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Veterinary Forum November 2008 (Vol 25, No 11)

IVECCS Update — Managing bite wounds in the ER

by Paul Basilio

    PHOENIX — When David Holt, BVSc, DACVS, lived in Australia, he saw few bite wounds in veterinary practice because local governments strictly enforced leash laws as a way to generate extra revenue.

    "And then I came to Philadelphia…" said Holt, who is chief of the section of surgery at the Matthew J. Ryan Veterinary Hospital, University of Pennsylvania.

    It is important to remember that the shearing force — when the tooth glances off the skin and creates a linear laceration — is highly visible, but is typically less of a concern.

    "The problems come when the dog is shaken," Holt said, in a session held here at the 14th International Veterinary Emergency & Critical Care Symposium (IVECCS). "Tension is applied to tissues — muscle is avulsed off bone, subcutaneous tissue is avulsed off muscle and skin is avulsed off subcutaneous tissue. You end up with all of this tissue having a compromised blood supply and lots of dead space."

    Compression forces from a crushing injury should be monitored carefully, he said. Many veterinarians who deal with bite wounds have often débrided and flushed out wounds, only to find that the wound looks worse a few days later.

    "The problem with a crushing injury is that the tissue will look healthy initially, then die," he said.

    For an animal with a puncture wound, veterinarians must decide how to assess the damage and whether the patient needs surgery.

    He said that radiographs are notoriously unreliable in measuring the amount of body cavity penetration. Inserting a probe into the wound also is unreliable because the probe tends to go where it wants, and that is not necessarily the path of the wound.

    "The take-home point is to always clip a lot more hair than you might need for [operating on a] small wound," Holt said. "You might end up in places you don't expect."

    When patients present with multiple bite wounds over the entire body, Holt warned that it is imperative not to under-read radiographs. "It's easy to be sucked in and say, 'Okay, here's the problem.' Instead say, 'Okay, I know about this one and this one, but I'm not sure about this other one. Let's center [the machine] over here and take another view.'"

    Holt explained that on about day 3 of healing, macrophages, neutrophils and platelets release cytokines, the messenger substances that make fibroblasts and allow new blood vessels to come in, mobilize and migrate to the epithelium.

    "But [with multiple bite wounds] you have a massive stimulation that can result in systemic inflammatory response syndrome [SIRS] and sepsis," he said. "Clinically, we see peripheral vasodilation and the cells within thrombosed vessels may release cytokines. With a severe stimulation, it is speculated that there is a loss of control or regulation of many of the inflammatory cascades, which can lead to edema, tissue damage, cardiovascular insufficiency, hypertension, poor tissue perfusion and death."

    When examining a dog presenting with rib fractures from several bite wounds on its chest wall, Holt said it is important to note that radiographic changes in the lung — whether from contusions or pneumonia — can lag up to 24 hours behind the clinical signs in the patient.

    "Even if you don't see pulmonary contusions [on the radiograph]," Holt said, "you have to think, 'If there's enough force to break the ribs, what do you think happened to the lungs underneath?' If you have bite wounds on the chest and the radiograph says there is no pneumothorax, it is not a guarantee that the wound is not going into the chest. If you have bite wounds on the abdomen and there is no free fluid in the abdomen, does that tell you those bite wounds don't go into the abdomen? Absolutely not."

    For more information:

    Holt D. Bite wounds: management and reconstruction. Presented at: The 14th International Veterinary Emergency & Critical Care Symposium. Phoenix, Ariz.; Sept. 18-21, 2008.

    Dr. Holt reported no potential conflict of interest relevant to this article.

    NEXT: IVECCS volunteers hold free spay/neuter clinics in Arizona

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