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EM/Surgery > Mammalian Bites/Tetanus/Rabies > Flashcards

Mammalian Bites/Tetanus/Rabies Flashcards

1
Q

What are the main aspects (7) of completing your evaluation of a Mammalian Bite?

A
  1. Time interval since injury.
  2. MOI.
  3. Anatomic Location.
  4. Depth of penetration.
  5. Tetanus Immunization Status.
  6. Meds and Allergies.
  7. Risk factors for Infection.
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2
Q

General guidelines when treatment a bite.

A
  1. ABCs, C-Spine?
  2. Clean wound w/antibacterial agent (ex. diluted povidone-iodine solution, NOT scrub).
  3. COPIOUS wound irrigation (NS).
  4. Consideration to suturing:
    - -Not always done; mostly left open to reduce risk of infection.
  5. Xray.
  6. Debridement of devitalized tissue.
  7. Abx consideration.
  8. Tetanus/Rabies considerations.
  9. Close follow-up.
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3
Q

What are some signs of infection?

A

Swelling/Edema, Erythema beyond wound margins, Pus or oozing, warmth, fever.

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4
Q

What is the most common organism involved in human bites?

A

Eikenella Corrodens – not common, but destructive!

  • 15% facultative anaerobe, gram-neg rod.
  • 7-29% especially in “fight bites.”
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5
Q

What are some other common organisms involved in human bites?

A

Strep. Viridans, Staph. aureus, Staph. epi, Bacteroides, Corynebacterium, Peptostreptococcus.

HSV/Hep B/C, Syphilis, Tetanus, Rabies, HIV are rare but have been reported.

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6
Q

What is an important thing to keep on your differential when a child presents with a human bite?

A

Child Abuse – evaluate the size of the bite, adult vs child size.

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7
Q

One of the most dangerous of all the mammalian bites?

A

Human bites.

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8
Q

What is the epidemiology (4) of human bites?

A
  1. UE often involved.
  2. MCP joint: clenched fist injury.
  3. M > F (hands, breasts, genitalia)
  4. 50% infection rates w/patient’s reluctant to seek treatment early.
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9
Q

What antibiotic is used most often in the treatment of human bites?

A

Amoxicillin/Clavulanate (Augmentin)
-875/125 mg PO BID or 500/125 mg PO TID.

Alts: Clindamycin, FQ, Bactrim.

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10
Q

What are the stats (4) of bites in the ED?

A
  1. 1% of all ED visits:
    - DOGS: 80-90%.
    - CATS: 5-15%.
    - HUMANS: 3%.
    - RODENTS: 2%.
  2. Incidence unknown due to underreported.
  3. Nearly 5 million (US) per year.
  4. Half of all Americans will be bitten by a human or animal during their lifetime.
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11
Q

What is an important education to teach parents so they can teach their children?

A

How to approach dogs properly to prevent getting bitten.

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12
Q

Epidemiology of Animal bites?

A
  1. Greatest incidence in warm weather (summer).
  2. M > F.
  3. Victim < 30 y/o.
  4. DOGS = 3/4 involve UE and LE more than the head, neck, trunk.
  5. CATS = hand, UE.
  6. Maulings/fatal attacks are infrequent; appears to be increasing.
    - -10-20 y/o in US (German Shepherd, Pit Bull, Rottweiler, Chows).
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13
Q

In the US, 80% of these are reported to be from an animal known to the victim?

A

Animal bite.

50% of injuries occur in or near victim’s home.

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14
Q

60-70% of all animal bites occur in what age?

A
  1. Kids; boys ages 5-9 MC.
    * Children often suffer dog bites to the face.
    * Cats = F > M; often hand puncture, ave. age 19.5 y/o.
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15
Q

What percentage of dog bites become infected? Most common organism?

A

20%; Pasteurella Multocida (dogs and cat bites).

  • -Sm, non-motile gram-neg rod.
  • -An aggressive, destructive infection.
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16
Q

Which organism is responsible for infection of dog or cat bites in the first 24 hrs? What is responsible after 24 hrs?

A

First 24 – Pasteurella Multocida.

After 24 – mixed infection with Staph and Strep.

