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Dog bites
Rabies risk is only the tip of
the iceberg
BY Faria Ajamian, MD and Mia E. Lang,
MD, PhD
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Courtney,
a previously well, fully vaccinated 5-year-old girl, arrives in the
emergency department (ED) with her parents because she was bit in
the face and hand by her pet dog. The accident happened 2 hours ago
when Courtney was "playing horsey" with the family's German shepherd
while he was feeding. The parents ask you if she needs any antibiotics
or a rabies shot, and whether they should "put the dog down."
Presentation
Physical examination
- alert, well and afebrile
- 1-cm puncture wound to her left hand,
with normal pulses and range of motion
- 3 full-thickness lacerations (2 cm
each) involving the cheek and vermillion border
Investigations
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Making the case
Dog bites are common -- the U.S. incidence is 2 million people per
year, which is likely an underestimate due to underreporting. Most
victims are children between the ages of 5 and 9, and they often
know the dog that bites them. Playing or other kinds of interaction
with the dog, especially during feeding, is an important risk factor.
Some studies show that dog bites are more common in boys than girls,
but new Canadian data suggests no gender difference (Lang ME, Klassen
T. CJEM 2005;7(5):309-14).
Dog bites are most frequent on the face. For injuries involving
the orbit, consult ophthalmology. For deep facial wounds, especially
those involving the vermillion border, consider plastic surgery
as well. Most dog bites need sutures, and occasionally are severe
enough to cause fractures or require operative repair. The hospitalization
rate for Canadian dog bite victims was 2.3 per 100,000 between 1991
and 1994, and was 4 times higher for children younger than 10. Unfortunately,
dog bites can be severe enough to kill; an average of 1 Canadian
per year dies as a result of a dog attack (Health Canada. Canadian
Hospitals Injury Reporting and Prevention Program (CHIRPP) July
1997, Issue 11). While any dog can bite, the most common breeds
reported are Rottweilers, German shepherds and pit bulls.
Investigations
In the ED, after initial assessment and stabilizing the patient,
inquire about the following:
- risk of infection (time of injury, previous treatment, health
status of the patient -- in particular immune status and liver
disease, immunization status -- especially tetanus, fever, chills
and drug allergies)
- risk of rabies (dog's vaccine status and behaviour)
- prevention (dog breed, restraint/supervision, past biting)
The physical exam includes vital signs, wound documentation (location,
size, depth), inspection for signs of infection (erythema, warmth,
swelling, pain, purulent discharge, regionalized lymphadenopathy)
and foreign bodies. If extremities are involved, they should be
checked for range of motion, deep tendon reflexes, pulses and perfusion.
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