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MBBS 4: Accidents and Emergency > Animal and Human Bites > Flashcards

Animal and Human Bites Flashcards

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1
Q

History of events?

A
  1. What bit the patient?
  2. Animal’s behavior: provocation, fearfulness, aggression
  3. Animal sickness: excessive drooling, difficulty swallowing, staggering, paralysis and seizures
  4. Rabies vaccine status
  5. When: Time since attack
  6. First aid given?
  7. Location
  8. Duration
  9. Tetanus vaccine status
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2
Q

General approach to injury from the bite?

A

▪ location and extent of all injuries.
▪ swelling, crush injuries, or devitalised tissue.
▪ Range of motion of affected areas.
▪ Distal neurovascular status.
▪ signs of infection, including regional adenopathy.
▪ joint or bone involvement

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3
Q

General Management of bites?

A
  1. Management of Life threatening conditions
  2. On-going management
    - Analgesia
    - Wound management
    - Prophylaxis e.g. Antibiotics, Tetanus, ??PEP
    - Antivenom
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4
Q

General risk factors for wound infection?

A
  • Injury > 8-12 hours old
  • Locations with poor blood supply (Leg and thigh > arms > feet > chest > back > face > scalp)
  • Contaminated wound
  • Blunt mechanism
  • Subcutaneous sutures
  • Repair material (sutures > staples)
  • High-velocity Missile injuries
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5
Q

High risk species?

A

Cat
Human
Primate
Pig
Camel

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6
Q

Low risk species?

A

Dog (excluding hand)
Rodent

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7
Q

High risk location of wound?

A

Hand
Over joint or superficial tendon (CFI)
Through-and-through oral
Below the knee

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8
Q

Low risk location of wound?

A

Face
Scalp
Mucosa

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9
Q

High risk wound type?

A

Puncture
Extensive tissue damage
Contaminated or devitalized tissue
Old (delayed presentation) or sutured

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10
Q

Low risk wound type?

A

Large
Superficial
Clean
Recent

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11
Q

High risk patients?

A

Immunosuppressed
HIV positive
Transplant patient
steroid dependent
Diabetes
cancer chemotherapy
Prosthetic valve patients
Peripheral vascular disease
Elderly alcoholic
cirrhosis
Social and compliance Problems

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12
Q

Indication for antibiotic prophylaxis?

A
  1. infceted wounds
  2. cat bites
  3. hand injuries
  4. full thickness puncture of hand, fce, or lower extremity
  5. puncture wounds
  6. wounds requiring surgical debridement
  7. wounds involving joints, tendons, ligaments or fractures
  8. immunocompromised patients
  9. wounds presenting >8hr after the event
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13
Q

Tetanus prophylaxis in clean and minor wounds?

A
  1. <3 doses/unknown - tetanus toxoid vaccine
  2. 3 doses - tetanus toxoid Only if last dose given >10 years ago
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14
Q

Tetanus prophylaxis in dirty and major wounds?

A
  1. <3 doses/unknown -give tetanus toxoid vaccine and human tetanus immune globulin
  2. 3 doses - give tetanus toxoid vaccine Only if last dose given >5 years ago
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15
Q

What is rabies?

A
  • Rabies is fatal, but infection can be prevented with proper wound
    care and post-exposure prophylaxis using rabies biologics
  • All bites from stray dogs, bats, foxes, raccoons, skunks should
    receive rabies vaccine and immunoglobulin
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16
Q

Wound care in rabies?

A
  • Wound care effective in a role in
    prevention of rabies transmission.
  • Wash with soap and water all bite and scratch areas
  • virucidal agent such as povidone-iodine should be applied if available
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17
Q

Indication for primary closure?

A
  1. Uninfected wound
  2. Wounds less than 24 hours
  3. Not hand, foot wounds
  4. Healthy immune system
18
Q

Investigations?

A

Clinical presentation will determine the investigations to order
* RBG
* FBC
* U&E + Cr
* Wound culture
* X-Ray of the affected area

19
Q

Complications of human bites?

A

Closed-fist injury (most dangerous)
Chopping injury to the finger
Bites to nose and ear
Puncture type wounds above the head caused by clashing with tooth

20
Q

Mangement of human bites?

A

General principles of contaminated wound management apply to human bite wounds

21
Q

Causes of infection in human bites?

A

Polymicrobial infections likely:
1. Staphylococcus aureus,
2. Streptococcus
3. Eikenella corrodens

22
Q

Investigations in bites?

A

According to clinical presentation
1. Radiographs
2. Closed fist injury need exclusion of
vertical articular fracture of metacarpal head
3. Underlying osteomyelitis
4. Foreign bodies (retained teeth)

23
Q

Mangement of bites?

