Dog Attack !

Dog Bite Injuries

Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences
Clinical Professor of Emergency Medicine
George Washington University

Dog Bite Injuries

Lecture Outline

Epidemiology
Clinical management
Sample cases
Advice on prevention
Rabies
Epidemiology
Recognition
Prophylaxis

Relative Annual Human

Death Rates (Worldwide)
Suicides : 400,000
Murders : 200,000
Snakebites : 60,000
Crocodiles : 1,000
Farm animals : 800 (mostly from kick injuries)
Tigers : 500 (?)
1 million people eaten over last 5 centuries
Lions : 400
Leopards : 300
So people are far
Hippos : 300
more dangerous to
people than are
Elephants : 200
animals !
Dogs : ? several hundred

Human Injuries from Wild Wolves

Asian Wolf is extremely dangerous
Reports of packs attacking rural villages
High incidence of rabies in Central Asia and
Iran
By contrast, for the two North American wolf
species (Gray and Red) there are no reports of
unprovoked human attacks in the last century
Bites from North American coyotes also very rare
unless directly provoked

Mammal Bites By Species in the

U.S.
New York City
Dogs
: 89 %
Cats
: 4.6 %
Rodents : 2.2 %
Humans : 3.6 % !
Ohio
Dogs
: 91.6 %
Cats
: 4.5 %
Rodents : 3 %
Humans : 0.03 %

Mammal Bites : Epidemiology

in U.S.

> 50 million pet cats & dogs in U.S.

> 1,000,000 bites / year in U.S.
200 to 800 bites / 100,000 people per year
80 to 90 % of bites due to dogs
1 to 2 % of bites need admission
10 to 12 deaths from dog bites per year
Tremendous economic cost

More Dog Bite Epidemiology

Overall 60 % of cases in males
Death rate 0.05 per 100,000 in U.S.
0.004 per 100,000 in Australia
70 to 80 % of deaths in children less than 10 years old
Next most common age group for death is > age 70
Highest incidence in one year old children in some
studies
For each U.S. fatality, there are 670 hospitalizations
and 16,000 E.D. visits
About 50 % of injuries in children are to face & scalp

Risk Factors for Death from

Dog Bites in U.S. Studies

More than one dog involved (64 %)

Owner's property (70 %)
History of prior aggression
Sleeping infant
Child's unauthorized access to fenced
yard or leashed dog
Dog escaping enclosure or restraint
Certain breeds (next 2 slides)

Incidence of Dog Bites (By Breed)

Decreasing

German Shepherd : most common

Incidence

Mixed breeds
Doberman
St. Bernard
Great Dane
Rottweiler
Collie
Pekingese

Incidence of Fatal Dog Bites (By

Breed)
Decreasing

Pit bull : most common

Incidence

Mixed pit bull breeds

Rottweiler
German Shepherd
Husky
Alaskan Malamute
Doberman
Great Dane

Fatal Dog Bites

Injuries concentrated about head and
neck (injuries only on limbs in most nonfatal bites)
Fatal attacks cannot be predicted from
the dog's prior behavior
Most offending dogs revert to normal
friendly behavior after the attack
Therefore infants and disabled should
never be left alone with a large dog

Different Bacteria Isolated from Dog

Bite Wounds
(over 50 genuses have been reported)
Most common :
Staph. aureus (30 %)
Staph. epidermidis (10 to 20%)
Strep. various species (50 %)
Corynebacterium (10 to 30 %)
Gram neg. such as E. coli

Anerobes :
Bacteroides
Fusobacterium
Peptostreptococcus
Actinomyces

Less common :
Pasturella multocida (zero
incidence in some reports but
up to 40 % in others)
Pasturella canis
Brucella canis
Eikenella corrodens
Moraxella sp.
Neisseria sp.
Capnocytophaga canimorsus
(DF2)

Capnocytophaga canimorsus
Infections from Dog Bites
Older reports quoted 25 % mortality rate
Can cause septic arthritis, endocarditis, renal
failure, D.I.C., sepsis, and / or meningitis
Recent review of 19 meningitis cases noted only
one death in this group
Immunocompromised, post-splenectomy, and
alcoholic patients at higher risk
Usually sensitive to penicillin, rifampin, &
quinolones
Usually resistant to aztreonam, aminoglycosides,
and trimethoprim

