The following wounds may be considered at high risk for infection: puncture wounds, hand or foot wounds, wounds provided initial care after 12 hours, cat or human bites, and wounds in immunosuppressed patients As a general rule, these wounds should not be sutured The use of prophylactic antibiotics is recommended, but controversial Suggested indications for antibiotics include the following: Human and cat bites through dermis Bites closed prematurely Bites more than hours old with significant crush injury or edema Potential damage to bones, joints, or tendons Bites to hands and feet Patients with increased risk of infection Signs of infection within 24 hours No single antibiotic is ideal for all the most common organisms involved in infected mammalian bite wounds Amoxicillin-clavulanic acid (Augmentin) (30 to 50 mg/kg/day) is effective for P multocida, Streptococcus, and anaerobes, as well as in providing methicillin-susceptible S aureus (MSSA) coverage Combination therapy with phenoxymethyl penicillin (penicillin VK) and cephalexin or dicloxacillin has been suggested by some An extended-spectrum cephalosporin or trimethoprim-sulfamethoxazole PLUS clindamycin is an alternative for the penicillin-allergic patient The initial dose of antibiotic should be given in the ED and continued for the next to days It must be emphasized that local care ultimately prevents infection more effectively than prophylactic antibiotics Studies indicate that prophylactic oral antibiotics for low-risk dog bite wounds are not indicated because the differences in the rate of infection are not significant, and the cost–benefit ratio is not worth the risk of allergic reaction Moderate to severe hand infections or other wounds that involve deep structures usually require debridement and exploration under general anesthesia Aerobic and anaerobic culture swabs should sample the depth of the wound; or, in cases of cellulitis, the specimen can be collected by needle aspiration of the leading edge of erythema While awaiting cultures, a Gram stain is often helpful in differentiating the probability of staphylococci or streptococci from P multocida Parenteral antibiotics and admission to the hospital are indicated if the child has systemic symptoms/signs or has wounds with potential functional or cosmetic morbidity The choice of parenteral antibiotics should be governed by the same factors considered in selection of prophylactic antibiotics and then modified by culture results Tetanus immunization status should be checked in every injury that violates the epidermis, regardless of the cause Recommendations for tetanus immunoglobulin and immunization are noted elsewhere (see Chapter 94 Infectious Disease Emergencies ) Concern for rabies is the factor that prompts many patients to seek medical care Although the incidence of rabies in the United States (one to five cases per year) is extremely low, the physician must always assess the possibility of rabies exposure and promptly initiate prophylaxis when indicated Dogs and cats account for only 5% of animal rabies in the United States The history should include the apparent health of the animal and any provocation for attack Wild carnivores and bats should generally be regarded as rabid; rodents (rats, mice, squirrels) and lagomorphs (rabbits) can usually be considered no risk Exposure to bats by a sleeping or very young child even without bite or scratch should warrant serious consideration of prophylaxis Rabies prophylaxis is not indicated in bites by a healthy dog or cat with a known owner, assuming the animal’s health does not deteriorate over the following 10 days Bites by strays and other domesticated mammals should be considered individually and with consultation of the local health department Scratches, abrasions, and animal saliva contact with the victim’s mucous membranes are capable of rabies spread If postexposure antirabies immunization is indicated both passive antibody (RIG, rabies immune globulin, human) and vaccine (HDCV, human diploid cell rabies vaccine) should be given (see also Chapter 94 Infectious Disease Emergencies ) Immunization with RIG is administered only once, in a dose of 20 IU/kg As much as possible is infiltrated locally around the wound and the remainder is given intramuscularly The HDCV immunization should be administered intramuscularly in the opposite deltoid (vastus lateralis in infants) from RIG on days 0, 3, 7, 14 for a total of four doses, each 1.0 mL For immunocompromised patients a fifth dose should be given on day 28 Suggested Readings and Key References Drowning Bain E, Keller AE, Jordan