What is the appropriate workup for a 14-year-old male with a facial dog bite and unknown vaccine status?

Management of Dog Bite to the Face in a 14-Year-Old Male with Unknown Vaccine Status

For a 14-year-old male with a facial dog bite and unknown vaccine status, immediate wound cleaning with soap and water should be performed, followed by rabies post-exposure prophylaxis consisting of both rabies immune globulin and a series of rabies vaccines, while also observing the dog for 10 days if available. 1

Initial Assessment and Wound Management

1. Immediate wound care:

   • Thoroughly clean the wound with soap and water
   • Apply virucidal agent such as povidone-iodine solution 1
   • Assess for tissue damage and potential for infection
   • Consider tetanus prophylaxis based on immunization history 2
   • Evaluate need for antibiotics to prevent bacterial infection

2. Dog status assessment:

   • Determine if the dog is:
     • Available for observation
     • Showing signs of illness
     • Vaccinated against rabies
     • A stray or owned animal
   • If the dog is available, it should be confined and observed for 10 days 2

Rabies Post-Exposure Prophylaxis (PEP)

Decision Algorithm:

1. If dog is available and healthy:

   • Confine and observe the dog for 10 days
   • No immediate rabies PEP needed unless dog develops signs of rabies 2
   • If signs of rabies develop in the dog, euthanize it, submit head for testing, and immediately start PEP

2. If dog is unavailable, stray, or showing signs of rabies:

   • Initiate immediate rabies PEP 1

3. For facial bites specifically:

   • Due to proximity to the central nervous system and shorter incubation period, facial bites warrant more aggressive management
   • Consider initiating PEP even if dog is available for observation, especially for severe bites 1

PEP Protocol:

• Rabies Immune Globulin (RIG):

  • Infiltrate as much as anatomically possible around the wound
  • Administer remaining volume intramuscularly at site distant from vaccine 2

• Rabies Vaccine:

  • Administer 4-dose schedule on days 0,3,7, and 14 3
  • Give intramuscularly in the deltoid (never in gluteal area) 2
  • Ensure compliance with full vaccination schedule 4

Special Considerations for Facial Bites

1. Cosmetic concerns:

   • Consider plastic surgery consultation for facial wounds
   • Balance need for wound closure against infection risk

2. Heightened rabies risk:

   • Facial bites have shorter incubation periods due to proximity to brain
   • More conservative approach to PEP may be warranted

3. Psychological impact:

   • Assess for psychological trauma, especially in adolescents
   • Consider referral for psychological support if needed

Follow-up Care

• Wound check within 48-72 hours
• Ensure compliance with rabies vaccination schedule
• Monitor for signs of infection or complications
• Report the bite to local health department and animal control

Common Pitfalls to Avoid

1. Delaying wound cleaning - immediate thorough cleaning is critical
2. Underestimating rabies risk - even minor bites can transmit rabies 1
3. Incomplete vaccination series - failure to complete all doses puts patient at risk 4
4. Failing to report to public health authorities - essential for proper surveillance
5. Not considering the dog's observation status - healthy dogs can be observed for 10 days before deciding on complete PEP 2

Human rabies is rare but almost universally fatal once symptoms develop, with no documented survivors of untreated rabies 5. Therefore, proper post-exposure management is essential, particularly for high-risk exposures like facial bites.