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McGowan, Maj, USAF, MCObjectives: Objectives Discuss general wound care principles Determine high risk vs low risk bites as related to antibiotic prophylaxis Determine need for tetanus prophylaxis Determine need for rabies prophylaxis Review common biting animals to include dogs, cats, humans, snakes, spiders, and ticks General Wound Care: General Wound Care Cleanse and debride wound Liberal application of ice or other cold packs Pressure to control bleeding Sterile dressing Hand and foot wounds require immobilization If wound high risk antibiotics should be started Consider need for tetanus/rabies High Risk Wounds: High Risk WoundsHigh Risk Wounds: High Risk WoundsLow Risk Wounds: Low Risk Wounds Face, scalp, ears, mouth Self-bite of buccal mucosa (not through and through) Large clean lacerations that can be thoroughly cleansed Partial thickness lacerations and abrasionsAntibiotics: Antibiotics Antibiotic prophylaxis if high risk wound Amoxicillin/clavulanate or ampicillin/sulbactam Cefoxitin or carbapenem for mild pcn allergy Vibramycin, trimethoprim/sulfamethoxazole, or a fluoroquinolone plus clindamycin if severe pcn reaction To Close or Not: To Close or Not Wound closure Puncture wounds, wounds that appear clinically infected, and wounds more than 24 hours old may have a better outcome with delayed primary closure May consider early primary closure if less than 8 hours old or located on face Tetanus Prophylaxis: Tetanus Prophylaxis CLEAN MINOR ALL OTHER WOUNDS WOUNDS HISTORY OF TETANUS PROPHYLAXIS Td TIG Td TIG Uncertain or Yes No Yes Yes < 3 doses > 3 doses last dose within 5 yrs No No No No last dose 5-10 yrs No No Yes No last dose > 10 yrs Yes No Yes No Rabies: Rabies Widespread vaccination of dogs against rabies in US Still reported cases of rabies virus associated with dog bites Most common source of rabies now is wild animals, specifically raccoons, skunks, and bats Rabies: Rabies Rabies: Rabies Nonprovoked dog/cat bites should be considered higher risk Owner reliable? confirm animal’s vaccination status observe pet in owner’s home Vaccinaton status unknown or animal ill observation by veterinarian is appropriate May need to sacrifice animal If animal cannot be quarantined for 10 days, the bite victim should receive rabies prophylaxis within 48 hoursRabies: Rabies Vaccination Status Treatment Regimen of bite victim Not vaccinated RIG 20 IU/kg around wounds or IM in site distant from vaccine site Vaccine Daily on days 0,3,7,14,28 Vaccinated RIG NO Vaccine Daily on days 0 and 3Dog Bites: Dog Bites Dog Bites: Dog Bites 80-90% of mammalian bites inflicted by dogs Only species whose bites have been well studied in large numbers Most contributing factors related to owner’s level of responsibilityDog Bites: Dog Bites Total annual US national cost of ED services for new dog bite-related injuries more than $102 million $165 million when combined with physican service charges and postdischarge care Dog Bites: Dog Bites Dogs under 1 year of age responsible for the highest incidence of bites Incidence of biting increases during warm summer months Most bites between 1-9PM Men bitten more often than women Pit bull breed of the Staffordshire terrier has been associated with the majority of dog bite related deaths in the United States Death usually from exsanguination Dog Bites: Dog Bites Most wounds minor Adult dogs can bite with up to 450 pounds of force Enough to puncture light sheet metal A dog’s bite can break human bones Characteristic pattern of lacerations and punctures Penetrating component causes most morbidity Dog Bites: Dog Bites Median of 5 bacterial isolates identified per culture for dog bites Pasteurella species the most common pathogen P. canis Streptococcus, Staphylococcus, Moraxella, Corynebacterium, NeisseriaDog Bites: Dog Bites Infection rate of non-bite lacerations 5-15% Similar rate to that of the typical dog bite