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17
Q

What percentage of cat bites become infected?

A

80% – Pasteurella Multocida.

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18
Q

Who is at greater risk of infection from a dog or cat bite?

A

> 50 y/o, DM, ETOH, Immunosuppressed.

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19
Q

Clinical presentation of an animal bite?

A

Pain, inflammation, D/C, adenopathy, systemic symptoms.

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20
Q

Anatomically, why is a more vascular area an efficacious area to be bitten?

A

Increased blood supply = less change of infection due to greater ability to flush out organism and better healing.

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21
Q

When do you consider prophylactic antibiotics?

A
  1. Bites that require repair in the OR.
  2. Human and Cat bites that extend thru dermis.
  3. Bites close primarily.
  4. Bites more than 8 hrs old with significant CRUSH injury or edema.
  5. Bites with potential damage to bones, joints or tendons.
  6. Bites to the hands or feet.
  7. Puncture wounds thru dermis.
  8. Bites in patients at increased risk for infection.
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22
Q

When is primary closure recommended when treating bites?

A
  1. Simple bite wounds of the TRUNK and EXTREMITIES (excluding hands and feet) that are less than 6 hrs old.
  2. Simple bite wounds of the HEAD and NECK less than 12 hrs old.

**If do suture, only LOOSELY APPROXIMATE with single layer closure with very close f/u (24-48 hrs).

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23
Q

When is primary closure NOT recommended when treating bites?

A
  1. CFI = clenched fist injuries.
  2. Puncture wounds.
  3. Hand and Foot.
  4. Bite wounds with extensive crush injuries.
  5. Bite wounds OLDER than 12 hrs or that show signs of infection.
  6. Lacerations smaller than 1.5 cm.
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24
Q

What is the preferred antibiotic for animal bites?

A

Amoxicillin/Clavulanate (Augmentin)

  • -875/125 mg PO BID.
  • -500/125 mg PO TID.
25
Q

What is the organism involved in Rabies, what does it attack and what are the most common animals involved in the US?

A
  1. RNA-containing rhabdovirus.
  2. It attacks the CNS that can lead to a fatal encephalitis.
  3. Skunks, Bats, Raccoons, Foxes.
26
Q

How is rabies transmitted?

A

By contact with infected animal saliva or brain material via a break in the skin or mucous membranes.

*Bite with known rabies, only 20% chance of successful transmission.

27
Q

Differentiate a provoked or unprovoked attacked from an animal?

A

Provoked:

  • approaching, disturbing, petting, feeding, kissing an animal.
  • animals bite in self or territorial defense; feel threatened, especially by small, quick moving, smiling children (normal animal response).

Unprovoked:

  • aggressive/unusual behavior, daytime activity in a nocturnal animal, loss of fear of humans.
  • drooling/frothy mouth, shaking head, appears ill, bites for no apparent reason (possible rabies).
28
Q

What are the 4 phases or clinical stages of a rabies infection?

A

Prodrome, Excitement, Dysfunctional, Recovery.

29
Q

Describe the Prodromal phase of a rabies infection?

A

Fever, HA, malaise, anorexia, N/V, non-productive cough.

30
Q

Describe the Excitement phase of a rabies infection?

A

aka Acute Neurologic Phase (2-7 days).

-Agitation, confusion, muscle spasm, hypersensitivity, opisthotonic posturing.

31
Q

Describe the Dysfunctional phase of a rabies infection?

A

Diplopia, Facial palsies, pharyngeal spasm with DYSPHAGIA or “Foaming at the mouth,” HYDROPHOBIA (site, mention of water, painful laryngospasm), Decreased respiration, coma, death.

32
Q

Describe the Recovery phase of a rabies infection?

A

RARE; no human since 1980 has recovered even with aggressive treatment.

-Prevention is the only means of avoiding death.

33
Q

What is Opisthotonic Posturing?

A

Abnormal posture where the back becomes extremely arched due to strong muscle spasms; usually a sign of serious brain conditions, such as meningitis, rabies, tetanus, trauma.

34
Q

Diagnosis of Rabies?

