Journal of Medicine & public health
MANAGEMENT BITE WOUNDS AT PEDIATRIC AGES. A RETROSPECTIVE ANALYSIS AT HOSPITAL CENTER "XHAFERR KONGOLI", ELBASAN AUTHORS: Violeta ZANAJ1, Blerina BANI2, Marsida KRASNIQI1, Milidin BAKALLI1 1
Department of Medicine, Faculty of Professional Studies, University of “Aleksandër Moisiu” Durrës, Albania
2
Deparment of Paraclinical and Clinical, Faculty of Technical Medicine Studies, University of “Aleksandër Xhuvani” Elbasan, Albania
[email protected]
ABSTRACT : INTRODUCTION: The bite wounds (volnus morsum) in children are a significant problem because of trauma and the high potential to be infected and to result in preventable death in children in our clinical practice in the past. Most of bites are caused by (domestic, stray) dogs, cats, rodents and humans (especially children during clashes with each other). PURPOSE: Evaluation of the wound as anatomic-pathologic entity, recognition of potential complications, careful treatment based on the cause and nature of the wound from the bite. METHOD: The study is descriptive retrospective. The study has taken in consideration 2011 patients with bite wounds, presented in the pediatric hospital in Elbasan during 2010-2016. The patients were evaluated for age, type of wound, clinic, cause, complications, method of treatment and prognosis. RESULTS: In the study were involved 497 children with an average age of 8.7 years (0-18 years) old; where 58% was male and 42% was female. In our study population was observed that 412 individuals had bites from the dog (83%), 35 from the cat (7%), 10 from human (2%), 40 from other species (8% ). 317 of the wounds were infected (63.7%). The most common cases are presented at the end of the spring season and the beginning of the summer. The main cause was Staphylococcus intermedius,Pasteurella multocida and Streptococcus. The most affected parts were the limbs, head, neck, body. Concerning the type of wound, 34% were lacerative wounds, 52% penetrating wounds, 14% skin-deep scratch (abrasion). The treatment consisted in cleaning and decontamination of the wound, administration of antibiotics and doing the anti-tetanus and antirabic vaccine. The surgical intervention is made in 184 wounds (37%).
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CONCLUSIONS: The rate of wound infection and broadband penetration greater than 3 cm was higher than in other wounds. It is recommended anti-tetanus prophylaxis, and antirabic antibiotic therapy.Amoxicillin/clavulanate is the first-line prophylactic antibioticEliminstion or isolation of dogs and cats as well as regular pet vaccination, will reduce the risk of these bite wounds. KEYWORDS: bite wounds, children, infection, antibiotic therapy. INTRODUCTION : Knowledge of wound problems, especially in children, has diagnostic and therapeutic significance. Wound assessment as anatomy-pathological entity is a prerequisite for successful medication. Every year, many people are bitten by animals or other people. In most cases it is about banal wounds that do not require the doctor's observation; In other cases, however, there are elements of importance associated with the trauma itself, or the possibility of bite being followed by a local or generalized infection. Bite wounds (vulnus morsum) are called the damages to the tissue as a result of the traumatic action of biting teeth from animals or humans. These wounds are highly complex depending on the dental formula that has caused the bite, leading to deterioration of anatomical complexion of the skin and mucous. They pose a risk because of the facility with which the phlegmonous and local suppurative inflammation processes begin. Given that, the number of domestic animals increases, there is an increased potential for bite wounds in children. Depending on the bite type, wounds are associated with local hemorrhage and pain. It is important to determine the extent, depth, localization and contamination of the wound. EPIDEMIOLOGY According to the literature, the majority of mammal bites are caused by dogs (85-90%, while cats are responsible for about 5-10% of wounds, rodents about 2-3% and people about 2-3 %.). Dogs have bigger teeth and can provoke lacerations and stiffness of the tissues. The most preferred regions to bite are the head and neck. Cats have thinner and sharp teeth, but although with a delicate bite, their teeth can penetrate in periost and articular capsules. Frequent locations are the hands. Majority of human bite is caused at the hands; the body may also be affected, especially in children during the fighting. By nature, children are very active and can often become anxious or aggressive. They can push, strike or bite another child. These bites tend to be infections. A bite above 3 cm should orient us for abuse of minors.
