Animal And Insect Bites

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  • Animal And Insect Bites

    1. 1. ANIMAL & INSECT BITES James Taclin C. Banez, MD, FPCS, FPSGS, DPBS, DPSA
    2. 2. RABIES <ul><li>In any mammalian animal </li></ul><ul><li>Rhabdovirus: </li></ul><ul><ul><li>Rabies – meningoencephalitis </li></ul></ul><ul><ul><li> - worldwide </li></ul></ul><ul><ul><li>Ebola – hemorrhagic fever </li></ul></ul><ul><ul><li>Marburg – hemorrhagic fever Africa </li></ul></ul>
    3. 3. RABIES <ul><li>Developed countries ---> raccoons, </li></ul><ul><li> skunks, bats, etc </li></ul><ul><li>Developing and under developed </li></ul><ul><ul><li>Dogs (90%-Phil.) </li></ul></ul><ul><li>Cats, cattle, horse, sheep, bats and exotic animals (5-10%) </li></ul><ul><li>Small rodents, birds and reptiles does not serve as reservoir of infection </li></ul>
    4. 4. Epidemiology (Rabies) <ul><li>Incidence rate: </li></ul><ul><ul><li>5–7/million </li></ul></ul><ul><ul><li>Average cases: 450 annually (Phil.) </li></ul></ul><ul><ul><li>Philippine is 3 rd worldwide </li></ul></ul><ul><ul><li>San Lazaro Hospital: </li></ul></ul><ul><ul><ul><li>Pet dogs – 88% of cases </li></ul></ul></ul><ul><ul><ul><li>Stray dogs – 10% of cases </li></ul></ul></ul><ul><ul><ul><li>Cats – 2% of cases </li></ul></ul></ul>
    5. 5. Prevention <ul><li>Avoidance of said animals </li></ul><ul><li>Vaccination of pets (dogs, cats) </li></ul><ul><li>Exotic animals: </li></ul><ul><ul><li>Quarantine for 90 days then vaccinate after another 30 days </li></ul></ul><ul><ul><li>Pet bitten by rabid animals: </li></ul></ul><ul><ul><ul><li>No previous vaccine ---> isolate for 6 months, vaccinate 1 month---->release </li></ul></ul></ul><ul><ul><ul><li>w/ vaccine ----> give vaccine again and isolated for 90 days </li></ul></ul></ul>
    6. 6. Transmission <ul><li>Bites of rabid animals </li></ul><ul><li>Licking of the mucosa or open wound </li></ul><ul><li>Period of communicability : </li></ul><ul><ul><li>Dogs & cats = 3-5 days before the onset of the symptoms until the entire course of the illness. </li></ul></ul>
    7. 7. Transmission <ul><li>Incubation periods (Human): </li></ul><ul><ul><li>1 days to 5 yrs. (average 8wks ) </li></ul></ul><ul><ul><li>Variations: </li></ul></ul><ul><ul><ul><li>Severity of the bite </li></ul></ul></ul><ul><ul><ul><li>Site of bite in relation to nerve supply and distance from CNS </li></ul></ul></ul><ul><ul><ul><li>Size of innoculum, protection offered by clothing and other factors </li></ul></ul></ul><ul><ul><ul><li>Age and immune status of the host </li></ul></ul></ul>
    8. 8. Transmission <ul><li>Virus stays in : </li></ul><ul><ul><li>CNS </li></ul></ul><ul><ul><li>Liver </li></ul></ul><ul><ul><li>Salivary gland </li></ul></ul><ul><li>Travels thru the nerve </li></ul><ul><li>Incubation periods: </li></ul><ul><ul><li>1 days to 5 yrs. (average 8wks) </li></ul></ul>
    9. 9. Diagnosis <ul><li>Circumstances of bite: </li></ul><ul><ul><li>Provokes/unprovoked (domestic) </li></ul></ul><ul><ul><li>Vaccination of dogs ----> 90% effective </li></ul></ul><ul><ul><li>Wild animal ----> considered rabid </li></ul></ul><ul><li>Extent & location of bite: </li></ul><ul><ul><li>Severe: </li></ul></ul><ul><ul><ul><li>multiple or deep puncture wound </li></ul></ul></ul><ul><ul><ul><li>Head, face, neck hands or fingers </li></ul></ul></ul><ul><ul><li>Mild: </li></ul></ul><ul><ul><ul><li>Superficial laceration, scratches </li></ul></ul></ul><ul><ul><ul><li>Bites on other sites mentioned </li></ul></ul></ul>
