Facial trauma from dog bite: A pediatric case study

When the little boy was wheeled into the trauma bay at Mayo Clinic, even seasoned trauma personnel were taken aback: The child's face was so severely injured. The dog had grabbed the boy by the face, and it took bystanders over five minutes to disengage the dog.

A nonfamily dog, yet an animal known to the child, attacked the boy. The injuries included lacerations involving the bridge of the nose, orbit, mandible and the back of the head; an open globe injury; a mandible fracture; fractures of the orbital floor and mediolateral wall; a canaliculus injury; and a completely avulsed eyelid. A multispecialty team cared for him, including personnel with expertise in pediatric surgery, plastic surgery, ENT, ophthalmology and psychology.

After CT scans to the head, spine and face, the boy went to the operating room (OR) for assessment under anesthesia. His initial surgery lasted several hours.

On the day the boy left the hospital, he had finally regained the ability to eat by mouth. Six more operations followed that spring.

Perspectives on the case

The mere fact that the child was taken to Mayo Clinic's Level I Pediatric Trauma Center in Rochester, Minnesota, demonstrated the severity of his injury, according to Denise B. Klinkner, M.D., M.Ed., Mayo Clinic pediatric surgeon and pediatric trauma medical director, noting the majority of dog bites are managed in the outpatient setting.

At Mayo Clinic Hospital, Saint Marys Campus, where the child was treated, 21 patients have been admitted for dog bites over the last five years. Each year in the United States, an estimated 4.5 million dog bites occur, according to a 2001-2003 survey with results published in the October 2008 issue of Injury Prevention.

"That's a lot of bites," says Dr. Klinkner. "It's usually due to an invasion of their space," she says, explaining that she grew up on a farm and was taught at a young age about animal behavior and how to handle herself around them.

The circumstances of dog bites in children

Though easy to imagine a snarling "stranger" dog inflicting bites on children, in the vast majority of cases the perpetrator is a family-owned pet or otherwise known to the child, such as the grandparents' or neighbors' dog.

False impressions about dog breeds that bite children also abound. "People always think it's a pit bull, but any dog can be aggressive — any animal can do it," says Dr. Klinkner.

The most common time for dog bite injuries to kids is the hours after school and work, from 4 to 8 p.m.

A dog bite is distinct from other mechanisms of injury due to its potentially complex nature, involving laceration or puncture, tissue loss, head injury from being shaken, or broken bones. It can also lead to death in some children due to blood loss. Exsanguination is a particular danger for smaller children, as dogs will frequently bite on the head and neck due to similarities in height. In this scenario, the animal can easily puncture the carotid artery or jugular vein, and the patient's small size can mean blood loss may have greater impact than in an adult patient.

Lessons learned

Looking back on this child's facial trauma from the dog bite, Dr. Klinkner cites the following points of practice application:

Emergency status

It's important to recognize dog bite facial trauma is a true emergency, due to the blood supply to the face and scalp and the risk of bleeding. Bites to the face may come with swelling, such as to the tongue, which can compromise a patient's airway. Although a dog bite may appear as a fairly minor puncture wound, the underlying crush from the bite may lead to sinus, mandible or other fractures.

Reporting

A bite case needs to be reported to the state department of health by animal control or a physician.

Stabilization

As with other trauma, priorities for pediatric patients bitten by a dog include the ABCs of trauma: attending to the airway, breathing and circulation. Prompt recognition of airway concerns will facilitate a better outcome for the child. It's also important to note that pediatric patients have less ability to vasoconstrict than their adult counterparts. Sustained tachycardia should be recognized as the first sign of potential shock in a child.

Wound care and infection mitigation

Since any dog bite is a dirty wound and may also involve an open fracture, antibiotics should be administered within an hour. If the dog is unknown, the rabies post-exposure prophylaxis regimen described by the Minnesota Department of Health should be implemented.

Imaging

Though imaging was necessary in this patient's case after the dog bite, in general, it is important to be conservative with imaging children due to radiation exposure to a growing body. If a pediatric patient with facial trauma will need multiple services requiring transfer, Dr. Klinkner recommends waiting to have imaging done at the facility where treatment will be performed.

Psychosocial

Pediatric patients who have suffered a significant dog bite not only will need psychosocial support in the hospital setting, but also will need to deal with meeting another dog at some point post-dismissal. For this to be successful, putting mechanisms and safety in place for this reintroduction under the guidance of psychiatry and psychology is critical.

Prevention

This case also illustrates two key aspects of pediatric dog bite prevention and public education: Children can and should be taught safe habits around animals.

Children need supervision with animals: Kids often won't know what a trigger for an animal is, and the animal may be intolerant.

The question of transfer

If the following services cannot be provided for a pediatric patient who has undergone facial trauma due to a dog bite, consider transferring the patient to a higher level of care:

Operating room

In a dog bite case, puncture wounds require washing out. If the patient's wounds would require 30 minutes or more for this procedure, it should be performed in a facility that has an OR.

Complicated, multidisciplinary care

Dog bite cases may necessitate complex care involving multiple services, including child psychiatry.

For further study on animal safety and dog bite prevention, Dr. Klinkner recommends resources from the American Academy of Pediatrics.

For more information

Gilchrist J, et al. Dog bites: still a problem? Injury Prevention. 2008; 14:296.

Rabies post-exposure prophylaxis regimen: Animal bites and rabies risk — A guide for health professionals. Minnesota Department of Health.

Dog bite prevention tips from the American Academy of Pediatrics. American Academy of Pediatrics.