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METHODOLOGY It is a retrospective descriptive study that includes all patients from 0-18 years of age present at the pediatric hospital of Elbasan district during January 2010-December 2016. There have been analyzed wounds of bite, child age, type, cause and condition of the bite, as well as the treatment.
RESULTS In order to analyze the results, a data base was created where data were evaluated in numeric and percentage values. There have been reviewed data of 497 pediatric patients from 0 to 18 years of age. Age distribution showed that the average age was 2 ± 8.7 years old, with 58% male and 42% females.(fig1) Causes of bite 500 400 300 200 100 0
Gender Distribution
Females 42%
Fig 1
Males 58%
Hum Othe an rs
Dog
Cat
412
35
10
40
Percentage 83%
7%
2%
8%
Cases
100% 80% 60% 40% 20% 0%
Fig 2
It was noted that the prevalence of bite wounds increased after the age of 3 years.Given the history and clinical data, were identified the causes of bite injuries, where dogs take the first place with 83% (412 cases), followed by cats with 75% (35 cases), than followed by human bites by 2% (10 cases) and 8% (40 cases) were mixed and from other animals such as donkey, horse, rat etc. (fig 2) Among the major complications of wound was its infection, specifically 317 cases (63.8%) were presented at different stages of infection and the rest still uninfected: 180 cases (36.2%).(fig 3)
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Number
Presence of infection 350 300 250 200 150 100 50 0
70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
63.8% 36.2%
317
180
Infected
Non-infected Cases
Fig 3
Percentage
In some cases it was possible to isolate the pathogen microorganisms of the animal that caused the bite. The pathogenic causes, responsible for infection of the wound, were: Staphylococcus intermedius, Pasteurella multocida and Streptococcus. (fig 4) 100% 80% 60% 40% 20% 0%
82%
67%
Pathogenic Microorganisms
58%
Fig 4
Regarding the residence settlement, it was noticed that the overwhelming majority of cases were from rural areas and only 28% from urban areas.It was noted that the peak of the cases was at the end of the spring season and the beginning of summer season.Concerning the location of the wound, the most affected parts were the limbs, the head and the body. The type of wound was dependent on the dental formula that had caused the bite. It was noted that about 525 were penetrating, 34% lacerative of about 14% had a surface scratch (abrasion). (fig 5)
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Percentage
Type of wound 60% 50% 40% 30% 20% 10% 0%
52% 34% 14%
Abrasive
Lacerative
Penetreting
Type of wound
Fig 5 The management of bite wound was depending on the degree of wound, presence or absence of infection and general condition alteration of the child. The treatment used extensively involved the cleaning and disinfection of the wound, the administration of antibiotics (amoxicillinclavulanic acid), and application of anti-tetanus and anti-rabies vaccines. The surgical procedure was performed in 184 wounds (37%) where the bite had led to serious damage to structures around the wound.
CONCLUSION : Biting injuries are a common cause for the child to appear in the medical care, so to prevent them, the need for education and the general information of the society is needed. Parents should not bring at home aggressive and non vaccinated pets, while children should avoid animal teasing or provocations. Wounds should be cleaned well to minimize the risk of infection. Amoxicillin / clavulanate is the first line of antibiotics as a prophylaxis. The infection degree of penetration wounds and with a size greater than 3 cm was higher than in other wounds. Antitetanus prophylaxis, anti-rabies and antibiotic therapy, are recommended. Removal or isolation of pariah dogs and cats, as well as regular vaccination of home pets, will reduce the risk of wounds from bites.
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