--- title: Most Missed Question in EM Exam Prep – Pediatric Dog Bite description: In children under 2 with scalp bite punctures/avulsion, CT head is often the next step to rule out skull fracture or intracranial penetration. image: https://challengercme.com/hubfs/Blog%20-%20Most%20Missed%20Question%20in%20EM%20Exam%20Prep%20%E2%80%93%20Pediatric%20Dog%20Bite.png --- [![Med-Challenger-green-logo-1024x244](https://challengercme.com/hubfs/Med-Challenger-green-logo-1024x244.webp) ](https://challengercme.com/) - [SHOP EXAM PREP & CME ](https://challengercme.com/blog/most-missed-question-in-em-exam-prep-pediatric-dog-bite#) ### [EMERGENCY MEDICINE](https://challengercme.com/emergency-medicine-exam-review-cme-course) [ABEM exam prep](https://challengercme.com/emergency-medicine-exam-review-cme-course), [MyEMCert](https://challengercme.com/emergency-medicine-myemcert-exam-review-course), etc. ### [FAMILY MEDICINE](https://challengercme.com/family-medicine-exam-review-cme-course) [ABFM exam prep](https://challengercme.com/family-medicine-exam-review-cme-course), [ABFM KSA](https://challengercme.com/family-medicine-moc-ksa-course), etc. ### [INTERNAL MEDICINE ABIM exam prep, MOC points, etc.](https://challengercme.com/internal-medicine-exam-review-cme-course) ### [OBGYN ABOG exam prep, CREOG, etc.](https://challengercme.com/obgyn-exam-review-cme-course) ### [PEDIATRICS ABP exam prep, MOCA-PEDS, etc.](https://challengercme.com/pediatric-medicine-exam-review-cme-course) ### [PEDIATRIC EM](https://challengercme.com/pediatric-emergency-medicine-3rd-edition) [ABP/ABEM exam prep Ed.3](https://challengercme.com/pediatric-emergency-medicine-3rd-edition), [Ed.2](https://challengercme.com/pediatric-emergency-medicine-pack2), etc. ### [SPECIAL PURPOSE / SPEX FSMB exam prep, etc.](https://challengercme.com/special-purpose-exam-review-spex-exam-preparation-course) ### [PHYSICIAN ASSISTANT](https://challengercme.com/physician-assistant-exam-review-cme-course) [PANCE / PANRE](https://challengercme.com/physician-assistant-exam-review-cme-course), [CAQ-EM](https://challengercme.com/pa-caq-em-review-course), etc ### [NURSE PRACTITIONER](https://challengercme.com/family-nurse-practitioner-exam-review-cme-course) [FNP](https://challengercme.com/family-nurse-practitioner-exam-review-cme-course), [ENP](https://challengercme.com/emergency-nurse-practitioner-exam-review-cne-course), [AGNP](https://challengercme.com/adult-gerontology-nurse-practitioner-exam-review-cne-course), [PNCB/CPNP](https://challengercme.com/pediatric-nurse-practitioner-exam-review-cne-course), etc. ### [NURSING / NCLEX NCLEX, CNE, etc.](https://challengercme.com/nursing-certification-nclex-exam-review-cne-courses) ### [STATE-REQUIRED CME / CE State CME requirements, etc.](https://challengercme.com/state-required-cme) ### [JOINT COMMISSION CME](https://challengercme.com/stroke-center-ce-review-course) [Stroke](https://challengercme.com/stroke-center-ce-review-course), [Cardiac](https://challengercme.com/cardiac-center-ce-review-course), [Trauma](https://challengercme.com/trauma-center-ce-review-course), [ALS](https://challengercme.com/advanced-life-support-and-resuscitation-center-ce-review-course), etc. ### [PROFESSIONALISM CME Professionalism review with CME](https://challengercme.com/professionalism-review-course) ### [DERMATOLOGY CME Dermatology review with CME](https://challengercme.com/dermatology-review-course) ### [USMLE STEP 2CK / STEP 3 USMLE exam prep, etc.](https://challengercme.com/usmle-certification-exam-review-clerkship-exams-shelf-exam-review) - [INSTITUTIONS ](https://challengercme.com/atlas-pro-inst) - [BLOG ](https://challengercme.com/blog) - [SUPPORT ](https://support.challengercme.com/knowledge) [SIGN IN ](https://fuse.challengercme.com/sign-in?redirectURL=%2Fuserdash) emergency medicine # Most Missed Question in EM Exam Prep – Pediatric Dog Bite In children under 2 with scalp bite punctures/avulsion, CT head is often the next step to rule out skull fracture or intracranial penetration. [ Challenger Corporation ](https://challengercme.com/blog/author/challenger-corporation) Feb 19, 2026 [Commonly Missed Questions](https://challengercme.com/blog/tag/commonly-missed-questions) [emergency