Animal Bites in Emergency Medicine Follow-up

M. Yusuf, MD

Background
Because many animal bites are never reported, determining the exact incidence of bite wounds in the United States, let alone the world, is difficult. An estimated 74.8 million dogs lived in the United States in 2007; these account for an estimated 5 million dog bites per year, over which 800,000 require medical attention[1] . Substantially more dog bites occur than cat bites. These two species account for the majority of (non-human) mammalian bite wounds encountered in the emergency department (ED).

Patophysiology
Dog bites typically cause a crushing-type wound because of their rounded teeth and strong jaws. An adult dog can exert 200 pounds per square inch (psi) of pressure, with some large dogs able to exert 450 psi.[2] Such extreme pressure may damage deeper structures such as bones, vessels, tendons, muscle, and nerves. A bite from a pit bull is shown below.

Animal bites. Wounds to the left arm and hip inflicted during a dog attack.

The sharp pointed teeth of cats usually cause puncture wounds and lacerations that may inoculate bacteria into deep tissues. Infections caused by cat bites generally develop faster than those of dogs.
[3, 4]

Limited literature is available on other mammalian bites. Monkey bites have a notorious reputation based largely on anecdotal reports. Several cases of unprovoked attacks on young children and infants by domesticated ferrets have been documented. The bites of foxes, raccoons, skunks, bats, dogs, and cats have been clearly linked to rabies exposure. Bites from large herbivores generally have a significant crush element because of the force involved. Bites of the hand generally have a high risk for infection because of the relatively poor blood supply of many structures in the hand and anatomic considerations that make adequate cleansing of the wound difficult. In general, the better the vascular supply and the easier the wound is to clean (ie, laceration vs puncture), the lower the risk of infection. A major concern in all bite wounds is subsequent infection. Infections can be caused by nearly any group of pathogens (bacteria, viruses, rickettsia, spirochetes, fungi). At least 64 species of bacteria are found in the canine mouth, causing nearly all infections to be mixed.[5, 6, 7] Common bacteria involved in bite wound infections include the following: o o o o o o o o o o o o o Dog bites Staphylococcus species Streptococcus species Eikenella species Pasteurella species Proteus species Klebsiella species Haemophilus species Enterobacter species DF-2 or Capnocytophaga canimorsus Bacteroides species Moraxella species Corynebacterium species Neisseria species

o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o

Fusobacterium species Prevotella species Porphyromonas species Cat bites Pasteurella species Actinomyces species Propionibacterium species Bacteroides species Fusobacterium species Clostridium species Wolinella species Peptostreptococcus species Staphylococcus species Streptococcus species Herbivore bites Actinobacillus lignieresii Actinobacillus suis Pasteurella multocida Pasteurella caballi Staphylococcus hyicus subsp hyicus Swine bites Pasteurella aerogenes Pasteurella multocida Bacteroides species Proteus species Actinobacillus suis Streptococcus species Flavobacterium species Mycoplasma species Rodent bites - Rat-bite fever Streptobacillus moniliformis Spirillum minus Primates Bacteroides species Fusobacterium species Eikenella corrodens Streptococcus species Enterococcus species Staphylococcus species Enterobacteriaceae Simian herpes virus Large reptiles (crocodiles, alligators) Aeromonas hydrophila Pseudomonas pseudomallei Pseudomonas aeruginosa Proteus species Enterococcus species Clostridium species

Epidemiology

Frequency
United States Of an estimated 3-6 million animal bites per year in the United States,[8]approximately 80-90% are from dogs, 5-15% are from cats, and 2-5% are from rodents, with the balance from other small animals (eg, rabbits, ferrets), farm animals, monkeys, reptiles, and others. Some estimate that 1% of

emergency visits are for dog bite wounds. Approximately 1% of dog bite wounds and 6% of cat bite wounds require hospitalization.[1, 9] International The lack of standard reporting in many countries makes accurate estimates of mammalian bite incidence difficult to determine. Depending on locale, the range of animals inflicting bites is wide and includes large cats (tigers, lions, leopards), wild dogs, hyenas, wolves (Eurasia), crocodiles, and other reptiles. As in the United States, most bites, however, are from domestic dogs. In developing countries, mammalian bites (especially bites by dogs, cats, foxes, skunks, and raccoons) carry a high risk of rabies infection.

