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Treating bites in a rural and remote setting

Treating bites in a rural and remote setting
Photo: Treating bites in a rural and remote setting
The RSPCA estimates that there are 33 million pets in total and 4.2 million pet dogs in Australia; that is 19 dogs for every 100 people. Cats are the second most common pet, with almost 29% of households owning a cat. Some of the various bites that you may see in rural and remote nursing include dog bites, cat scratches or puncture wounds, and human bites. Human bites or puncture wounds of the hands that have come into contact with teeth can be particularly problematic and should have red flags attached whenever they present. Envenomation can also be a possibility depending on where you are working. Scorpions, ticks and spider bites and snake bites can be seasonal. You may also be asked to give advice on or treatment to injured animals if there is not a vet in town. For example, pig hunting dogs can present with horrific injuries if the pig gets to take revenge. Remember to follow your workplace policies for treatment of animals and remember your own safety in these scenarios.

A medical student (Gaudry, 2011) conducted some interesting research at the Canberra Hospital from 2006-2008 which confirmed that dog bite injuries are a common and important problem in emergency medicine. As many as 50% of children are predicted to experience a dog bite in their childhood. This may be even higher as many do not seek attention at a hospital. These are frightening statistics to any parent or would-be parent.

Clinical considerations for risks and treatments of bites include factoring in minimal timeframes for interventions. The University of Tasmania has produced a resource titled B.I.T.E.S A systematic approach to the assessment of bite wounds. It includes 5 essential checkpoints. This resource has been published and is available on www.australiandoctor.com.au. The chart has been developed by Janelle White who is an extended care paramedic and lecturer at the school of medicine at the University of Tasmania. In this resource it is suggested that irrigation should occur immediately. It is recommended that the irrigation is performed under pressure for up to 20 minutes with normal saline irrigation (0.9%). A plastic cannula without the needle insert can be attached to a syringe to create sufficient high pressure to irrigate the wound. The timeframe for primary closure is optimally less than 6 hours and prophylactic measures should be addressed within 24 hours.

The infection rate for dog bites is thought to be around 18%, however some researchers estimate this to be even higher. It is estimated that 80% of cat bites will become infected. Additionally, MRSA can be transmitted from human to animal and back to human. It is known that human bites may involve up to 40 pathogens.

Some bites will require surgical interventions as jagged edges may prevent clean neat wound closure. In remote settings this often requires transfer to a larger centre and sometimes plastic surgery.

Research completed by Broom and Woods (2006) concluded that clenched fist injuries are the most severe of human bite injuries. They can frequently present as a puncture wound over the metacarpophalangeal joints of the dominant hand as a result of a patient striking another person’s teeth with a clenched fist. If the puncture wound breaches the metacarpophalangeal joint space there is a risk of septic arthritis or osteomyelitis. In a remote setting it is important to remember that referrals should be made sooner rather than later as a hand surgeon may need to assess if there is a need for further exploration to prevent loss of function.

Intravenous antibiotics may also be required. Bacterial infections are usually polymicrobial and are often mixtures of aerobes and anaerobes, therefore careful consideration needs to be given to the appropriate antibiotic choice.

Other considerations include tetanus status, hepatitis risk and any condition that will compromise a patient and increase their risk factors. Conditions such as diabetes, liver disease and asplenia may also increase complications so need to be taken into consideration.

The NSW Rural Adult Emergency Clinical Guidelines state that when snake or spider bites are suspected that a medical officer must be contacted immediately.  History prompts include the time of the bite; the number of bites; the time of first aid applied; pre-hospital treatment; drug/alcohol intoxication; activity since bite; bite site location and any associated symptoms. Other important information includes relevant past history, previous envenomation or antivenom administration, medication history and allergies. The clinical severity prompts include neurotoxic paralysis/diplopia/dysphagia; convulsions; abdominal pain; headache; nausea/vomiting. Ensure first aid measures have been implemented and consider early transfer.

Conclusion
Appropriate management will take into consideration the type of animal that has perpetrated the bite and should include any patient risk factors for infection, local and systemic indicators of infection, and the patient’s vaccination status.

Allergies need to be checked cautiously and remember early surgical consultation for wound debridement is advised, particularly if there is a chance that the bite has penetrated deep into the tissues or if there could possibly be any bone involvement.

In Australia there are four Poison Information Centres operating in Queensland, New South Wales, Western Australia and Victoria. These centres provide toxicological advice on the management of exposures to prescription and non-prescription pharmaceuticals; household and industrial chemicals; plants; animal envenomations; pesticides and other agricultural products. The contact no is 13 11 26, which is available 24 hours including public holidays.

References
Australian Doctor (2013) “A guide to bites” Available at: www.australiandoctor.com.au
(Accessed at 24 June 2014).

Broom J, Woods M (2006) “Management of bite injuries”, Australian Prescriber, 29(1) (online) Available at: www.australian prescriber.com
(Accessed 24 June 2014).

White, J University of Tasmania B.I.T.E.S Available at: www.australiandoctor.com.au
(Accessed 24 June 2014).

Gaudry, A. Richardson, D. “Treatment of dog bites in the emergency department of the Canberra Hospital 2006-2008”
MSJA, Volume 3, Issue 1, June 2011.

RSPCA. Available at: www.kb.rspca.org.au
(Accessed at 22 June 2014).

NSW Health NSW Rural Adult Emergency Clinical Guideline. 3rd Edn-version 3.1 pg 52, NSW Health: NSW Govt Publishers
(Accessed 24 June 2014).

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