What is the management for a patient with a dog bite to the hand that is still bleeding after 12 hours?

Management of Dog Bite to Hand with Persistent Bleeding

For a dog bite to the hand that is still bleeding after 12 hours, immediate medical attention is required with thorough wound irrigation, consideration for surgical exploration, broad-spectrum antibiotics, and tetanus prophylaxis. 1

Initial Assessment and Management

1. Control bleeding:

   • Apply direct pressure with sterile gauze
   • Elevate the hand above heart level to reduce bleeding 1
   • If bleeding persists despite pressure, surgical exploration may be necessary to identify and address damaged blood vessels

2. Wound assessment:

   • Thoroughly examine for:
     • Depth of wound
     • Involvement of tendons, joints, nerves, or blood vessels
     • Foreign material
     • Signs of infection (redness, warmth, swelling)
   • Hand bites are high-risk injuries with potential for serious complications 1

3. Wound cleansing:

   • Perform copious irrigation with sterile normal saline 1
   • Remove any superficial debris
   • Avoid deeper debridement unless absolutely necessary 1

Antibiotic Therapy

Start broad-spectrum antibiotics immediately as hand bites have high infection risk:

• First-line: Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days 1
• For penicillin-allergic patients:
  • Doxycycline 100 mg twice daily, OR
  • Fluoroquinolone plus metronidazole, OR
  • Clindamycin plus TMP-SMZ 1

This coverage is essential as dog bite wounds typically contain multiple bacterial species including Pasteurella (in 50%), Staphylococci, Streptococci, and anaerobes 1, 2.

Tetanus and Rabies Prophylaxis

• Tetanus prophylaxis: Administer tetanus toxoid (0.5 mL intramuscularly) if vaccination is outdated (>5 years) or status is unknown 1
• Rabies assessment: Evaluate need based on:
  • Vaccination status of the dog
  • Circumstances of the bite
  • Whether the dog can be observed for 10 days 1

Wound Closure Considerations

• Do not close infected wounds 1
• Persistent bleeding after 12 hours suggests potential vascular injury or coagulopathy requiring surgical evaluation
• Hand bites over joints or tendons warrant consultation with a hand specialist 1

Follow-up and Monitoring

• Schedule follow-up within 24-48 hours to assess for signs of infection 1
• Monitor for increasing redness, swelling, pain, warmth, or drainage 1
• Consider hospitalization if:
  • Bleeding cannot be controlled
  • Infection progresses despite appropriate therapy
  • Significant tissue damage is present

Special Considerations for Hand Bites

• Hand bites have higher infection rates than bites to other body parts 1, 3
• Potential complications include:
  • Osteomyelitis
  • Synovitis
  • Nerve or tendon injury
  • Compartment syndrome
  • Post-infectious arthritis 1

Common Pitfalls to Avoid

• Do not underestimate hand bites: Even small wounds can lead to serious infections and functional impairment 4
• Do not delay antibiotics: Early antibiotic prophylaxis significantly reduces infection risk 5, 4
• Do not miss deep structure injuries: Carefully assess for tendon, nerve, joint, and vascular involvement
• Do not close infected wounds: This can lead to abscess formation and worsening infection 1
• Do not neglect immobilization: Consider passive immobilization methods to promote healing 1

Hand bites with persistent bleeding require aggressive management due to the high risk of infection and potential for serious functional impairment.