not always necessary and depends on the extent of the injury.

X-rays: The doctor may order X-rays to look for fractures of bones or to make sure nothing remains in the wound. Although certain objects such as metal always show up on X-ray, some objects such as dirt and grass do not usually appear. That's why careful inspection and washing out the wound are key to proper care. Despite best efforts, there is always a risk that foreign material will be missed and may be in the wound.

Irrigation: This is very important to preventing infection as it helps clean the wound of debris. Several techniques are used but the idea is the same. The health care professional will spray irrigation solution (usually saline solution or tap water) into the wound with either an irrigation device or a syringe (without the needle) in order to wash out anything that may contaminate the wound. Despite best efforts and intentions, infections can and still do occur in animal bites.

Debridement (tissue removal): Dog bites are noted for being crush type injuries. This will macerate and tear apart the skin and tissue in humans. The result is that skin tears often are not repairable because of the amount of damage or the significant crushing mechanism. These areas usually have either no blood supply to them or decreased blood supply and will not survive and are considered to be dead tissue that needs to be removed. The risk of infection increases significantly in these types of crush injuries.

• In some cases, it may be necessary for the doctor to remove or debride the skin. This involves numbing the wound with lidocaine and then cutting the skin with either small scissors or a scalpel to remove the tissue.
• This not only will reduce the risk of infection but also will promote quicker healing and may even allow the doctor to obtain better wound closure.

Closure: Not all animal bites need to be or can be closed with stitches. Some wounds are sutured (stitched) immediately after they occur (this is referred to as primary closure). Some are repaired a few days later (referred to as delayed closure). Some animal bites are never sutured.

• Relatively clean wounds or those that can be easily cleansed may be stitched immediately. Also bites to cosmetic areas (such as the face) are usually sutured immediately. The patient's health care professional will discuss the advantages and risks of primary closure with the patient.
• Delayed closure or no closure at all will most likely occur in any wound that is on an arm or leg because of decreased blood flow and increased risk of infection. Also, delayed closure is more likely if the wound is heavily contaminated (dirty) or has a significant amount of tissue damage or crushed tissue. It is important to note that animal bites to the hand have a very high risk of infection so they are generally not sutured immediately. Bite wounds to hands are excellent candidates for delayed closure.
• Keep in mind that the potential for scarring is increased when a wound or bite is not closed or sutured at the time of the event. Unfortunately this has to be the case in some settings as the risk of an infection is too great to allow the health care professional suture the wound. Sometimes the health care professional will suture the wound, but will usually have a detailed discussion with the patient prior regarding the risks of infection and the signs and symptoms to monitor in the event that an infection does begin, and what to do in that situation.

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