Mortality/Morbidity
Dog attacks kill approximately 20-35 people annually in the United States.[8, 10, 11]Many of these fatalities, unfortunately, are young children. While local infection and cellulitis are the leading causes of morbidity, sepsis is a potential complication of bite wounds, particularly C canimorsus (DF-2) sepsis in immunocompromised individuals. Pasteurella multocida infection (the most common pathogen contracted from cat bites) also may be complicated by sepsis.Meningitis, osteomyelitis, tenosynovitis, abscesses, pneumonia, endocarditis, andseptic arthritis are additional concerns in bite wounds. When rabies occurs, it is almost uniformly fatal (Rabies).

Sex
Women are more frequently bitten by cats, whereas men are more often bitten by dogs (despite being man's best friend).[12]

Age
Peak incidence of animal bites occurs among children aged 5-9 years.[9, 8, 10]

History
History for animal bites should include the following: Time and location of event Type of animal and its status (ie, health, rabies vaccination history, behavior, whereabouts) Circumstances surrounding the bite (ie, provoked or defensive bite versus unprovoked bite) Location of bites (most commonly on the upper extremities and face) Prehospital treatment Patients medical history (immunocompromise, peripheral vascular disease, diabetes, tetanus and rabies vaccination history)

Major resuscitation rarely is required. Because patients typically are children, reassurance and parental presence may facilitate examination. Where applicable, consider the following: Distal neurovascular status Tendon or tendon sheath involvement Bone injury, particularly of the skull in infants and young children Joint space violation Visceral injury Foreign bodies (eg, teeth) in the wound Significant damage due to bites is shown in the images below

Animal bites. The devastating damage sustained by a preadolescent male during a dog attack. Almost lost in this photograph is the soft tissue damage to this victim's thigh. This patient required 2 units of O- blood and several liters of isotonic crystalloid. Repair of these wounds required a pediatric surgeon, an experienced orthopedic surgeon, and a plastic surgeon. Attacks such as these have caused a movement in some areas of the country to ban certain dog breeds.

Animal bites. Massive soft tissue damage of the right leg caused by a dog attack. This patient was transferred to a level one pediatric trauma center for care. At times, staff members may need counseling after caring for mauled patients.

Animal bites. Massive soft tissue damage of the lower left leg caused from a dog attack. Most of the fatalities from dog bites are children.

Animal bites. A different angle of the patient in Image 3 showing the massive soft tissue damage to this child's left lower leg.

Animal bites. Wounds to the left arm and hip inflicted during a dog attack

Bite wounds from cats and dogs can occur without provocation, but provoked bites, such as disturbing animals while they are eating, are more common. Older animals often are less tolerant of disturbances, especially by children. Most dog bites involve a dog that belongs to the family or friend of the victim and approximately half occur on the pet owner's property.[10] Certainly, unprovoked bites by wild or sick-appearing animals (most notably by dogs, cats, raccoons, foxes, skunks, and bats) further raise underlying concerns about likelihood of rabies exposure.

Differential Diagnoses
Bites, Human Cellulitis Fractures, Cervical Spine Hand Infections Neck Trauma Osteomyelitis Rabies Tetanus

Laboratory Studies
Fresh bite wounds without signs of infection do not need to be cultured. Infected bite wounds should be cultured to help guide future antibiotic therapy. Other laboratory tests are indicated as the patient's condition dictates (eg, CBC and blood cultures for patients with sepsis).

If C canimorsus sepsis is suspected, examine the peripheral smear for the organism, a bacillus.

Imaging Studies
Radiography is indicated if any concerns exist that deep structures are at risk (eg, hand wounds; deep punctures; crushing bites, especially over joints). Occult fractures or osteomyelitis may be discovered. Radiographs may find foreign bodies in the wound (eg, teeth). Children who have been bitten in the head should be examined for bony penetration with plain films or CT scan. If the child was shaken, consider cervical spine evaluation.

Prehospital Care
Obtaining the history of the bite event is of major importance, including home treatment of wounds, body parts involved, and other symptoms (see History). Rinse bite wounds, if possible, and cover with a sterile dressing. Tap water has been shown to be as effective for irrigation as sterile saline.[13] Encourage patients to seek prompt care.

