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Introduction to Animal Bites in ED CRASH in to Emergency Medicine . Frank LoVecchio, DO, MPH, FACEP, ABMT Co-Medical Director, Banner Good Samaritan Poison and Drug Information Center Maricopa Medical Center, Research Director Vice-Chair, Department of Emergency Medicine

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introduction to animal bites in ed crash in to emergency medicine

Introduction to Animal Bites in EDCRASH in to Emergency Medicine

Frank LoVecchio, DO, MPH, FACEP, ABMT

Co-Medical Director, Banner Good Samaritan Poison and Drug Information Center

Maricopa Medical Center, Research Director

Vice-Chair, Department of Emergency Medicine

Professor University of AZ College of Medicine

Phoenix, AZ

disclosure
DISCLOSURE

Relevant Financial Relationship(s)

I am a principle investigator for various research projects, including NIH funding involving antibiotics, antivenoms, heparins, asthma and acute coronary syndromes

They pay the hospital and occasionally patients.

I receive no money directly.

Off Label Usage

None

goals
Goals
  • To discuss presentation animals bites and some stings encountered in the ED
  • To discuss the treatment of animal bites and stings
  • Occasionally laugh
dog bites
Dog bites
  • low risk for infection (5%-10%) unless hand involved (13%-30%); well vascularized areas at low risk
  • most wounds that do become infected usually easily treated with first-generation cephalosporin on outpatient basis; only 1% of patients hospitalized usually for cosmetic surgery
  • 1986 study showed most infected dog bite wounds healed with cephalexin (Keflex), suggesting that in multiorganism infections, only predominant organisms need be treated
cat bites
Cat Bites
  • 75% of cat bites have Pasteurella, mostly pathogenic species, eg, Pasteurella multocida
dog cat bite wound infections microbiology
Dog & Cat Bite Wound Infections Microbiology

Cat Dog

Pasteurella sp. 75% 50%

Streptococcus sp. 46% 46%

Staphylococcus sp. 35% 46%

Fusobacterium sp. 33% 32%

Bacteroides sp. 28% 30%

Porphyromonas sp. 30% 28%

Prevotella sp. 19% 28%

Talan DA, Citron DM, Abrahamian FM, Moran GM, Goldstein EJC. NEJM 1999;340:85.

dog cat bite wound infections microbiology1
Dog & Cat Bite Wound InfectionsMicrobiology

Dog Cat

Aerobic/anaerobic 48% 63%

Aerobes only 42% 32%

Anaerobes only 1% 0%

No growth 8% 5%

Talan DA, Citron DM, Abrahamian FM, Moran GM, Goldstein EJC. NEJM 1999;340:85.

cat bites1
Cat bites
  • Infection rate 30- 50%; greater morbidity in local and systemic infection
  • Cats have sharp teeth that often penetrate to bone, tendon, and joint; cat biting owner on hand most common; patients generally delay treatment when bitten by own cat (present only if bite becomes infected)
  • 70% of cats have Pasteurella in their saliva (50% of dogs); when Pasteurella present, likely to be sole pathogen
what works on pasteurella
What Works on Pasteurella

* TMP/SMX: Trimethoprim/sulfamethoxazole

Goldstein EJC. Antimicrob Agents Chemother 1998;41:391.

Goldstein EJC. Antimicrob Agents Chemother 1997;41:1552.

prophylaxis for dog bites favors antibiotic favors placebo
Prophylaxis for Dog BitesFavors Antibiotic Favors Placebo

(n = 62)

(46)

(55)

(33)

(113)

(96)

(39)

(185)

Summary

Relative risk 0.56

0.1 0.125 0.25 0.5 1 2 4 8 10

Cummings P. Ann Emerg Med 1994;23:535.

