dogbite

1. MANAGEMENT
OF DOG BITE
Dr Dike Victor .O
(MBBCH,
FMC,FM)
.

2. OUTLINES
 Introduction
 Epidemiology.
 Classification
 Clinical presentation.
 Investigation
 Treatment
 Prevention.

4. MY WORRY
 Do all dogs bite?
 Should I treat all dog bites, and
with what?.
 Are all stray dogs rabid?
 Does a dog bite mean rabies?
 So, when should I commence
antirabies after a dog bite?
 For how long?`

5. INTRODUCTION
 Dog are house pets, which are strong swift and
cunny. They have predator instincts and are
equiped with strong sharp teeth which are used
most times for offence and defence!
 Dog bite is said to have taken place when there
is a breech in the skin following dog contact, or
contact with a breached skin or mucous
membrane of a victim.

6. INTRODUCTION
 Dog bite can involve the skin, bones, muscles,
tendons. Blood vessels, and nerves.
 Dog bite constitutes a significant number of
medical consultation in the accident and
emergency.
 Dog bites alone constitutes more than 80% of
animal bites

7. INTRODUCTION
 Not all contacts with dogs are of clinical
significance.
 A normal dog can get infected with rabies any
day following bits from other rabid dog,
foxes,bats etc.
 Contact with a rabid dog is a huge concern.
 Death from rabies within days is almost
certain.

8. EPIDEMIOLOGY
 There are about 75 million dogs in the USA.
 And about 45 million dogs in India.
 Most cases of dog bites do not present for
medical treatment.
 There is estimated 4.5million dogbites in the
USA.
 Approximately 880,000 present for med care
annually.

9. EPIDEMIOLOGY
 More than 30,000 victims undergo
reconstructive surgery.
 Case fatality is as high as 10-20% in US and up
to 26 % in India.
 Children between 5 and 9 years are more at
risk.
 Most people who present for medical treatment
are usually children.
 Most bites are provoked.
 More men are affected than women
 Bites involve the extremities in most cases.

10. epidemiology
 Not all dog contacts result in rabies.
 But contact with arabid dog is of great
concern.
 Fatality of rabies is hundred per cent.
 Responsible for more than 50,000 human
deaths
 And more than one million animal death,
globally yearly.

11. FMC OWERRI.A&E RECORDS
MONTHS
No of males No of female TOTAL
JAN **** **** ****
FEB **** **** ****
MAR **** **** ****
APR 3 5 8
MAY 3 2 5
JUNE 5 7 12
JUL 5 7 12
AUG 4 0 4
SEPT 4 5 9
OCT 9 6 15
NOV * 7 2 9

12. AGE DISTRIBUTION IN FMC OWERI.
0 -10 22
11- 20 16
21-30 14
31-40 7
41-50 6
.>-50 9

13. RISKS
 Little children.
 Keeping dogs as household pets.
 The higher the number of dogs the higher the
risk!
 Intervention in dogs fight.
 Challenging dogs food or water.
 Encroaching into a dogs territory!
 Sick dogs.
 Sense of insecurity.

14. TYPE OF INJURIES.
 Bruises
 Puncture wounds.
 Lacerations and tears.
 Fractures.
 Blunt soft tissue injuries.

15. ORGANISMS
 Streptococcus canis
 Staphylococcus intermedius
 E coli
 Klebsiella spp.
 Proteus spp.
 Pasteurella multocida and pasteurella canis.
 Aeromonas spp
 Capnocytophaga canimorsus.
 Parvovirus.
 Rabies virus.

16. WHO CLASSIFICATION.
 CATEGORY1; Touching or feeding suspect
animals, but no skin intact. Animal licks intact skin.
 CAREGORY 2. minor scratches,
abrasionswithout bleeding from contacts.
 Animal licks broken skin.
 CATEGORY3; one or more transdermal bites,
scratches
 Licks on broken skin or mucous membranes
 Other contacts that breaks the skin
 Exposure to bats.

17.  RISK OF RABIES INCREASES IF;
 If bitting animal is known to have rabies
 Exposure occurs in rabies endemic area
 Animal looks sick or displays abnormal
behaviour
 Wound or mucous membrane is contaminated
with saliva
 Bite was unprovoked
 Animal has not been vacinated.

