Hospital referral, further investigation, wound closure

• further investigations include:
  • FBC and U+Es be carried out in patients with severe wounds or who are systemically unwell
  • X-rays or ultrasound examination should be carried out if the bite is on the hand or could have damaged bones or joints, or if a foreign body could be lodged in the wound or in the bone
    
    
• hospital admission and referral
  • due to the high risk of penetrating injury and bone, joint or tendon damage or infection, people with bites must be referred to a plastic or orthopaedic surgeon for surgical exploration, washout and debridement if they have crush wounds; puncture wounds over or near a joint or tendons; bites on the hand or forearm; bites with significant necrosis; or where a foreign body may be present
  • hospital admission may be indicated if a patient has fever; sepsis; spreading cellulitis; significant oedema or crush injury; loss of function in an affected limb; or they are immunocompromised or unlikely to adhere to therapy
  • patients exposed to simian herpes virus should be hospitalised and isolated with strict barrier precautions
    
    
• wound closure:
  • bite wounds carry a high risk of infection owing to inoculation of oral bacteria
  • not all wounds should be closed
  • wound closure considerations (2)
    
    • small wounds
      • may be left open to heal by secondary intention with daily non-stick dressing changes until the skin has re-epithelialised
    • gaping wounds
      • can be approximated and closed after copious irrigation and debridement
    • wounds to the face from any animal
      • can be closed (for cosmesis; the face has no higher risk of infection than elsewhere)
    • feline bite
      • should avoid closing all non-facial wounds
    • canine bites
      • majority can be closed except in the hands or feet, where infection risk is much higher
    • human bites
      • should avoid closing non-facial wounds or facial wounds more than 24 hours after injury
      • requires follow up with a plastic surgeon
    • puncture wounds
      • have an especially high risk of infection
      • should let all puncture wounds heal by secondary intention (after irrigation)
• tetanus prevention - see linked item

Reference:

1. Drug and Therapeutics Bulletin (2004);42:65-72.
2. Colmers-Gray I N, Tulloch J S, Dostaler G, Bai A D. Management of mammalian bites BMJ 2023; 380 :e071921 doi:10.1136/bmj-2022-071921