    10. 10. Diagnosis <ul><li>Laboratory diagnosis: </li></ul><ul><ul><li>Pre-mortem (human): </li></ul></ul><ul><ul><ul><li>Fluorescent microscopy of skin biopsies from nape of the neck. </li></ul></ul></ul><ul><ul><ul><li>Isolation of virus from saliva and CSF </li></ul></ul></ul><ul><ul><ul><li>Detection of antibody in serum and CSF in unvaccinated person </li></ul></ul></ul><ul><ul><li>Postmortem (human): </li></ul></ul><ul><ul><ul><li>Fluorescent microscopy of brain and salivary gland </li></ul></ul></ul><ul><ul><li>Animal brain : </li></ul></ul><ul><ul><ul><li>Histology = negri bodies </li></ul></ul></ul><ul><ul><ul><ul><li>Demonstration of virus in brain tissue </li></ul></ul></ul></ul>
    11. 11. Natural History of Clinical Rabies in Man <ul><li>Infected pts. usually go through 4 stages: </li></ul><ul><li>Exposure: </li></ul><ul><li>Incubation Period 20-90 days: </li></ul><ul><ul><li>>95% present s/sx w/in 6 months of exposure </li></ul></ul><ul><ul><li>>98% w/in 1 yr. </li></ul></ul><ul><li>First Symptoms (Prodrome) 2-10 days </li></ul><ul><ul><li>Virus reaches the spinal cord </li></ul></ul><ul><ul><li>Nonspecific s/sx: </li></ul></ul><ul><ul><ul><li>Fever, Anorexia, N/V, Headache, Malaise, lethargy </li></ul></ul></ul><ul><ul><li>1 st rabies specific symptom: </li></ul></ul><ul><ul><ul><li>Pain , itching or paresthesias at site of bite </li></ul></ul></ul>
    12. 12. Natural History of Clinical Rabies in Man <ul><li>First Neurological Signs/Acute Neurological Phase: 2-7 days </li></ul><ul><ul><li>Virus reaches the brain, multiplies and disseminates rapidly to the rest of the body organs notably the salivary glands </li></ul></ul><ul><ul><li>Pt may die at this stage </li></ul></ul>
    13. 13. Natural History of Clinical Rabies in Man <ul><li>First Neurological Signs/Acute Neurological Phase: 2-7 days </li></ul><ul><ul><li>May present in 2 ways: </li></ul></ul><ul><ul><li>Encephalitic or Furious rabies (80%): </li></ul></ul><ul><ul><ul><li>Hyperactive episodes: </li></ul></ul></ul><ul><ul><ul><ul><li>Combative, presents bizarre behavior, may be very agitated or apprehensive </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Alternating w/ lucid moments where pt appears well </li></ul></ul></ul></ul><ul><ul><ul><li>Hydrophobia – elicited by giving pt glass of water; positive rxn. – agitation, caused by painful contraction of laryngeal muscles upon drinking </li></ul></ul></ul><ul><ul><ul><li>Aerophobia – elicited by fanning the pt </li></ul></ul></ul>
    14. 14. Natural History of Clinical Rabies in Man <ul><li>First Neurological Signs/Acute Neurological Phase: 2-7 days </li></ul><ul><ul><li>May present in 2 ways: </li></ul></ul><ul><ul><li>Paralytic or “dumb” rabies (20%) </li></ul></ul><ul><ul><ul><li>Starts as paralysis of the bitten area w/c spreads to involve all limbs and eventually ends in respiratory paralysis </li></ul></ul></ul><ul><ul><ul><li>Most often missed due to absent hydrophobia and aerophobia </li></ul></ul></ul><ul><ul><ul><li>High index of suspicion who came in w/ paralysis or encephalitis of undetermined etiology. </li></ul></ul></ul><ul><ul><ul><li>Hx of prior exposure (bite or non-bite) </li></ul></ul></ul>
