BITES

Question 1

Common pathogens in order of prevalence (found in animal bites)

Answer 1

Pasteurella spp, staph , streph, anaerobic spp

Capnocytophaga canimorsus* (virulent!)

Bartonella (Cat bites)

Question 2

Bacteria spa that is particularly virulent, can lead to sepsis - especially in a splenic / alcoholic / hepatitis pts

Answer 2

Capnocytophaga canimorsus

Question 3

Bacteria found in “cat scratch fever”

Answer 3

Bartonella

Question 4

Lymphadenopathy vs lymphangitis

Answer 4

swollen node vs red streaky tracks

Question 5

Complications from animal bites include

Answer 5

Subcutaneous abscesses,

osteomyelitis,

septic arthritis,

tendonitis,

bacteremia and sepsis

Question 6

Labs for animal bites

Answer 6

CBC (for WBC count)
CRP / ESR

Blood cultures PRIOR to antibiotic therapy (in pts with fever / infected bite)

Wound culture (if bite appears to be infected)

Question 7

What might an elevated CRP / ESR might indicate in animal bite

Answer 7

Cellulitis, joint infection, osteomyelitis, sepsis

Question 8

Bacteria - other than staph / streph - found in human bites, often misidentified

Answer 8

Eikenella corrodens

Question 9

Wound cultures indicated in a clinically uninfected bite wounds?

Answer 9

NO

Question 10

Indication for x-ray in animal bite

Answer 10

Deep bite wounds near joints (AP / lateral film)

Markedly infected wounds to detect

• bony/soft tissue injury
• subcutaneous gas (infection or trapped air)
• osteomyelitis

Question 11

If bite is deep enough to disrupt bone, how does classification of injury change?

Answer 11

Changes to include “open fracture”

Question 12

Use of ultrasound in animal bite?

Answer 12

Can help identify abscess formation

Question 13

Use of head CT in animal bites?

Answer 13

Dog bites to the head - esp children - can penetrate skull

Question 14

Criteria for primary closure of animal bites

Answer 14

• Clinically uninfected
• Less than 12 hours old
• Less than 24 hours old if wound is on the face
• NOT located on the hand or foot

Question 15

Steps to take when choosing primary closure

Answer 15

• Extensive irrigation
• Debridement
• Avoidance of deep sutures
• Use prophylactic antibiotics
• Close follow up

DO NOT use cyanoacrylate tissue adhesive

Question 16

Ok to use glue closure for animal bite?

Answer 16

NO

Question 17

Types of wound NOT TO CLOSE due to high risk of infection

Answer 17

Crush injuries

Puncture wounds

Bites on hands or feet

Wounds more than 12 hrs old (24 hrs on face)

Cats or human bites, except those on face*

Bite wounds in compromised hosts (asplenic, immuno) or papery skin

Question 18

Recommended to close cat or human bites?

Answer 18

NO! Unless it’s on the face

Question 19

Surgical consult recommended for the following wounds:

Answer 19

Deep wounds that penetrate bone, tendons, joints, etc

Complex facial lacerations

Neurovascular compromise

Complex infections (abscess, osteomyelitis, hand or joint infections)

Question 20

Two important questions to ask right away when patient presents with dog bite

Answer 20

Dog’s rabies shot up to date?

Did patient have tetanus booster within less than 5 years?

Question 21

Common/relatively safe Antibiotic which is good for animal bites

Answer 21

Augmentin

Question 22

Complication of cat bite to the hand

Answer 22

Flexor Tenosynovitis

Question 23

Physical exam finding of cat bite to the hand which indicates flexor tenosynovitis

Answer 23

Kanavel sign - flexor tendon sheath infection, which are as follows:
Finger held in slight flexion
Fusiform swelling
Tenderness along the flexor tendon sheath
Pain with passive extension of the digit

Question 24

On physical exam of patient with cat bite to the hand includes :
Finger held in slight flexion
Fusiform swelling
Tenderness along the flexor tendon sheath
Pain with passive extension of the digit

Answer 24

Kanavel sign

Question 25

Treatment for flexor tenosynovitis

Answer 25

Surgical drainage

Question 26

Non-immunized treatment regiment for Rabies Prophylaxis

Answer 26

1. Wound cleansing - immediate soap and water - virucidal agent, povidine-iodine solution if available 2. Rabies Immunoglobulin - Full Dose infiltrated around any wounds - Remaining volume administered IM, at site distant from wound 3. Vaccine - HDCV or PCECV 1.0 mL, IM (deltoid area ), one each on days 0 , 3, 7, and 14

Question 27

Virucidal cleaning agent?

