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Surgical management
Expedite surgical management when
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this is required . Delays to surgical | |||||
management are associated with | |||||
longer and more invasive treatment . | |||||
The process of surgical wound management |
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appears in box 4 . 9
TENDON OR MUSCLE INJURIES Surgical management is indicated for patients with soft tissue injury pen-
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Figure 7 . Macaque monkey biting an Oregon resident in a public park in Thailand and the resultant wound — 2018 . |
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etrating fascia with a significant skin |
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breach . Table 2 classifies the severity of mammalian bites . 10
SURGICAL MANAGEMENT OF SPECIFIC BITES Cat bites These need special attention , so refer even a grade 1 bite to ED . Cat bites are deeper and have a higher incidence of tooth breakage and retention of foreign bodies in the bite wound given the cat ’ s long slender incisor teeth . Benign looking wounds may have bite penetration extending into the deep fascia . Assume that a bite mark over a joint is infected and refer for appro-
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Table 2 . Classification of severity of mammalian bites
Grade Description Management
1 Superficial bruising / scratch on the skin / superficial single wound with one bite mark Minimal subcutaneous abrasion
2 Bites reaching the fascia and muscles
3 Wounds with soft tissue necrosis
Medical outpatient management by GP Unlikely to require inpatient management : Oral antibiotics ( as indicated by the type of bite and risk factors ) and analgesia Consider an outpatient X-ray to rule out a foreign body
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A |
Images courtesy Dr T Geertsma www . ultrasoundcases . info |
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priate specialist treatment . |
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Dog bites These are more superficial and result |
Table 3 . Antibiotic options for prophylaxis after mammalian bites 13
Options
Detail
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in crush injuries rather than deep penetrating wounds .
Grade 1 dog bites require irrigation and small wounds ( less than 3cm ) can be treated with primary
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Primary Amoxycillin – clavulanate 875 + 125mg ( child two months or older : 22.5 + 3.2mg / kg up to 875 + 125mg ) orally , 12-hourly for three days
IM alternative
Procaine benzylpenicillin 1.5g ( child : 50mg / kg up to 1.5g ) IM , as a single dose in the community while awaiting oral therapy
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B |
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closure under local anaesthesia . Grade 2 and 3 infections may require surgical intervention . Refer the patient appropriately , depending on the site of injury ( for example , to an orthopaedic or hand surgeon ).
Facial wounds
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Oral alternative |
Metronidazole 400mg ( child : 10mg / kg up to 400mg ) orally , 12-hourly for three days PLUS doxycycline orally , 12-hourly for three days Adult : 100mg Child eight years or older and less than 26kg : 50mg Child eight years or older and 26-35kg : 75mg Child eight years or older and more than 35kg : 100mg |
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Around 15 % of bite injuries are facial wounds . 11 The ear and nose are common sites of human inflicted facial |
Oral alternative |
Trimethoprim – sulfamethoxazole 160 + 800mg ( child one month or older : 4 + 20mg / kg up to 160 + 800mg ) orally , 12-hourly for three days |
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wounds . The greater vascularity of the |
Source : Therapeutic Guidelines 2022 13A |
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face does reduce the chance of infection |
somewhat , and wounds are often closed early for cosmetic reasons ( with |
Box 4 . Surgical management |
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antibiotic prophylaxis to reduce the chance of infection ). Plastic surgery consultation ( or other appropriate surgical specialties depending on the injury ) early on will assist in expediting surgical management .
Infected wounds Wounds presenting with active infection ( or presenting after initial management with subsequent infection ) should be left open ( or reopened if previously closed ) to allow for drainage . The World Society of Emergency Surgery consensus recommendations for the management of incisional skin and soft tissue infections
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• Wound assessment under appropriate analgesic coverage : — Decontamination with a disinfectant . — Irrigation with 0.9 % sodium chloride solution .
• Imaging to rule out a foreign body , collection , or underlying fracture ( X-ray / ultrasound ).
• Debridement of devitalised and torn skin tissues , suturing of the wound ( or commonly leaving it open to heal via secondary intention ), exploration of suspicious foreign body on imaging in theatre and appropriate debridement .
• Secondary suturing after inflammation has resolved .
prophylaxis . Box 2 lists the high-risk bite injuries that require antimicrobial prophylaxis . In general , amoxycillin – clavulanate for three days ( see table 3 ) is first-line antimicro-
benzylpenicillin 1.5g IM as a single dose while awaiting oral therapy . For more extensive antimicrobial guidance , including treatment of infected wounds , see the Australian Antibi-
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C |
Figure 8 . Osteomyelitis and tenosynovitis of the thumb after a dog bite .
A . Ultrasound ( longitudinal view ) of tenosynovitis .
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appear in box 5 . 12
Antibiotic and postexposure prophylaxis
Not all bite wounds require antibiotic
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bial prophylaxis for mammalian bite injuries , with alternatives for allergic or intolerant patients . If community access to oral treatment is likely to be delayed , administer procaine |
otic Therapeutic Guidelines . 13
Antiviral prophylaxis
HERPES B Herpes B virus is an
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B . Osteomyelitis with hypervascularisation .
C . Osteomyelitis on X-ray .
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