18. PRESENTATION
 PC;contact or attack by dog.
 Anxiety and fear.
 Wounds– punture, laceration etc.
 Bleeding from wound.
 Pain
 Limb deformity

19. PRESENTATION
Tetanus
Rabies.

20. MANAGEMENT
 DETAILED HISTORY.
 Biodata.
 Presenting complaints.
 Time, duration,
 Circumstances surrounding the bite.
 Provoked or unprovoked.
 Household pets or stray dogs.
 Associated symptoms.

21. MANAGEMENT
 DETAILED HISTORY.
 Other sites of injury.
 Other victims
 Immunization status of dog .
 History of care
 Immunisation status of victims.
 Past medical history and co moribd
conditions.

22. MANAGEMENT
 DETAILED HISTORY.
 DRUG AND ALLERGIES.
 Family history and social
classification.

23. MANAGEMENT
 FIFE;
 FEARS--- THE FIRST THING THAT COMES
TO MIND IS RABIES…. And its high fatality rate.
 Associated tetanus.
 Fear of other complications.
 IDEAS
 What the patient thinks about the illness.
 Beliefs, and myths.

24. MANAGEMENT
FIFE.
FUNCTION. How much his movement, job,
sleep, social activities have been affected.
EXPECTATION;
Proper treatment to prevent grievous
consequences.

25. MANAGEMENT
 General physical examination.
 Inspect wounds.
 Check for loss of function.
 Check for any distal
neurovascular deficit
 Systemic examinations.

26. MANAGEMENT
INVESTIGATIONS
 Hb
 Urinalysis
 fbs/rbs
 X-ray of affected limb.
 Wound swab m/c/s.

27. MANAGEMENT
IMMUNIZATION
STATUS OF THE DOG
DOES NOT AFFECT THE
MODALITY OF
TREATMENT!!!..its just
for the dogs benefit.

28. MANAGEMENT
 CATEGORY 1. NO TREATMENT
REQUIRED.
 CATEGORY 2. WOUND CARE+ VACCINE.
 CATEGORY 3. WOUND CARE+VACCINE +
IMMUNOGLOBULIN.

29. Principles of management
 General measures.
 Wound care.
 Post exposure prophylaxis.
 For tetanus
 For rabies.
 May require other specialists.

30. management
General.
 Move patient to a safe place.
 Reassure patient and relatives.
 Allay fears and educate them.
 Affected limb may be elavated or splinted.

31. management
WOUND CARE.
 Depends on the wound size.
 Irrigate wounds immediately, copiously in
running water.
 Then normal saline irrigation.
 Wound exploration under anaesthesia.
 Give analgesics for pain.

32. Wound care
Wound
dressing
done
regularly

33. MANAGEMENT OF
DOGBITE

34. MANAGEMENT
 Wound care.
 Immediate wound closure is controversial.
 It increases primary healing intention, good scar
and cosmesis.
 But has increased risk of infection.
 Good clinical judgement for risk/ benefit.
 Don’t apply herbs, oil etc
 Application of povidone iodine could be beneficial.
 Antibiotic coverage is essential. Broad spectrum,
cover anaerobes.

35. POST EXPOSURE PROPHYLAXIS
 Start PEP immediately.
 Tetanus PEP is 0.5mls, I.M STAT. ???
 RABIES PEP
 Indicated only for category 2 and 3.
 Both the immunoglobulins and vaccines must be given.
 Immunoglobullins are given on day 0 stat, while the
vaccines are given on days, 0, 3 , 7 , 14 , 28. (5 doses).
 If the dog is caged, it must be monitored for up to 10
days, to see if it will develop signs of rabies, WHILE
PEP IS ON.

36. PEP
 If no signs of rabies PEP may be discontinued
after the 3rd
dose. ie 7th
day in( 10 days
observation.).
 If signs of rabies develop in the dog, PEP MUST be
completed.
 If it is a stray dog, or dog attacked and killed. PEP
MUST be completed.
 Immunoglobulin must be started on day 0, same
day with the vaccine it is indicated .
 After the 7th
day (3rd
day of vaccine)
immunoglobulin may not be useful again !!!.

37. PEP
 IMMUNOGLOBULINS.
HUMAN RABIES IMMUNOGLOBULIN. (HRIG)
 EQUINE RABIES IMMUNOGLOBULIN.(ERIG)
 VACCINES.
 HUMAN DIPLOID CELL VACCINE.(HDCV)
 PURIFIED VERO CELL VACCINE (PCECV)
 PURIFIED CHICK EMRYO RABIES VACCINE

38. PEP
 IMMUNOGLOBULINS.
 DOSE.
 HRIG—20IU/ kg stat.
 ERIG---40IU/kg stat( after a test dose.)
 ROUTE OF ADMIN. Infiltrate around the
wound(s) full dose or half of it and the
remaining given IM… AT A DIFFERENT SITE
FROM THE VACCINE..
 SIDE EFFECTS.
 Local pain, swelling, erythema, anaphylaxis etc.

