Bites, Stings, Australian Things and Travel medicine

Question 1

What are some of the causes for acute infectious diarrhoea?

(4 categories)

Answer 1

Viral pathogens

Toxin mediated either from a bacteria or from toxins from food like fish

Infective proctitis. caused by STIs (gonorrhoea and chlamydia) or amoebas. Bigger risk if having receptive anal sex

Bacterial

Question 2

What are some basic safety measures to prevent traveller’s diarrhoea when travelling?

Answer 2

1. Eat freshly cooked foods served steaming hot
2. Stick to eating fruit that need peeling
3. Only have beverages that are bottled, canned or recently boiled
4. Avoid roadside vendor food
5. Avoid the opposite of the above three including avoiding use of ice in beverages, fresh salads, raw or undercooked meat, unpasteurised milk products and unboiled water.

Question 3

For travellers diarrhoea antibiotics are not needed for mild disease (i.e. normal activities still able to be done)

Severe disease- patient incapacitated and may need admission

However with moderate disease, where there are significant enough symptoms to cause disruption to daily life but not enough for hospital can be treated. What is the first line treatment?

Answer 3

Azithromycin 1gram, (20mg/kg), orally as a single dose.

OR

also first line
norfloxacin 800 mg (child: 20 mg/kg up to 800 mg) orally, as a single dose

Question 4

When should you avoid using anti-motility drugs with infectious diarrhoea?

Answer 4

If there is a fever or bloody stools

Question 5

If there is a fever, blood stools or initial single dose treatment for traveller’s diarrhoea hasn’t helped, then what can you do?

Answer 5

Azithromycin
After the initial 1gram (20mg/kg) orally
then
500mg (10mg/kg), orally, daily for 2 days

So that’s three days total.

Question 6

If there is a persistent diarrhoea in a returned traveller what other conditions can be considered?

What investigations can you do?

If none of those, what can you trial treatment for?

Answer 6

A
IBS - can develop after acute infectious diarrhoea
Coeliac disease of persistent diarrhoea in a returned traveller
Lactose intolerance

B. Stool MCS including parasites and ova

C. Trial treatment for giardiasis with something like tinidazole

Question 7

When should you consider malaria as a diagnosis?

Answer 7

Any fever in a returned traveller that has been to an endemic area.

Usually symptoms occur weeks after exposure.

Question 8

How can you avoid mosquito bites overseas?

(6)

Answer 8

1. Applying effective insect repellent
2. using other insecticide products (coils or vaporising mats)
3. wearing light-coloured long trousers and long-sleeved shirts in the evening
4. Sleeping in screened/netted accomodation or in a closed room with an aircon
5. Avoid activities at dusk and dawn
6. avoid perfumes and aftershaves

Question 9

What is a first line prophylactic medication for malaria?

Answer 9

For adults and children over 40kg

Malarone 250+100
(atovaquone+proguanil)

1 tablet orally with fatty food or full-fat milk, daily (starting 1 to 2 days before entering, and continuing for 7 days after leaving, the malarious area)

OR

Doxycycline 100mg, orally, daily started 1-2 days prior to entering endemic area and for 4 weeks afterwards.
If children are under 26kg, then need dose adjustment

Question 10

If travelling to countries in Africa (not south africa) or central and south america (but not costa rica) what vaccination should you consider?

Answer 10

Yellow fever vaccine
This is best done 4 weeks prior to departure

Whilst it is a good idea and strongly recommended, return into Australia will not be denied if you cannot provide vaccination evidence or are unvaccinated.

Question 11

What is “break bone fever” known as?
Where do you catch this and
What are the characteristic symptoms?

What time frame would you expect symptoms?

Answer 11

Dengue fever - caused by a mosquito transmitting an flavivirus.

Usually south east Asia, Africa and the Americas

Characeterised by myalgias, fevers, retro-orbital pain, headaches and a rash.
Usually will occur within 2 weeks of exposure, so anyone with symptoms after 2 weeks from return is not likely to have Dengue.

Question 12

Is there a vaccination for Japenese Encephalitis?

When should you get it?

