Bites Bites Bites

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    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

     

    Catsimg_8213

    • 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

     

    Dogsimg_0448

    • 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

     

    Monkey

    • 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

     

    Lizards

    • 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.

    References

    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. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&Sectionid=109449392. 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. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1163&Sectionid=65102317. Accessed January 05, 2017.
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