Emergency Department Care

Most bite wounds can be treated in the ED. Essentials of treatment are inspection, debridement, irrigation, and closure, if indicated. Complete trauma evaluation occasionally is indicated. Carefully inspect bite wounds to identify deep injury and devitalized tissue. Obtaining an adequate inspection of a bite wound without it first being anesthetized is nearly impossible. Care should be taken to visualize the bottom of the wound and, if applicable, to examine the wound through a range of motion. Debridement is an effective means of preventing infection. Removing devitalized tissue, particulate matter, and clots prevents these from becoming a source of infection, much like any foreign body. Clean surgical wound edges result in smaller scars and promote faster healing. Irrigation is another important means of infection prevention. A 19-gauge blunt needle and a 35-mL syringe provide adequate pressure (7 psi) and volume to clean most bite wounds. In general, 100-200 mL of irrigation solution per inch of wound is required.[13] Heavily contaminated bite wounds require more irrigation. Large dirty wounds may require irrigation in the operating room. Isotonic sodium chloride solution is a safe, available, effective, and inexpensive irrigating solution. Few of the numerous other solutions and mixtures of saline and antibiotics have any advantages over saline. If a shieldlike device is used, take care to prevent the irrigating solution from returning to the wound, which decreases the effectiveness of the irrigation. Primary closure may be considered in limited bite wounds that can be cleansed effectively (this excludes puncture wounds, ie, cat bites). Other wounds are best treated by delayed primary closure. Facial wounds, because of the excellent blood supply, are at low risk for infection, even if closed primarily, but the risk of superinfection must be discussed with the patient prior to closure. Bite wounds to the hands and lower extremities, with a delay in presentation, or in immunocompromised hosts, generally should be left open.[7] If a bite wound involves the hand, consider immobilizing in a bulky dressing or splint to limit use and promote elevation. Consider tetanus and rabies prophylaxis for all wounds. Antirabies treatment may be indicated for bites by dogs and cats whose rabies status can not be obtained, or in foxes, bats, raccoons, or skunks in the Americas (see Rabies and Tetanusfor treatment and dosing information). Oehler et al have established a wound management strategy following animal bites to prevent severe complications that include the following steps:[14] Culture for aerobes and anaerobes if abscess, severe cellulitis, devitalized tissue, or sepsis is present. Use saline solution for wound irrigation.

 Debride necrotic tissue and remove any foreign bodies. If fracture or bone penetration, radiography is indicated (MRI or CT may also be indicated). Initiate prophylactic antibiotics in selected cases (based on type and specific animal involved). If methicillin-resistant Staphylococcus aureus (MRSA) is suspected, first-line antibiotics include trimethoprim-sulfamethoxazole, doxycycline, minocycline, and clindamycin. Hospitalization is indicated if fever, sepsis, spreading cellulitis, severe edema, crush injury, or loss of function is present. Also consider hospitalization for patients who are immunocompromised or are likely to be noncompliant. Administer tetanus booster (if none given in past year) or initiate primary series in nonvaccinated individuals (See Tetanus for further recommendations). Assess the need for rabies vaccine and immunoglobulin (See Rabies for further recommendations).

Consultations
Extensive wounds, those involving tissue loss, or those involving complex structures may require plastic surgery consultation. If the skull is penetrated, neurosurgery consultation is indicated. Local public health authorities should be notified of all bites and may help with recommendations for rabies prophylaxis.

Medication Summary
This is one of most controversial subjects in wound care. Remember that proper wound care (inspection, debridement, irrigation, closure, if indicated) reduces infection more than antibiotics. In general, low-risk wounds do not require prophylactic antibiotics. However, therapy is recommended for high-risk wounds (eg, cat bites that are a true puncture, bites to the hand, massive crush injury, late presentation, poor general health).[15] The goal of initial therapy is to cover staphylococci, streptococci, anaerobes, andPasteurella species. Prophylactic antibiotics may be given for a 3- to 5-day course. The first-line oral therapy is amoxicillinclavulanate. For higher risk infections, a first dose of intravenous antibiotic may be given (ie, ampicillin-sulbactam, ticarcillin-clavulanate, piperacillin-tazobactam, or a carbapenem). Other combinations of oral therapy include cefuroxime plus clindamycin or metronidazole, a fluoroquinolone plus clindamycin or metronidazole, sulfamethoxazole and trimethoprim plus clindamycin or metronidazole, penicillin plus clindamycin or metronidazole, amoxicillin plus clindamycin or metronidazole and less effective azithromycin or doxycycline plus clindamycin or metronidazole.[16, 6, 7] If the wound is infected on presentation, a course of 10 days or longer is recommended. For monkey bites, postexposure prophylaxis valacyclovir or acyclovir should be given for 14 days.

Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
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Levofloxacin
For pseudomonal infections and infections due to multidrug resistant gram-negative organisms.
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Metronidazole

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for C difficile enterocolitis).
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Ampicillin and sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.
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Ticarcillin and clavulanate potassium (Timentin)

Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth. Antipseudomonal penicillin plus beta-lactamase inhibitor that provides coverage against most grampositive organisms, most gram-negative organisms, and most anaerobes.
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Piperacillin and tazobactam sodium (Zosyn)

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.
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Imipenem and cilastatin (Primaxin)

For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity.
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Ertapenem (Invanz)
Bactericidal activity results from inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin-binding proteins. Stable against hydrolysis by a variety of beta-lactamases including penicillinases, cephalosporinases, and extended-spectrum beta-lactamases. Hydrolyzed by metallo-beta-lactamases.
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Meropenem (Merrem IV)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria. Has slightly increased activity against gram-negatives and slightly decreased activity against staphylococci and streptococci compared to imipenem.
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Amoxicillin and clavulanate (Augmentin)

Drug combination that extends antibiotic spectrum of penicillin to include bacteria normally resistant to beta-lactam antibiotics. Indicated for skin and skin structure infections caused by beta-lactamase producing strains of Staphylococcus aureus.

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Cefuroxime (Ceftin, Kefurox, Zinacef)

Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; adds activity against P mirabilis, H influenzae, E coli, K pneumoniae, and M catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.
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Ciprofloxacin (Cipro)
Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, S epidermidis, and most gram-negative organisms, but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth.
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Clindamycin (Cleocin)
Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
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Sulfamethoxazole/trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
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Amoxicillin (Trimox, Biomox, Amoxil)

Alone, this drug is effective against Pasteurella species. However, not indicated for skin and skin structure infections caused by beta-lactamaseproducing strains ofStaphylococcus aureus. A second antibiotic such as cephalexin is needed forStaphylococcus infections.
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Azithromycin (Zithromax)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Treats mild-to-moderate microbial infections
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Doxycycline (Doryx, Vibramycin, Bio-Tab)

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.

Antiviral agents
Class Summary

These agents inhibit viral replication.

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Acyclovir (Zovirax)
Prodrug activated by phosphorylation by virus-specific thymidine kinase that inhibits viral replication. Herpes virus thymidine kinase (TK), but not host cells' TK, uses acyclovir as a purine nucleoside, converting it into acyclovir monophosphate, a nucleotide analogue. Guanylate kinase converts the monophosphate form into diphosphate and triphosphate analogues that inhibit viral DNA replication. Has affinity for viral thymidine kinase and, once phosphorylated, causes DNA chain termination when acted on by DNA polymerase. Has activity against a number of herpesviruses, including herpes virus B. Primarily available in preparations for PO and IV use. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks. Early initiation of therapy is imperative.
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Valacyclovir (Valtrex)
Hydrochloride salt of the L-valyl ester of acyclovir. Rapidly converted into acyclovir after prompt absorption from the gut via first-pass intestinal or hepatic metabolism. An alternative to acyclovir for prophylaxis (or possibly treatment).

Toxoids
Class Summary
Tetanus results from elaboration of an exotoxin from Clostridium tetani. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome. Patients who may not have been immunized against C tetani products (eg, immigrants, the elderly) should receive tetanus immune globulin.
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Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap, Adacel, Boostrix)
Promotes active immunity to diphtheria, tetanus, and pertussis by inducing production of specific neutralizing antibodies and antitoxins. Indicated for active booster immunization for tetanus, diphtheria, and pertussis prevention for persons aged 10-64 y (Adacel approved for 11-64 y, Boostrix approved for 10-18 y). Preferred vaccine for adolescents scheduled for booster.

Tetanus toxoid
No longer available in the United States. Used to induce active immunity against tetanus in selected patients. The immunizing agent of choice for most adults and children > 7 years are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life. The CDC recommends Td for pregnant patients who have urgent indication tor tetanus toxoid or diphtheria toxoid vaccination. In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is the mid-thigh laterally.

Immune Globulin

Class Summary
Indicated in previously unvaccinated individuals to provide passive immunity to tetanus when individuals become exposed.
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Tetanus immune globulin (HyperTET S/D)

Used for passive immunization of any person with a wound that might be contaminated with tetanus spores.
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Rabies Immune Globulin (Imogam Rabies-HT, HyperRab S/D)

Provides passive protection to individuals exposed to rabies virus. About 1/2 the dose should be administered into and around the bite wound as much as possible (given anatomic constraints), and the rest given intramuscularly at a site remote from the vaccine administration area in the gluteal or deltoid muscle.

Vaccine, Inactivated Virus

Class Summary
Inactivated forms of virus that promote immunity by inducing an active immune response.
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Rabies vaccine (Rabavert, Imovax Rabies Vaccine)

Inactivated form of virus grown in primary cultures of chicken fibroblasts; offers active immunity and, when used in combination with human rabies immune globulin (HRIG) and local wound treatment, protects postexposure patients of all age groups; also used for preexposure immunization in both primary series and booster dose. Fourteen days after initiating immunization series, anti-rabies antibody titers reach levels well above minimal protective level of 0.5 IU/mL. Vaccine must be injected IM and never SC, ID, or IV. In adults, inject into deltoid muscle area. In small children, administer into anterolateral zone of thigh.