H, et al Drowning in epilepsy: a population-based case series Epilepsy Res 2018;145:123–126 Bauman BD, Louiselle A, Nygaard RM, et al Treatment of hypothermic cardiac arrest in the pediatric drowning victim, a case report, and systematic review Pediatr Emerg Care 2019 Jan 29 doi: 10.1097/PEC.0000000000001735 [Epub ahead of print] Causey AL, Tilelli JA, Swanson ME Predicting discharge in uncomplicated neardrowning Am J Emerg Med 2000;18:9–11 Dowd MD Dry drowning: myths and misconceptions Pediatr Ann 2017;46(10):e354–e357 Szpilman D, Bierens JJ, Handley AJ, et al Drowning N Engl J Med 2012;366(22):2102–2110 Smoke Inhalation Committee on injury and poison prevention, American academy of pediatrics Reducing the number of deaths and injuries from residential fires Pediatrics 2000;5:1355–1357 Enkhbaatar P, Pruitt BA Jr, Suman O, et al Pathophysiology, research challenges, and clinical management of smoke Lancet 2016;388(10052):1437–1446 Jones SW, Williams FN, Cairns BA, et al Inhalation injury: pathophysiology, diagnosis, and treatment Clin Plast Surg 2017;44(3):505–511 Palmieri TL, Warner P, Mlcak RP, et al Inhalation injury in children: a 10 year experience at Shriners Hospitals for children J Burn Care Res 2009;30:206– 208 Pierre EJ, Zwischengerger JB, Angel C, et al Extracorporeal membrane oxygenation in the treatment of respiratory failure in pediatric patients with burns J Burn Care Rehabil 1998;19:131–134 Carbon Monoxide Poisoning Chambers CA, Hopkins RO, Weaver LK, et al Cognitive and affective outcomes of more severe as compared to less severe carbon monoxide poisoning Brain Inj 2008;22:387–395 Chang YC, Lee HY, Huang JL, et al Risk factors and outcome analysis in children with carbon monoxide poisoning Pediatr Neonatol 2017;58(2):171– 177 Cho CH, Chiu NC, Ho CS, et al Carbon monoxide poisoning in children Pediatr Neonatol 2008;49:121–125 Geller R, Barthold C, Saiers JA, et al Pediatric cyanide poisoning: causes, manifestations, management, and unmet needs Pediatrics 2006;118:2146– 2158 Weaver LK Clinical practice Carbon monoxide poisoning N Engl J Med 2009;360:1217–1225 Environmental and Exertional Heat Illness Hadad E, Rav-Acha M, Heled Y, et al Heat stroke: a review of cooling methods Sports Med 2004;34:501–511 Martin TJ, Martin JS Special issues and concerns for the high school- and college-aged athletes Pediatr Clin North Am 2002;49:533–552 Wexler RK Evaluation and treatment of heat-related illnesses Am Fam Physician 2002;65(11):2307–2314 Accidental Hypothermia Corneli HM Accidental hypothermia Pediatr Emerg Care 2012;28(5):475–480; quiz 481–482 Hughes A, Riou P, Day C Full neurological recovery from profound (18.0 degrees C) acute accidental hypothermia: successful resuscitation using active invasive rewarming techniques Emerg Med J 2007;24:511–512 Laniewics M, Lyn-Kew K, Silbergleit R Rapid endovascular warming for profound hypothermia Ann Emerg Med 2008;51:160–163 Ulrich SA, Rathlev NK Hypothermia and localized cold injuries Emerg Med Clin North Am 2004;22:281–298 High-Altitude Illness Basnyat B, Murdoch DR High-altitude illness Lancet 2003;361:1967–1974 Bloch JC, Duplain H, Rimoldi SF, et al Prevalence and time course of acute mountain sickness in older children and adolescents after rapid ascent to 3450 meters Pediatrics 2009;123:1–5 Davis C, Hackett P Advances in the prevention and treatment of high altitude illness Emerg Med Clin North Am 2017;35(2):241–260 Liptzin DR, Abman SH, Giesenhagen A, et al An approach to children with pulmonary edema at high altitude High Alt Med Biol 2018;19(1):91–98 Electrical Injuries Adekoya N, Nolte KB Struck-by-lightning deaths in the United States J Environ Health 2005;67(9):45–50, 58 Garcia CT, Smith GA, Cohen DM, et al Electrical injuries in a pediatric emergency department Ann Emerg Med 1995;26:604–608 Koumbourlis AC Electrical injuries Crit Care Med 2002;30(11 Suppl):S424– S430 Roberts S, Meltzer JA An evidence-based approach to electrical injuries in children Pediatr Emerg Med Pract 2013;10(9):1–16 ... Committee on injury and poison prevention, American academy of pediatrics Reducing the number of deaths and injuries from residential fires Pediatrics 2000;5:1355–1357 Enkhbaatar P, Pruitt BA Jr, Suman... 2008;49:121–125 Geller R, Barthold C, Saiers JA, et al Pediatric cyanide poisoning: causes, manifestations, management, and unmet needs Pediatrics 2006;118:2146– 2158 Weaver LK Clinical practice... Health 2005;67(9):45–50, 58 Garcia CT, Smith GA, Cohen DM, et al Electrical injuries in a pediatric emergency department Ann Emerg Med 1995;26:604–608 Koumbourlis AC Electrical injuries Crit