key: cord-0693255-79vteunp authors: Chicco, M; Torres-Grau, J; Gardiner, M title: Management and outcomes of mammalian bite injuries during COVID-19 and implications for future practice date: 2020-11-07 journal: J Plast Reconstr Aesthet Surg DOI: 10.1016/j.bjps.2020.10.090 sha: b14583984217af74288a98506bf64782bf66a6d5 doc_id: 693255 cord_uid: 79vteunp Mammalian bites are common injuries, but management has been shown to vary widely. The aim of this study was to assess how the COVID-19 pandemic impacted management of mammalian bite injuries and resulting outcomes. We conducted a retrospective review of prospectively collected data on mammalian bite injuries assessed in our Plastic and Reconstructive Surgery department during April and May 2020. 37 patients presented with mammalian bite injuries during this period. Median age was 27 (range 1-75) with equal gender distribution. The majority presented on the day or day after injury. Bites were from dogs (78%), humans (14%) and cats (8%). Body parts involved were finger/hand (21), face (8), arm/forearm (5) and thigh/leg (3). 6 wounds were superficial (i.e. not penetrating the full-thickness of the skin) and 4 were associated with a fracture or significant soft tissue damage. 30 out of 31 non-superficial injuries were washed out under local anaesthesia, patients received a tetanus booster (if required) and were discharged with oral antibiotics and safety net advice. One wound associated with extensor tendon injury and metacarpal fracture was admitted and treated in the operating theatre. No complications were registered and only one patient represented with an infected wound, which was washed out under local anaesthesia and the patient discharged. Our experience during the COVID-19 pandemic suggests that the majority of mammalian bite injuries can safely be managed with washout under local anaesthesia, oral antibiotics and discharge on the same day with safety net advice. Going forward, healthcare resources can be optimised by taking these results into account. Mammalian bites are common injuries, but management has been shown to vary widely. The aim of this study was to assess how the COVID-19 pandemic impacted management of mammalian bite injuries and resulting outcomes. We conducted a retrospective review of prospectively collected data on mammalian bite injuries assessed in our Plastic and Reconstructive Surgery department during April and May 2020. 37 patients presented with mammalian bite injuries during this period. Median age was 27 (range 1-75) with equal gender distribution. The majority presented on the day or day after injury. Bites were from dogs (78%), humans (14%) and cats (8%). Body parts involved were finger/hand (21), face (8), arm/forearm (5) and thigh/leg (3) . 6 wounds were superficial (i.e. not penetrating the full-thickness of the skin) and 4 were associated with a fracture or significant soft tissue damage. 30 out of 31 non-superficial injuries were washed out under local anaesthesia, patients received a tetanus booster (if required) and were discharged with oral antibiotics and safety net advice. One wound associated with extensor tendon injury and metacarpal fracture was admitted and treated in the operating theatre. No complications were registered and only one patient represented with an infected wound, which was washed out under local anaesthesia and the patient discharged. Our experience during the COVID-19 pandemic suggests that the majority of mammalian bite injuries can safely be managed with washout under local 3 anaesthesia, oral antibiotics and discharge on the same day with safety net advice. Going forward, healthcare resources can be optimised by taking these results into account. Mammalian bites, dog bites, cat bites, human bites Mammalian bite injuries account for a large number of attendances to emergency departments and approximately 7,000 hospital admissions annually in England. 1 There are no treatment guidelines available and there is clinical uncertainty surrounding their management. 2 In our department, these patients were often admitted for washout under local anesthesia in the minor operations theatre, with overnight stay for elevation and intravenous antibiotics. In March 2020, resources were redistributed to manage the COVID-19 pandemic. Our Plastic and Reconstructive Surgery department took over the minor injuries service and non-COVID-19 admissions and theatre usage were limited to essential cases. This study aims to assess how constraints imposed by the pandemic impacted 4 management of mammalian bite injuries in our hospital and resulting patient outcomes. During the pandemic, our team prospectively maintained an Excel spreadsheet record of all patients assessed. In addition, a formal clinic letter was dictated, which was uploaded in the electronic patient record system. The Excel spreadsheet and electronic patient record system were searched in order to identify all patients treated for mammalian bite injuries in our department in April and May 2020. MC and JTG independently extracted data on the following parameters: patient age and gender, type, location and extent of injury, timing of presentation, treatment administered, follow-up rate, complications and representation to our hospital. In order to capture representation to other healthcare providers, patients with an available telephone contact were called at the end of June 2020 and asked about complications and need for further treatment. 37 patients presented with mammalian bite injuries in April and May 2020. Median age was 27 (range 1-75) with equal gender distribution. The majority of patients presented on the day of injury or day after. 78% were dog bites, 14% human and 8% cat. Body parts involved were fingers and hand (21/37), face and ears (8/37), arm and forearm (5/37), thigh and leg (3/37). 6 wounds were superficial (i.e. not penetrating the full-thickness of the skin), while 4 were associated with significant soft tissue damage and/or fracture (2 distal phalanx fractures, 1 extensor tendon injury and metacarpal neck fracture, 1 significant soft tissue loss to a finger). patients received a tetanus booster (if required) and were discharged with oral antibiotics. The patient with extensor tendon injury and metacarpal neck fracture was admitted and treated with intravenous antibiotics and washout in theatre. In April, 57% of patients were followed-up face-to-face or by virtual consultation, one to two days after initial presentation: no complications were recorded. Followup decreased to 26% in May and, again, no complications were recorded. Patients who were not followed-up were given advice on symptoms and signs to look out for, as well as an email and telephone contact. One patient returned with a wound infection, which was washed out under local anaesthesia in clinic. The patient 6 was discharged on the same day and did not experience any further complications. Out of 35 patients managed without admission and who did not represent to our department, 27 were contacted by telephone at the end of June 2020 (4 did not have a registered telephone number and 4 could not be reached). None of the patients developed complications or required treatment by another healthcare provider. Surgery services in the UK 1 and overall estimated costs amount to £9.5 million per year. 3 Interestingly, recent evidence suggests that emergency department attendance for mammalian bite injuries has further increased during the COVID-19 pandemic. 4 Evidence for the management of mammalian bite injuries is limited. A recent systematic review sought to determine optimal wound management to reduce the risk of infection in non-hand mammalian bite wounds: the authors identified only two eligible studies and no clear evidence to define best practice. 5 In our hospital during the pandemic, the Plastic and Reconstructive Surgery department took over the minor injuries service and assessed the majority of mammalian bites presenting to the emergency department in April and May 2020. We managed 97% of bite injuries (36/37) with washout under local anaesthesia in clinic and discharge with oral antibiotics and safety net advice, with a complication rate of 2.8% (1/36). Our experience will help to inform the database development for the Bite Injury Treatment Evaluation (BITE) study. This will be an international prospective multicenter service evaluation of mammalian bite wounds supported by the Reconstructive Surgery Trials Network (RSTN). The aim of the study is to describe the current clinical practice and inform future research and guideline development for the management of mammalian bite injuries. Our experience during the COVID-19 pandemic suggests that the majority of mammalian bite injuries can safely be managed with washout under local anaesthesia and oral antibiotics and discharged on the same day with safety net advice. Going forward, healthcare resources can be optimised by taking these results into account. None. None. Not a plastic surgeon's best friend: dog bites an increasing burden on UK plastic surgery services Barking up the wrong tree? A survey of dog bite wound management Communication Workers Union Environment, Food and Rural Affairs Committee Dog bites in children surge during COVID-19: a case for enhanced prevention What is optimal wound management to prevent infection in non-hand mammalian bite Injuries? A systematic review