Resident Manual of Trauma to the Face, Head and Neck

Chapter 9: Soft Tissue Injuries of the Face, Head, and Neck

wound can then be irrigated and loosely closed with one or two dermal sutures after instillation of antibiotic ointment, preferably mupirocin, within its depth. Tissue flaps and associated wounds should be minimally debrided and copiously irrigated. Surrounding tissue may be slightly elevated to facilitate dermal closure with rather loosely placed 4-0 or 5-0 chromic catgut suture (or polyglactin suture if some tension exists). Loosely placed epidermal sutures of 6-0 polypropylene or 5-0 fast-absorbing catgut (in children) then complete the repair. 1. Animal Bites a. Dog and Cat Bites Dog bites are most common. They yield puncture wounds, and more commonly, lacerations. Infected dog and cat bites are likely to be populated by Pasteurella multocida, Staphylococcus aureus, and Streptococcus viridans. Cat bites are exceedingly more likely than dog bites to become infected (80 percent versus <5 percent). b. Rabies Virus Transmission Animal bites pose the risk of rabies virus transmission. If rabies is a possibility, the patient should receive a first dose of immune globulin on the day of the injury, followed by the vaccine at days 0, 3, 7, 14, and 28. Because povidone-iodine is a known virocidal and can eliminate 90 percent of the rabies risk, the wound should be irrigated and cleansed with this agent as well. 2. Human Bites Human bites are less common than animal bites. Human bites are less likely to penetrate deeply into facial tissue than animal bites, owing to the length and shape of the anterior human teeth. a. Primary Closure and Open Packing Primary closure is selected only in the most favorable of wounds. Human bites deemed not safe for primary closure may be packed open with frequent dressing changes and application of topical antimicrobi- als, then closed in a delayed fashion 2–4 days after wounding (if clean) or left to heal by second intention. The latter will likely require subse- quent scar revision. b. Broad-Spectrum Antibiotics A polymicrobial population, including anaerobic and aerobic organisms, contaminates most human bites. Thus, it is common to utilize broad- spectrum antibiotics with excellent anaerobic and microaerophilic efficacy.

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Resident Manual of Trauma to the Face, Head, and Neck