DOG BITE INJURIES IN MAXILLOFACIAL TRAUMA: A CASE REPORT.

Position of face in head and neck region make it more exposed as comparison to other region to dog bite injuries. Combination of this fact along with short stature of children make them more prone to dog bite. The surgical approach regarding dog bite injury continues to be debatable. Main controversial topic of discussion in animal bite cases is the ideal time for wound debridement along with initial wound suturing as well as the use of prophylactic antibiotics. Early management, most appropriate prophylaxis

Position of face in head and neck region make it more exposed as comparison to other region to dog bite injuries. Combination of this fact along with short stature of children make them more prone to dog bite. The surgical approach regarding dog bite injury continues to be debatable. Main controversial topic of discussion in animal bite cases is the ideal time for wound debridement along with initial wound suturing as well as the use of prophylactic antibiotics. Early management, most appropriate prophylaxis in addition to precise evaluation are definitely critical for attaining desired results. This case report is to throw a light on epidemiology, presentation, management and recent advances in case of emergency like animal bite.

…………………………………………………………………………………………………….... Introduction:-
In present scenario dog bite or we can say animal bite is a matter of concern as it pose a serious physical, functional and psychological trauma to wide majority of population especially children as it not only transmits disease but also increase treatment costs. The most common location of dogbite is face in children [1] and it is often seen that most of dogs are familiar with the child [2]. While in children most affected area is head region, adults are commonly affected in body [3,4].Age is the major factor in determining location of injury. In younger chidren , most affected areas are the head,face and neck. As the chid grows, bites to extremities are common. More than 1000 species of pathogenic bacteria are present in the oral cavity of dog and treatment is difficult because of risk of infection especially in extensive injuries. About 3-20% dog bite wounds develop infections [5].The treatment of injuries caused by dog bites is done by cleaning, debridement and primary closure of the lesion, anti-rabies and tetanus control and antibiotic prophylaxis.

Classification Of Dog Bite Victims
GROUP 1 -Victim presents within 8-12 h of the incident withfears of contracting rabies or other infections and/or withconcerns of permanent disfiguration of the injured body part. These wounds are often contaminated with bacteria but do not show evidence of infection [6] ISSN: 2320-5407 Int. J. Adv. Res. 7(6), 795-801 796 GROUP 2-Victim presents more than 12 h after the incident,most often presenting with signs and symptoms of developing infections [6] Case Report:-A 5yr child,victim of dog bite was admitted to trauma center of our institute on an urgent basis.The child has multiple extensive laceration over face involving right infraorbital region ,nose and left cheek with some amount of tissue loss at infraorbital region. (Fig .1) Informed consent was taken from the parents.The surgical procedure was performed under general anaesthesia and oral intubation had been done.Local infiltration given with 2% lignocaine with adrenaline, cleaning of surgical area and irrigation with 0.9% normal saline solution was done, necrosed tissue carefully debrided and rabies immunoglobulin infiltrated around wound and remaining is given IM at an anatomic site distant from vaccination.Wound edges were stabilized and primary closure performed in layers with 4-0 vicryl and then skin closure with 5-0 prolene( fig.2,3),followed by pressure dressing.
Post-operatively patient was medicated with antirabies,analgesic and antibiotics and patient was discharged on the 4 th post-operative day and patient came for followup on 1 st week ( fig.4)and 3 rd week (fig.5) after discharge, healing was satisfactory and no any local or systemic complications seen.

