Trauma, Bites and Iatrogenic

Question 1

What is the main organism in cat bites?

Answer 1

Pasteurella
Also Capnocytophaga canimorsus

Question 2

Which cat bites should get Abx and what type?

Answer 2

High risk for infection, all should get ABx (Amoxicillin/Clavulanate 1st line)
Thorough irrigation and ADT

Question 3

What factors can be implemented to reduce the rate of PIVC associated bacteraemia?

Answer 3

• Hand hygiene
• Aseptic technique training
• Reduce unnecessary PIVC insertion
• Standardize cannula equipment
• Resite pre-hospital IV’s
• Education resources and guidelines
• Credentialing of staff
• Audit outcomes
• Date/Time all PIVC’s, resite every 72hrs

Question 4

What investigations should be performed for when considering post exposure prophylaxis?

Answer 4

• Chlamydia/Gonorrhoea PCR
• HIV serology
• Syphilis serology
• Hepatitis A antibodies
• Hep B HBsAg, Anti-HBc, Anti-HBs
• Hep C Ab and PCR
• LFT and UEC

Question 5

What is the advice given to patients starting on PEP when leaving the ED?

Answer 5

• Importance of PEP adherence
• Possibility of side effects
• Use of condoms
• Contact tracing by patient and/or GP, can be done anonymously
• HIV seroconversion Sx/Sy
• Encourage regular screening
• Follow up with GP/ID/Sexual health clinic for results, further meds
• Hep A/B/HPV vax if not already done

Question 6

What are the MO’s involved in human bites?

Answer 6

• S. aureus
• GAS
• Eikenella
• Fusobacterium

Question 7

What are the antibiotics of choice for human bite prophylaxis? Infected wound treatment?

Answer 7

Prophylaxis
- Amoxi/clav BD 5 days
OR
- Bactrim 160/800 BD + Metronidazole 500mg TDS 5 days

Treatment
- IV Tazocin TDS
Or
- Ceftriaxone 1gm BD + Metronidazole IV 500mg TDS

Consider Vancomyic if high risk for MRSA
Antibiotics need to cover Eikenella and beta-lactamase producting anaerobes

Question 8

What are the indications for tetanus immunoglobulin?

Answer 8

• A tetanus prone wound
  +
  1 or more of…
• Not previously received full course of tetanus vaccine or dubious vaccination history
• Boosters not up to date
• Humeral immune deficiency (ie poorly controlled HIV)

Question 9

What is the definition of a tetanus prone wound? What is the dosing of tetanus immunoglobulin?

Answer 9

Tetanus prone wound
- Wounds/burns needing surgery but delayed by >6hrs
- FB containing wounds
- Compound fractures
- Wounds or burns in patients with signs of systemic sepsis
- Wounds/burns with large amounts of devitalised tissue
- Puncture wounds that have had contact with soil or manure

Very high risk
- Any of the above heavily contaminated with with material likely to contain tetanus spores and/or extensive devitalised tissue

Dosing
- <24hrs = 250 IU IM
- >24hrs or very high risk = 500 IU IM

Question 10

What is the treatment for Tetanus?

Answer 10

Antibiotics
- Metronidazole 500mg QID IV
+
- 1.2 - 2.4gm of Benpen IV QID

Spasm control
- Intubation and sedation
- Roc/Vecuronium
- Baclofen
- Benzos for both sedation and muscle spasms

Toxin Control
- Active immunization
- IM 500 IU immunoglobulin

Autonomic Dysfunction
- IV magnesium load 4gm followed by 1-2gm/hr, also helps with muscle spasms
- Morphine, Labetalol, Dexmetetomidine

Question 11

What are the atypical presentations of tetanus?

Answer 11

• Umbilical stump infection in neonates
• Septic abortions in obstetrics
• Male circumcision in Sub-saharan africa
• Necrotic bowel infections with release of bowel flora
• IVDU very high risk
• Immunocompromised, particularly with HIV
• Infected extremites in diabetics
• Dental infections

Question 12

What are the typical findings in Tetanus?

Answer 12

Cephalic
- Isolated to cranial nerves
- Lockjaw
- Stroke mimic

Neonatal
- Very rapid onset
- Poor feeding, smile
- Feet dorsiflex, hands clenched
- Opisthotonus

Local
- Localised spasm

General
- 80% of cases, 7-21 days
- Trismus, opisthotonus
- Rigid neck, torticollis
- Board-like rigid abdomen
- Dysphagia (hydrophobia)
- Autonomic instability

Question 13

When should tetanus updates and immunoglobulin be given to children? When are the normal vaccinations and boosters?

Answer 13

Vaccination
- Initial doses at 2, 4 and 6monhts
- Boosters at 18months, 4yrs, 13yrs
- An update given for pregnancy and if >5yrs + wound
- Age group 9-13 are at risk and need booster as previous booster was at 4yrs of age

Tetanus prone wounds
- Compound fractures
- Bite wounds
- Deep penetrating wounds
- Wounds containing foreign bodies/splinters
- Pyogenic wounds
- Extensive tissue damage (contusions, burns etc)
- Any wound heavily contaminated with soil, dust or horse manure
- If UTD then consider booster but doesnt need IgG
- Give booster and IgG if did not complete 3 vaccinations

Clean wounds
- If UTD then no IgG, consider booster if due
- If not fully vaccinated then give booster but doesn’t need IgG

Question 14

What are the main legal/ethical issues that must be addressed when performing discharge counselling after occupational exposure?

Answer 14

• Confidential labelling of patients specimens will be performed
• The appropriate work authorities need to be notified
• The patient will be given a work cover certificate