Answer 27

Povidine-iodine solution

Question 28

Rabies vaccine administration details

Answer 28

HDCV or PCECV 1.0 mL, IM (deltoid area ), one each on days 0 , 3, 7, and 14

Question 29

Where should rabies immunoglobulin be administered

Answer 29

- Full dose infiltrated around wounds | - Remaining volume administered IM at anatomical site distant to wound

Question 30

Clenched fist injuries (human bites via fist fight) can lead to

Answer 30

Septic arthritis of the MCP joint - rapidly destructive

Question 31

If a patient presents with a human bite, and wound does not appear to be infected, do they get prophylactic antibiotics?

Answer 31

YES - all human bites get prophylactics. Very prone to infection

Question 32

Groups of common bacteria found in human bites

Answer 32

Streptococci, Staphylococcus aureus ``` Eikenella Fusobacterium Peptostreptococcus Prevotella Porphyromonas ```

Question 33

Eikenella spp (from human bites) are resistant to

Answer 33

Clindamycin, Erythromycin, Aminoglycosides, anti-staph penicillins, first gen cephalosporin

Question 34

Recommended antibiotics for human bites

Answer 34

Augmentin, Moxifloxicin

Question 35

Treatment protocols for human bites

Answer 35

cellulitis 10-14 days 3 weeks for tenosynovitis, 4 weeks for septic arthritis 6 weeks for osteomyelitis

Question 36

Prophylaxis treatment period for human bites

Answer 36

3-5 days

Question 37

Order of insects that cause more venom deaths in US than any other

Answer 37

Hymenoptera Apis species (bees--European, African), vespids (wasps, yellow jackets [a type of wasp], hornets), and ants

Question 38

Initial assessment for insect bites/stings

Answer 38

Assess for airway obstruction from angioedema: stridor, hoarseness, difficulty swallowing/pooling saliva Assess breathing: rate, pulse ox, auscultation for adequate air movement/absence of wheezing Assess circulation for signs of shock: blood pressure, nail bed capillary refill, mental status

Question 39

Anaphylaxis with signs of impending airway obstruction from angioedema and/or respiratory collapse:

Answer 39

Intubate the patient with rapid sequence technique Two large-bore IV lines to provide a route for meds/fluid bolus Continuous pulse ox, cardiac monitor

Question 40

Anaphylaxis with obstructive angioedema, protocols

Answer 40

Obtain a surgical airway through cricothyrotomy | Cricothyrotomy contraindicated < 8 years

Question 41

If patient is < 8 years, has anaphylaxis with obstructive angioedema

Answer 41

- temporarily obtain needle cricothyrotomy with largest-bore needle practical - give parenteral beta agonists, antihistamines, and glucocorticoids - consult anesthesia/ENT for definitive airway management in the OR

Question 42

Drug of choice for anaphylaxis

Answer 42

Epinephrine IM/SC: 0.2-0.5 mg q5-15min (1:1,000 solution; 1 mg/mL) if cardiovascularly stable IV: 3-5 mL (0.3-0.5 mg) of the 1:10,000 solution (0.1 mg/mL) diluted in 10 mL of normal saline or distilled water flush slowly over 1-2 minutes ET tube: 3-5 mL of 1:10,000 solution and flush

Question 43

Antihistamines for anaphylaxis

Answer 43

parenteral H1 blocker diphenhydramine (Benadryl) 50mg IV parenteral H2 blocker (eg, Ranitidine [Zantac] 50mg IV or Pepcid 20mg IV)

Question 44

Corticosteroids for anaphylaxis

Answer 44

methylprednisolone 125 mg IV (delayed onset)

Question 45

Tx for hypotension from insect bites/stings

Answer 45

IV crystalloid fluid boluses Epinephrine via continuous infusion (1 mg in 250 mL of normal saline at a rate of 0.5-1 mL/min)