when managed properly with irrigation and debridement Dog bite wounds that are NOT high risk are probably no more infection prone than non-bite, accidental cutaneous lacerationsDog Bites: Dog Bites Low risk bites—general wound care principles High risk bites—antibiotic prophylaxis Amoxicillin/clavulanate or ampicillin/sulbactam Cefoxitin or carbapenem for mild pcn allergy Vibramycin, trimethoprim/sulfamethoxazole, or a fluoroquinolone plus clindamycin if severe pcn reactionCat Bites: Cat Bites Cat Bites: Cat Bites 5-10% of mammalian bites inflicted by cats Increasing problem in US as stray population has exploded to over 90 million Women more likely than men to be bitten 63% of bites on hand or fingerCat Bites: Cat Bites Weaker biting force than dogs Sharp slender teeth Deep puncture wounds Notorious for high infection rate 15-80% become infected Pasteurella multocida and septica Typically two risk factors for infection Hand location Depth of puncture Most considered high risk and abx prophylaxis warranted Human Bites: Human Bites 2-3% of mammalian bites Most occur during fights At least 42 different species of bacteria in human saliva Bacteroides fragilis, Prevotella, Porphyromonas, Peptostreptococcus, Fusobacterium, Veillonella, Clostridium, Strep, Staph,Haemophilus, Eikenella Human Bites: Human Bites Transmission of actinomycosis, syphillis, herpes, hepatitis C, hepatitis B, and tuberculosis have been reported after a human bite Not thought to pose significant HIV risk as HIV usually not present in saliva Is thought to have been mode of transmission in at least two cases Slovenia man bitten while trying to control airway Lip bite to a male from a female prostituteHuman Bites: Human Bites Infection rate of 17.7% compared with 5-15% infection rate of non-bite lacerations Hand wounds particularly at risk of infection and considered high risk Human Bites: Human Bites Fight bite 60-80% occur in males Deep laceration that disrupts superficial and deep fasciae, extensor tendon and bursa, and joint capsule Once fingers extend skin and tendon retract and seal off contaminated woundHuman Bites: Human Bites Any penetrating wound in vicinity of MCP joint should be considered a human fight bite until proven otherwise Need xrays and up to 70% have positive findings Need rapid and aggressive treatment Human Bites: Human Bites Fight bite Significant injuries should be explored and debrided in OR In field wounds should be thoroughly irrigated and left open Hand should be immobilized Abx should be started ASAPHuman Bites: Human Bites Forensics Bite marks as well as any DNA that can be recovered can be used as evidence Photograph wound and consult forensic pathologist or dentist through local law enforcement agencySnake Bites: Snake Bites 8,000 venomous snake bites/yr in US Most occur in April and October Venom from four families toxic to humans More common worldwide than in USSnake Bites: Snake Bites In US 99% of snake bites are caused by pit vipers Rattlesnakes Copperheads CottonmouthsSnake Bites: Snake Bites Coral snakes also a US snake Snake Bites: Snake Bites Initial treatment Avoid excessive activity Immobilize bitten extremity in a functional position below the level of the heart Quickly transport patient to nearest hospital May consider wide flat constriction band proximal to bite Blocks only superficial venous and lymphatic flow Venom extractor—may be beneficial if applied within 5 minutes of the bite and left in place for 30 minutesSnake Bites: Snake Bites If possible try to identify snake from a safe distance Digitial photo Do not try to catch the snake Be wary of an apparently dead snakeSnake Bite: Snake Bite Venomous vs Non-venomous Venomous snakes Triangular shaped head Elliptical pupil Hollow retractable fangs Non-venomous snake Round head Round pupil No fangs Coral snakes Recognize banding patternSnake Bites: Snake Bites Clinical effects of a snake bite Mild local reaction Severe