A
  • CSF.
  • Nuccal Bx (hair follicles).
  • Lab test = direct rapid immunohistochemical test (from the animal; brain material).
  • Sample goes to local public health lab, then to CDC.
35
Q

Treatment of Rabies?

A
  1. Definitive Dx = post-mortem brain Bx (fluorescent antibody, most sensitive method).
  2. Assess risk.
  3. Public health and animal control notification.
  4. Local wound care.
  5. Consider Abx for other infection.
  6. Tetanus consideration.
36
Q

Considerations for Post-Exposure Prophylaxis in the treatment of Rabies?

A
  1. Exposed persons by proven or suspected animal should begin treatment within 24 hrs, unless animal is captured and found to NOT be rabid (can be delayed up to one week while attempt to obtain animal).
  2. If animal NOT obtained, HISTORY is critical (behavior, prov. vs. unprovoked attack, type of exposure, geographic prevalence.
  3. Average cost of $3800 each for meds alone; not included in ED visit.
37
Q

Post-Exposure Prophylaxis drugs?

A 
1. HDCV (Imovax) - Human Diploid Cell Vaccine
or PCEC (RabAvert) - Purified Chicken Embryo Cell Cx.
  • FOUR 1 mL doses given IM (Deltoid) in adults; outer thigh in kids – ASAP after exposure, DAY 0.
  • Additional doses given on days 3, 7, 14.

-AND-

  1. HRIG/RIG (Imogam or HyperRab) - Human Rabies Immune Globulin.
    - Provides coverage until pt. makes their own antibodies.
    - No serum sickness reaction.
    - May get low grade fever, mild pain.
    * Dose 20 IU/kg with the full dose infiltrated locally @ the bite, if anatomically feasible, the rest given IM (gluteal) on Day 0.
38
Q

What is the medication for PRE-Exposure Prophylaxis to Rabies?

A

*Vets, Lab techs, Groomers.

HDCV or PCEC = 1 mL IM on day 0, 7, 21, 28 in deltoids.

  • Frequent Ab TITER checks (Q6 months to 2 years depending on exposure risk) to determine adequacy.
  • BOOSTER Q2 yrs.
39
Q

Considerations of Pre-Exposure Prophylaxis?

A

People with previous pre-exposure prophylaxis who have been exposed and deemed to require post-exposure prophylaxis NEED to receive ONLY 2 1 mL doses of HDCV IM on day 0 and day 3; they DO NOT REQUIRE HRIG.

40
Q

92.4% of the animal cases reported with rabies were what?

A

WILD animals:

  • 30.9% BATS.
  • 29.4% RACCOONS.
  • 24.8% skunks.
  • 5.9% foxes.
41
Q

92.4% of the animal cases reported with rabies were what?

A

WILD animals:

  • 30.9% BATS.
  • 29.4% RACCOONS.
  • 24.8% skunks.
  • 5.9% foxes.
42
Q

What is Tetanus and the organism involved?

A

Tetanus is an acute and frequently fatal disease resulting from an infection with the organism Clostridium Tetani.

*Clostridium Tetani is a gram-pos anaerobic motile, spore-forming, slender rod shaped “drumstick” bacteria found in soil, feces, dirt.

43
Q

What wounds are considered “Tetanus Prone?”

A
  1. Wound greater than 6 hrs old.
  2. Depth > 1 cm.
  3. Stellate, Avulsion or Crush injuries.
  4. Devitalized tissue.
  5. Contaminated.
  6. Missile, Burns, Frostbite.
44
Q

What are the 3 forms that Tetanus is categorized into?

A
  1. Generalized = most common (80%); skeletal muscle hypertoxicity.
  2. Local = uncommon; persistent muscle contractions, rigidity near site. Mild or severe, may progress to generalized but most do not.
  3. Cephalic = rare; trismus and paralysis (face and cranial nerves).
45
Q

What are the 3 forms that Tetanus is categorized into?

A
  1. Generalized = most common (80%); skeletal muscle hypertoxicity.
  2. Local = uncommon; persistent muscle contractions, rigidity near site.
  3. Cephalic = rare; trismus and paralysis (face and cranial nerves).
46
Q

Describe Trismus and Risus Sardonicus?

A

Trismus = lockjaw.