A
  1. General principles apply here
  2. Cleanse wound and debridement
  3. Tetanus prophylaxis as indicated
  4. Antibiotics prophylaxis
  5. Leave wound open for delayed primary closure
  6. Bulky dressing, splintage, elevation,
    physiotherapy
24
Q

Most common animal bites?

A

Most commonly dogs and cats. Other less common bites are from crocodiles, hyenas, skunk, bat, raccoon

25
Q

Most common locations for animal bites?

A
  1. fingers of dominant hand
  2. Defense mechanism
26
Q

Types of injuries in animal bites?

A

It may cause crushing and tearing injury to underlying bone, muscle, tendons, ligaments and nerves
Note: Risk of infection is high

27
Q

Animal bite crushing injury?

A

dogs, large, herbivores, reptiles

28
Q

Animal bite puncture injury?

A

cats

29
Q

What kind of bite has a low risk of infection?

A

Highly vascularised areas have low risk of infection

30
Q

Microbiological causes of infection in animal bites?

A
  1. Polymicrobial: bacteria, viruses, rickettsia, spirochetes, fungi
  2. Bacterias commonly found are Pasteurella spp, Capnocytophaga
    spp, Bartonella henselae
31
Q

Microbiology of dog wounds?

A
  1. Polymicrobial infections. Sources are the oral flora, environment and
    human skin normal flora
  2. Pasteurella, streptococci, staphylococci, Neisseria species, Moraxella species, Fusobacterium, Bacteroides, Capnocytophaga Canimorsus
  3. Capnocytophaga Canimorsus causes systemic infection; vomiting,
    diarrhoea, abdominal pain, headache, confusion, peripheral gangrene and
    cellulitis
    - MPatients may develop sepsis and DIC
32
Q

Microbiology of cat wounds?

A

Pasteurella species are highly prevalent in cat wounds than other
bacterias such as streptococci, staphylococci, Moraxella, Bacteroides,
Fusobacterium, Porphyromonas, and Prevotella
- Pasteurella species mostly present with cellulitis. Additional less likely clinical features are regional lymphadenopathy and purulent discharge on the wound

33
Q

Assessment of animal bites?

A
  • Distal neurovascular status
  • Tendon or tendon sheath involvement
  • Bone injury
  • Joint space violation
  • Visceral injury
  • Foreign bodies in the wound eg teeth, fur
34
Q

Management of animal bites?

A
  1. Inspection: identify depth, devitalised tissue
  2. Cleansing: copious irrigation of wound
  3. Debridement
  4. Closure:
    - If indicated in limited bite wounds that can be cleansed effectively
    - Contraindicated in puncture wounds, high risk animals eg cats, primates, pigs
  5. Facial wounds can be closed
    - Highly vascularised
  6. Tetenus and rabies prophylaxis for all wounds
35
Q

Complications of animal bites?

A

Complications of bite wounds include:
* Wound infection
* Sepsis
* Cosmetic deformity
* Loss of limb
* Loss of function

36
Q

Venom classification in snake bites?

A
  1. Local toxins
    * Swelling, blisters, tissue necrosis and pain
  2. Systemic
    * Neurotoxic,
    * Cytotoxic
    * Heamatoxic
    * Myotoxin
37
Q

Death from snake bites result from?

A
  1. Respiratory failure due to muscle
    paralysis
  2. haemorrhage
  3. renal failure
38
Q

Investigations of snake bites?

A

FBC
Coagulation studies
Fibrinogen, d-dimer
Electrolytes, BUN/creatinine
Glucose
Creatine phosphokinase (CPK)
Urinalysis
Group and cross-match

39
Q

Management of snake bites?

A
  1. Immobilise body part
  2. Analgesia
  3. Antivenom
  4. Steroids and antibiotics not
    routinely required
40
Q

Bite wound disposition; surgery?

A
  1. ICU, HDU, main wards, theatre
  2. ICU Critical condition
  3. HDU -Severe condition
  4. Main ward -Moderate and mild condition
  5. Theatre -Wounds requiring immediate debridement
41
Q

Bite wound disposition for critical conditions?

A
  1. Hemodynamic instability (e.g septic shock requiring vasopressors),
    hemorrhagic shock ( requiring massive transfusion)
  2. Respiratory compromise requiring intubation
  3. All cardio-respiratory arrests
  4. Reduced level of consciousness plus any of the above
42
Q

Bite wound disposition in severe condition?

A
  1. Hypoxia responding oxygen
  2. Haemodynamic instability responding to crystalloids or colloids
  3. All patients requiring close monitoring

MBBS 4: Accidents and Emergency (34 decks)

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