Monday, June 5, 2017

Management of Facial Bite Wounds

Department of Pediatric Dentistry
Lutheran Medical Center


Resident’s Name:  Nicholas Paquin                                                             Date: 06/06/2016
Article Title: Management of Facial Bite Wounds
Author(s):  P. Stefanopoulos, DDS, A. Tarantzopoulou, DDS
Journal:  Dental Clinics of North America
Date:  2009
Major Topic: Management of Bite Wounds
Type of Article: Review and Guidelines
Main Purpose: Present best practice for facial bite wounds
Summary of article:  15% of all dog (“hold and tear, mostly on the lips, nose or cheeks), cat (puncture)and human bites (crush wounds, tend to involve the ear, sometimes the lower lip) are located on the face and are considered complex injuries contaminated with unique polymicrobial inoculu.  These can be life-threatening and have enough force to cause structural damage to the facial skeleton. 

Bites:
·      soft tissue wounds – punctures, lacerations and avulsions, with and without actual tissue defect. 
·      Bacteria found in bite wounds can be both aerobic and anaerobic.  Virus are also something to be aware of hepatitis B and C, HIV, syphilis from human bites, rabies from animals. 
·      Facial wounds are generally have low infection rates due to the rich blood supply.  Dog bites have moderate risk for infection especially if treated with in 6-12 hours.  Cat bites are higher in infection due to the deep puncture wound, human bites usually exceed the threshold bacteria count due to bacteria in the saliva. 

Treatment: 
·      Life preserving emergency treatment first. 
·      Assess and rule out facial fractures.  Lacerations to the eye are of particular concern due to damage to underlying structures. 
·      Assess for infection.  Tetanus-prone, if it has been more then 5 years since last tetanus immunization, booster is recommended. 
·      Most superficial bites can be treated in the outpatient setting but those with system toxicity, rapidly advancing cellulitis, or infection constitute hospitalization, also those with more serious injuries.  I
·      Irrigate the bite with normal saline (19-gauage catheter on the 30-60ml syringe, which delivers about 5-8psi, 250ml- 500ml), remove necrotic tissue.  Avoid high pressure irrigation in area containing loose areolar tissue, example eye lids and children’s cheeks to avoid excessive edema.  Surgical debridement if needed but take care not to remove excessive tissue that maybe needed for reconstruction.
·      Primary wound closure is recommended within 24 hours of an uninfected facial bite lacerations.  IF beyond that delayed treatment may be necessary due to edema, wait 4-5 days.  If repaired after 24 hours there might be a higher risk for infection but lower risk for scaring.  Over infection may preclude closure and then revisions may have to be made. 
·      Antibiotics:  Administration can be prophylactic or therapeutic.  It is unclear that healthy patient with fresh clinically uninfected wound benefit from prophylactic antibiotics.  However a cat puncture wound it is recommended due to the high-risk characters.

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