[MUSIC] [MUSIC] [MUSIC] Well, Mr. Roy, please take a seat on this chair. >> Thank you! >> Please put your coat there, and roll up your sleeves. Now, what has happened to you today? >> A cat has bitten me there. >> Was it your own cat? >> No, I'm a keeper at an animal shelter and Emma was meant to get an injection, and she did not cope so well with it, and eventually me neither [LAUGHS]. >> It was a work accident then, I'll quickly inform our professor. Hallo, this is Kanz speaking. >> Hallo, >> Mr. Roy is presenting to our department with a cat bite injury. >> Cat bites, they might look insignificant, but they should not be underestimated >> A mere trifle! >> No, that's not a trifle. >> The skin is penetreated there. >> Bite injuries are a relevant problem in surgical emergency departments worldwide. About 1 to 2% of all patients presenting to surgical emergency departments have suffered from bite injuries. 60 to 80% of these are caused by dogs, 10 to 20% by cats and 2 to 3% by human beings. Men are more frequently bitten by dogs, women more frequently by cats and children more frequently than adults. In about 20% of cases there are deeper infections. Rinse out the bite wound immediately with water. If the bite injury was caused by a human being, you should ascertain whether the assailant could be infected with hepatitis or HIV, and then perform an post-exposure prophylaxis. In all bite injuries, you have to ascertain whether X-ray imaging is necessary, for example in case of dog bites to rule out a potential fracture. Cat bites can lead to the infiltration with foreign bodies caused by broken cat teeth. The bite injury should be debrided thouroughly under local anaesthesia. Revise the wound and consider, whether an adaptation suture is possible. In some cases, the extremity has to be immobilised. The bite injury should be treated with antibiotics. >> In this case, we have to open up the wound under local anaesthesia. >> Open it up? >> Yes, dogs or human beings are not that dangerous? >> Why? >> Cats have germs in their mouths, which are very pathogenic, and can cause horrible inflammations. The hand itself is well supplied with blood, but the tendon sheats aren't. If the wound closes now, the pus cannot discharge and then, the infection can spread to the whole hand. This is why we have to open up the wound under local anaesthesia, debride it and then the pus can discharge, if the wound suppurates. Subsequently, we have to splint your thumb for a few days so that the tendon is immobilised and the germs cannot spread within your hand. >> Oh, that's a fine mess! >> Well, yes it is. And then we have to prescribe you with an antibiotic for five days. >> You must be kidding. >> There are cases, in which patients lost their hands. These germs can lead to really severe infections. >> What comes into your mind when you see the following images? This patient has been bitten into his finger by a pitbull. This close-up clearly shows the extent of destruction induced by the dog bite. In case of a bite injury, it has to be ascertained, whether a fracture or an infiltrated foreign body are present. These can be ruled out by means of an X-ray image. This photograph from the clinic shows how the wound was immediately rinsed with a bulb-headed probe. This photograph from the clinic shows the application of a local anaesthetic. >> That's the way it is when you are bitten by a cat. >> But it's not a problem, we perform local anaesthesia and then we open up the wound. >> What must be, must be. >> Yes, please prepare everything
Ja, vielleicht richten Sie mir for me and I have to quickly visit another patient and then I'm coming back. >> Thank you! >> You're welcome! >> Are you vaccinated against Tetanus, Mr. Roy? >> Yes, certainly. >> When was your last vaccination? >> Three quarters of a year ago. >> Fine, that is sufficient. Now, Mr. Roy, you can take a seat on this stretcher and lay down. I'll make all preparations. >> For the optimal debridement of a bite injury to the fingers, a tourniquet can be helpful. Here, the application of a tourniquet by means of a finger cot is shown. This photograph from the clinic shows the significant destruction of soft tissue caused by the dog bite. The destroyed soft tissue has to be debrided completely as a prophylaxis against infections. Due to the highly probable contamination caused by bite wounds, primary wound closure should be omitted. Wound edges can be approximated with an adaptation suture, as shown here. Immobilisation is a truly important part of therapy. It prevents germs from reaching far remote body regions along the tendon sheaths. There should be no primary wound closure after bite injuries caused by cats, foxes or big cats, in case of all stitch-shaped wounds with additional severe soft tissue trauma, when joints or tendons are affected or the injury is located at the forearms, the hands or the feet. In case of additional disturbances of the blood flow or immunosuppression