human bite infections microbiology
Human Bite InfectionsMicrobiology

ß-lactamase producer

Streptococcus sp. 84%

Staphylococcus sp. 54% >80%

Eikenella corrodens 30%

Haemophilus sp. 22%

Prevotella sp. 36% >50%

Fusobacterium sp. 34%

Veillonella sp. 24% ~10%

Talan DA, Abrahamian FM, Moran GJ, et al. Clin Infec Dis 2003:37:1481-89.

what works on e corrodens
What Works on E corrodens

* TMP/SMX: Trimethoprim/sulfamethoxazole

Griego RD, et al. J Am AcadDermatol 1995;33:1019.

human bite infections antimicrobial therapy
Human Bite Infections Antimicrobial Therapy

EikenellaStaph.Anaerobes

Amoxicillin/clav. + + +

Ampicillin/sulbac. + + +

Cefoxitin + + +/-

Azithromycin + + +/-

Levofloxacin + + +/-

Moxifloxacin + + +

Pen/cephalexin + + +/-

Clindamycin + Cipro. + + +

http www youtube com watch v sunmlundil8 feature related
http://www.youtube.com/watch?v=SUNmLuNdiL8&feature=related
  • <iframe title="YouTube video player" width="480" height="390" src="http://www.youtube.com/embed/SUNmLuNdiL8?rel=0" frameborder="0" allowfullscreen></iframe>
  • YouTube - Probably the Funniest Cat Video You'll Ever See
a sick patient after a dog bite
A sick patient after a dog bite
  • A 40 year old with sickle cell disease, is admitted for septic shock.
  • A history of a dog bite 5 days prior and the wound is mildly infected
  • Despite aggressive care dies on hospital day 3
  • All blood cultures are negative
capnocytophaga canimorsus dysgonic fermenter 2 df 2
Capnocytophaga canimorsus (dysgonic fermenter-2; DF-2):
  • Gram-negative facultatively anaerobic rod that has caused sepsis in small number of people; can be fatal; 75% of victims immunosuppressed in unusual way (ie, but have no spleen, have lung disease, taking steroids, or alcoholic)
  • 25% have no apparent underlying illness; associated with contact with dog or cat; causes generalized sepsis with hypotension, petechiae, purpura, and adrenal hemorrhage; ≈25% mortality; susceptible to most drugs used for sepsis of unknown etiology and for prophylaxis of wounds (prophylaxis indicated in any immunosuppressed patient with dog bite)
  • Very slow growing (warn laboratory not to throw out blood culture too soon);
summary
Summary
  • Dog bites low risk except for hands; Pasteurella multocida not major threat; patients with infections can generally be treated as outpatients; consider DF-2 in patients with risk factors
  • Cat bites are bad
  • Augmentin is your friend
  • No substitute for good wound care
rodents
Rodents
  • Wound infection rate 2%; bites usually cause local cellulitis that can be easily treated with first-generation cephalosporin or dicloxacillin
  • No cases of rodent transmission of rabies to humans in United States (bats are not rodents and have high risk for rabies)
ferrets
Ferrets
  • Third most common pet in United States; members of skunk and weasel family; outlawed in California and Hawaii; 500,000 pet ferrets in California
  • Known for sudden, unprovoked, disfiguring attacks on infants (feed on suckling animals in wild); cage not protective (ferrets known to escape, hide for days, then attack)
  • Can carry and transmit rabies, although no cases in United States (rabies vaccine available for ferrets, even in states where ferrets outlawed)
case a new antidote for an old problem
Case: A new antidote for an old problem
  • A 30 year old man is envenomated by a rattlesnake.
  • He has no history or asthma and takes no meds
  • He has no allergies
slide30

RULE ONE:

PLEASE DON’T KISS SNAKES

slide32

34

5 patients 6 bites

first aid for snakes
First Aid for Snakes
  • ABC’s
  • Analgesics
  • Volume Support
  • Don’t do anything stupid
  • Go to ER
legitimacy of snakebite
Legitimacy of Snakebite
  • Legitimate Bite
    • did not recognize encounter with snake before being bitten
    • recognized encounter and immediately attempted to move away, but was bitten anyway
  • Illegitimate Bite
    • recognized encounter with snake, but did not try to immediately move away
    • pet snakes, moving snakes, killing snakes, kissing snakes, playing with snakes, feeding snakes
slide40