Risus Sardonicus = classic facial expression caused by trismus/lockjaw; original JOKER smile from batman.

47
Q

Describe Trismus and Risus Sardonicus?

A

Trismus = lockjaw.

Risus Sardonicus = classic facial expression caused by trismus/lockjaw; original JOKER smile from batman.

48
Q

What is Neonatal Tetanus?

A

A form of generalized tetanus that occurs due to inadequate maternal immunization and poor umbilical cord care, with Sx typically presenting by the 2nd week of life and associated with an extremely high mortality rate.

  • MC in underdeveloped countries; 1 ex = cow dung placed on umbilical site.
  • Presentation = irritability, poor sucking and swallowing., general spasms develop quickly.
49
Q

What is Neonatal Tetanus?

A

A form of generalized tetanus that occurs due to inadequate maternal immunization and poor umbilical cord care, with Sx typically presenting by the 2nd week of life and associated with an extremely high mortality rate.

  • MC in underdeveloped countries; 1 ex = cow dung placed on umbilical site.
  • Presentation = irritability, poor sucking and swallowing., general spasms develop quickly.
50
Q

Workup of Tetanus?

A
  1. LP/CT to r/o other.
  2. Serum Ca++ to r/o Hypocalcemia
    - CHVOSTEK’s/face and TROUSSEAU’s/carpal.
  3. Toxicology to r/o poisoning or OD (ex. Strychnine or pesticide of rodents or birds).
51
Q

What is Chvostek’s and Trousseau’s sign?

A

Both seen in Hypocalcemia.

  • Chvostek’s sign = abnormal reaction (twitching) to the stimulation of the facial nerve.
  • Trousseau’s sign = characteristic posture of the hand when the BP cuff is inflated above the systolic blood pressure within 3 minutes.
52
Q

What is Chvostek’s and Trousseau’s sign?

A

Both seen in Hypocalcemia.

  • Chvostek’s sign = abnormal reaction (twitching) to the stimulation of the facial nerve.
  • Trousseau’s sign = characteristic posture of the hand when the BP cuff is inflated above the systolic blood pressure within 3 minutes.
53
Q

What is the initial treatment of Tetanus?

A
  1. Monitor cardiac and respirations closely.
  2. Protect airway, be ready to intubate.
  3. IVF, manage electrolytes.
  4. Gentle handling to minimize spasm.
  5. BZDs to minimize spasm and anxiety.
  6. Consider NMB agents.
  7. Consider Dantrolene = direct muscle relaxant with CNS activity.
  8. ICU Admission.
54
Q

How does HTIG work?

A

This Antitoxin does not neutralize toxin already in CNS, but DOES NEUTRALIZE TOXIN IN THE BLOOD STREAM.

  • 250-500 units IM (not into site).
  • TIG and Toxoid should be given at different sites (TIG Ab levels at 48-72 hrs).
55
Q

How does HTIG work?

A

This Antitoxin does not neutralize toxin already in CNS, but DOES NEUTRALIZE TOXIN IN THE BLOOD STREAM.

  • 250-500 units IM (not into site).
  • TIG and Toxoid should be given at different sites (TIG Ab levels at 48-72 hrs).
56
Q

Which vaccines if for who – DTap vs Tdap?

A
  • DTap is for little people (D comes first in the alphabet).

* Tdap is for big people (T comes later in alphabet).

57
Q

What is the dosing schedule for DTap?

A

5 doses @ 2/4/6 mo, 15-18 mo, 4-6 yrs.

*DT for those who cannot tolerate pertussis vaccine.

58
Q

What is Td?

A

Tetanus-Diptheria vaccine given to adolescents and adults as a BOOSTER shot every 10 yrs, or after an exposure to tetanus under some circumstances.

59
Q

What is Tdap?

A

Similar to Td with the pertussis vaccine.

  • Adolescents at age 11-18 (preferred at 11-12) and adults 19-64 get a single dose of Tdap.
  • Adults >65 should receive if not previously vaccinated.
  • Given to 7-10 y/o NOT fully immunized against pertussis.
  • Tdap can be given no matter when Td last received.

EM/Surgery (4 decks)

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