Answer 12

Yes

Should receive it 10 days prior to travel

IF likely to be in rural areas for > 1 month in Asia or New Guinea especially during the wet season
or < 1 month if there is a current endemic
or spending a year or more in Asia (any parts) - except singapore

Question 13

Which is worse to be bitten by? A big black spider or a small red spider?

Answer 13

Big black - could be a funnel web, they are the most dangerous in Australia, especially the eastern states. Needs E.D with anti-venom.

Small red spiders- red back spiders- can cause pain but are not life threatening bites.

Question 14

How do you treat a red back spider bite

Answer 14

DO NOT use a pressure bandage - can make pain worse.

Otherwise just regular analgesia
paracetamol and NSAIDs and in this case opioids if needed

Observe patient until either they are asymptomatic or pain is adequately controlled.

Advise that Pain can last about 5 days- so have enough analgesia for that

Question 15

Snake bites in Australia usually cause systemic effects (Not local). What are the two most important systemic effect to investigate ?

Answer 15

VICC (venom induced consumption coagulopathy)
so the clotting factors get used up and leads to coagulopathy i.e. bleeding

On the flipside there are snake venoms that have anticoagulants in them which leads to an anticoagulation coagulopathy

Question 16

What is thrombotic microangiopathy?

Answer 16

This is associated with VICC in a snake bite.

It causes AKI, thrombocytopenia and microangiopathic haemolytic anaemia

Question 17

What is the first aid management of a snake bite?

(5)

Answer 17

Do not wipe away the venom

if presenting within 4 hours - apply a pressure bandage similar to a funnel web bite (15cm wrap distal the proximal covering the whole limb.

immobilise the limb and patient

monitor and manage the airway, breathing and circulation

Contact a clinical toxicologist if snake envenoming is suspected

Question 18

When can you remove a pressure bandage after a snake bite?

Answer 18

either
1. after antivenom treatment has begun

or
2. if bloods do not show a coagulopathy

Question 19

What are key investigations with a snake bite?

(6)

Answer 19

Coagulation studies; PT, APPT, fibrinogen quantitative D-Dimer

FBC with blood film to detect for thrombotic microangiopathy

EUC for AKI

Lactate dehydrogenase- cell damage

Serum creatine kinase concentration - heart cell damage

urinalysis- myoglobulinuria

Question 20

What are the main symptoms of Ross River Virus

(4)FRAP

Answer 20

Fever
Rash
Arthralgia
Polyarthritis

Question 21

After the acute phase of RRV (ross river virus) what can last for months?

Answer 21

Tiredness

Question 22

How do you confirm a diagnosis of Ross River Virus?

Answer 22

IgM

But then two weeks letter an IgG

Why?
IgM can be positive years after exposure
then why wait two weeks?
Well in the instance it’s not from a prior infection, you need to wait for seroconversion.

Question 23

Management for Ross River virus?

(4)

Answer 23

NSAIDs/Paracetamol

Rest

Swimming, hydrotherapy, physiotherapy

Notification to public health

Question 24

What organism is responsible for Q fever?

How is this transmitted to humans?

Answer 24

1. Coxiella burnetii.
2. breathing in dust that has been contaminated by infected animal feces, urine, milk, and birth products that contain Coxiella burnetii. Doesn’t usually spread from human to human.

hence while it usually occurs in rural farm lands, it can occur in urban settings if the wind brings it or a truck drives past spraying the dust.

Question 25

Treatment for Q fever?

Answer 25

Mostly supportive but can start
doxycycline 100mg, orally, 12hourly, 14 days

Question 26

How do you detect Q fever?

Answer 26

PCR test is the fastest
Serology with a second 7 days later
Don’t use a MCS

Question 27

Biggest complications post Q fever?

Answer 27

Endocarditis
Infection of vascular or valvular grafts
Osteomyelitis (mostly in children)
Hepatitis
Post Q fever fatigue

Question 28

Can you be vaccinated for q fever?

Answer 28

Yes you can, but only limited to those who are at risk of exposure
livestock workers
vets
contractors to high risk areas
wildlife carers or zoo keepers

Question 29

What is brucelliosus?

