6. Bites 2013

Report
Bites
Dr. Stella Yiu
Staff Emergency Physician
Insect bites: LMCC Objectives
Determine what complications they
caused
List critical investigations
Construct management plan
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Complications
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3 complications in insect bites
1. Local reaction/ Allergic reaction
2. Toxins
3. Infection
4
Complications -1. Local reaction
5
Complications - 1.Allergic reaction
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CDMQ:Treat anaphylaxis to bee sting (7)
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CDMQ:Treat anaphylaxis to bee sting (7)
Airway: im Epi, intubate if needed
Breathing:Ventolin
Circulation: iv fluids, iv epi
Antihistamines (H1, H2)
Steroids
Remove stinger
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Complications - 2.Toxins
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Brown recluse spider: in SE Ont and S Quebec
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Brown recluse spider: Necrosis + Systemic collapse
Venom digests tissues
Systemic:
Fever
DIC
Renal failure
Seizures, Coma
11
Black widow spider: Neuro + Autonomic
Muscle
cramping/rigid
(large muscle)
N/v, headache
HR, BP
12
Treatment: Supportive & Specific
Iv fluids, pressors, Benzo (GABA)
Surgical debridement (Brown recluse)
Specific:
Antivenom (Black widow spider)
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Complications - 3. Infections
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Ticks
15
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Lyme disease
Early (weeks)
Rash, bell’s palsy, joint pain
Late (months)
Joint pain, Neuro symptoms
Treatment?
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Mosquito
Malaria
West Nile
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Malaria = Flu like illness form endemic area
Cough
Fatigue, malaise
Arthalgia/Myalgia
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Severe malaria = Systemic involvment
Brain: Coma
Hem: Severe anemia, thrombocytopenia
Resp: Pulmonary edema
20
MCQ 6: Pt returned from Congo with fever
q48h. What is the most life-threatening
infection that need to be ruled-out?
A. Plasmodium Ovale
B. Plasmodium Vivax
C. Salmonella Typhi
D. Dengue Fever
E. Plasmodium Falciparum
21
CDMQ: Order bloodwork (5)
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CDMQ: List bloodwork to be ordered
Hb, platelet
Liver function, Creatinine, Lytes (Na)
Hemolysis screen (LDH, haptoglobin)
Malaria screen
Thick and thin smear
23
1 negative smear does not rule out malaria
(repeat)
24
West Nile encephalitis
Similar investigations to other encephalitis
25
Insect bites: LMCC Objectives
Determine what complications they
caused
- Allergy, toxins, infections
List critical investigations
Construct management plan
26
Animal bites: LMCC objectives
Risk of transmissible infection from bites
Manage animal bites including reporting
27
MCQ 7:Who does not need antibiotic?
A. 35 yo hx of splenectomy with dog bite
to face
B. 7 yo with dog bite to face
C. 15 yo with cat bite to foot
D. 25 yo asthmatic with fight bite to hand
E. 40 yo DM with cat bite to face
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Dog
Cat
Human
Needlestick
29
Dog bites – Wound management
Do we treat with antibiotics?
Do we close?
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Dog bites - Infections
Bacteria:
Anaerobes, Strep, Staph (5% infected)
31
Dog bite = No antibiotics except
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Dog bite –What wound to close?
35
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Dog bites – Deciding rabies risk
Rabies vaccine status (stray, unknown)
Behavior
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Dog bites – Deciding rabies risk
Observe animal x 10 days
If treat:
Rabies Immunoglobulin
+ Rabies vaccine
39
Cat bite
What infections do we worry about?
What is the risk of infection?
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Cat bite: Pasturella, 80% infection rate
41
Cat bite = Abx + immobilize
Prophylaxis: Clavulin, cefuroxime
Treat: iv Ceftriaxone
Splint
Frequent reassessments, r/o osteomyelitis
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What other animals do we worry
about rabies?
Fox
Raccoon
Skunk
Bat
Needs bites, contact with open wound or
mucous membrane
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Patient presents with this. List your mgt steps (7).
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1.
2.
3.
4.
5.
6.
7.
8.
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Rule out foreign body (teeth)
Irrigation ++
Abx
Rule out fracture or tendon injury
Tetanus
Discuss HIV prophylaxis + Hep B imm
Do not close, repeated assessments
(Splint)
Rule out Tendon Injury
46
Human bites: Dirty!
50% infection rate:
Bacteria: Staph, Strep, Eikenella
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Human bites: Dirty!
50% infection rate:
Bacteria: Staph, Strep, Eikenella
Prophylaxis: Clavulin, Cefuroxime,
Cellulitis: iv Ceftriaxone + flagyl
Close wound?
48
Viruses from human bites: Hep B, Hep C, HIV
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Hep B
If primary series done:
Check immunity (anti-HBsAgAb):
give HBIg + booster if low
If no primary series: HBIg + HBV vaccines
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Hep C
No Prophylaxis
Follow up with serology
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PEP
Determine risk
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Needlestick Injury: PEP
Baseline risk: 0.3%
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Risk increases if:
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Animal bites: LMCC objectives
Risk of transmissible infection from bites
- Abx: Clavulin, Cefuroxime, Ceftriaxone
Manage animal bites including reporting
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