Rabies vaccine adsorbed (RVA; BioPort Corp under US Department of Defense contract for military use only)
Inactivated virus vaccine, which promotes immunity by inducing active immune response. May be given IM only, never ID.

Follow Up Further Inpatient Care

Patients with infected animal bites may need inpatient care. This depends on the general health of the patient, the extent and nature of the infection, and the patient's compliance. Consider admitting patients with hand bites that become infected (generally involving deep structures). Consider consultation with hand surgery service if deep infection, such as involving the tendon sheath or other structures, is suspected as surgical irrigation may be indicated.

Further Outpatient Care

Close follow-up care is essential in animal bite wounds. Reevaluate a low-risk bite for signs of infection within 48 hours and a high-risk bite within 24 hours. In some centers that have an observation unit, admission to that area for direct clinical observation and repeat doses of parenteral antibiotics can be considered on a case-by-case basis.

Transfer
Patients who require extensive repair or prolonged inpatient care may need transfer to a tertiary care facility.

Complications
Complications of bite wounds may include the following: Wound infection Sepsis Cosmetic deformity Loss of limb Loss of function

Prognosis
The prognosis of animal bite wounds is generally excellent.

Patient Education
Educating patients about the risk of infection despite proper wound care, antibiotics (if indicated), and close follow-up care is very important. Even bite wounds that have received the best care may become infected. Teach patients the signs of infection and the need for prompt attention if the wound should become infected. For patient education resources, see the Bites and Stings Center and Bacterial and Viral Infections Center, as well as Animal Bites and Rabies.

References
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Chambers GH, Payne JF. Treatment of dog bite wounds. Minn Med. 1969;52:427430. [Medline]. Freer L. Bites and injuries inflicted by wild and domestic animals. In: Auerbach PS, ed. Wilderness Medicine. 5th ed. Mosby; 2007:1133-55. Dire DJ. Cat bite wounds: risk factors for infection. Ann Emerg Med. Sep 1991;20(9):9739. [Medline]. Talan DA, Citron DM, Abrahamian FM, et al. Bacteriologic analysis of infected dog and cat bites. N Engl J Med. Jan 14 1999;340(2):85-92. [Medline]. Abrahamian FM. Dog Bites: Bacteriology, Management, and Prevention. Curr Infect Dis Rep. Oct 2000;2(5):446-453. [Medline]. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. Nov 15 2005;41(10):1373406. [Medline]. Gilchrist J, Sacks JJ, White D, Kresnow MJ. Dog bites: still a problem?. Inj Prev. Oct 2008;14(5):296-301.[Medline]. Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments.JAMA. Jan 7 1998;279(1):51-3. [Medline]. [Full Text]. Sacks JJ, Lockwood R, Hornreich J, Sattin RW. Fatal dog attacks, 1989-1994. Pediatrics. Jun 1996;97(6 Pt 1):891-895. [Medline]. Animal People. Dog attack deaths and maimings, US and Canada. September 1982 to December 26, 2011. Dogsbite.org. Available at http://www.dogsbite.org/pdf/dog-attackdeaths-maimings-merritt-clifton-2011.pdf. Accessed May 9, 2012. Palacio J, Leon-Artozqui M, Pastor-Villalba E, Carrera-Martin F, Garcia-Belenguer S. Incidence of and risk factors for cat bites: a first step in prevention and treatment of feline aggression. J Feline Med Surg. Jun 2007;9(3):188-95. [Medline]. Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Academic Emergency Medicine. May 2007;14 (5):404-9.[Medline]. Oehler RL, Velez AP, Mizrachi M, Lamarche J, Gompf S. Bite-related and septic syndromes caused by cats and dogs. Lancet Infect Dis. Jul 2009;9(7):439-47. Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a metaanalysis of randomized trials. Ann Emerg Med. Mar 1994;23(3):535-40. [Medline]. Gilbert DN, Moellering RC, Eliopoulos FM, Sande MA, eds. Bites. In: The Sanford Guide to Antimicrobial Therapy. 37th ed. 2007:46,47,140. Guy RJ, Zook EG. Successful treatment of acute head and neck dog bite wounds without antibiotics. Ann Plast Surg. Jul 1986;17(1):45-8. [Medline]. Trott A. Bite wounds. In: Wounds and Lacerations Emergency Care and Closure. 2nd ed. St Louis, Mo: Mosby-Year Book Inc; 1997:265-84. Weber EJ. Mammalian bites. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Mosby; 2006:906-21.

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