What is the treatment for a 3-year-old with a small laceration under the left eye from a dog bite?

Treatment of Small Periorbital Laceration from Dog Bite in a 3-Year-Old

For this 3-year-old with a small laceration under the left eye from a dog bite, perform copious irrigation with sterile normal saline, cautious debridement of devitalized tissue, initiate prophylactic amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days, ensure tetanus prophylaxis is current, assess rabies risk with local health officials, and perform primary closure of the facial wound for optimal cosmetic outcomes. 1

Immediate Wound Management

Facial dog bite wounds are an exception to the general rule against primary closure and should be closed primarily after meticulous wound care. 2, 1 The rich vascular supply of the face provides excellent infection resistance and cosmetic outcomes justify primary closure. 1

Critical Initial Steps:

• Irrigate copiously with sterile normal saline using a 20-mL or larger syringe to adequately cleanse the wound and reduce bacterial load 1
• Perform cautious debridement of devitalized tissue while preserving as much viable facial tissue as possible, as aggressive debridement can impair skin closure and worsen cosmetic outcomes 2, 1
• Examine carefully for deeper injury, particularly in periorbital locations where seemingly small lacerations may mask orbital fractures, lacrimal canalicular involvement, or penetrating injuries 3, 4
• Assess for potential nerve or tendon damage that may require specialized repair 1

Antibiotic Prophylaxis

All facial dog bite wounds require preemptive antibiotic therapy regardless of appearance. 5, 1 This differs from non-facial wounds where antibiotics may be reserved for high-risk cases.

• Amoxicillin-clavulanate 875/125 mg twice daily for 3-5 days is the first-line antibiotic, providing coverage against both aerobic bacteria (including Pasteurella multocida) and anaerobic organisms commonly found in dog bite wounds 5, 1
• For penicillin-allergic patients, doxycycline 100 mg twice daily is the preferred alternative with excellent activity against Pasteurella multocida 5, 1
• Avoid first-generation cephalosporins, macrolides, or clindamycin alone as they have poor activity against Pasteurella multocida 1

Tetanus Prophylaxis

• Administer tetanus toxoid (0.5 mL intramuscularly) if vaccination is not current within the past 5 years for this contaminated wound 2, 1
• Tdap is preferred over Td if the patient has not previously received Tdap 5

Rabies Risk Assessment and Prophylaxis

Consult local health officials immediately to determine if rabies post-exposure prophylaxis is indicated. 5, 1 The decision depends on the dog's vaccination status, ability to observe the animal, and local rabies epidemiology.

Rabies Management Algorithm:

• If the dog is healthy and can be confined, observe the animal for 10 days without initiating rabies prophylaxis 2, 5
• If the dog develops signs suggestive of rabies during observation, euthanize the animal and submit the head for brain examination, then initiate rabies post-exposure prophylaxis immediately 2, 5
• If the dog is stray, unwanted, or cannot be observed, initiate rabies post-exposure prophylaxis immediately, which includes both rabies immunoglobulin and vaccine for previously unvaccinated individuals 5, 1
• Do not administer rabies vaccine to the dog during the 10-day observation period 5

Sedation Considerations for Wound Repair

For a 3-year-old undergoing facial laceration repair, many brief procedures can be accomplished with distraction techniques, guided imagery, topical/local anesthetics, and minimal sedation if needed. 2 However, children younger than 6 years often require deeper sedation for procedures requiring immobility. 2

• If sedation is required, ensure personnel skilled in pediatric airway rescue are present, as children commonly pass from the intended level of sedation to deeper, unintended levels 2
• Children younger than 6 years are at greatest risk of adverse sedation events, particularly respiratory depression and airway obstruction 2
• Consider non-pharmacologic approaches first, including parental presence, distraction with age-appropriate games or videos, and child life specialist techniques to reduce the depth of sedation needed 2

Follow-Up Care

• Schedule follow-up within 48-72 hours to assess for signs of infection including increasing pain, redness, swelling, or purulent discharge 5, 1
• Elevate the injured area to reduce swelling using passive positioning methods 5
• If infection progresses despite appropriate antimicrobial therapy, hospitalization should be considered 2, 5

Critical Pitfalls to Avoid

• Do not delay primary closure of facial wounds, as this leads to poorer cosmetic outcomes 1
• Do not underestimate the depth of injury in periorbital dog bites in young children, as small external lacerations may mask orbital fractures or deeper penetrating injuries requiring imaging 4
• Do not close the wound if purulent discharge is already present; infection must be controlled first 1
• Do not use inadequate irrigation volume, as thorough cleansing is essential to prevent infection 1
• Do not fail to assess lacrimal canalicular involvement in periorbital injuries, as these structures are frequently damaged and require specialized repair 3, 6

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