GP Case study 1

I was on-call for GP this weekend. (Yes, I know. Don't ask me why GP needs to be on-call). The local ED was overflowing with patients. 90 % of them were inappropriate presentations. They should be sent home and present to their regular GP on Monday. The following was one of the cases I saw, not avcommon day to day presentation at GP clinic, however, still relevant.


Scenario 
21 F with b/g history of rheumatoid arthritis on Celebrex presented to ED after a dog bite. The dog bit her on the right thumb close to the 1st MCP. (Please see figure 1).



On examination, the patient's right thumb was neurovascularly intact. How would you manage this patient?

Answer: This wound is at high risk of getting infected. If you pay attention at the photo, you will also see a puncture wound on the palmer aspect of the thumb. It is likely that the puncture wound went through the 1st metacarpal phalangeal joint. It needs to debrided and washed out surgically. I contacted the local friendly plastic registrar to organise a surgical debridement the next day. I also organised a right thumb x-ray, IV Tazocin (Piperacillin + Tazobactam) and a right thumb superficial irrigation at ED with a ring block.

According to Australain therapeutic guideline 2015.

- The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria.
- Cat bites have a higher incidence of deep infection than dog bites.
- Postexposure rabies or lyssavirus prophylaxis is required for some bites, for example bat bites
- In all cases, the patient's tetanus immunisation status must be ascertained
- The recommended management of clenched fist injuries, and human and animal bites, is through cleaning, debridement, irrigation, elevation and immobilisation.

Antibiotic therapy is necessary for bites and clenched fist injuries with a high risk of infection. These include:
- wounds with delayed presentation ( 8 hours or more)
- Puncture wounds that cannot be derided adequately
- wounds on the hand, feet or face. (will usually require surgical consultation)
- Wounds involving deeper tissues (e.g. bones, joints, tendons)
- Wounds in immunocompromised patients

End.