an adaptation suture is recommended. What comes into your mind when you see the following images? This photograph from the clinic shows a bite injury caused by a cat in the forest. This close-up of a bite injury shows how deep the injury caused by the cat's tooth is. These injuries can allow bacteria or foreign bodies to infiltrate into the deep layers of tissue. Due to the displaced soft tissues above, there is a significant risk of infection that can easily be overlooked. [MUSIC] >> Now, Mr. Roy, I'll now make all necessary preparations for the treatment of your thumb. >> Thank you! [MUSIC] [MUSIC] [MUSIC] >> How are you doing at the moment, Mr. Roi, are you in pain? >> Still fine! [MUSIC} >> The range of pathogens of the infiltrating bacteria is on the one hand dependent on the skin flora of the person bitten and on the other hand on the oral flora of the person/animal inflicting the bite. In 85% of cases, pathogenic germs and in 60% aerobic-anaerobic mixed infections occur. Staphylococci and streptococci are found in 40% of cases. Pasteurella species can be identified in 75% of cat bites and in 50% of dog bites. Eikenella corrodens are frequently found in bites caused by human beings. Capnacytophaga canimorsus can be the cause for a generalised sepsis,
insbesondere nach Splenektomie particularly after splenectomies. Cat scratch disease can be induced by bite injuries, too. The germs responsible for this are called Bartonella henselae. Papule at the inoculation site can typically be found after 3-10 days. In most cases, a self-limiting localised lymphadenitis occurs. In rare cases, a systemic infection of the spleen, liver, CNS can occur, accompanied by fever and headaches. In the case of immunosuppression, you should be vigilant about vascular proliferation. Due to the significant infectious complications, a standard antibiotic should be applied in case of all bite injuries. Amoxicillin-clavulanic acid is a suitable compound for this. Alternatively, Cefuroxim or Fluoroquinolones can be applied. Please be aware of the fact that both the person bitten and the animal/person causing the bite can also be colonised with MRSA. It is important to check vaccination status of the person bitten. If the originator of the bite is known, his/her vaccination status should also be documented. Regarding rabies, it can be stated that no cases have been recorded in the Munich region for many years. Bite injuries can be critical in foreign countries, particularly if the rabies virus still occurs there. Alright, I'll now disinfect your thumb and afterwards we wait for a while. Then, we perform a local anaesthesia and your thumb will get numb and after approximately 5 minutes you won't feel anything. And then, we'll debride the wound. And in case it hurts really bad, you just let me know. Sometimes you can have a metallic taste in your mouth when the anaesthetic goes through your veins. In this case, you have to tell me and then I'll know that it happened and also if you feel an electric zap when I am down to your nerve. But normally it does not hurt at all, it's not as hurtful as a visit at your dentist's. And now I'll apply the disinfectant. That is little cold and wet. Now,[MUSIC] [MUSIC] we'll go down to the deep layers. [MUSIC] I stick in the direction of my own finger, because then I'll know exactly where I am, when I'm not hurting myself. [MUSIC] Good. [MUSIC] [MUSIC] [MUSIC] Now, I would like to ask you to put your finger through this hole. Yes, that's very good. [MUSIC] [MUSIC] And now I'll rinse the germs out of your wound, simply with water. Yes, and I flush the wound thoroughly so that it's drained properly. And I'll not apply a wound suture, the wound has to stay open and will then heal and close on its own. And finally, you'll get a bandage from one of our nurses and you'll get a splint for your thumb so that it's immobilised and you'll get a prescription for antibiotics. >> Thank you professor. [MUSIC] >> What comes into your mind when you see the following images? These photographs from the clinic show a beginning phlegmone of the hand, status post dog bite injury approximately 4 days ago. When zooming in, the swelling and reddening can be seen clearly. What comes into your mind when you see the following image? This patient was bitten by cat 2 days ago. You can clearly see a swelling and reddening with progressive infection. In summary, it can be stated that all bite injuries are associated with a high risk of infeciton. Bite injuries with affected joints or tendons are particularly at risk, or those affecting the forearms, the hands and the feet, in case circulatory disturbances or immunosuppression are present. Bite injuries should not undergo primary wound suture, but should instead be treated by means of adaptation sutures. Amoxicillin-clavulanic acid can be administered as antibiotic prophylaxis particularly for cover against Pasteurella species or Eikenella corrodens. [MUSIC] [MUSIC] [MUSIC]
