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Pediatric Infectious Diseases Division. Pediatric Residents International Track Seminar. Animal Bites By Hossam M. Al-Tatari, M.D. What are we going to talk about today?. Animal bites in U.S. How to manage an animal bite in general.

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Pediatric residents international track seminar

Pediatric Infectious

Diseases Division

Pediatric Residents International Track Seminar

Animal Bites

By

Hossam M. Al-Tatari, M.D.

Hossam M.Al-Tatari, M.D.


What are we going to talk about today

What are we going to talk about today?

  • Animal bites in U.S.

  • How to manage an animal bite in general.

  • Some weared animal bite mainly for the international travelers

  • Actually……even for non travelers!!!

Hossam M.Al-Tatari, M.D.


Introduction

Introduction

  • 1% of all visits to pediatric emergency centers

  • 4.7 million dog bites, 400 000 cat bites, and 250 000 human bites occur annually in the United States.

  • The incidence of infection

    • cat bites:50%

    • dog or human bites:15% to 20%

Hossam M.Al-Tatari, M.D.


Etiologic agents

Etiologic agents

  • More than 50% are mixed.

  • CatsPasteurella multocida

  • DogsPasteurella Canis

  • HumansEikenella corrodens,Streptococcus pyogenes

  • HorsesActinobacillus species

  • FishHalomonas vensuta, Aeromonas hydrophilia, Psuedomonas species and Vibrio species.

Hossam M.Al-Tatari, M.D.


Clinical approach

Clinical approach

  • Questions to be asked

    • Home pet or a wild animal?

    • Would the animal be available for observation over the next 10days?

    • Provoked or not?

    • How long ago was the bite?

    • Assess tetanus immunization status.

    • In case of human bite assess the risk of Hep B and HIV in the offender.

  • Careful exam: e.g.: Clenched-Fist injuries.

Hossam M.Al-Tatari, M.D.


Laboratory testing

Laboratory testing

  • Wound cultures:

    • Both aerobic and anaerobic

    • Inform the lab

    • If the wound is contaminated with soil, consider Mycobacteria and fungal cultures

  • Blood cultures

  • Imaging

Hossam M.Al-Tatari, M.D.


Management wound

Management, wound

Hossam M.Al-Tatari, M.D.


Management wound1

Management, wound

Hossam M.Al-Tatari, M.D.


Management wound2

Management, wound

Hossam M.Al-Tatari, M.D.


Management wound3

Management, wound

Hossam M.Al-Tatari, M.D.


Management wound4

Management, wound

Hossam M.Al-Tatari, M.D.


Management antibiotics prophylaxis

Management, antibiotics prophylaxis

  • Indications for antibiotics prophylaxis:

    • Moderate or severe bite wounds, especially if edema or crush injury is present

    • Puncture wounds, especially if bone, tendon sheath, or joint penetration may have occurred

    • Facial bites

    • Hand and foot bites

    • Genital area bites

    • Wounds in immunocompromised and in asplenic persons

Hossam M.Al-Tatari, M.D.


Management antibiotics prophylaxis1

Management, antibiotics prophylaxis

Hossam M.Al-Tatari, M.D.


Management antibiotics prophylaxis2

Management, antibiotics prophylaxis

Hossam M.Al-Tatari, M.D.


Management tetanus

Management, tetanus

Clean, minor wound All other wounds

Hossam M.Al-Tatari, M.D.


Management tetanus1

Management, tetanus

  • Tetanus Immune Globulin (human) (TIG) :3000 to 6000 U IM for children and adults.

  • In tetanus neonatorum: smaller doses (as small as 500 U)

  • Some recommend infiltration around the wound. The efficacy has not been proven.

  • Where TIG is not available, equine tetanus antitoxin may be available. It is administered as a single dose of 50 000 to 100 000 U after testing for sensitivity.Part of this dose (20 000 U) should be given intravenously.

  • Intravenous Immune Globulin contains antibodies to tetanus and can be considered for treatment if TIG is not available.

Hossam M.Al-Tatari, M.D.


Management rabies

Management, rabies

Hossam M.Al-Tatari, M.D.


Management rabies1

Management, rabies

  • Passive post-exposure prophylaxis

    • Human RIG should be used concomitantly with the first dose of vaccine.

    • Dose of RIG is 20 IU/kg of body weight.

    • As much of the dose as possible should be used to infiltrate the wound(s). Dilute if needed for large wounds.