life-threatening systemic reaction Depends on species of snake, size of snake, location of bite, volume on venom injected, age/size/health of victim Snake venom Hemotoxic NeurotoxicSnake Bites: Snake Bites Hemotoxic symptoms Intense pain Edema Weakness Swelling Numbness/Tingling Rapid pulse Ecchymoses Muscle fasciculation Unusual metallic taste Vomiting Confusion Bleeding disorders Neurotoxic symptoms Minimal pain Ptosis Weakness Paresthesia/Numbness at bite Diplopia Dysphagia Sweating Salivation Diaphoresis Hyporeflexia Respiratory depression ParalysisSnake Bites: Snake Bites Croatalinae subfamily Rattlesnakes, copperheads, cottonmouths Hemotoxic Local tissue destruction, coagulopathy, hypotension Mojave rattlesnake is only rattlesnake associated with significant neurotoxicity Elapidae family—In US –coral snakes Neurotoxic Snake Bites: Snake Bites Evaluation/Treatment General wound care Exam Hypotension, tachycardia, oozing, blistering, LAD, local tissue damage, signs of bleeding For suspected coral snake or mojave rattlesnake need serial neurologic exams Laboratory evaluation: CBC, PT, PTT, fibrinogen, FDPs ASAP and recheck in 12 hours Blood type and cross match, electrolytes, glucose, BUN, LFTs, Bilirubin, CK, Stool hemoccult EKG if over 50 or with heart dz ABGs if respiratory compromise Snake Bites: Snake Bites Antibiotics Snake bites may result in inoculation of Gram negative anaerobic bacteria Local bacterial wound infections rare when abx not prescribed Use abx only for established infection or if first aid measures have involved an incisionSnake Bites: Snake Bites Degree of envenomation Presentation Treatment 0. None Puncture, abrasions, pain Wound care or tenderness at bite site I. Mild Pain, tenderness, edema Antivenom perioral paresthesias II. Moderate Pain, tenderness, erythema Antivenom beyond area adjacent to bite systemic cx, coagulopathy III. Severe Intense pain/swelling of entire Antivenom extremity, severe systemic sx coagulopathy IV. Life-threatening Marked abnl signs/symptoms Antivenom severe coagulopathy Snake Bites: Snake Bites Polyvalent Crotalidae ovine immune Fab (FabAV) --Fab fragments from sheep Ig immunized with four snakes --western and eastern diamondbacks, mojave rattlesnake, cottonmouth --Effective for all NA rattlesnakes --Approved for copperheads as well --Safe and effective in children --Lower adverse events than ACP --indicated with any grade of envenomation --dosing 4-6 ampules repeated if no response in one hour Crotalidae polyvalent antivenom (ACP) --made from horse serum --produced from venom from 4 snakes --western/eastern diamondbacks, SA/Brazilian rattlesnake, SA pit viper --may be effective against other species as well --dosing based on severity of envenomation --serum sickness and anaphylactic reactions common AntivenomsSnake Bites: Snake Bites Coral snake bites far less common in US Envenomation occurs following majority of bites and neurotoxicity can occur in the absence of obvious fang marks Symptoms onset immediate up to 12 hours later Horse serum based antivenom available and effective against Eastern and Texas coral snakes, but not others such as the Arizona coral snake Antivenin (Micrurus fulvius)Spider Bites: Spider Bites Approx 3,000 species of spiders in NA and all are poisonous Most too small or have too little poison to bother humans Only a few species have powerful enough chelicerae to penetrate human skinSpider bites: Spider bites Most dangerous spiders to humans in NA Latrodectus—widow spiders Loxosceles—brown spidersSpider Bites: Spider Bites Can attribute a local or systemic reaction to a spider bite if: Spider seen during biting Spider recovered, collected, sent for ID Other conditions such as vasculitis, infection, allergic reaction other than to the spider venom, vascular problems, and anxiety/panic must be ruled outSpider Bites: Spider Bites Black Widow Bite (Latrodectus species) Latrodectism Caused by alpha-latrotoxin—neurotoxic—causes