    15. 15. Natural History of Clinical Rabies in Man <ul><li>Onset of Coma 0-14d </li></ul><ul><ul><li>Pituitary dysfunction </li></ul></ul><ul><ul><li>Hypoventilation, apnea </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Cardiac arrhythmia, cardiac arrest </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><li>Death: </li></ul><ul><ul><li>Secondary infection, nutritional deficiency and respiratory problem </li></ul></ul>
    16. 16. Management <ul><li>Biting animals: </li></ul><ul><ul><li>Domestic = observe for 10 days </li></ul></ul><ul><ul><li>Wild = vaccine shd. be given </li></ul></ul><ul><li>Patients management: </li></ul><ul><ul><li>Immediate local care: </li></ul></ul><ul><ul><ul><li>Thorough irrigation w/ copious water/soap </li></ul></ul></ul><ul><ul><ul><li>Debridement / antibiotic / tetanus toxoid </li></ul></ul></ul><ul><ul><ul><li>Immediate suturing of wound (not advisable) </li></ul></ul></ul>
    17. 17. Management <ul><li>Patients management: </li></ul><ul><ul><li>Immediate local care : </li></ul></ul><ul><ul><ul><li>Head & neck bites: </li></ul></ul></ul><ul><ul><ul><ul><li>Healing by secondary intention produces an unacceptable scar. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Primary closure has best outcome w/ less risk of infection </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Severe human bite and avulsion injuries of the face requires flaps to close the wound </li></ul></ul></ul></ul>
    18. 18. Management <ul><li>Patients management: </li></ul><ul><ul><li>Immediate local care: </li></ul></ul><ul><ul><ul><li>Hand Injuries: </li></ul></ul></ul><ul><ul><ul><ul><li>1/3 of dog bites in the hand becomes infected even w/ adequate therapy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Healing by secondary intention is recommended for most hand laceration. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>All tendons and nerve injuries should be managed by delayed repair </li></ul></ul></ul></ul><ul><ul><ul><ul><li>After thorough exploration, irrigation and debridement, the hand shd. be immobilized, wrapped in a bulky dressing </li></ul></ul></ul></ul>
    19. 19. Management <ul><li>Patients management: </li></ul><ul><ul><li>Immediate local care: </li></ul></ul><ul><ul><ul><li>Other parts of the body: </li></ul></ul></ul>
    20. 20. Management <ul><li>Patients management: </li></ul><ul><ul><li>Prophylaxis: </li></ul></ul><ul><ul><li>Post-exposure prophylaxis: </li></ul></ul><ul><ul><ul><li>Incubation period 10 days to 1 year (20-90d) </li></ul></ul></ul><ul><ul><ul><li>Incubation of <30 days (head & neck, upper extremities) </li></ul></ul></ul>
    21. 21. Management <ul><li>Prophylaxis: </li></ul><ul><ul><li>Immunization: </li></ul></ul><ul><ul><li>Passive: </li></ul></ul><ul><ul><ul><li>Human Rabies Immune Globulin (HRIG) </li></ul></ul></ul><ul><ul><ul><ul><li>20 I.U./KgBW </li></ul></ul></ul></ul><ul><ul><ul><li>Equine Rabies Immune Globulin </li></ul></ul></ul><ul><ul><ul><ul><li>40 I.U./KgBW </li></ul></ul></ul></ul><ul><ul><li>A portion is infiltrated into the wound </li></ul></ul><ul><ul><li>Given with in 8 days </li></ul></ul>
    22. 22. Management <ul><li>Prophylaxis: </li></ul><ul><ul><li>Immunization: </li></ul></ul><ul><ul><li>Active: </li></ul></ul><ul><ul><ul><li>Human Diploid Cell Vaccine (HDCV) </li></ul></ul></ul><ul><ul><ul><ul><li>5 dose IM (1ml) ----> 0, 3 rd , 7 th ,14 th and 28 th days WHO - 90 th day </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Booster: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>HDCV – 2 dose (0 and 3 rd day) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Antibodies levels checked every 6 months </li></ul></ul></ul></ul></ul>
