Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 80–85
Surgical delay in the management of dog bite injuries in children, does it increase the risk of infection?* N. Akhtar*, M.J. Smith, S. McKirdy, R.E. Page Department of Plastic and Reconstructive Surgery, Northern General Hospital, Sheffield, UK Received 4 June 2004; accepted 17 May 2005
KEYWORDS Dog bites; NCEPOD guidelines; Delayed surgery; Infection rate
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 (O12 h). We suggest that delaying the surgical treatment of dog bites in children to avoid operating at night does not increase the infection rate. q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Presented at the Winter Meeting of the British Association of Plastic Surgeons, London, UK, December 2003. * Corresponding author. Address: 45 Glebe Crescent, Kenton, Harrow, Middlesex HA3 9LB, UK. Tel.: C44 208 204 6712. E-mail addresses:
[email protected] (N. Akhtar),
[email protected] (N. Akhtar).
Dog bites are relatively common injuries. Incidence varies from 174 to 720 per 100 000 per year and as many as 75% of those attacked are children.1–3 Current opinion advocates early surgical treatment with irrigation of the wound, minimal debridement and direct closure where possible.1,4–8 Many hospitals in the United Kingdom have developed
S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2005.05.005
Surgical delay in the management of dog bite injuries in children, does it increase the risk of infection? 81 guidelines to prioritise emergency surgery and reduce ‘out-of-hours’ operating. These guidelines have evolved from the reports and recommendations of the National Confidential Enquiry into Perioperative Deaths, now known as the National Confidential Enquiry into Patient Outcomes and Deaths, which was originally published in 1997 and subsequently revised in November 2003.9 We conducted a study to determine if delaying the surgical treatment of dog bites in children to conform to local operating guidelines resulted in an increased rate of infection.
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 interventions, grade of surgeon and procedure. (d) Infection rate.
steady rise in the number of admissions during the study period from 19 in 1998 to 30 in 2002 (Fig. 1).
Patient demographics Sixty-one patients (52%) were referred from the casualty department of Sheffield Children’s Hospital and the 57 (48%) from peripheral units. The male to female ratio was 1.4:1 with a mean age of 6.6 years. Attacks peaked in the summer months (36%) and were least common in the winter months. In 68% of cases the attacks occurred at home and in 99% of cases by a single dog. Seventy-five percent of the dogs were pets and in 66% of cases the dogs were known to the child. There were three cases of provoked attack; the child teasing the dog with food, the child pulling the dog’s ear and the child pulling the dog’s lead. In cases where the breed of the dog was recorded, the most common was the Alsatian (18%), closely followed by the Japanese Akita and Rotweiller (16%).
Injury demographics The average number of injuries per child was three (range 1–18). The type and distribution of injuries are listed in Tables 1 and 2. The most common injury pattern was the single laceration (32%). For facial injuries the mostly frequently affected area was the middle third of the face (55%). There were no fatalities.
Treatment details
Results We identified 122 patients. Notes were obtained for 118, giving a retrieval rate of 97%. There was a
Figure 1
Seventy-three percent of patients were admitted within 6 h of injury and 87% within 12 h. Three cases were referred from casualty clinics and admitted after a delay of more than 24 h. Sixty-eight percent
The number of patients admitted with dog bite injuries each year.
82 Table 1
N. Akhtar et al. Table 3
Types of injury
Procedures performed
Types of injury
Number
Operations
Number
Lacerations Punctures Avulsion injuries Fractures Tendon injuries
118 (75%) 32 (20%) 4 (2.8%) 2 (1.4%) 1 (0.7%)
Debridement and direct closure Debridement only Debridement and SSG Debridement and FTSG Debridement and partial closure Debridement and local flap Replantation of tooth K-wire fixation of fracture Repair of flexor tendon Repair of digital nerve Nail bed repair
101 5 2 1 1 1 1 1 1 1 1
of patients had their wounds cleaned and dressed prior to theatre and most of these (84%) by staff in the referring casualty department. One hundred and seventeen of the 118 patients received antibiotic therapy pre-operatively with one case having antibiotics commenced post-operatively. The most common antibiotic used was co-amoxiclav (80%). One hundred and fourteen cases (96%) were taken to theatre. All cases were performed under general anaesthesia. One hundred and seven (94%) of the procedures were carried out by specialist registrars, 5% by consultant staff and 1% by a career grade surgeon (for operations performed see Table 3). Fifty-seven patients (50%) had surgery within 12 h of their injury and 57 patients after 12 h. The numbers of cases taken to theatre after midnight are shown in Fig. 2. All patients were followed up in the plastic surgery dressing clinic.