39. PEP
 VACCINES:
 DOSE.
-HDCV- 0.5MLS or 1ml.
 ROUTE OF ADMIN. Intramuscular in the deltoid
region. AVOID THE GLEUTAL MUSLE.
 TIMING. Days 0, 3, 7, 14, 28.
 SIDE EFFECTS.
 Pain, swelling, fever, etc.

40. PEP
 PURIFIED CHICK EMBRYO CELL VACCINE(.rabipur)
 Purified vero cell rabies vaccine. (verorab)
 DOSE; 0.2MLor 0.1ML(rabipur) 0.1ML. (verorab)
 Minimum antigenic potency—25iu/ampule
 ROUTE; intradermally.
 TWO SITE REGIMEN ; on days 0,3,7,28.
 (2-2-2-0-1-1)
 8 SITE REGIMEN:
 DAY 0.- 8 doses at 8 diff sites.
 DAY7 – 4 doses.
 DAY 28- 1dose.
 DAY 90- 1 DOSE.
 (8-0-4-0-1-1)

41. PEP

42. PEP
 NOTE: immunosuppression, malnutrition,
steroid therapy,anticancer meds, pregnancy,
lactation, infancy, old age, illness, are no
contraindication to rabies pep.

43. PRE EXPOSURE PROPHYLAXIS
 INDICATED FOR:
 - veterinarians
 -lab and health personnel working with rabies virus
 -dog catchers.
 zoo staff, forest staff, postmen, courier boys.
 school children in endemic countries.
 VACCINES.
 HDCV. /PCECV: 1ml. On days 0, 7, 21, 28.
 ROUTE OF ADMIN. INTRAMUSCULAR.
 BOOSTER DOSE: 1ml stat. IM. For those at frequent risk or continuous
risk.

44. RE-EXPOSURE
 VACCINES. HDCV.
 If previous vaccination was complete following
exposure, or patient had pre exp prophylaxis..
 DOSE 0.5mils. Two doses. on day 0 and day 3
 ROUTE OF ADMIN ; Intramuscular.
 Immunoglobulin may not be necessary.
 If previous vaccination was not complete , or no pre
exp prophylaxis. Treat patient like a fresh case. Ie 5
doses. May or may not require immunoglobulin's
esp if antibody titer is at least 0.5iu/ml.

45. COMPLICATIONS
Tetanus
Rabies.

46. RABIES
 A viral zoonosis of high mortality.
 Incubation period: 2-8weeks
 MODE OF TRANSMISSION.
 Infection to man often through the bite OR
SALIVA of an infected dog or cat.
 Infection to dog, from another dogbite, or
contact with other animals.
 VECTORS/RESERVOIRS.
 Jackals, wolf,bats,mongoose, wild cats, skunks,
raccons, other infected dogs or cats..

47. RABIES
 Rabies virus, a rhabdoviridae.
 Bullet haped, rna virus. Like
mokola and duvehage.

48. RABIES
 Pathogenesis.
 Innoculation of virus into tissues.
 Migrates to muscles to multiply.
 Enters peripherial nerves axoplasm, spreads centripetally
to CNS. –brain and spinal ganglia.
 Then spreads centrifugally via the axoplasm to all the
neurons in the body.
 Virus detectable in brain tissues, peripherial
nerves,CSF,SALIVA AND URINE.
 Profound nervous involvement presents with, motor,
autonomic symptoms…….like tetanus.
 As such, victims can manifest as furious or paralytic.

49.  UNCONFIRMED
 Inhalation
 Human to human
 Organ transplant
 Consumption of raw meat.

50. RABIES
 CLINICAL PRESENTATION.
 Furious type
 Paralytic type.

51. Rabies.
 IN ANIMALS
 Earliest– loss of appetite and inability to drink
water.
 FURIOUS OR ENCEPHALITIC
 Usually between 2-8 weeks..
 Restless, apprehensive, aggressive.
 Attacks man, animals and objects.
 Travel long distance with jaw hanging open,
saliva dribbling.
 Altered barking.