    23. 23. Management WHO GUIDE FOR POST-EXPOSURE TREATMENT: Assess Nature of Contact or Injury and the Biting Animals TYPE OF EXPOSURE TREATMENT HEALTHY SICK/RABID Category I: Touching or feeding, licking of healthy skin w/ no open wound, no documented contact of saliva w/ mucous membrane, reliable history No treatment No treatment Category II: Nibbling of uncovered skin, superficial scratch that doesn’t break skin, licking over broken skin or healing wounds. Category I w/ unrealiable history Vaccine + observe Vaccine (full course) Category III: Single or multiple transdermal bite or scratch which penetrates skin at any location; licking of mucous membrane Vaccine + RIG + observe Vaccine + RIG + (Full course)
    24. 24. Management <ul><li>Side effects of Vaccine (HBCV): </li></ul><ul><ul><li>Sickness, pain and swelling of injection site </li></ul></ul><ul><ul><li>Fever, N/V, diarrhea, lymphadenopathy </li></ul></ul><ul><ul><li>Headache and dizziness </li></ul></ul><ul><li>Contraindications: </li></ul><ul><ul><li>Immuno-suppressive agents (measure antibody titer) </li></ul></ul><ul><ul><li>Allergies (antihistamine and epinephrine) </li></ul></ul><ul><ul><li>Pregnancy (not accepted nor documented) </li></ul></ul>
    25. 25. Management <ul><li>Treatment for symptomatic patients: </li></ul><ul><li>Supportive: </li></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><li>Respiratory support </li></ul></ul><ul><ul><li>Management heart arrhythmia and seizures </li></ul></ul><ul><ul><li>Nursing care </li></ul></ul><ul><ul><li>INTERFERON (not effective) </li></ul></ul>
    26. 26. SNAKE BITE
    27. 27. SNAKE BITES Characteristic Poisonous Nonpoisonous a. Shape of head triangular round b. Pit (+) (-) c. Pupils elliptical Round d. Bite marks Fang marks 2 rows of teeth e. Caudal plates Single row Double row f. Color body Red ring next to yellow (coral snakes) Alternating color
    28. 28. Venom Snakes <ul><li>Toxicology: </li></ul><ul><ul><li>Peptides: </li></ul></ul><ul><ul><ul><li>Damages the endothelium: </li></ul></ul></ul><ul><ul><ul><ul><li>Increase vascular permeability </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Edema and hypovolemic </li></ul></ul></ul></ul></ul><ul><ul><li>Enzymes: </li></ul></ul><ul><ul><ul><li>Proteases & L-amino acid oxidase : </li></ul></ul></ul><ul><ul><ul><ul><li>Cause tissue necrosis </li></ul></ul></ul></ul><ul><ul><ul><li>Hyaluronidase: </li></ul></ul></ul><ul><ul><ul><ul><li>Facilitate spread of venom through tissue </li></ul></ul></ul></ul><ul><ul><ul><li>Phospholipase A2: </li></ul></ul></ul><ul><ul><ul><ul><li>Damages erythrocytes and muscle cells. </li></ul></ul></ul></ul>
    29. 29. Venom Snakes <ul><ul><li>Neurotoxin: </li></ul></ul><ul><ul><ul><li>Blocks neuromuscular junction </li></ul></ul></ul><ul><ul><li>Others: </li></ul></ul><ul><ul><ul><li>Endonuclease, alkaline and acid phosphatase, cholinesterase </li></ul></ul></ul><ul><li>Other deleterious effect: </li></ul><ul><ul><li>Affects cardiovascular, pulmonary, renal and neurologic systems </li></ul></ul><ul><ul><li>Affects coagulation, fibrinolysis, platelet function and vascular integrity causing hemorrhagic or thrombotic sequelae </li></ul></ul>
