Dog bite in a child: rabies, wound closure and consent

Exposure category: Category III. Transdermal bites with bleeding, especially from a stray dog that cannot be observed, carry a high risk of rabies. Category III requires rabies immunoglobulin plus vaccine, irrespective of the time since exposure.

Immediate wound care:

• Wash both wounds thoroughly with soap and copious running water for at least 15 minutes. This is the single most effective first-aid measure against rabies - it physically removes virus from the wound.
• Irrigate the deep laceration with sterile water or saline under pressure.
• Apply povidone-iodine to the wound edges.
• Control bleeding with pressure; do not cauterise or apply irritants such as chili or kerosene.
• Do not suture immediately. Bite wounds, especially on the hand, have a high infection risk, and primary closure traps bacteria. Leave the wound open, cover with a sterile dressing, and plan delayed primary closure after 3–5 days if clean.
• Immobilise and elevate the forearm to reduce swelling.

Explain to the mother why stitching today is not safe: the wound must drain, and closure can worsen infection. The hand wound is deep and over a joint space; it needs assessment at the aimag hospital.

Vaccine: start rabies vaccine today - do not wait for the aimag transfer. Use the national schedule. The Essen regimen is 5 doses on days 0, 3, 7, 14 and 28. The Zagreb regimen is 4 doses: two injections on day 0 (one in each deltoid), then one on day 7 and one on day 21. Both are acceptable if the vaccine brand and national guidance allow; record the batch number and site (deltoid, not buttock).

Immunoglobulin: rabies immunoglobulin is not available at the soum. It should be infiltrated into and around the wound, with any remainder given intramuscularly at a site distant from the vaccine. It is most effective within 7 days of the first vaccine dose. Because the aimag is 3 hours away, arrange same-day transfer for immunoglobulin after the first vaccine dose. Do not delay vaccine while looking for immunoglobulin.

Counselling: explain that rabies is almost always fatal once symptoms start but can be prevented by completing the schedule. The child must return for every dose; missing doses reduces protection. Give written dates and a phone reminder. The dog cannot be observed, so the full course is mandatory. Watch for fever, local reaction or neurological symptoms and report them.

Antibiotics: give prophylactic amoxicillin-clavulanate because this is a deep bite wound, especially on the hand. Dose at 45 mg/kg/day divided into two doses, for 3–5 days (5–7 days for the deep hand wound if infection is present). Check for allergy. If the wound is already infected, treat for 7–10 days and consider referral.

Tetanus: her last booster was at age 6, so it is 3 years ago. For a dirty wound, a booster is indicated if more than 5 years have passed; at 3 years, it is not strictly needed. Check the vaccination card. If there is any doubt, give tetanus toxoid - it is safe. Do not give tetanus immunoglobulin unless she has never completed a primary course.

Closure: do not suture the hand puncture wound. For the forearm laceration, after cleaning and immunoglobulin infiltration, loose approximation or delayed primary closure is safer than tight suturing. Refer the hand wound to the aimag surgical team because of tendon and joint involvement risk.

Document and notify: record the date and time of bite, dog description, wound sites and size, cleaning performed, vaccine brand and batch, immunoglobulin given or referred, antibiotics, tetanus status and consent from the mother. Rabies exposure is notifiable; report to the soum and aimag veterinary and public health authorities so the dog can be sought and other exposures identified.