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Bites

Bites. Michael A. Renzi, DO, FACP Advocare Heights Primary Care. Epidemiology. 1% of ED visits 80-90% are from dogs 5-15% are from cats. Human Deaths from Animal Attacks. Humans – 200,000(US-3,400) Snake – 60,000 Crocodile– 1000 Tiger – 800-1600 Lion –60-200 Leopard—30-125

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Bites

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  1. Bites Michael A. Renzi, DO, FACP Advocare Heights Primary Care

  2. Epidemiology • 1% of ED visits • 80-90% are from dogs • 5-15% are from cats

  3. Human Deaths from Animal Attacks • Humans – 200,000(US-3,400) • Snake – 60,000 • Crocodile– 1000 • Tiger – 800-1600 • Lion –60-200 • Leopard—30-125 • Hippopotamus 200-300

  4. Open Mouth Clenched Fist Human Bites

  5. 80% S. aureus Mouth Anaerobes Group A β-hemolytic Strep Eikenella Microbiology

  6. Cat Bite Pit Bull Bite Dog/Cat Bites

  7. Dogs, Man’s BFF? • 4.7 million bits annually • 750,000 visits • 66% of bites are not reported • 59 per 10,000 incidence • 250 per 10,000 in India • 96% percent of rabies cases Chhabra M. Humna rabies in Delhi, Indian Journal of Peds, 2004; 71;217-220 CDC, US, 2001. MMWR 2003;52:605-610

  8. Cat Bites • 400,000 bits annually • Mostly female cats • Mostly female victims Smith Treating Mammalian bite wounds, J Clinical Pharm , 2000; 25:85-99

  9. Microbiology • Pasteurellamultocida –60% • S. aureus • Cynocatophagia • Anaerobes • The average dog has 64 different bacterial isolates in mouth

  10. Marine Bites • Shark, fish, eel • Vibrio(cirrhotics) • Aeromonas(GNR)

  11. Evaluation • Provoked or unprovoked? • Penicillin allergy • Tetanus status • Evaluate for injury below the skin

  12. Treatment • Aggressive debridement and wound lavage • Closure of lacerations within 24 hours • May avoid antibiotics in superficial dermis non-extremity wounds(scalp) • All hand bites get prophylactic antibiotics • ABX may be warranted in immuno-compromised hosts

  13. Antibiotic Selection • Amoxicillin/Clavulanate • Azithromycin • Cipro

  14. Rabies Prophylaxis • Live captured animal is best • Need the head • Keep it in the frig until it can be analyzed • Unprovoked aggression • Lack of fear of humans • Daylight attacks

  15. Which Animals? • Racoons • Skunks • Bats • Foxes • Cats • Dogs • Cattle • Horses

  16. Bumble bee Paper wasp Honey bee Yellow jacket Bees/Wasps

  17. Bee Stings • Local edema • Prednisone—for local edema • H1 blockade –for urticaria • Epinephrine-laryngeal edema

  18. Flea Bites

  19. Chiggers

  20. Tick Line Up

  21. EyrthemaChronicaMigrans

  22. Evidence for the Evidence • Grade A—Good evidence to support use • Grade B—Moderate Evidence • Grade C—Poor Evidence • Grade D—Moderate Evidence Against use • Grade E—Good Evidence Against use

  23. Quality of the Evidence • I—One positive randomized controlled trial • II—One well designed trial • Without randomization • Cohort • Case controlled • III—Evidence and opinions from authorities based on clinical experience or expert committes

  24. Prophylaxis • Routine use of antibiotics or serologic testing after tic bite(E-1, D-III) • Remove attached tic ASAP(A-III) • Treatment with ticks attached longer than 48 hours (C-III)

  25. Who to Treat • All Patients with ECM(A-I) • All patients who develop a rash or high fever (>100F) within 30 days of bite (A-II) • Erlichiciosis or Babesiosis • All patients with positive ELISA(A-1)

  26. Spiders

  27. Some Basics • Offending critter rarely recovered • Bite thin-skinned areas • Areas where clothing presses tightly • Appearance of the wound does not help with diagnosis

  28. Spiders-Brown Recluse

  29. Brown Recluse Bite

  30. Daddy Long Legs House Spider Harmless

  31. Black widow • Found in every state in US • Usually warmer climates • Highly venomous • Have them bring in the spider

  32. Yellow Sac • Bites feel like bee sting • Serum Sickness • Eschar not always present

  33. Scabies

  34. Nice People Get Scabies • Without treatment, infection may last indefinitely • Nocturnal itching is hallmark of scabies • 4-6 weeks between infestation and symptoms

  35. Treatment • Permethrin (A) • Launder clothing and sheets • Launder the kids, spouse • Zoloft may be necessary

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