Continuing Education Activity
Human bites account for a relatively low percentage (3%) of the total bites encountered in the ED, but they have the potential for severe morbidity due to challenges in identifying the injuries and late presentations complicated by established infection. The greater cost of care in these injuries is from infection and post-infection treatment, and therefore all efforts should be made to make the diagnosis early and prevent further deterioration. This activity reviews the pathophysiology of human bites and highlights the role of the interprofessional team in the management of these patients.
Objectives:
- Describe the pathophysiology of human bites.
- Review the evaluation of a patient with a human bite.
- Outline the treatment and management options available for human bite.
- Summarize the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by human bites.
Introduction
Human bites account for a relatively low percentage (3%) of the total bites encountered in the ED, but they have the potential for severe morbidity due to challenges in identifying the injuries and late presentations complicated by established infection. The greater cost of care in these injuries is from infection and post-infection treatment, and therefore all efforts should be made to make the diagnosis early and prevent further deterioration. [1][2]
Etiology
Unlike other animal bites, human bites are commonly acquired as a closed-fist injury where one individual punches another in the face and lacerates their hand on the other’s teeth. Occlusion bites have the same risk profile as closed-fist injuries but are more easily recognized and have less prevalence of skin penetration over areas with structures directly below the skin. [3]
Epidemiology
Human bites represent about 3% of the total bite injuries seen in the emergency department and are most commonly closed-fist injuries. Bites in children are most often occlusion bites to the face and upper body from rough playing, while bites in the other age ranges are commonly at the metacarpal-phalangeal joint from striking another individual in the face or contact with another person’s teeth. These wounds are most typically found on the third, fourth, and fifth fingers at the MCP-joint. Occlusion bites predominate in presentation though this distribution may be skewed due to occlusion bites presenting as a known bite while closed-fist injuries (fight bites) typically present under altercation, assault, or other complaints that do not lend themselves to data collection and may only be incidentally found amongst other injuries. Fight bites are most commonly found in the teenage to young adult males. [4]
Pathophysiology
The physical trauma from a human bite is rarely spectacular with relatively minor lacerations and occlusion bruising being the main initial findings. Human oral flora and contagious disease spread to account for the greater amount of morbidity with human bites. Eikenella corrodens, as well as more common aerobic and anaerobic bacteria, are normal human flora. Herpes, hepatitis, and human immunodeficiency viruses are all transmissible through bite injuries. Closed-fist injuries show a predication for infection due to the injury overlying the joint capsule of the MCP and the extensor tendon sheath. Direct joint and tendon sheath inoculation after the fist is relaxed allow bacteria deep penetration to normally sterile anaerobic environments. Local infection, disseminated infection, tenosynovitis, and septic arthritis are all possible complications from human bite wounds.
History and Physical
Focused H&P should determine the circumstances surrounding the bite, location of the bite, whether the bite was contaminated with blood, the infectious state of both individuals involved, time since the occurrence, whether the patient has been febrile, local erythema, swelling, warmth, or purulent drainage from the bite site. Careful examination and measurement of occlusion bites in children are important as any bite with an intra-canine distance great than 3cm most likely came from an adult and should raise suspicion of abuse. Any patient arriving after or due to an altercation should have his or her hands examined for possible fight bites. Conversely, anyone with lacerations on their hands, or especially over the MCP joint should be questioned about the source of the injuries and educated on the danger of not having human bites treated as some patients are apprehensive to admit to the altercation. Immunization status of the person with an injury is important in cases where transmission of disease is a concern.
Evaluation
Wounds that were recently acquired are usually minor, less than 2cm long, and rather superficial which makes them easy to overlook or dismiss especially in light of other injuries or complaints. Contaminated or otherwise obscured skin on hands should be cleaned thoroughly to evaluate for a possible fight bite especially in intoxicated individuals who cannot provide a reliable history. Infected joints or tendon sheaths are more apparent but also warrant surgical consultation and IV antibiotics. If a bite in a child is suspicious for abuse a thorough exam should be performed, a broadened history should be taken, and CPS should be contacted.[1][3]
Treatment / Management
All wounds should be extensively irrigated and the patient’s tetanus status updated if necessary. Provide appropriate pain management before exploration, irrigation, or debridement of the wounds. All human bite wounds that pierce the skin should receive amoxicillin-clavulanate prophylaxis for a week, and the patient is given strict wound care precautions. The patient's TDaP status should be updated if necessary. Any laceration to the MCP-joint is a closed-fist injury until proven otherwise. If signs or symptoms of infection in a joint space or tendon sheath are present orthopedics should be consulted for evaluation for surgical washout and inpatient treatment with IV antibiotics. Repair of lacerations from human bites should follow the same principles as that of other bites and in most cases should be left to heal by secondary intention to prevent providing a more hospitable environment for bacteria to reproduce. [5][6]
Differential Diagnosis
- Animal bites to the head and neck
- Inflammatory breast carcinoma
Complications
- Cosmetic deformity
- Loss of function
- Infectious tenosynovitis
- Necrotizing fasciitis
- Abscess formation
- Amputation
- Osteomyelitis
- Septic joint
Consultations
- Hand Surgeon
- Plastic surgeon
- Infectious disease consult
Pearls and Other Issues
The transmission of HIV through bite wounds is concerning though exceedingly rare. HIV prophylaxis is only indicated if the wound is percutaneous and the mouth was contaminated with blood. Otherwise, the side effect profile of prophylaxis is more dangerous than the risk of transmission. A thorough discussion with the patient about the risks and benefits is warranted and should be documented with the appropriate outpatient follow up recommended/referred. For medical professionals, there has been no reported transmission of HIV from any occupational exposure.
Herpetic whitlow is caused by transmission of the herpes virus to the finger and appears as painful grouped vesicles on an erythematous base. It is most typically from a child sticking fingers into adults’ mouths and should be considered whenever a child presents with lesions on the distal fingers.
There is no post-exposure prophylaxis for Hepatitis C exposure, simply monitoring for signs of infection with outpatient follow-up. Hepatitis B exposure requires immune globulin only if the person bitten by an infected individual has never been immunized or is a known non-responder to the vaccine. Anyone who has never had their response to the vaccine measured and is exposed should be tested for the anti-HBs response and treated if negative.
Enhancing Healthcare Team Outcomes
Human bites can be very serious and are best managed by an interprofessional team of healthcare professionals. Loss of function and cosmetic deformity are very common complications. All patients should understand the signs of an infection following a human bite and when to seek treatment. Patients need to understand that long-term follow-up is necessary to prevent loss of function of the hand or fingers. In addition, the pharmacist should emphasize the importance of antibiotic compliance. Finally, all patients must be told that they may require a plastic surgery procedure later to improve function or cosmesis. Nurses can perform an initial evaluation and chart treatment progress, as well as answering patient questions, and reporting any concerns to the treating clinician.[7]
Outcomes
Patients who seek immediate care after a human bite have excellent outcomes. However, patients who delay treatment tend to have adverse outcomes. In most cases, a florid infection develops which can involve the entire hand. In delayed cases, not only is there is a significant cosmetic deformity, but there is also a functional loss of the hand and fingers. Human bites on the nose, ear, or tips of the finger are difficult to cure and often require extensive plastic surgery. Scarring is another major complication of a human bite.
Human Bites