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ED nurses seeing more dog-bite-injured patients
Dog-bite injuries resulting in hospital admissions have increased drastically in recent years, from 5100 cases in 1993 to 9500 in 2008, according to a recent report from the Agency for Healthcare Research and Quality (AHRQ).1 More than 316,000 ED visits in 2008 were for dog bites, says the report.
"Hospitalizations seem to be going up, and the vast majority come through the ED," says Anne Elixhauser, PhD, one of the study's authors and a senior research scientist at AHRQ. More than half of the dog-bite-related hospitalizations involved a procedure such as wound debridement, stitches, or skin grafting, says the report.
To improve care of patients with dog bites, use these practices recommended by Leora Wile, BSN, RN, an ED nurse at Thomas Jefferson University Hospital in Philadelphia, PA:
Get a detailed history.
Obtain the time of the event, the dog's rabies status, and the location of bites, says Wile, and document whether the bites are abrasions, puncture wounds, or lacerations.
Have the patient get completely undressed and into a gown.
"There may be bites under clothing, even though the patient's clothing is not damaged," says Wile. Wile cared for a patient with dog bites to the hands who denied any other injury, but she saw the woman was limping. "When the patient was changed into a gown, I noticed a large bruised area with tears in skin on the shin," she says. "There were no tears or rips in her pants. This would have been missed if the patient was not undressed."
Do a full neurovascular and functional assessment of all extremities with bites on them.
"Dog bites may cause a crushing injury, besides puncture wounds, abrasions, and lacerations," she explains. "Do the same assessment as if the patient had twisted the ankle, knee, elbow, or wrist."
Check movement of extremities, capillary refill, sensation, and pulses, says Wile, due to the potential for compartment syndrome from severe bites. "If bites are in the elbow area or knee, the swelling may limit mobility," she says. "This needs to be documented, so that follow-up exams can have a baseline from the time of injury."
Irrigate all wounds with copious amounts of saline to decrease the risk of infection.
"Wounds may need to be injected with lidocaine prior to irrigating for patient comfort," says Wile.
Remember to wear face mask and eye protection to avoid getting fluids splashed in your face.
"Avoid shield-like devices for irrigation to prevent the irrigating solution from returning to the wound," Wile says. "This decreases the effectiveness of the irrigation." (See clinical tip, below, on treatment prior to the patient's ED visit.)
For more information on dog-bite injuries in the ED, contact:
Ask about treatment for dog-bite injury
If a patient presents with a dog-bite injury, Leora Wile, BSN, RN, an ED nurse at Thomas Jefferson University Hospital in Philadelphia, PA, says to find out what treatment, if any, was received by the patient prior to arriving in the ED. "It is important to find out if the patient irrigated the wound prior to arrival," she says. "Rabies is very fragile, and early washing of the wound will help decrease the risk of infection."
Ask if the patient has taken any over-the-counter medications, so no overdoses of acetaminophen occur, says Wile. "Also, some patients may have put a tourniquet on an arm or leg to stop the bleeding, and it may still be on under a jacket or pants," she says. "This would cause you to immediately check the extremity."