SA266

BITE WOUNDS & OTHER PENETRATING TRAUMAS

Armelle de Laforcade, DVM, Dipl. ACVECC
Tufts Cummings School of Veterinary Medicine
North Grafton, MA, USA

Trauma, including thoracic trauma, is an exceeding common presenting complaint in small
animal emergency medicine. Following a primary survey that includes evaluation and
stabilization of the major body systems, a secondary evaluation for specific injuries can be
performed. This hour will focus on penetrating thoracic trauma with some specific discussion of
bite wounds to the chest.

Thoracic puncture wounds:
All wounds located over the thorax should be explored and penetration into the thorax must be
ruled out. Chest radiographs are always indicated for identification of pneumothorax,
pulmonary contusion, and rib fractures. In some cases radiolucent gas patterns in the body
wall can increase the index of suspicion for penetration into the thoracic cavity. In general,
basic principles of wound management apply in the patient with wounds located over the
thorax. With bite wounds in particular the extent of soft tissue injury may not be readily
appreciated from visible puncture wounds and wound exploration under anesthesia is highly
recommended. Trauma patients with wounds located over the chest should, however, always
be intubated and closely monitored during the procedure. While it may seem extreme in some
cases, it is not uncommon for manipulation of wound edges in severe trauma to result in a
pneumothorax and controlling the airway makes it easy for manual positive pressure
ventilation to be initiated. An exploratory thoracotomy is indicated when penetration into the
thorax has been identified, so that the thoracic structures can be assessed for further damage.

Penetrating thoracic foreign bodies:
Penetrating foreign bodies over the thoracic cavity should be approached with caution. For
example, the dog that presents with a stick protruding from the thoracic cavity should have
minimal wound exploration performed prior to a thoracotomy. Instead, a primary survey should
be performed and resuscitation should proceed prior to addressing the foreign body. With the
airway captured a sterile prep can be performed the foreign body removed in an OR setting.
This will allow for rapid hemostasis should a major vessel be affected, and additional foreign
debris can be removed. Premature removal of the penetrating foreign body may lead to
pneumothorax, hemothorax, and rapid cardiovascular decompensation.

Bite wounds to the chest:
Because dogs possess such powerful jaws, bite wounds inflicted by dogs typically cause
severe crushing injury in addition to punctures and lacerations. Once the teeth penetrate
through the skin, shaking and pulling frequently result in avulsion of the skin from its
subcutaneous attachments and tearing of the subcutaneous tissue, muscle, vasculature, and
underlying structures. The skin itself may still appear relatively intact as it tends to be more
elastic and moveable than the underlying structures. For this reason, superficial-appearing
skin wounds should be regarded as only the tip of the iceberg.

Western Veterinary Conference 2013
Bacteria from the attackers mouth, as well as hair and debris from the victims skin may be
driven deep into the wounds, leading to contamination of devitalized tissues. The presence of
dead space and accumulation of fluid or blood further contribute to the development of severe
infections. Up to two-thirds of dog bite wounds in veterinary patients may become infected,
frequently with multiple isolates. The most common aerobic isolates include Staphylococcus
intermedius, Enterococcus, S. coagulase negative, and E. coli. There tends to be a
predominance of anaerobes in the oral flora of dogs and cats, and as a result, Bacillus spp,
Clostridium spp, and corynebacterium spp, have been frequently isolated from dog bite
wounds as well. Cat bite attacks are more likely to result in small, deep puncture wounds
because of their sharp, pointed teeth and lesser tendency to shake their victims. Cat bite
wounds are also more likely than dog-inflicted wounds to become infected, with Pasteurella
spp most commonly isolated.

