Surgical delay in the management of dog bite injuries in children, does it increase the risk of infection?

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Summary

Dog bites are contaminated wounds and convention dictates that any surgical treatment should be performed at the earliest opportunity. This practice, however, may be in direct conflict with NCEPOD guidelines to reduce night time operating. We audited our treatment of dog bite injuries in children over a 5-year period (1998–2002) to determine whether delaying surgery to conform to operating guidelines increased the incidence of infection.

A retrospective case note study identified 118 patients admitted to Sheffield Children's Hospital with dog bite injuries. Details of their injury, treatment and outcome were recorded. There were 70 males and 48 females and an average age of 6.6 years (range 1–15 years). The most common type of injury was a single laceration (32%) and the most frequent site of injury was the face (59%). The majority of wounds (68%) were cleaned and dressed before theatre and 89% were closed directly after minimal debridement. All patients received prophylactic antibiotics. Of the 114 patients that required surgery, 57 (50%) were operated on within 12 h of their injury and 57 (50%) after 12 h. There were three cases of infection in the early group (<12 h) and none in the delayed group (>12 h).

We suggest that delaying the surgical treatment of dog bites in children to avoid operating at night does not increase the infection rate.

Section snippets

Methodology

A retrospective case note analysis was performed from 1998 to 2002. Clinical coding identified all patients with a dog bite injury admitted under the care of the Plastic Surgery Department at the Sheffield's Children Hospital. This was cross-referenced against casualty admission records and theatre logbooks. We looked at the following:

  • (a)

    Patient demographics: age, sex, referral source and the location of attack.

  • (b)

    Injury demographics: site, type and number of injuries.

  • (c)

    Treatment details: pre-operative

Results

We identified 122 patients. Notes were obtained for 118, giving a retrieval rate of 97%. There was a steady rise in the number of admissions during the study period from 19 in 1998 to 30 in 2002 (Fig. 1).

Discussion

Dog bites are relatively common injuries with a reported incidence from 172 to 740 per 100 000 of the population per year.3 This range reflects the finding that the proportion of bites that are actually reported and for whom medical advice is sought is variable (10–50%).1, 4, 10 Dog bites account for between 0.5–1% of all casualty attendances,4, 11, 12 and 50–75% of these are in children under the age of 12.1, 2

Dog bite injuries result from the crushing and tearing of the tissues, made worse

Conclusion

Current surgical opinion advocates early washout, debridement and primary repair of dog bite injuries to avoid infection and to achieve the best possible functional and cosmetic results. The development of NCEPOD based guidelines to prioritise those procedures that need to be done in the late night period or early hours of the morning, appeared to be in conflict with this surgical practice. However, our study suggests that confirming to these guidelines does not compromise patient care.

Acknowledgements

We would like to acknowledge the help of Christobel Hargraves, Chief Executive NCEPOD, and Ian Martin, Clinical Coordinator NCEPOD and consultant maxillofacial surgeon for their assistance in all our NCEPOD based queries.

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Presented at the Winter Meeting of the British Association of Plastic Surgeons, London, UK, December 2003.

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