Focused H&P should determine the circumstances surrounding the bite, location of the bite, type of animal, time of occurrence, whether the patient has been febrile, local erythema, swelling, warmth, or purulent drainage.  If the patient is stable, the wound should be thoroughly explored after local or regional anesthesia to determine the potential for damage to underlying structures and foreign body inoculation. Local and distal neurovascular status should undergo assessment after anesthesia, as well as pain and apprehension, which may affect patient compliance with the exam.  Pertinent history includes any immunosuppression, be it iatrogenic (transplant, rheumatic disease treatment) or a disease process (diabetes, HIV/AIDS, sickle cell disease.)

As with all traumas, the initial evaluation is to ensure airway, breathing, and circulation is intact. Active venous bleeding should be controlled with direct pressure, while arterial bleeding will typically necessitate consult services. The examiner should explore the wound for foreign bodies such as broken teeth, claws, dirt, and plant material. When analyzing the wound, underlying structures require assessment for potential damage as well. During exploration, the patient should range the underlying structures through a full range of motion to ensure no injuries to those underlying structures.[2]

All wounds require extensive irrigation, and the patient’s tetanus status updated if necessary. Provide appropriate pain management before exploration, irrigation, or debridement of the wounds. The patient’s TDaP status should be updated if necessary. For uncomplicated dog bites, the patient should be educated on the risk/benefit of closure versus healing by secondary intention and the decision made with the provider. If the patient presents delayed from the initial bite, the risks of closing the wound almost certainly outweigh the cosmetic benefits of closure. If the wound is closed, the patient should be discharged with a week’s course of amoxicillin-clavulanate.

Complicated dog bites should be stabilized and referred for the appropriate consultation service. Cat bites deeper than superficial need thorough irrigation under local anesthesia and the wound left open. The patient should be discharged with a week’s course of amoxicillin-clavulanate and given strict wound care precautions. All bites to the hands or feet, bites in immunocompromised individuals, bites that already show signs of infection, and bites with a puncture characteristic require treatment with amoxicillin-clavulanate. For patients with penicillin allergies, second-line therapy is doxycycline or TMP-SMX plus metronidazole or clindamycin. The appropriate consult service should see patients with extensive local infection; patients with evidence of disseminated infection should be treated with broad-spectrum IV antibiotics and admitted for further care.[6][7][8]

• Cellulitis

• Cervical spine fracture evaluation

• Emergency treatment of rabies

• Hand infections

• Human bites

• Neck trauma

• Osteomyelitis in emergency medicine

• Tetanus

The prognosis for most animal bites is excellent. However, it is essential to know that, on average, about 30 to 50 people die from dog bites each year.

• Cellulitis
• Tenosynovitis
• Endocarditis
• Osteomyelitis
• Abscess
• Meningitis
• Tendon rupture
• Nerve injury
• Post-traumatic stress disorder
• Rabies

Patients with animal bites need to be seen within 48 to 72 hours after the initial treatment to ensure that they are not developing an infection. The animal should be removed from the home and placed in a different location.

Patients should be encouraged to get an updated tetanus vaccination.

1. Rabies is rarely a concern due to the broad vaccination program in domesticated animals and the fact that the patient usually knows the animal. Depending on the local prevalence of the disease, one may be able to defer rabies prophylaxis for dog and cat bites. 
2. If the status of the animal is unknown, rabies prophylaxis may be deferred if the animal is in custody and may be observed or has an evaluation for rabies.  Most commonly, rabies originates in bat and skunk populations. 
3. Any bite or suspected bite from a bat should require rabies prophylaxis.  Rabies prophylaxis initiation in the ED requires the rabies vaccine provided in a distant site from the injury with as much of the required rabies immune globulin being given local to the wound. 
4. Further rabies vaccine doses are necessary on days three, seven, and fourteen. 
5. Immunocompromised individuals with cat bites or scratches should be covered with TMP-SMX, ciprofloxacin, or rifampin as prophylaxis against cat-scratch disease.
6. Sepsis from Capnocytophaga is covered by standard prophylaxis in dog bites in immunocompromised individuals. 
7. Bites from K-9 officers should be treated similarly to the above with the additional documentation that the officers will require. 

About 300,000 people with dog bites visit the emergency room or the primary care provider each year—the earlier the treatment, the better the outcome. Managing animal bites requires an interprofessional approach as the bite may occur on any part of the body. There should be no hesitancy in consulting with the appropriate specialist if the bite is on the eyes, nose, hands, genitals, or the scalp. Several guidelines exist on managing specific animal bites like the dog, cat, snake, scorpion, bees, ants, or other wildlife. Healthcare workers who manage animal bites should be aware of the latest guidelines and be aware of the organisms and the antibiotics needed to manage such injuries. Since many animal bites present to the primary care provider or the emergency room, the first treatment is to ensure that the wound is irrigated and cleaned. Debridement of necrotic or dead tissue is the next step. If there is any doubt in the management, the injury is severe, or to the hand, it merits a consult with a specialist. for example, serious injury from dog bites always require management by an interprofessional group of healthcare professionals.[9][10] [Level 3]

Outcomes and Evidence

The majority of people with animal bites have an excellent outcome. However, injuries to the face, groin, and hands can lead to high morbidity. The available literature reveals conflicting opinions on management, and until evidence-based medical evidence is available, the treatment will remain empirical.[11] [Level 5]