Bites Bites Bites


    Bites Bites Bites

    Animal Bites (Cat, Dog, Monkey, Lizard, Snake)

    Quick bullets to prep for in-training, let’s review

    Management for ALL animal bites

    • X-ray if suspect foreign body
    • Remove teeth
    • Routine wound care/irrigation
    • Update tetanus



    • Pathogens: Pasteurella, Bartonella (cat scratch)
    • Treatment
      • Leave the wound open (don’t suture)
      • Strongly consider antibiotics for ALL bites
        •  Amoxicillin/clavulanate
        • PCN allergic: Metronidazole or Clindamycin AND doxycycline, trimethoprim-sulfamethoxazole, moxifloxacin, or cefuroxime



    • Pathogens: Staph and Strep most predominant, Pasteurella
    • Treatment
      • Primary closure if on cosmetic part of the body
      • Antibiotics only if signs of infection, comorbidities, large wounds with gross contamination, wounds on the hand, delayed presentation
        • Amoxicillin/clavulanate
      • Rabies immunoglobulin and vaccination if unknown vaccination status of the dog



    • Pathogens: Herpes B, Rabies
    • Herpes B virus
      • Found in Macaques
      • Fatal if untreated
      • Paresthesias > vesicles > encephalitis
      • High infection rate if untreated
    • Treatment:
      • Leave the wound open (don’t suture)
      • Acyclovir for herpes prophylaxis
      • Rabies immunoglobulin and vaccination
      • Consider bacterial prophylaxis



    • Venomous: Mexican beaded lizard, Gila monster
    • Symptoms: Local symptoms, nausea and vomiting, rarely hypotension
    • Treatment
      • Observe for 6 hours for systemic effects
      • If hypotensive treat as if anaphylactoid reaction with IVF, epinephrine, steroids, antihistamine
      • Antibiotics only if signs of infection, comorbidities, large wounds with gross contamination


    Snakes (US)

    • 4 Families
      • Viperidae
        • Crotalinae > Pit vipers
      • Elapidae
      • Colubridae
      • Atractaspidinae
    • Viper Family / Pit Vipers
      Ref 3

      Ref 3

      • Includes: Rattlesnakes, cottonmouth, copperheads, western diamondbacks
      • Account for the majority of snake envenomations in North America
      • Identification
        • Triangular shaped head
        • Nostril pits
        • Elliptical pupils
      • Majority are dry bites
      • Local effects
        • Severe pain
        • Edema
        • Erythema
        • Rhabdomyolysis
        • Compartment syndrome
      • Systemic effects
        • Paresthesias
        • Generalized weakness
        • Chest pain
        • Thrombocytopenia, bleeding complications
      • Testing: CBC, fibrinogen, PT, PTT, INR
      • Treatment
        • If asymptomatic observe for 8 -12 hours and repeat blood work
        • Supportive care
        • Moderate to severe envenomations may use Croatlidae polyvalent immune Fab (CroFab)
    • Elapidae
      Ref 3

      Ref 3

      • Coral snakes
      • Identification: red on yellow kills a fellow; red on black, venom lack.
      • Symptoms
        • Neurotoxicity – paresthesias, fasciculations, slurred speech, ptosis, diplopia, dysphagia, stridor, paralysis, respiratory failure from neuromuscular blockade
        • Serious neurotoxicity may initially be asymptomatic for a number of hours
      • Treatment
        • Antivenin if strong suspicion of coral snakebite, even in absence of signs of envenomation
        • Admit for monitoring given risk of delayed neurologic manifestations and respiratory failure

    Note: All fuzzy animals are nice and haven’t bitten people.


    1. James Q. Puncture Wounds and Bites. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill; 2016. Accessed January 05, 2017.
    2. Johnston WF et al. Exposure to Macaque Monkey Bite. J Emerg Med. 2015; 49(5): 624-7. PMID: 26281802
    3. Ruha A, Pizon AF. Native (US) Venomous Snakes and Lizards. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank’s Toxicologic Emergencies, 10e. New York, NY: McGraw-Hill; 2015. Accessed January 05, 2017.
    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • Put down that FOBT

      “The HgB has dropped, have you checked a guaic?” How many times have you checked a FOBT in your workup for anemia? Let’s take a look at what FOBT is supposed to be used for. FOBTRead more

    • A ‘normal’ chest Xray

      What do you see when you take a look at this Chest radiograph? It isn’t immediately noticeable (and was read as normal), and is a good reminder of why you should always check your ownRead more

    • Overshot that INR

      There have been a few cases of supra-therapeutic INR in the Sinai ED recently, and at the request of one of our superstar interns, below you will find a brief set of recommendations regarding SupratherapeuticRead more

    • Ketamine PSA with Desaturation

      During a busy day in the ED, it becomes apparent that the pulling and yanking on your patient’s shoulder has done absolutely nothing to reduce their shoulder. You perform your pre-procedure PSA Checklist, know that thisRead more

    • Sinusitis In Pediatrics?

      You’re working in pediatrics, when a mother comes in stating her 5 year old has sinusitis. He presents with fever, cough, runny nose, and some discomfort over where his frontal sinuses are. Does he haveRead more

    • Ring Removal

      Over the past week, we’ve had a strange uptick in number of patients presenting to the ER with rings stuck on their finger. This is a quick review on the options that you have regardingRead more

    • TPA For Minor Stroke?

        So, you’re working in the ED when a new stroke code is activated. You walk over and see a young gentleman with the complaint of left facial tingling, right arm and leg weakness withRead more

    • Central Line Wizardry

      I was scrolling through twitter this morning when I came across a quick video from @CriticalCareNow for an awesome central line trick. And then I went to his feed and found some more. They areRead more