    • The remainder is given intramuscularly using a separate syringe and needle.

    • Vaccine should be administered in a different site.

  • Purified equine RIG or antisera containing rabies antibodies is available outside the United States

Hossam M.Al-Tatari, M.D.


Management rabies2

Management, rabies

  • Active Immunization (Postexposure).

    • A 1.0-mL dose of any of the 3 vaccines is given intramuscularly in the deltoid area or anterolateral aspect of the thigh on the first day of post-exposure prophylaxis, and repeated doses are given on days 3, 7, 14, and 28 after the first dose.

    • An immunization series should be initiated and completed with 1 vaccine product.

    • Serologic testing to document seroconversion after administration is advised occasionally only for recipients who may be immunocompromised.

Hossam M.Al-Tatari, M.D.


Complications

Complications

  • Cellulitis and soft tissue necrosis.

  • Pyogenic arthritis.

  • Osteomyelitis.

  • Septicemia.

  • Meningitis.

  • Brain abscess.

Hossam M.Al-Tatari, M.D.


Animal bites and complications

Weared Bites

Hossam M.Al-Tatari, M.D.


Animal bites and complications

Hossam M.Al-Tatari, M.D.


Animal bites and complications

Hossam M.Al-Tatari, M.D.


Snake bites

Snake bites

  • 45000 reported annually in US

  • Only 8000 are venomous

  • Toxins are species specific

    • Nuerotoxic: Death results from respiratory suppression

    • Cytolytic: Death results from hemorrhagic shock, adult respiratory distress syndrome or renal failure.

  • Antivenins should be administered within <4 hours when indicated and before the presence of any symptoms.

  • They pose a small but significant risk of immediate hypersensitivity reaction.

Hossam M.Al-Tatari, M.D.


Animal bites and complications

Hossam M.Al-Tatari, M.D.


Alligator bites

Alligator bites

Hossam M.Al-Tatari, M.D.


Alligator bites1

Alligator bites

  • Open thumb fracture resulting from an alligator bite became infected with Aeromonas hydrophila, Enterobacter agglomerans, and Citrobacter diversus.

  • Cultures obtained from the mouth of ten alligators !!!

  • Initial empiric therapy after alligator bites should be directed at gram-negative species,

Initial antibiotic therapy for alligator bites: characterization of the oral flora of Alligator mississippiensis.Flandry F, et alDepartment of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, La.

Hossam M.Al-Tatari, M.D.


Animal bites and complications

Hossam M.Al-Tatari, M.D.


Alligator bites2

Alligator bites

  • 16 reported crocodile attacks in Northern Australia (1981-1991)

  • Four of these were fatal.

  • Most attacks resulted from swimming or wading in shallow water (13/16)

  • Half the victims were known to be affected by alcohol.

  • The majority of attacks occurred in failing light or at night (10/16).

  • Injuries in survivors ranged from minor lacerations and puncture wounds to major abdominal, chest and limb trauma.

  • Death in fatal attacks was caused by transection of the torso or decapitation.

  • Microorganisms isolated from wound swabs included Pseudomonas, Enterococcus, Aeromonas and Clostridium species.

Hossam M.Al-Tatari, M.D.


Camel bites

Camel bites

  • In western countries are mostly inflicted by zoo or circus camels.

  • Highest risk during the mating season between December and March

  • Cause significant injuries by biting, throwing the victim, kicking in any direction (forward, sideways, and backwards), trampling, or squeezing with their whole body (weight, 450–690 kg) .

  • Nigeria: 32 patients with facial animal bites

    • Cows (n=14)

    • Camels (n=9)

    • Donkeys (n=6)

    • Dog (n=3)

Hossam M.Al-Tatari, M.D.


Animal bites and complications

Hossam M.Al-Tatari, M.D.


Lion bites

Lion bites

  • Big cats attack at the nape of the neck. By Loefler IJ. in journal of trauma 1996.

    • Reviewed 20 cases of lion bites

    • “Wild cats” bite the neck

    • “Domestic large animals” bite the peripheral limbs

    • Main organisms are Pasteurella multocida and septica

  • In a case report from Kansas: the arm was found to be unsuitable for reimplantation because of the near complete soft tissue loss while in possession of the lion.

Hossam M.Al-Tatari, M.D.


Lion bites1

Lion bites

Hossam M.Al-Tatari, M.D.


Animal bites and complications

Hossam M.Al-Tatari, M.D.


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