BITES Flashcards
Common pathogens in order of prevalence (found in animal bites)
Pasteurella spp, staph , streph, anaerobic spp
Capnocytophaga canimorsus* (virulent!)
Bartonella (Cat bites)
Bacteria spa that is particularly virulent, can lead to sepsis - especially in a splenic / alcoholic / hepatitis pts
Capnocytophaga canimorsus
Bacteria found in “cat scratch fever”
Bartonella
Lymphadenopathy vs lymphangitis
swollen node vs red streaky tracks
Complications from animal bites include
Subcutaneous abscesses,
osteomyelitis,
septic arthritis,
tendonitis,
bacteremia and sepsis
Labs for animal bites
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)
What might an elevated CRP / ESR might indicate in animal bite
Cellulitis, joint infection, osteomyelitis, sepsis
Bacteria - other than staph / streph - found in human bites, often misidentified
Eikenella corrodens
Wound cultures indicated in a clinically uninfected bite wounds?
NO
Indication for x-ray in animal bite
Deep bite wounds near joints (AP / lateral film)
Markedly infected wounds to detect
- bony/soft tissue injury
- subcutaneous gas (infection or trapped air)
- osteomyelitis
If bite is deep enough to disrupt bone, how does classification of injury change?
Changes to include “open fracture”
Use of ultrasound in animal bite?
Can help identify abscess formation
Use of head CT in animal bites?
Dog bites to the head - esp children - can penetrate skull
Criteria for primary closure of animal bites
- 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
Steps to take when choosing primary closure
- Extensive irrigation
- Debridement
- Avoidance of deep sutures
- Use prophylactic antibiotics
- Close follow up
DO NOT use cyanoacrylate tissue adhesive
Ok to use glue closure for animal bite?
NO
Types of wound NOT TO CLOSE due to high risk of infection
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
Recommended to close cat or human bites?
NO! Unless it’s on the face
Surgical consult recommended for the following wounds:
Deep wounds that penetrate bone, tendons, joints, etc
Complex facial lacerations
Neurovascular compromise
Complex infections (abscess, osteomyelitis, hand or joint infections)
Two important questions to ask right away when patient presents with dog bite
Dog’s rabies shot up to date?
Did patient have tetanus booster within less than 5 years?
Common/relatively safe Antibiotic which is good for animal bites
Augmentin
Complication of cat bite to the hand
Flexor Tenosynovitis
Physical exam finding of cat bite to the hand which indicates flexor tenosynovitis
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
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
Kanavel sign
Treatment for flexor tenosynovitis
Surgical drainage
Non-immunized treatment regiment for Rabies Prophylaxis
- Wound cleansing
- immediate soap and water
- virucidal agent, povidine-iodine solution if available - Rabies Immunoglobulin
- Full Dose infiltrated around any wounds
- Remaining volume administered IM, at site distant from wound - Vaccine
- HDCV or PCECV 1.0 mL, IM (deltoid area ), one each on days 0 , 3, 7, and 14
Virucidal cleaning agent?
Povidine-iodine solution
Rabies vaccine administration details
HDCV or PCECV 1.0 mL, IM (deltoid area ), one each on days 0 , 3, 7, and 14
Where should rabies immunoglobulin be administered
- Full dose infiltrated around wounds
- Remaining volume administered IM at anatomical site distant to wound
Clenched fist injuries (human bites via fist fight) can lead to
Septic arthritis of the MCP joint - rapidly destructive
If a patient presents with a human bite, and wound does not appear to be infected, do they get prophylactic antibiotics?
YES - all human bites get prophylactics. Very prone to infection
Groups of common bacteria found in human bites
Streptococci, Staphylococcus aureus
Eikenella Fusobacterium Peptostreptococcus Prevotella Porphyromonas
Eikenella spp (from human bites) are resistant to
Clindamycin, Erythromycin, Aminoglycosides, anti-staph penicillins, first gen cephalosporin
Recommended antibiotics for human bites
Augmentin, Moxifloxicin
Treatment protocols for human bites
cellulitis 10-14 days
3 weeks for tenosynovitis,
4 weeks for septic arthritis
6 weeks for osteomyelitis
Prophylaxis treatment period for human bites
3-5 days
Order of insects that cause more venom deaths in US than any other
Hymenoptera
Apis species (bees–European, African), vespids (wasps, yellow jackets [a type of wasp], hornets), and ants
Initial assessment for insect bites/stings
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
Anaphylaxis with signs of impending airway obstruction from angioedema and/or respiratory collapse:
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
Anaphylaxis with obstructive angioedema, protocols
Obtain a surgical airway through cricothyrotomy
Cricothyrotomy contraindicated < 8 years
If patient is < 8 years, has anaphylaxis with obstructive angioedema
- 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
Drug of choice for anaphylaxis
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
Antihistamines for anaphylaxis
parenteral H1 blocker diphenhydramine (Benadryl) 50mg IV
parenteral H2 blocker (eg, Ranitidine [Zantac] 50mg IV or Pepcid 20mg IV)
Corticosteroids for anaphylaxis
methylprednisolone 125 mg IV (delayed onset)
Tx for hypotension from insect bites/stings
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)
