Bites, Stings, Australian Things and Travel medicine Flashcards
What are some of the causes for acute infectious diarrhoea?
(4 categories)
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
What are some basic safety measures to prevent traveller’s diarrhoea when travelling?
- Eat freshly cooked foods served steaming hot
- Stick to eating fruit that need peeling
- Only have beverages that are bottled, canned or recently boiled
- Avoid roadside vendor food
- 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.
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?
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
When should you avoid using anti-motility drugs with infectious diarrhoea?
If there is a fever or bloody stools
If there is a fever, blood stools or initial single dose treatment for traveller’s diarrhoea hasn’t helped, then what can you do?
Azithromycin
After the initial 1gram (20mg/kg) orally
then
500mg (10mg/kg), orally, daily for 2 days
So that’s three days total.
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?
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
When should you consider malaria as a diagnosis?
Any fever in a returned traveller that has been to an endemic area.
Usually symptoms occur weeks after exposure.
How can you avoid mosquito bites overseas?
(6)
- Applying effective insect repellent
- using other insecticide products (coils or vaporising mats)
- wearing light-coloured long trousers and long-sleeved shirts in the evening
- Sleeping in screened/netted accomodation or in a closed room with an aircon
- Avoid activities at dusk and dawn
- avoid perfumes and aftershaves
What is a first line prophylactic medication for malaria?
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
If travelling to countries in Africa (not south africa) or central and south america (but not costa rica) what vaccination should you consider?
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.
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?
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.
Is there a vaccination for Japenese Encephalitis?
When should you get it?
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
Which is worse to be bitten by? A big black spider or a small red spider?
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.
How do you treat a red back spider bite
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
Snake bites in Australia usually cause systemic effects (Not local). What are the two most important systemic effect to investigate ?
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
What is thrombotic microangiopathy?
This is associated with VICC in a snake bite.
It causes AKI, thrombocytopenia and microangiopathic haemolytic anaemia
What is the first aid management of a snake bite?
(5)
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
When can you remove a pressure bandage after a snake bite?
either
1. after antivenom treatment has begun
or
2. if bloods do not show a coagulopathy
What are key investigations with a snake bite?
(6)
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
What are the main symptoms of Ross River Virus
(4)FRAP
Fever
Rash
Arthralgia
Polyarthritis
After the acute phase of RRV (ross river virus) what can last for months?
Tiredness
How do you confirm a diagnosis of Ross River Virus?
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.
Management for Ross River virus?
(4)
NSAIDs/Paracetamol
Rest
Swimming, hydrotherapy, physiotherapy
Notification to public health
What organism is responsible for Q fever?
How is this transmitted to humans?
- Coxiella burnetii.
- 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.
Treatment for Q fever?
Mostly supportive but can start
doxycycline 100mg, orally, 12hourly, 14 days
How do you detect Q fever?
PCR test is the fastest
Serology with a second 7 days later
Don’t use a MCS
Biggest complications post Q fever?
Endocarditis
Infection of vascular or valvular grafts
Osteomyelitis (mostly in children)
Hepatitis
Post Q fever fatigue
Can you be vaccinated for q fever?
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
What is brucelliosus?
Who catches this?
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.
What symptoms do you get with brucelliosis , and how is it generally treated?
Flu like symptoms: fever, weight loss and weaknesss
Treated with antibiotics (Doxy and rifamicin)
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?
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
How to approach management of a bite?
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
What is the first aid management for Major box jellyfish?
- If unconscious start CPR
- Remove tentacles
- Apply vinegar (stops the discharge of venom)
Which type of jellyfish is most dangerous? what can it cause?
Australian Box Jellyfish
Difficulty breathing
Hypotension
Irritability and restlessness
Faintness and collapse
Cardiac arrhythmias
Cardiac arrest.
What kind of treatment do you need with a bluebottle jellyfish sting?
These are painful, but are not usually life threatening.
Can be managed without even seeking medical attention
Non clinical/out of hospital management for Blue Bottles/ Portugese man o wars?
Wash site with salt water
Remove tentacles
Hot water immersion for 45 minutes
DO NOT apply vinegar
What is this?
How dangerous is this type?
Irukandji Jellyfish
Is serious.
Needs transfer to hospital for cardiac monitoring and serology for cardiac effects
As well as analgesia
When should you consider presumptive therapy (with antibiotics) for a bite injury?
(7)
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.
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).
A. NOT
B. small
C. 8
D. Debrided
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)
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.