0071643192.pdf

ENVIRONMENTAL EMERGENCIES

DIAGNOSIS

■ X-ray to rule out foreign body or fracture

■ Check blood sugar to see if diabetic.

GENERALTREATMENT

■ Anesthetize, clean and irrigate, debride devitalized tissue.

■ Explore in full flexion and extension for ligamentous or tendon injury.

■ If present, surgical consultation and admission is warranted.

■ Tetanus prophylaxis

■ Consider rabies prophylaxis (animal bites).

■ No evidence for infection:

■ Okay to close wound unlesshigh-risk wound

■ Give antibiotic prophylaxis if high-risk wound (see Table 13.2).

■ Evidence for infection:

■ Admit for IV antibiotics if high-risk wound or patient, otherwise treat

with oral antibiotics.

■ Arrange follow-up in 48 hours for discharged patients.

HUMANBITES

Infections are commonly polymicrobial:

■ Viridans streptococcus

■ Staphylococcus

■ Bacteroidessp.

■ Corynebacteriumsp.

■ E. corrodens(a Gram-negative rod found in dental plaque)

■ Other transmitted infections include syphilis, herpes

■ HIV and hepatitis transmission should be considered if exposure to blood

occurred.

A special concern is the closed-fist injury which is associated with joint infec-

tion, osteomyelitis, and tenosynovitis.

TREATMENT

■ General treatment, as above

■ Antibiotic of choice for prophylaxis = amoxicillin/clavulanate.

All wounds at high risk for

infection should be left open

and treated with antibiotic

prophylaxis.

Most human bite wound

infections are polymicrobial,

including Gram-positive,

Gram-negative, and

anaerobic organisms.

TABLE 13.2. Indication for Prophylactic Antibiotics in Mammalian Bites

Cat bites

Immunocompromised or elderly patients

Presence of peripheral vascular disease

Presence of prosthetic valve

Deep puncture wounds

Intraoral, hand, below knee, or joint wounds

Delayed presentation