Infection rate There were only three cases of infection (2.5%). The first child developed an abscess growing Staphylococcus aureus in a facial wound 48 h after surgery. This was drained on the ward and closed directly a week later. The second child sustained a tendon injury to the index finger of the right hand and a compound fracture of the proximal phalanx of the middle finger. The fracture was K-wired and the flexor digitorum superficialis tendon and ulnar digital nerve of the index finger repaired. When reviewed a week later, both wounds were infected with Pseudomonas and required treated with oral ciprofloxacin. The third child sustained lacerations and puncture wounds to the face, right upper arm Table 2
Sites of injury
Areas of the body injured
Number
Face Upper limb Scalp Lower limb Others
81 (59%) 28 (20%) 9 (7%) 8 (6%) 11 (8%)
and both hands. Cellulitis developed in the upper arm wound without a collection. Despite a serous discharge, no organism was grown and the infection resolved with oral co-amoxiclav. All three patients had had their wounds cleaned and dressed and received prophylactic antibiotics in the referring casualty units. Each patient was operated on within 12 h of injury and before midnight on the day of admission.
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 when the victim is shaken.1,2,13,14 The crushing force between a dog’s jaw can generate a pressure of 450 psi,1,8 and as much as 1800 psi in the American Pit Bull.2 Injuries can range from simple scratches and punctures, to larger defects of soft tissue and bone.1,2,8,13,14 There is a tendency towards infection as a result of primary bacterial inoculation from the normal flora in a dog’s mouth. The incidence of infection reported varies from 5 to 30%.8 The most common pathogens are Staphlococcus aureus and Pasturella multicoda.1,2,12,15 The management of dog bite injuries has evolved over the years. In the past, accepted surgical practice involved delayed closure or healing by secondary intention. It was thought that because of the risk of infection, dog bite injuries should not be
Surgical delay in the management of dog bite injuries in children, does it increase the risk of infection? 83
Figure 2
The number of patients operated on after midnight each year.
closed primarily.1,16 Pinsolle et al. reviewed their series of dog bite injuries between 1979 and 1980. Treatment involved initial surgical exploration, followed by daily dressing with hydrogen peroxide and secondary repair 2–7 days later depending on the severity of the injury.17 More recently there has been a move to more early and definitive treatment, with authors advocating early washout and debridement of wounds and primary closure. These changes have arisen from findings that the infection rate increased if treatment was delayed following injury,15 that debridement reduced the incidence of infection by as much as 30-fold,15 and that primary treatment produced the best cosmetic and functional results.1,4,8,15,18 Our results are consistent with the previous studies.1,4,12 We demonstrated a male predisposition, with a male to female ratio of 1.4:1 and confirmed that younger children were most at risk, with a mean age of 6.6 years. The greatest number of attacks took place in the summer and in a home environment. Overall and Love accounted for this by the greater interaction between children and dogs at that time of year.10 In our study, the most common type of injury was a laceration and, as in other series, the most common site of injury was the face (59%).1,4,13,14 For the facial injuries the most frequently affected area was the middle third (55%). This reflects the findings of Palmer and Rees who called this the ‘central target area’. 7 The small stature of children, the disproportionate size of the head relative to the body, their willingness to bring their faces close to the animal and limited motor skills to provide defence is believed to account for this.10 We found 73% of all cases were admitted within 6 h of injury and only 14 patients whose admission was more than 12 h following injury. Of these patients we found that four had been referred from