52. RABIES
 PARALYTIC OR DUMB TYPE.
 Apathetic, lies around.
 Paralysis of jaw neck and hindquarters
 Foams in the mouth.
 Disorientation, incoordination,
staggering,
 Most of them die before 10 days.
 Please note that some dogs can be
asymptomatic carriers.

53. RABIES
 IN MAN.
 Incubation can be between 2-8wweeks.
 Shorter in children, because most bites are in the
head region.
 General. Malaise, anorexia, fever, fatigue, pain,
paraesthesia, anxiety, apprehension, irritability.
 Neurological. Hyperactivity, bizzarre behavior,
hallucinations, siesures, neck stiffness, paralysis.
 Hydrophobia. Aerophobia.
 ANS symptoms. Hyperventilation, arrhythmias,
hypersalivation, hyperpyrexia.

54. rabies
 INVESTIGATIONS FOR
RABIES
 Direct flourescent antibody test.
 Virus isolation
 Histopathology of dogs brain tissue. (Negri bodies,
mononuclear infiltration,perivascular cuffing of
lymphocytes, babes nodules).
 Immunohistochemistry.
 Insitu hybridysation.
 PCR

55. RABIES
 TREATMENT.
 ONCE DIAGNOSIS IS MADE, DEATH IS
INEVITABLE!!!!!!!!!!!!!!!!
 Those who manage to survive , with serious
neurological sequeli, after intensive care are those
who must have had PEP, / pre exp prophylaxis.
 Care when given is simply PALLIATIVE, in a
facility that has both the expertise and the
technology …. to prepare for the evil day 3weeks
max!

56. RABIES
 TREATMENT.
 Some people have tried:
 Sedatives--- diazepam, chlopromazine etc.
 Narcotics
 Interferon alpha.
 ribavirin
 ketamine
 Steroids.
 Monoclonal antibodies…..
 Prognosis has remained very very poor!!!!

57. RABIES
 The best treatment :
 prevent the dometic animals
from getting rabies virus!!!!
 Prevent bites from domestic
animals and contacts with other
at risk animals .
 PEP

58. PREVENTION…..
 SAFETY BITS TO AVOID DOG BITE!!!
 Do not approach a stray or unfamiliar dog, especially
if the owner is not present.
 Do not approach a dog with quick motions or from
above.
 Allow dog time to acknowledge your presence before
attempting to pet it.
 Prior to contact ask the owner if it is safe to pet dog.
 If confrontation occurs, do not make eye contact with
the dog, do not scream and do not run!

59. PREVENTION
 SAFETY BITS
 Do not approach unfamiliar dog while it is eating, sleeping
or caring for puppies.
 Don’t leave young children or infants unattended with a dog.
 If threatened, hold something high above your head!!!
 Don’t turn your back on a dog, or run away instead you back
away!
 Talk calmly to a dog while planning the best exit route and
evaluate any weapon that you muster in that moment of
forced callmness.
 …. CDC recommendations.

60. PREVENTION
 Immunize all dogs.
 Immuinzation must start before the third
month of life.
 Each dog must receive at least 2 doses of anti
rabies within one year of life.
 Fully immunised dog must get a booster dose
after a suspected rabies exposure. And kept
und

61. PREVENTION… FAMILY PHYSICIAN ROLE!
 EDUCATOR–
 Health education.
 Protection of at risk individuals. Mostly infants.
 Encourage immunization. For animals and at risk individuals.
 COMMUNITY LEADER.
 Community sensitisation.
 Encourage community participation.
 Advocacy role:
 LEGISLATION on proper pet care and immunisation.

62. PREVENTION….FAMILY PHYSICIAN
ROLE.
CAREGIVER.
 Immunization.
 Pre exposure prophylaxis.
 Post exposure prophylaxis.
 Wound care.
 Treatment of associated illness.
Tetanus, encephalitis.

63. PREVENTION
 CO-ORDINATOR.
 Coordinates other health care professionals.
 Surgeons – for patients who may need
reconstructive surgeries.
 Physiotherapists.
 Counsellors!
 Other stakeholders, donor agencies. Etc.

64. Despite
all….
Dogs are
man's best
animal
companion
.

65. CONCLUSION
 DOGS are household pets which are of
immense benefits to man.
 However, in certain circumstances can turn
around and inflict serious injuries to man,
especially to owners, family members , and
other vulnerable individuals.
 Therefore adequate knowledge and timely
interventions are necessary, to forestall serious
consequences from a dog bite.

66. Meanwhile….
THANK
YOU FOR
LISTENI
NG