Discussion:-
Animal bite such as by dog poses a significant public health risk because it can cause infections,functional,aesthetic problems and may some times leads to widespread morbidity especially when affecting head and neck region. [1] Chidren being most affected with dogbite as they lack awareness of danger.This might be the most appropriate theory why chidrens are more vulnerable for animal attack.Since height childrens are less,head and neck region being most commonly affected.
Dog bite injuries are mostly superficial abrasions and lacerations [7].The typical dog bite results in a combination of torn tissues and adjacent punctures, and they are called "hole-and-tear"effect [8].The force delivered by dog jaws while biting can be as high as 200-450 psi and result in devitalisation of the wound tissue with associated ripping and tearing motion [9,10] and it can lead to severe deep laceration and may include facial bone and cranial fractures. In some cases dog bite injuries may lead to amputations, including severe vascular and nerve or bony destruction. The nose,lips and cheeks are most commonly affected and known as 'central target area' [4].
Amoxycillin-clavulanate for 3 to 5 days is the first-line antimicrobial prophylaxis for high-risk dog wounds in healthy patients [11] . Alternatively, ampicillin-sulbactam might be given intravenously if the patient is unable to take oral antibiotics. If the patient is allergic to penicillin,first-line treatment is an extended-spectrum cephalosporin or trimethoprim-sulfamethoxazole plus clindamycin [11]. The duration of prophylaxis should be 3-5 days while infected wounds need to be covered with 7-14 days of antibiotic cover [11].Debridement should be adequate so as to reduce risk of infection in dog bite cases so as eliminate crushed or devitalized tissue which would may serve as source of infection.Thorough irrigation is necessary to remove all particulate matter.Povidne iodine and ethanol mixture diluted with saline serve as a good irrigant [12,13].
Un-infected wound less than 24hr old can be primarily repaired [14,15]. Success rate of facial wounds closure is high owing to its high vascularity and absence of dependent edema.Subcutaneous sutures should be kept to a minimum as they can precipitate infection. Avulsive injuries which have significant tissue loss where primary repair cant be done can be managed with local or regional flaps ,skin grafts or microvascular reconstruction [16]. Tetanus immunization status must be evaluated and treated with immunization or immunoglobulin administration was indicated [17].[table 2] Table 1:-WHO 10 general considerations in rabies post exposure prophylaxis 1.wound must be immediately washed for 15 minutes and disinfected. 2.rabies PEP should be institutedimmediately.PEP consists of a course of potent,effective rabies vaccine that meets WHO recommendations and administration of rabies immunoglobulin 3.PEP must be applied using vaccine regimensand administration routes that have been proven to be safe and effective. 797 4.Pregnancy and infancy are not contraindications to PEP. 5.if rabies vaccine is not available on first visit,it can be delayed up to 7days from the date of first vaccine dose. 6.initiation of PEP should not await the results of laboratory diagnosis or be delayed bydog observation when rabies is suspected 7.when suspect rabid animal contacts occur in areas free of carnivore-mediated rabiesand where there isadequate surveillance in place,PEP may not be reqired 8Patients presenting for rabies PEP even monthsafter having bittwenshould be treated asif the contact has recently occurred 9.PEP sould be administered even if the suspect animal is not available for ttesting or observation 10.In areas enzootic for rabies,PEP should be instituted immediately unless adequate laboratory surveillance and dataindicates that the species involved is not a vector of rabies.

Conclusion:-
Dog bites are quite common injuries that preferably affect children, and the head and neck region is the most affected region. Trauma can leave aesthetic and psychological sequelae to victims, so the treatment must involve a multidisciplinary team in order to minimize the damages caused. Immediate surgical intervention provides a better aesthetic result and antibiotic prophylaxis reduces or prevents the risk of infection. .

RIG
Vaccine RIG should not be administered d HDCV, RVA, or PCEC 1.0 mL, IM (deltoid area b ), once daily on days 0 c and 3

RIG
Vaccine Administer 20 IU/kg body weight. If anatomically feasible, the full dose should be infiltrated around the wound(s) and any remaining volume should be administered IM at an anatomic site distant from vaccine administration. Also, RIG should not be administered in the same syringe as vaccine. Because RIG may partially suppress active production of antibody, no more than the recommended dose be given HDCV, RVA, or PCEC 1 mL, IM (deltoid area b ), once daily on 798