---

Dog Bite: OPD Presentation, Protocol & Management

---

How to Present a Dog Bite Case in OPD

• Time of the bite (< 6 hours or > 6 hours - impacts infection risk and suturing decision)
• Circumstances - provoked vs. unprovoked (unprovoked = higher rabies risk)
• Animal details - domestic/stray, owned/unowned, vaccination status (rabies), current whereabouts/availability for observation
• Breed - German shepherds, Rottweilers, pit bulls cause more severe injuries with higher risk of deep structure damage
• Wound site - face, hand, foot, over a joint (high-risk sites)
• Patient history - tetanus immunization status, immunocompromised state, medications (anticoagulants), allergies
• First aid given - was wound washed?

"Mr. X, 35M, presents with a dog bite wound on the right forearm, sustained 2 hours ago by a stray unvaccinated dog (unprovoked). He washed the wound at home. No prior tetanus immunization recalled. No known co-morbidities. On examination: 2 cm laceration with surrounding erythema, no signs of active infection. Neurovascular exam - intact."

---

Step-by-Step OPD Management Protocol

STEP 1 - Immediate Local Wound Treatment (Most Important Step)

STEP 2 - Wound Closure Decision

• Rosen's Emergency Medicine, p. 775

Note: Do not suture bite wounds primarily to prevent virus spread into deeper tissues. If suturing is absolutely necessary, delay 24-48 hours, use minimum stitches, and provide RIG locally. - Park's, p. 323

---

STEP 3 - WHO Exposure Category Classification and PEP Decision

• Animal is a known rabies reservoir/vector
• Animal looks sick or has abnormal behaviour
• Wound or mucous membrane contaminated with saliva
• Bite was unprovoked
• Animal not vaccinated
• Biting animal cannot be traced or identified

---

STEP 4 - Post-Exposure Prophylaxis (PEP) - Rabies Vaccines

Intramuscular Regimens

• 1 IM dose on Days 0, 3, 7, 14, 28
• Volume: 1.0 ml or 0.5 ml into deltoid muscle (anterolateral thigh in children < 2 years)

• Day 0: 2 doses (1 in each deltoid)
• Day 7: 1 dose
• Day 21: 1 dose

• Days 0, 3, 7, and 14

Intradermal Regimen (2-site)

• 0.1 ml at 2 sites on Days 0, 3, 7, and 28 (day 14 dose omitted)
• Only in countries where endorsed by national health authorities
• One-fifth the cost of IM regimen

Previously Vaccinated Patients

• Only 2 doses IM on Days 0 and 3
• RIG is NOT given

---

STEP 5 - Rabies Immunoglobulin (RIG) - Category III Only

• Administer only once, as early as possible (within 7 days of first vaccine dose - beyond day 7 it is not indicated as active immunity has developed)
• All of the RIG, or as much as anatomically possible, should be infiltrated into and around the wound site
• Remaining volume injected IM at a site distant from vaccine administration
• RIG may be diluted to adequate volume to infiltrate all wounds
• Do NOT give RIG to previously vaccinated individuals

---

STEP 6 - Antibiotics (Infection Prophylaxis/Treatment)

• Pasteurella canis/multocida (50% of dog bites), Staph aureus, Streptococcus viridans, Capnocytophaga canimorsus (serious/fatal in asplenic patients), Bacteroides, Fusobacteria, Prevotella (anaerobes)

• Wounds with gross contamination
• Severe crush injuries
• Immunocompromised patients
• Bites on hands, feet, face, genitals
• Bites over joints
• Puncture wounds
• Cat bites (50% infection rate)

• Roberts & Hedges' Clinical Procedures, p. 767; Rosen's, p. 779; Washington Manual, p. 7653

---

STEP 7 - Tetanus Prophylaxis

In patients > 70 years, immigrants, or those with no education beyond grade school - tetanus histories are often unreliable; treat as unimmunized. - Rosen's, p. 779

---

STEP 8 - Disposition & Follow-Up

• Wound check at 48 hours - assess for signs of infection, remove any loose dressing, reconsider delayed primary closure if no infection
• Tetanus status documentation
• 10-day animal observation - if animal is available and healthy at 10 days, PEP can be discontinued
• Report to public health authorities (required in most regions)
• Pain management - adequate analgesia before wound examination

---

OPD Documentation Checklist (Quick Reference)

1. Time of bite recorded
2. Animal details (domestic/stray, vaccinated, available for observation)
3. Provoked vs. unprovoked
4. Wound site, size, depth noted
5. Neurovascular exam documented
6. Wound irrigation done (soap + water ≥ 15 min)
7. WHO exposure category assigned (I / II / III)
8. Tetanus status checked and addressed
9. Antibiotic prophylaxis decision documented
10. PEP initiated if Category II/III (vaccine schedule + RIG for Cat III)
11. Follow-up at 48 hours arranged
12. Animal observation plan documented

---

• WASH - CLASSIFY - VACCINATE - IMMUNOGLOBULIN - ANTIBIOTICS - TETANUS (the OPD sequence)
• RIG only for Category III and only within 7 days of first vaccine dose
• Never suture puncture wounds or wounds > 12 hours old
• Animal observation for 10 days - if healthy, stop PEP