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Key Points

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  1. Identification of the offending organism is of paramount importance in determining the most appropriate course of treatment.

  2. The administration of antibiotic prophylaxis should be based on the degree of wound contamination or documented microbiology, but is mandated for bites from cats and humans.

  3. Verbal reports of spider bites are often erroneous, and surgeons should have a high index of suspicion for other causes.

  4. The only antivenins readily available in the United States are for indigenous snakes and black widow spiders. Arizona has an antivenin for scorpions.

  5. Be alert for secondary injuries in the patient who has sustained an animal bite, as it is not uncommon and can be life-threatening.

  6. Human bite wounds may raise suspicion of child abuse, and HIV/hepatitis infection must be considered.

  7. The efficacy of negative pressure wound therapy has been shown, and it is an appropriate addition to the wound care armamentarium.

  8. The symptoms of envenomation progress more rapidly in young children due to their low body weight, and the importance of timely treatment cannot be overstated.

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General Principles

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Despite the wide variability in offending organisms and specific considerations related to each, adoption of a systematic approach to the evaluation and treatment of all bite injuries is possible. Three basic concepts should be addressed, and the use of common sense cannot be overemphasized.

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(1) Type of bite. This includes identification of the offender, when possible, and determination of whether or not envenomation took place. Geography often dictates the incidence and exposure to a specific animal, and knowledge of the regional population is extremely helpful in determining the type of agent injected. Proof of envenomation includes both a visible injection site (fang marks, stingers, and bites) and local tissue reaction (swelling, local hemorrhage, pustules, erythema). The exceptions are direct venous injection or coral snake envenomation which cause little, if any, local reaction.

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(2) Degree of injury. An assessment should be made of the extent of both local and systemic damage. The mechanism of the injury may influence the intensity of treatment. An uncomplicated dog bite injury to the hand can be treated with cleansing and closure, while a bite from a large mammal such as a horse can be both cutting and crushing, and contaminated with bacterial flora of soil and plant origin. In cases involving a large attacker, the possibility of secondary traumatic injuries must also be considered.

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Signs and symptoms of systemic illness due to envenomation include coagulopathy, neurologic involvement, respiratory compromise or failure, or even cardiovascular collapse. Awareness of these signs will give the clinician a high index of suspicion in appropriate situations and guide timely intervention. When envenomation is documented by local wound criteria, admission for observation and further treatment is appropriate.

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(3) Treatment. Treatment is also focused on both local and systemic effects of the injury. Although the choice of antibiotics plays a critical role ...

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