Synopsis
Assess bite depth and anatomical injury, irrigate and debride early, select proportionate antimicrobial prophylaxis or treatment and complete tetanus, rabies and blood-borne-virus prevention.
- Document species, ownership and health, location and country, provocation, time, wound mechanism and the patient's immune and vaccination status.
- Immediate high-volume irrigation, removal of foreign material and appropriate debridement reduces inoculum and allows true depth assessment.
- Examine distal perfusion, sensation, tendon function and joint movement before local anaesthetic or repair whenever possible.
- Human bites contain oral streptococci, staphylococci, anaerobes and Eikenella; cat punctures commonly inoculate Pasteurella deep into tissue.
- NICE first-choice oral prophylaxis and treatment is co-amoxiclav 625 mg three times daily: three days for prophylaxis and five days for treatment.
- In penicillin allergy when pregnancy is excluded, NICE uses doxycycline 200 mg on day one then 100 to 200 mg daily plus metronidazole 400 mg three times daily.
- Do not close infected, heavily contaminated or high-risk puncture wounds routinely; facial wounds and selected clean wounds need specialist closure judgment.
- Assess tetanus for every wound, rabies for relevant mammalian or bat exposure and hepatitis B, hepatitis C and HIV risk after human bites involving blood.
Key red flags
A clenched-fist wound over a metacarpophalangeal joint can penetrate tendon and joint despite a tiny opening.
Reduced movement, severe pain on passive motion or tendon dysfunction suggests sheath, joint or structural injury.
Absent pulse, delayed capillary return, sensory loss or uncontrolled bleeding requires emergency surgical assessment.
Fever, lymphangitis, rapidly spreading erythema or hypotension indicates invasive infection and possible sepsis.
Deep puncture to hand, face, genitals, foot or near a prosthetic joint has high functional or infection consequence.
An overseas mammalian exposure or bat contact requires urgent rabies-risk assessment without waiting for symptoms.
A small dorsal wound over a metacarpophalangeal joint after punching teeth may track through extensor tendon into the joint.
Narrow deep punctures, particularly to hand or near a joint, can seal over and develop rapid Pasteurella cellulitis, tenosynovitis or abscess.
Dog bites may cause irregular laceration, tissue devitalisation, fracture and nerve or vascular injury in addition to bacterial inoculation.
Fusiform swelling, flexed posture, tenderness along the sheath and pain on passive extension requires emergency hand-surgical evaluation.
Investigation priorities
Define depth, devitalised tissue, retained tooth, tendon, joint, nerve and vascular injury.
Management branches
Any human or animal bite has broken the skin or caused crush injury.
- Control bleeding, remove jewellery, provide analgesia and irrigate copiously with potable water or saline while removing visible contamination and foreign material.
- Record species, location, timing, provocation, country, animal availability, host immune status, allergies and vaccination history.
- Assess depth, tissue viability, perfusion, sensation, tendon function and joint penetration and obtain radiography when tooth, fracture or joint injury is possible.
- Refer hand, face, genital, neurovascular, tendon, joint, fracture or extensive-crush injuries for specialist exploration and closure decisions.