the casualty department of the Sheffield Children’s Hospital and 10 from peripheral units. Review of the timing of these patient showed that 11 had been referred late at night and it was felt more appropriate to see them in the morning. The remaining three patients had been referred to our unit at more than 24 h post-injury. All three patients had initially been followed up in casualty clinics and subsequently referred when a more senior clinician deemed the injury warranted plastic surgery review. All of the patients received antibiotics, 117 of 118 patients pre-operatively and one post-operatively. Previous studies have shown no difference in the incidence of infection between patients given antibiotic prophylaxis and those not.1,15,18–20 This has been confirmed in a recent meta-analysis.11 Many authors, however, still advocate antibiotics for patients most at risk, i.e. diabetics,1,5,8,11,15 and it is our departmental policy to treat all patients with antibiotics on admission and to continue for 1 week. Despite the majority of patients being admitted within 6 h of their injury, only 50% had operations within 12 h (the early group). The main reason for the delay in surgery was the unavailability of emergency theatres. Patients still waiting after midnight on the day of admission were then postponed till the following day in accordance with NCEPOD based guidelines. Despite this delay, we had only three cases of post-operative infection. This gave us an infection rate of 2.5%. Surprisingly, all three patients belonged to the early group. There were no cases of infection in the delayed group, i.e. those patients that had their surgery more than 12 h post-injury. Reviewing the three cases that developed infection; one had been referred to us directly from the casualty department of the Sheffield Children’s Hospital, the other two from peripheral hospitals. All three cases had
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received prophylactic antibiotics before admission and had had their wounds cleaned and dressed prior to theatre. Each was operated on within the trusts NCEPOD guidelines at 19:00, 22:30 and 23:00 h, respectively. We compared the early group and the delayed group with regards to; age, number of injuries, types of injuries and cleaning and dressing of the wounds pre-operatively. We found that the two groups were similar in every respect except that 42% of patients in the early group had had their wounds cleaned and dressed pre-operatively compared to 61% of the delayed group (Table 4). This discrepancy between the two groups may have been caused by the staff having insufficient time to attend properly to the wounds before theatre, or alternatively, knowing that the patients were to be operated on shortly, deliberately not performing this essential task. The aim of this study was to identify any conflict between accepted surgical practice for dog bite injuries advocated in the literature and NCEPOD based operating theatres guidelines. In 1987, the first of now many NCEPOD guidelines was published.9 The NCEPOD reports and recommendation whilst not directly stating which procedures should be or not be performed in the ‘out-of-hours’ period, did suggest that very few procedures needed to be performed late at night or in the early hours. As a result, many NHS trusts developed their own guidelines for the management of surgical emergencies during this time period. In our own trust only ‘life or limb threatening procedures’ can be done after midnight with all other cases being delayed until normal working hours. However, the system is flexible and allows a surgeon and anaesthetist to decide to operate at this time if Table 4 A comparison between those patients who were operated on within 12 h of their injury (early group) and those operated on after 12 h (delayed group)
Total number of patients Male:female ratio Average age Attack occurring at home One injury Two or more injuries Lacerations only Wounds cleaned and dressed Operating surgeons (SpR) Wounds undergoing debridement and direct closure
Early group
Delayed group
57 1.3:1 5.8 41 19 40 39 35 56 50
57 1.8:1 6.1 38 22 37 41 43 53 51
they feel it necessary. In this study, we limited the number of patients with dog bite injuries operated on after midnight to conform to our own NCEPOD based guidelines. By postponing surgery to the following day, 50% of the patients had to wait more than 12 h after injury for their operation. Despite this, there was no increase in the rate of infection in this delayed group.
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. Surgeons should feel more comfortable postponing the surgical intervention of dog bites until the following day, knowing that with appropriate preoperative treatment of the wounds there is no increase in the rate of infection.
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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