Considerations About Pasturella

multocida Infections from Dog
Bites
Can cause very rapid cellulitis (erythema within 2
hours)
Can cause complications in up to 40 % :
Local septic arthritis
Osteomyelitis
Tenosynovitis
Bacteremia
Rarely pneumonia or pulmonary abscess in
immunocpmpromised patients
Disseminated pasteurellosis in patients with liver
disease

Other Uncommon Dog Bite

Infections

Fungi
Myocobacteria such as M. fortuitum
Clostridium tetani (Tetanus)
Rabies

Average Infection Rates From

Mammal Bites
2 to 5 %*
Dogs :
:
:
Monkeys :
Humans :

Cats
Rats

30 to 50 %
2 to 10 %
25 %
13 to 50 %**

*However up to 30 % for hand bites

**Higher rates reported mainly from delayed
presentations

Dog Bites :
Increased Infection Risk Factors

Age < 2 or > 50 years

Diabetes
Immunosuppressive illness
Chronic alcoholism
Puncture wounds
Large wounds
Extremities
Delayed (> 4 hours) presentation

Dog Bites :
Use of Wound Cultures
Initial (fresh) animal bite wound cultures
:
Not recommended
Initial culture results do not correlate
with later proven infecting organisms
However if the patient presents
delayed, with signs of infection, then
wound cultures are useful

Summary of Emergency
Department Management of
Dog Bite Injuries
Usual assessment for blood loss or dangerous associated
injuries, control any active bleeding.
Consider need for radiographs (see next slide).
Culture wound if already infected or delayed presentation.
Copiously irrigate wound (+/- debridement as needed).
Primary suture repair for most wounds (may elect secondary
delayed closure for large, delayed, already infected, hand, or
foot wounds).
Consider antibiotic prophylaxis.
Consider need for rabies vaccination ; check tetanus status.
Report to police or local animal authority.

Considerations About Radiographs

for Dog Bite Cases
Large dogs can generate forces > 500 footpounds per square inch with their jaws
Therefore can cause extremity long bone
fractures
Also can cause dural penetration from
scalp bites in small children (this can lead
to fatal meningitis if missed in the E.D.)
So skull films may be needed to see if
there is inner table penetration from teeth

Dog Bites :
Rules for Prophylactic Antibiotics
5 studies have found prophylaxis not
indicated
However several studies advise prophylaxis
for hand, foot, and delayed presentation bites
Also consider for very large bites requiring
suture repair, and if any question of tooth
penetration into periosteum
Clearly not needed for simple shallow bites of
the face or scalp

Best Prophylactic Antibiotic

Choices for Dog Bites
Need to cover for Staph. aureus :
Dicloxacillin or cephalexin 500 mg PO qid x 7 days
Erythromycin or azithromycin if patient PCN allergic
Penicillin VK 500 mg PO qid x 7 days if Pasteurella
multocida suspected (Pasteurella usually resistant to
cephalosporins, tetracycline, erythromycin)

Note : Amoxicillin / clavulanate often touted as antibiotic of

choice for bites but THERE IS ZERO LITERATURE EVIDENCE
FOR THIS (is expensive & has high % side effects ; also in my study from
1994 the only empiric failures were in those given amoxicillin / clavulanate)

Dog Bites
Criteria for Hospital Admission
Admit to hospital if :
Patient presents with deep established
infection
Possible penetration of joint capsule
Surgical (Operating Room) repair required
Such as for tooth penetration of dura
Associated fracture present

Dog bite lacerations of the face

Same patient after primary suture repair

Same patient after healing, with good cosmetic outcome

Left flexor tenosynovitis from dog bite requiring surgical

management

Child bitten by a ferret

Another child bitten by a ferret

All these should have primary suture repair

Facial
lacerations from
dog bite before
and after repair

Cost Comparisons of Some

Rx Items for Animal Bites
(Pennsylvania, 2006)

Penicillin VK 500 mg PO qid for 7 days :

Dicloxacillin 500 mg PO qid for 7 days :
Cefalexin 500 mg PO qid for 7 days :
Augmentin 500 mg PO tid for 7 days :
Cefazolin 1 gram IV :
Nafcillin 1 gram IV :
Ceftriaxone 1 gram IV :
5 cc. Rabies Immune Globulin IM :
5 one cc. doses HDCV :
Wound culture / sensitivity :