medicine](https://challengercme.com/blog/tag/emergency-medicine) ### < [All Posts](https://challengercme.com/blog) ABEM Exam Prep + CME Med-Challenger Emergency Medicine Pass-guaranteed ABEM exam review with CME built-in. Try it for free. On sale now. [START EM REVIEW](https://fuse.challengercme.com/fulltrial/184) --- ### Share this article [mailto:?subject=Check%20out%20https://challengercme.com/blog/most-missed-question-in-em-exam-prep-pediatric-dog-bite&utm_medium=social&utm_source=email%20&body=Check%20out%20https://challengercme.com/blog/most-missed-question-in-em-exam-prep-pediatric-dog-bite&utm_medium=social&utm_source=email](mailto:?subject=Check%20out%20https://challengercme.com/blog/most-missed-question-in-em-exam-prep-pediatric-dog-bite&utm_medium=social&utm_source=email%20&body=Check%20out%20https://challengercme.com/blog/most-missed-question-in-em-exam-prep-pediatric-dog-bite&utm_medium=social&utm_source=email) ### Subscribe ### Subscribe ![Pediatric Scalp Dog Bite: When to Get CT Head (EM)](https://challengercme.com/hubfs/Blog%20-%20Most%20Missed%20Question%20in%20EM%20Exam%20Prep%20%E2%80%93%20Pediatric%20Dog%20Bite.png) ## For scalp bite wounds in children <2 years where deeper injury is hard to assess, head CT is the exam-favored next step to rule out skull fracture/penetration before closure. [![Want more control over your program's outcomes? Learn about Institutional Programs](https://no-cache.hubspot.com/cta/default/9106197/interactive-194510541423.png) ](https://challengercme.com/hs/cta/wi/redirect?encryptedPayload=AVxigLISNVa85qw9iWdLqmc9631OQbpR8w1a08ZAlznCgQVPavAz0eJDgVGRMdLZmEQO%2BsYBWzTLycqtNQSS%2BjFWU4MJPSEYBxbz8z7jmv2M9VqeKfqeY7QgVOryb6Bvt4sdeMKlz6KC1E%2Fjvo5XzyEr8Js7jt1s8yWZO5L6yKjGLDuiwitNHEzqJvGV488O1Q%3D%3D&webInteractiveContentId=194510541423&portalId=9106197) ## **Question - Next Step for Dog Bite** An 18-month-old girl is brought in to see you by her parents after she was attacked by a neighbor’s dog and sustained a bite wound to the scalp. On examination, she is awake and crying, with partial avulsion of the scalp and puncture wounds that are not actively bleeding. Her tetanus immunization is up to date Which of the following is the best NEXT step in the management of this patient's condition? Answer Options: A. irrigation and primary closure of the wounds B. computed tomography (CT) of the head C. irrigation and debridement of the wounds D. transcranial ultrasonography   This is a young child (<2 years) with a scalp dog bite involving puncture wounds and partial avulsion. In this age group, skull penetration/open or depressed fracture and intracranial injury can be present despite a deceptively limited external exam, because soft tissues and hair obscure assessment and the calvarium is thinner. The management priority is therefore to exclude open/depressed skull fracture or penetrating injury before proceeding with closure or bedside-only wound management. Contemporary head injury guidance (e.g., NICE Head Injury guideline NG232, 2023) supports urgent CT imaging in children when there is concern for suspected open or depressed skull fracture or penetrating injury. Similarly, ACR Appropriateness Criteria: Head Trauma—Child (2020) supports CT when there is clinical suspicion of skull fracture/penetration. While dog bites aren’t the classic “blunt head injury” population, the same principle applies: if penetration/open fracture is on the table, image first. After CT excludes intracranial extension or skull fracture, the next steps typically include copious irrigation, selective debridement, consideration of primary closure for cosmetically important facial/scalp wounds when appropriate, antibiotic prophylaxis (commonly amoxicillin-clavulanate), and surgical consultation if deeper injury is present. **   ## **Why This Emergency Medicine Question Is Often Missed** - Test-takers treat this as a “routine dog bite” question and jump to irrigation/closure/antibiotics without addressing occult intracranial injury risk in infants. - Many candidates overapply blunt head trauma rules and underestimate penetrating mechanisms (puncture wounds). - The phrase “awake and crying” misleadingly reassures, but normal mental status doesn’t exclude skull fracture/penetration. ## **What the Distractors Indicate** | **Option** | **What It Tests / Implies** | **Why It’s Wrong Here** | | --- | --- | --- | | irrigation and primary closure of the wounds  | Standard dog-bite wound care and cosmesis  | Premature before ruling out open/depressed fracture or intracranial penetration in a high-risk age/mechanism scenario.  | | computed tomography (CT) of the head  | Prioritizing evaluation for skull fracture/penetration | Correct: CT is the best next step when deeper injury can’t be safely excluded on exam in a toddler with puncture/avulsion scalp bite.  | | irrigation and debridement of the wounds  | Basic wound care  | Necessary eventually, but still secondary to excluding intracranial injury when penetration/fracture is plausible.  | | transcranial ultrasonography | Non-ionizing imaging idea for infants  |  Not the standard test to evaluate skull fracture/penetrating intracranial injury in this setting; CT is faster and definitive for bone/air/foreign body concerns. |   ## High-Yield Pearl for ABEM Exam Prep > In children <2 years with scalp bite punctures/avulsion, think occult skull fracture/penetration—CT head before closure is the exam-safe move.   ## **Core Learning Objectives** 1. Identify when pediatric scalp bite wounds warrant CT head to evaluate for skull fracture or intracranial penetration. 2. Sequence initial management of pediatric dog bites by prioritizing life-/limb-threatening and deep-structure injuries before definitive wound repair. ## **The Exam Trick at Play** The stem tempts you into “dog bite = irrigate + antibiotics + close (sometimes)” thinking. Boards often invert the order: when the wound location/mechanism suggests hidden deep injury (here, infant scalp punctures/avulsion), the “next step” is diagnostic confirmation (CT) before you do the satisfying procedural choices.   [![Want more control over your program's outcomes? Learn about Institutional Programs](https://no-cache.hubspot.com/cta/default/9106197/interactive-194510541423.png) ](https://challengercme.com/hs/cta/wi/redirect?encryptedPayload=AVxigLISNVa85qw9iWdLqmc9631OQbpR8w1a08ZAlznCgQVPavAz0eJDgVGRMdLZmEQO%2BsYBWzTLycqtNQSS%2BjFWU4MJPSEYBxbz8z7jmv2M9VqeKfqeY7QgVOryb6Bvt4sdeMKlz6KC1E%2Fjvo5XzyEr8Js7jt1s8yWZO5L6yKjGLDuiwitNHEzqJvGV488O1Q%3D%3D&webInteractiveContentId=194510541423&portalId=9106197)   ## Additional Practice Questions & Remediation for Pediatric Scalp Bite / Head Trauma Imaging    ### **Emergency Medicine Practice Question 1 — ****“Scalp puncture, preverbal” ** A 14-month-old has two small puncture wounds to the parietal scalp after a dog bite. He is consolable, neurologically normal, and the exam is limited by swelling and hair. Next best step? - A. Discharge with amoxicillin-clavulanate only - B. Noncontrast CT head - C. Primary closure without imaging - D. Transcranial ultrasound - E. Observe 6 hours, then discharge if stable Answer and Remediation A — Review: Antibiotics don’t address possible skull penetration/fracture. B — Correct response!: In infants with scalp punctures where skull integrity can’t be assessed, CT evaluates for open/depressed fracture/penetration (NICE 2023; ACR 2020 principles). C — Review: Closure before excluding deeper injury risks entrapping contamination and missing open fracture. D — Review: Not definitive for bone/penetration evaluation. E — Review: Observation is inappropriate when penetrating injury/open fracture is suspected. ### **Emergency Medicine **Practice Question 2 —  “Obvious skull defect”  A 20-month-old is bitten on the scalp. You palpate a step-off with visible bone. Best next step? - A. CT head and urgent neurosurgical consultation - B. Irrigation and primary closure in the ED - C. Pressure dressing and discharge - D. Plain skull radiographs only - E. Bedside ultrasound for fracture Answer and Remediation A — Correct response!: Findings suggest open/depressed skull fracture—CT plus urgent surgical involvement. B — Review: Do not close an open/depressed fracture in the ED. C — Review: Dangerous; missed intracranial injury risk. D — Review: Radiographs are insufficient for intracranial/penetrating assessment. E — Review: Ultrasound is not the standard definitive test here. ### **Emergency Medicine **Practice Question 3 —  “Low-risk superficial laceration”  A 6-year-old sustains a superficial scalp laceration from a vaccinated family dog. No punctures, no avulsion, normal neuro exam, wound fully visualized to galea without deeper extension. Next step?  - A. CT head - B. Copious irrigation and consider primary closure - C. MRI brain - D. Transcranial ultrasound - E. No cleaning needed; bandage only Answer and Remediation A — Review: Imaging isn’t routine when the wound is clearly superficial and deeper injury is confidently excluded. B — Correct response!: Standard wound care; scalp/facial wounds may be closed primarily when appropriate after irrigation. C — Review: MRI is not indicated for routine bite wound evaluation. D — Review: Not useful here. E — Review: Infection prevention requires irrigation/cleansing. ### **Emergency Medicine ****Practice Question 4 —  “Antibiotic choice” ** A 2-year-old has a dog bite to the scalp. CT is negative for fracture/penetration, and the wound will be closed. Best prophylactic antibiotic? - A. Cephalexin - B**. **Amoxicillin-clavulanate - C. TMP-SMX alone - D. Azithromycin - E. Metronidazole alone Answer and Remediation A — Review: Poor Pasteurella/anaerobe coverage. B — Correct response!: First-line bite prophylaxis—covers Pasteurella, streptococci, MSSA, and anaerobes. C — Review: Needs additional coverage (e.g., anaerobes/streptococci) if used. D — Review: Inadequate broad bite flora coverage. E — Review: Misses key aerobes (e.g., Pasteurella). ### **Emergency Medicine ****Practice Question 5 —  “Rabies decision” ** A toddler is bitten on the scalp by a stray dog that cannot be captured for observation. Tetanus is up to date. Next step regarding rabies? - A. No rabies prophylaxis needed in the US - B. Begin rabies post-exposure prophylaxis (immune globulin + vaccine series) after wound care - C. Vaccine only; no immune globulin - D. Immune globulin only; no vaccine - E. Wait 10 days to see if the dog gets sick Answer and Remediation A — Review: If the animal can’t be observed/tested, PEP is generally indicated based on exposure risk. B — Correct response!: Unavailable animal = cannot observe; initiate PEP per public health recommendations. C — Review: HRIG is recommended for previously unvaccinated patients (infiltrate around wound + remainder IM). D — Review: Vaccine is required for active immunity. E — Review: Observation is only valid if the animal is available for quarantine/monitoring. ## ** ** ## **Mini Case Discussion Prompt** > How would your management differ between (1) a fully visualized superficial scalp laceration in a 7-year-old and (2) puncture scalp wounds with swelling in a 14-month-old—specifically regarding imaging, closure strategy, and consultation?    ## Mini-FAQ  - *Q1: Why does age <2 years change the imaging threshold for scalp bites?* A1: Exams like ABEM/EM boards expect you to recognize that infants/toddlers have thinner calvaria and less reliable exams, so puncture bites can hide skull fracture/penetration—CT becomes the safer next step. - *Q2: Would observation alone ever be acceptable for this stem?* A2: Not when there’s plausible penetrating injury/open fracture risk. Observation strategies are primarily for low-risk blunt head trauma, not unclear-depth puncture wounds. - *Q3: Why not use ultrasound to look for skull fracture?* A3: While ultrasound may detect some skull fractures in select settings, boards typically consider CT the definitive test when ruling out open/depressed fracture or intracranial injury is essential. - *Q4: After a negative CT, is primary closure acceptable for scalp dog bites?* A4: Often yes when the wound is clean/irrigated and there’s no deep-structure involvement; the scalp is highly vascular and tends to heal well—this is commonly tested as “closure can be considered” once deeper injury is excluded. --- Find this and other Emergency Medicine exam prep questions in [Med-Challenger Emergency Medicine Review with CME](https://challengercme.com/emergency-medicine-exam-review-cme-course) [Try for free and save](https://fuse.challengercme.com/product/184). Ace your exams and meet your CME/MOC requirements for just $35 a month! 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