Antibiotic use should be strongly considered for moderate to severe bite wounds in veterinary
patients. Although antibiotic therapy is considered controversial in human patients with dog-
inflicted bite wounds, veterinary patients are more likely to have their wounds become
contaminated with fur and debris, and may be at greater risk for sepsis. Because gram
positive, gram negative, and anaerobic pathogens are frequently isolated from bite wounds,
broad spectrum coverage with an antibiotic such as amoxicillin/clavulanate potassium is
indicated. Alternatively, combined therapy with amoxicillin and enrofloxacin may be used. First
generation cephalosporins alone are not considered appropriate therapy as they may not be
effective against anaerobes or gram negative bacteria such as Pasteurella spp.

Wound management:
Appropriate management of thoracic wounds consists of clipping and cleansing, wound
debridement, lavage, establishment of drainage, and antibiotic therapy (in most cases). All
dog-inflicted bite wounds (with the possible exception of the distal extremities) should be
surgically explored, as superficial skin wounds frequently hide more significant underlying
damage. The practice of probing bite wounds with an instrument should not be performed as it
frequently underestimates injury severity. Probes may not be able to follow the path of a bite
wound through the various planes of moveable fascia and may therefore fail to identify large
pockets of dead space.

The cleaning and debridement process should proceed from the outside in (ie. starting with the
skin and wound margins before moving on to the deeper portions of the wound) in order to
avoid dragging contaminated material from the periphery deeper into the wound. A small
amount of sterile, water-based jelly may first be applied to the wound to prevent contamination
of the deeper tissues with hair and debris. Once the wound has been clipped, the skin
surrounding the wound may then be scrubbed with a surgical scrub solution such as povidone-
iodine or chlorhexidine. The interior of the wound should not be scrubbed with these
preparations, as they may be irritating to the delicate tissues. Hydrogen peroxide is not
considered an effective antimicrobial, and its use within wounds should also be avoided.

Sterile gloves and drapes should be used for wound debridement. The contaminated wound
margins should be excised, and the incision extended if needed to facilitate exploration of the
wound. All devitalized tissues should be excised using a scalpel blade or metzenbaum
scissors. Lavage should be performed during the debridement process to facilitate removal of
bacteria, hair, and debris from the wound. Sterile saline is typically adequate for this purpose.
The addition of antibiotics to lavage solutions has not been shown to be beneficial. Lavage
may be performed using a bulb syringe, a plastic 1 liter bottle of sterile saline with several
holes punched in the lid, or a 35-ml syringe with 18 g needle. This syringe may be attached by
3-way stopcock to a bag of sterile saline in cases when copious lavage is needed.

Once a wound has been adequately debrided, the decision can then be made as to whether
the wound may be safely closed or should be left open for drainage. It is never appropriate to
close bite wounds that have not been aggressively debrided. Wounds in which all devitalized
tissue has been removed, with adequate blood supply, negligible dead space, and no evidence
of infection may be closed primarily. More commonly, some form of drainage is needed
because of the presence of dead space, compromised blood supply, or contamination. For
wounds with moderate amounts of dead space, passive drainage using or penrose
drains may be employed. Following debridement, penrose drains are anchored at the dorsal
aspect of the wound and allowed to exit from a separate site ventral to the wound. The drain
should not be run directly underneath the suture line as this may decrease blood flow to the
healing incision, nor should the drain exit directly from the wound.

Closed-suction drains may also be used in large wounds. A poor mans drain can be
constructed from a butterfly catheter and vacutainer tube. The luer-lock is cut from the plastic
tubing of the butterfly catheter, and the tubing is then fenestrated using a scalpel blade. The
plastic tubing is inserted into the wound through a separate exit site, and a purse-stringed is
used to secure it in place. Following wound closure, a vacutainer may be attached to the
butterfly needle to provide continuous suction, and may be changed each time it becomes full.
Larger closed-suction drainage systems are commercially available. Advantages to closed-
suction drains include the provision of drainage in areas with poor dependent drainage, the
ability to keep wounds and dressings dry, reduced risk of ascending infection, and the ability to
quantitate discharge. Disadvantages include expense, need for in-hospital maintenance, and
possible occlusion of drains as a result of kinking or thick discharge.