What is the appropriate management for a patient with a finger amputated due to a human bite?

Management of Traumatic Finger Amputation from Human Bite

Immediately control hemorrhage with direct pressure or a tourniquet if bleeding is life-threatening, irrigate copiously with water or saline, administer prophylactic antibiotics (amoxicillin-clavulanate), update tetanus prophylaxis, and arrange urgent surgical evaluation—do not attempt to close the wound. 1, 2

Immediate Hemorrhage Control

Life-threatening bleeding takes absolute priority and must be controlled within minutes to prevent exsanguination. 2

• Apply direct pressure first using gauze pads directly over the bleeding site—this remains the most effective initial intervention for hemorrhage control 3, 4
• If direct pressure fails or the patient has no radial pulse, apply a tourniquet immediately as it represents the fastest and potentially life-saving technique available 2
• For finger/hand amputations with uncontrolled arterial bleeding, a tourniquet is simple and efficient for acute hemorrhage control 2
• Minimize time to surgical bleeding control—transport immediately to a trauma center or emergency department capable of hand surgery 2
• Tourniquets should remain in place until surgical control is achieved but keep duration as short as possible (ideally <2 hours, though up to 6 hours has been tolerated) 2

Wound Management

Copious irrigation is critical and must be performed immediately. 2

• Irrigate the wound with copious amounts of running tap water or sterile saline until no visible debris or contamination remains 1, 2
• Running tap water is as effective as sterile saline and superior to antiseptic solutions like povidone-iodine 1
• Do not use iodine or antibiotic-containing solutions for irrigation—they provide no benefit over water/saline 2, 1
• Remove only superficial debris; avoid aggressive debridement that causes additional tissue damage 2, 1
• Do not close the wound—infected wounds and those presenting >8 hours after injury should never be sutured 2, 1
• Cover the wound with a sterile occlusive dressing after irrigation 2, 1

Antibiotic Prophylaxis (Critical)

Human bites require immediate prophylactic antibiotics regardless of wound appearance—they are more serious than animal bites with infection rates of 10-20%. 2

• Amoxicillin-clavulanate is the first-line antibiotic for both prophylaxis and treatment of human bite wounds 1, 2
• Human bite wounds contain mixed aerobic and anaerobic oral flora including streptococci (80%), staphylococci, Haemophilus species, Eikenella corrodens, Fusobacterium species, peptostreptococci, Prevotella species, and Porphyromonas species 2
• Many anaerobes produce β-lactamases, making them resistant to penicillin and first-generation cephalosporins 2
• For penicillin-allergic patients, use doxycycline, or a fluoroquinolone plus metronidazole or clindamycin 1, 2
• Avoid first-generation cephalosporins, penicillinase-resistant penicillins alone, macrolides, and clindamycin monotherapy—these have poor activity against the polymicrobial flora in human bites 1, 2

Tetanus Prophylaxis

Update tetanus status immediately. 2, 1, 5

• Administer tetanus toxoid (0.5 mL intramuscularly) if vaccination status is outdated or unknown 2, 1, 5
• Give booster if >5 years since last dose for contaminated wounds like human bites 1, 5
• For patients with uncertain or incomplete primary vaccination series, administer both tetanus immune globulin (250 units IM in a different extremity) and tetanus toxoid 5

Urgent Surgical Consultation

Hand wounds from human bites require immediate expert hand surgery evaluation. 2

• Clenched-fist injuries and finger amputations have extremely high risk of joint capsule penetration, septic arthritis, and osteomyelitis 2, 1
• Hand wounds are the highest risk location for infection and complications from bite injuries 1, 2
• Pain disproportionate to injury severity near a bone or joint suggests periosteal penetration requiring prolonged therapy (4-6 weeks for osteomyelitis, 3-4 weeks for septic arthritis) 2
• Minimize elapsed time between injury and surgical evaluation—early intervention improves survival and outcomes 2

Additional Wound Care

• Elevate the injured hand, especially if swollen, to accelerate healing 2, 1
• Use a sling for outpatients or tubular stockinet with IV pole for inpatients 2
• Follow up within 24 hours by phone or office visit 2, 1
• Signs requiring immediate re-evaluation include redness, swelling, foul-smelling drainage, increased pain, or fever 1

Critical Pitfalls to Avoid

• Do not attempt wound closure—this dramatically increases infection risk 2, 1
• Do not delay antibiotic administration—human bites require prophylaxis regardless of appearance 2
• Do not use inadequate antibiotic coverage—avoid cephalexin, macrolides, or clindamycin alone 1, 2
• Do not underestimate the severity—human bites are often more serious than animal bites and finger amputations require urgent hand surgery evaluation 2, 1
• Do not use antiseptic solutions for irrigation—water and saline are superior 2, 1

Human bites also carry potential for transmission of hepatitis B, hepatitis C, and HIV—consider appropriate testing and prophylaxis based on exposure risk assessment 2