$ 4.20
$ 11.76
$ 6.44
$ 40.32
$ 0.89
$ 5.83
$ 32.21
$ 302.85
$ 517.80
$ 66.00

Note : the IV costs listed do not include the nursing

administration fees

Aspects of Dog Behavior Which

Influence Dog Bite Prevention
Measures

Dogs sniff as a means of communication

Dogs like to chase moving objects
Dogs run faster than humans
Screaming may incite predatory behavior
Direct eye contact may be interpreted as aggression
Lying on the ground provokes attack
Dogs tend to attack extemities, face, and neck
Dogs which are fighting tend to bite at anything else
that is near

Standard Advice to Lessen

Risk of Dog Bite Attacks

Before petting a dog, let it sniff you

Do not run past dogs
Do not try to outrun a dog
Remain calm if a dog approaches
Do not hug or kiss a dog
Avoid direct eye contact with dogs
If attacked, hold feet together and protect neck and
face
Do not try to stop 2 fighting dogs
Do not disturb a dog which is eating, sleeping, or
caring for puppies
Educate children to do all of the above

Rabies
Caused by an RNA rhabdovirus
Transmitted by inoculation of infectious saliva
Rarely can be transmitted by inhalation (from
bats in caves)
Causes a severe, uniformly fatal encephalitis
Only 5 documented survivors worldwide so
far

Rabies Incidence in U.S.A.

4,000 proven domestic animals / year
Predominately dogs, cats, cattle
15,000 proven wild animals / year
Represents sampling by state labs so true
incidence is much higher
Average 1 human death / year (about 800
worldwide human deaths reported per year)

Rabies : Clinical
Progression
Bite
Incubation period : weeks to months (no
symptoms) ; shorter for head or neck bites
Prodromal phase : 2 days to 2 weeks
Neurologic symptoms : one week or more
Paralytic phase : several weeks to months

Rabies : Symptom Progression

Prodrome phase : fever, malaise,
headache, sore throat
Neurologic phase : paresthesias at bite
site, anxiety, restlessness, insomnia,
dysphagia, hydrophobia (from fear of
painful esophageal spasms), spasms,
seizures
Flaccid paralysis : leads to coma
Cardiovascular collapse
Supportive treatment generally ineffective
to date

Risk of Rabies Transmission

from Animal Bite
High Risk
Intermediate
Bats
Risk
Raccoons
"Outdoor" cats
Foxes
and dogs
Coyotes /
Cattle in Midwest
bobcats
USA
Other carnivores

Low Risk
Rodents
Lagomorphs
(hares &
rabbits)
Farm animals
Indoor cats and
dogs

Rabies Prophylaxis for

Mammal Bite Wounds
Pennsylvania currently has second highest state
rate in U.S. of wild animal rabies
Raccoon - based epidemic in eastern U.S. since
late 1970's
State Public Health Laboratories will do exams of
sacrificed animals for rabies
Human Diploid Cell Vaccine (HDCV) is current
agent of choice (replaces Duck Embryo Vaccine)
Followup antibody titer after completion of series
no longer recommended

Protocol for Starting Rabies

Prophylaxis
High risk bite & animal escapes : give prophylaxis
High risk bite & animal captured : send animal's head
to State Health Lab for path exam ; treat only if lab
confirms rabid animal (brain sections show Negri
bodies)
Low risk animal & animal escapes : consider
prophylaxis only if bite clearly unprovoked
Low risk animal & animal captured : keep animal under
reliable observation one week ; if animal gets sick :
immediate check by veterinarian or State Health Lab ;
if animal remains well 7 days : no Rx needed

Rabies Prophylaxis
Post-exposure :
HDCV 1.0 ml IM on days 0, 3, 7, 14, 28
Plus Rabies Immune Globulin (RIG) 20 IU / kg IM
on day 0
Pre-exposure :
HDCV 1.0 ml IM on days 0, 7, 21
This is utilized for forest rangers, veterinarians, &
others who have higher risk of encountering
rabies
Still requires booster dose after each exposure

Countries Without
Animal Rabies
Pacific Islands
Caribbean
Islands
United
Kingdom
Iceland
Singapore
Australia

Portugal
Spain
Sweden
Japan
Taiwan

Dog Bites
Lecture Summary
Consider need for radiographs
Always perform careful wound cleansing
& irrigation
Decide if antibiotics & suture closure are
indicated
Assess for risk of rabies & tetanus
Assure close followup