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Animal Bites in Emergency Medicine

Author: Alisha Perkins Garth, MD; Chief Editor: Joe Alcock, MD, MS more...

Updated: Apr 7, 2014
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. In 2012, there were approximately 70 million pet dogs and
74 million pet cats in the US.
[1]
Recent reports estimate 4.5 million dog bites per year
[2]
and in 2008 this
resulted in approximately 316,000 emergency department (ED) visits.
[3]
Substantially more dog bites
occur than cat bites. These two species account for the majority of (non-human) mammalian bite
wounds encountered in the ED.
Pathophysiology
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.
[4]
Such extreme pressure may damage deeper structures such as bones, vessels, tendons,
muscle, and nerves.
A bite from a dog 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.
[5,
6]
Limited literature is available on other mammalian bites. Monkey bites have a notorious reputation
based largely on anecdotal reports. Domesticated ferrets have been responsible for several
documented cases of unprovoked attacks on young children and infants. The bites of foxes, raccoons,
skunks, bats, dogs, and cats have been clearly linked to rabies exposure. Bites from large herbivores
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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.
[7, 8, 9]
Common bacteria involved in
bite wound infections include the following:
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
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
Animal Bites in Emergency Medicine http://emedicine.medscape.com/article/768875-overview
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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,
[10]
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.
Out of the 4.5 million estimated dog bites that occur each year, nearly 1 out of every 5 requires medical
attention.
[2]
Reports estimate that in 2008, of the 316,000 ED visits, 2.5% required hospital admission.
This number has been on this rise since 1993. There is also increased frequency in rural areas and in
the Midwest and Northeast regions.
[3]
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-bite related deaths range from 20-35 in the United States each year
[10, 11, 12]
with a 0.5% dog-bite
related in-hospital mortality rate.
[3]
Factors contributing to these fatalities have been reviewed and most
commonly include the following
[13]
:
No able-bodied person present to intervene
The victim having no familiar relationship with the animal
Animal Bites in Emergency Medicine http://emedicine.medscape.com/article/768875-overview
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Owners failing to neuter/spay the animal
Victim's compromised ability (age or physical condition)
Animal kept not as a pet (kept in isolation or away from interaction with people)
Prior mismanagement and abuse or neglect of the animal
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 infection contracted from cat bites) also may be complicated by
sepsis. Meningitis, osteomyelitis, tenosynovitis, abscesses, pneumonia, endocarditis, and septic
arthritis are additional concerns in bite wounds. When rabies occurs, it is almost uniformly fatal (see
Rabies).
Sex
Women are more frequently bitten by cats, whereas men are more often bitten by dogs (despite being
"man's best friend").
[14]
For dog bites specifically, men comprise a higher percentage of those
presenting to the emergency department (110.4 versus 97.8 visits/100,000), but the sexes are nearly
equal for those admitted to the hospital.
[3]
Age
The average age of an individual presenting with a dog bite is approximately 30 years, and 75% of all
animal bite patients are less than 45 years of age.
[3]
The peak incidence of animal bites, specifically dog
bites, occurs among children aged 5-9 years.
[15, 10, 11]
Hospital admission rates are higher at the
extremes of age.
[3]

Contributor Information and Disclosures
Author
Alisha Perkins Garth, MD Staff Physician, Exempla St Joseph Hospital, Denver, Colorado
Alisha Perkins Garth, MD is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Emergency Medicine, and American College of Emergency Physicians
Disclosure: Nothing to disclose.
Coauthor(s)
Renee N Salas, MD, MS Fellow in Wilderness Medicine, Attending Emergency Medicine Physician,
Massachusetts General Hospital; Clinical Instructor of Surgery, Harvard Medical School
Renee N Salas, MD, MS is a member of the following medical societies: American College of
Emergency Physicians, American Medical Association, Emergency Medicine Residents Association,
Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.
N Stuart Harris, MD, MFA, FACEP Chief, Division of Wilderness Medicine, Massachusetts General
Hospital (MGH) Fellowship Director, MGH Wilderness Medicine Fellowship. Attending Physician,
MGH Assistant Professor in Surgery, Harvard Medical School
N Stuart Harris, MD, MFA, FACEP is a member of the following medical societies: American
Academy of Emergency Medicine, American College of Emergency Physicians, International Society
for Mountain Medicine, and Massachusetts Medical Society
Disclosure: Nothing to disclose.
Animal Bites in Emergency Medicine http://emedicine.medscape.com/article/768875-overview
4 of 7 31/05/2014 4:53 PM
Clifford S Spanierman, MD Consulting Staff, Departments of Emergency Medicine and Pediatrics,
Lutheran General Hospital of Oak Brook, Advocate Health System
Disclosure: Nothing to disclose.
Specialty Editor Board
Robert M McNamara, MD, FAAEM Chair and Professor, Department of Emergency Medicine,
Temple University School of Medicine
Robert M McNamara, MD, FAAEM is a member of the following medical societies: American
Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and
Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical
Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
James Steven Walker, DO, MS Clinical Professor of Surgery, Department of Surgery, University of
Oklahoma College of Medicine
James Steven Walker, DO, MS is a member of the following medical societies: American Academy of
Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic
Emergency Physicians, and American Osteopathic Association
Disclosure: Nothing to disclose.
John D Halamka, MD, MS Associate Professor of Medicine, Harvard Medical School, Beth Israel
Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard
Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess
Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of
Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for
Academic Emergency Medicine
Disclosure: Nothing to disclose.
Chief Editor
Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New
Mexico Health Sciences Center
Joe Alcock, MD, MS is a member of the following medical societies: American Academy of
Emergency Medicine
Disclosure: Nothing to disclose.
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