A 47-year-old man is brought to urgent care by his wife after he was bitten on his right lower leg by an unknown, uncollared dog while jogging on a trail near a creek a couple of miles from his home. The bite occurred about 3 hours prior to presentation. The patient takes lisinopril for hypertension and simvastatin for hyperlipidemia, and his tetanus status is known to be current. The patient has never been vaccinated against rabies. No obvious wounds were seen on the offending dog, which the patient describes as medium- to large-sized with black and brown fur. He is not optimistic that the animal could be easily captured for observation/testing.
On examination, the patient has normal vital signs other than a blood pressure of 158/97 mm Hg. There is a moderately gaping, V-shaped wound that oozes venous blood and measures about 6 cm overlying the lateral right lower leg above the ankle; 2 to 3 more small puncture wounds are also evident near the larger laceration. The lower leg and foot are found to be intact from a neurovascular standpoint.
Which of the following would be the best next steps in management of this patient?
A. Cleanse and irrigate the wound copiously with tap water (or saline) plus iodine-based antiseptic; bandage the wound with saline-soaked gauze; immediately refer the patient to the emergency department (ED) for postexposure prophylaxis (PEP) plus laceration repair
B. Cleanse and irrigate the wound copiously with tap water (or saline) plus iodine-based antiseptic; anesthetize the wound with lidocaine/epinephrine locally; loosely reapproximate the wound with sutures; report the bite to local animal control services; discharge the patient with amoxicillin/clavulanate, wound care instructions, and instructions to follow up with animal control for further advice
C. Irrigate the wound with sterile saline; anesthetize the wound and repair it with sutures; refer the patient to the ED for PEP
D. Call EMS for transport to the ED for possible rabies exposure and wound repair
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Answer: A. This is a fairly worrisome exposure since the dog was not collared, had no identifiable owner, and is unlikely to be quickly captured for quarantine/testing. These features will make it nearly impossible for the clinician to quickly ascertain the animal’s rabies status, so PEP is warranted. Since this patient needs human rabies immune globulin (HRIG) in addition to the first dose of vaccine, it is best not to close the laceration before the HRIG can be infiltrated into the wound.
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Last Updated on January 26, 2023