Compartment Syndrome

  • Other management options
    • Antivenom
    • Antivenom and mannitol
slide41

edema and ischemia

inflammation

ANTIVENOM

NECROSIS

venom

ProTNFa

+

+

ECM protein degradation

VMPs

TNFa

only effective if antivenom infused within a few minutes of envenomation

HMP activation

types of poisonous snakes
Types of Poisonous Snakes
  • 19 of 115 snake species in the U.S. are poisonous
  • Crotalidae are the pit vipers
  • Elapidae are the coral snakes
what not to do
What Not To Do!
  • Don’t use ice as this may worsen the tissue damage
  • Doe not use the snakebite kits
  • Do not use electric shock treatment as it is ineffective & has resulted in electrical injuries
  • The Sawyer Extractor Vacuum Pump produces up to 750 mmHg of suction & may be helpful in theory
emergency care of snakebites
Emergency Care of Snakebites
  • Serial exams & lab evaluations are a must to follow envenomation & effectiveness of treatment
    • Measure limb circumference at several sites above & below the bite & reevaluate every 30 – 60 minutes
    • Repeat labs after each round of antivenin or every 4 hours, whichever is most current
emergency care of snakebites1
Emergency Care of Snakebites
  • Wound care
    • Remember to clean the wound & update tetanus if needed
    • Antibiotics & steroids are not needed
coral snake bites
Coral Snake Bites
  • There are three species
    • Eastern
    • Texas
    • Sonoran
  • Identification of a coral snake
    • “Red on yellow, kill a fellow; red on black, venom lack” (this is true on in the U.S.)
    • Coral snakes have short, fixed, anterior fangs & their venom is primarily neurotoxic
signs of coral snake envenomation
Signs of Coral Snake Envenomation
  • Tremors
  • Salivation
  • Dysarthria
  • Diplopia, ptosis
  • Seizures
  • Dyspnea, respiratory paralysis
  • Signs of coral snake envenomation may be delayed up to 12 hours; therefore, admit all potential coral snake bites for observation
treatment of coral snake bites
Treatment of Coral Snake Bites
  • Give 3 vials of antivenom for definite bites
  • If signs of envenomation occur give additional antivenin
  • Antivenin may not reverse symptoms that have already developed (give antivenin early)
the bark scorpion
The Bark Scorpion
  • Body fluoresces under UV light
  • Resides in or near trees; wood
    • Climbs, but not up glass
antivenin
Antivenin
  • Recommended for Grade III and IV envenomations
  • Results in rapid reversal of neurologic and respiratory toxicity within one hour
  • Risks
    • Hypersensitivity reactions
    • Serum sickness
the case of the concerned citizen
The Case of the Concerned Citizen
  • A guy on I-17

The Alleged Scene

slide62

Venomous Lizards

Helodermatidae

Helodermasuspectum

GilaMonster

Heloderma horridum

Mexican Beaded Lizard

H. s. suspectum

H.s. cinctum

H. h. horridum

H. h. exasperatum

H. h. alvarezi

gila monster distribution
Gila Monster Distribution

Banded Gila Monster

H. s. cinctum

Reticulated Gila Monster

H. s. suspectum

gila monster venom delivery
Gila MonsterVenom Delivery
  • Venom glands on mandible
  • Ducts lead to labial mucosa
  • Venom flows through grooved teeth and into wounds
slide66

Gila Monster bite

Resulting in allergic rxn

...and tabloid story!

removing a gila monster
Removing a Gila Monster
  • Pry mouth apart with pliers
  • Jam screwdriver down monster’s throat
  • Dip monster in gasoline and set on fire
  • Pour gasoline into mouth and set on fire
  • Place fire under jaw without gasoline
  • Strike back of lizard’s head with large stone