Who catches this?

Answer 29

Brucellosis is a bacterial disease caused by various Brucella species.

Usually catch the disease from eating unpasteurised milk or cheese from cows, camels, goat or sheep.

Can also enter the body from skin wounds or mucus membranes. so others at risk include slaughter house workers, meat packing plant employees. Those who hunt animals are at risk too: elk, wild hogs/pigs due to accidentally eating uncooked meat or having skin wounds or inhaling the bacteria up close.

Question 30

What symptoms do you get with brucelliosis , and how is it generally treated?

Answer 30

Flu like symptoms: fever, weight loss and weaknesss

Treated with antibiotics (Doxy and rifamicin)

Question 31

What antibiotic can you use for a dog or cat or even human bite?

First and second line
and if not likely to have follow up?

Answer 31

Amoxyclav 875+125mg, orally, 12 hourly, 5
3 days. May need longer

If not likely to get oral therapy quickly then start with a IM injection of procaine benzylpenicillin 1.5 g (child: 50 mg/kg up to 1.5 g) whilst awaiting access to oral medication

Second line for hypersensitivity to penicillin or known resistance

metronidazole 400 mg (child: 10 mg/kg up to 400 mg) orally, 12-hourly for 5
3 days
PLUS
doxycycline 100mg orally, 12-hourly for 5
3 days

Question 32

How to approach management of a bite?

Answer 32

thorough cleaning, irrigation, elevation and immobilisation

Should get a tissue sample for gram staining and culture

Ensure tetanus is UTD

Either presumptive or empiric course of antibiotics if indicated

Question 33

What is the first aid management for Major box jellyfish?

Answer 33

1. If unconscious start CPR
2. Remove tentacles
3. Apply vinegar (stops the discharge of venom)

Question 34

Which type of jellyfish is most dangerous? what can it cause?

Answer 34

Australian Box Jellyfish

Difficulty breathing
Hypotension
Irritability and restlessness
Faintness and collapse
Cardiac arrhythmias
Cardiac arrest.

Question 35

What kind of treatment do you need with a bluebottle jellyfish sting?

Answer 35

These are painful, but are not usually life threatening.

Can be managed without even seeking medical attention

Question 36

Non clinical/out of hospital management for Blue Bottles/ Portugese man o wars?

Answer 36

Wash site with salt water

Remove tentacles

Hot water immersion for 45 minutes

DO NOT apply vinegar

Question 37

What is this?

How dangerous is this type?

Answer 37

Irukandji Jellyfish

Is serious.
Needs transfer to hospital for cardiac monitoring and serology for cardiac effects
As well as analgesia

Question 38

When should you consider presumptive therapy (with antibiotics) for a bite injury?

(7)

Answer 38

presentation to medical care is delayed by 8 hours or more

the wound is a puncture wound that cannot be debrided adequately

the wound is on the hands, feet or face

the wound involves deeper tissues (eg bones, joints, tendons)

the wound involves an open fracture—see Open fractures for management

the patient is immunocompromised (eg due to asplenia or immunosuppressive medications), or has alcoholic liver disease or diabetes

the wound is a cat bite.

Question 39

For bites and clenched-fist injuries that are not infected, antibiotic therapy is usually __(a)__ necessary for otherwise healthy individuals if the risk of wound infection is low (eg __(b)___ wounds not involving deeper tissues that present within __(c)__ hours and can be adequately __(d)__ and irrigated).

Answer 39

A. NOT

B. small

C. 8

D. Debrided

Question 40

Prophylaxis is required for traumatic water-immersed wounds that require surgical management or are significantly contaminated. Presumptive therapy is required for marine animal bite wounds at high risk of infection.

A. What is the empirical antibiotic regime for prophylaxis or presumptive therapy in water based wound?
(2)
B. What else should you do to aid antibiotic treatment?
(1)

Answer 40

A
Doxycycline 100mg, oral, 12 hourly (need to look up specifically for paediatric dosing)

PLUS

Flucloxacilllin 500mg (15mg/kg), oral, 6 hourly

Usually for 5 days

B
Take appropriate samples and alter therapy based on sensitivities.