massive presynaptic release of most neurotransmitters including acetylcholine, norepi, dopamine, and glutamate Severe muscle spasm, nausea, vomiting, deaths in less than 1% of patients Local wound care, analgesia, bzd Initial labs to include cbc, ua, ck, ldh Latrodectus antivenom for severe regional or systemic toxicity and for patients with uncontrolled HTN, seizures, or respiratory arrestSpider Bites: Spider Bites Brown Recluse Bite (Loxosceles reclusa) Necrotic arachnidism Sphingomyelinase D Immediate wound care Debridement of necrotic tissue, culture directed abx, delayed excision of eschars with split thickness skin grafting as needed With proper care necrotic wounds heal over 8 weeks with a 10-15% incidence of major scarringTick Bites: Tick Bites Nearly painless bites. May not be notice until after it is attached Important to remove ASAP after it is discovered Need to also remove tick completely Risk of Lyme dz tranmission increases significantly after 24 hours of attachment and is even higher after more than 48 hours Tick Bites: Tick Bites Removing a Tick Manual extraction Blunt tipped angled forceps to grasp tick as close to skin as possible Use perpendicular traction to remove Do not twist Do NOT Do Use sharp instruments Crush or puncture the tick’s body Apply substances Use heat Twist or jerk Handle with bare handsTick Bites: Tick BitesTick Bites: Tick Bites Tick-borne Diseases Lyme—Borrelia burgdorferi Ixodes scapularis tick—Deer tick Symptoms 7-10 days after tick bite Early localized form—Stage 1 Erythema migrans and flu like illness Early disseminated—Stage 2 AV block, carditis, fatigue, meningitis, Bell’s palsy Late chronic—Stage 3 Arthritis, encephalopathyTick Bites: Tick Bites Lyme Dz If erythema migrans present make dx and begin tx, otherwise determine pretest probability AFP 7/15/2005Tick Bites: Tick Bites Tick-borne Diseases Ehrlichiosis—Ehrlichia Ixodes tick Human monocytic and Human granulocytic 7-10 day incubation period Fever, headache, myalgias, chills Leukopenia, thrombocytopenia, and elevated liver transaminases Dx base in H&P and common lab findings Doxycycline is drug of choice Tick Bites: Tick Bites Tick-borne Diseases Rocky Mountain Spotted Fever—Rickettsia Hard-bodied ticks—American dog tick/wood tick 7 day incubation period Fever, headache, myalgia, malaise, vomiting Rash within first week Depressed WBC, thrombocytopenia, elevated liver transaminases, hyponatremia Encephalitis, pulmonary edema, ARDS, cardiac dysrhythmias, coagulopathies, GI bleeding, skin necrosis. Death in 8-15 days if left untreated Mortality 25% if untreated and 5% if treated Tick Bites: Tick Bites Rocky Mountain Spotted Fever Diagnose by H&P Treat with tetracycline and chloramphenicolTick Bites: Tick Bites Tick-borne diseases Tularemia—Francisella tularensis 3-5 day incubation Fever, chills, headache, malaise, anorexia, fatigue, cough, myalgies, chest discomfort, vomiting, sore throat, abdominal pain, diarrhea In addition one of six classic patterns of disease Tick Bites: Tick Bites Tularemia Ulceroglandular pattern—most common Enlarged, tender, localized LAD-cervical/occipital Painful skin ulcer Glandular pattern Similar, but without ulcer Oculoglandular 90% unilateral Photophobia, lacrimation, lid edema, conjunctivitis, scleral injection, conjunctival ulcers Pharyngeal Severe sore throat, exudative pharyngitis Typhoidal Watery diarrhea Pneumonic Acute respiratory illnessTick Bites: Tick Bites Tularemia H&P to diagnose Streptomycin unless meningits is present Gent, tetracycline, chloramphenicol, fluroquinolonesSummary: Summary Discussed general wound care principles Reviewed high risk vs low risk bites as related to antibiotic prophylaxis Reviewed need for tetanus prophylaxis Reviewed need for rabies prophylaxis Reviewed common biting animals to include dogs, cats, humans, snakes, spiders, and ticks Slide64: ?QUESTIONS? 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