    30. 30. Clinical Manifestations <ul><li>Local: </li></ul><ul><ul><li>20% of pit vipers do not cause envenomation </li></ul></ul><ul><ul><li>Venom causes burning pain w/in minutes, followed by edema and erythema ----> edema progresses over the next few hrs w/ development of ecchymoses and hemorrhagic bullae </li></ul></ul>
    31. 31. Clinical Manifestations <ul><li>Systemic: </li></ul><ul><ul><li>Pt usually complain of weakness, N/V, perioral paresthesias, metallic taste and fasiculations. </li></ul></ul><ul><ul><li>Continuing capillary leak leads to hypotension ---> shock, pulmonary edema </li></ul></ul><ul><ul><li>Coagulopathy can develop w/in an hour and manifest: </li></ul></ul><ul><ul><ul><li>Bleeding (gingiva, bite site, venipuncture site and recent wounds </li></ul></ul></ul><ul><ul><ul><li>Leads to DIC (disseminated intravascular coagulopathy) </li></ul></ul></ul>
    32. 32. Clinical Manifestations <ul><li>Systemic: </li></ul><ul><ul><li>Acute renal failure due to: </li></ul></ul><ul><ul><ul><li>Direct nephrotoxin </li></ul></ul></ul><ul><ul><ul><li>Circulatory collapse </li></ul></ul></ul><ul><ul><ul><li>Consumption coagulopathy </li></ul></ul></ul><ul><ul><li>Neurotoxic venom (black mamba/coral snake/sea snake): </li></ul></ul><ul><ul><ul><li>Local injury is minimal or absent </li></ul></ul></ul><ul><ul><ul><li>Cranial nerve dysfunction and loss of deep tendon reflexes </li></ul></ul></ul><ul><ul><ul><li>Progress to respiratory depression and paralysis after several hours. </li></ul></ul></ul>
    33. 33. Laboratory Examination <ul><ul><li>CBC </li></ul></ul><ul><ul><li>DIC panel </li></ul></ul><ul><ul><li>Serum electrolyte </li></ul></ul><ul><ul><li>BUN, Creatinine </li></ul></ul><ul><ul><li>Urinalysis </li></ul></ul><ul><ul><li>ECG </li></ul></ul>
    34. 34. Management <ul><li>Field Therapy: </li></ul><ul><ul><li>Calm the pt. / cleansed / immobilized below the level of the heart. </li></ul></ul><ul><ul><li>Tourniquet , to occlude the vein; removed when: </li></ul></ul><ul><ul><ul><li>as soon as IVF is started </li></ul></ul></ul><ul><ul><ul><li>Antivenom is ready for administration </li></ul></ul></ul><ul><ul><ul><li>Patient is not in shock </li></ul></ul></ul>
    35. 35. Management <ul><li>Field Therapy: </li></ul><ul><ul><li>Incision & Suction: </li></ul></ul><ul><ul><ul><li>Effective if done w/in 5 mins and continued for at least 30 minutes. </li></ul></ul></ul><ul><ul><ul><li>If done > 5mins ----> loss 50% 0f it’s value </li></ul></ul></ul><ul><ul><ul><li>If delayed > 30mins ----> loss 100% value </li></ul></ul></ul><ul><ul><li>Excision of the bite wound: </li></ul></ul><ul><ul><ul><li>In severe bites </li></ul></ul></ul><ul><ul><ul><li>Pt allergic to horse serum </li></ul></ul></ul><ul><ul><ul><li>Those pt. seen w/in 1 hr. following the bit </li></ul></ul></ul><ul><ul><li>Cryotherapy – not recommended </li></ul></ul>
    36. 36. Management <ul><li>Hospital Management: </li></ul><ul><ul><li>History: </li></ul></ul><ul><ul><ul><li>Hx. Of incident </li></ul></ul></ul><ul><ul><ul><li>Type of snake </li></ul></ul></ul><ul><ul><ul><li>Field management and prior antivenin tx. </li></ul></ul></ul><ul><ul><li>PE: </li></ul></ul><ul><ul><ul><li>Vital signs </li></ul></ul></ul><ul><ul><ul><li>Size and wound appearance (degree of envenomation / neurological examination for coral snake) </li></ul></ul></ul>
    37. 37. Management <ul><li>Hospital Management: </li></ul><ul><li>Wound care: </li></ul><ul><ul><li>Cleansed thoroughly and extremity splinted </li></ul></ul><ul><ul><li>Debridement if necessary </li></ul></ul><ul><ul><li>Tetanus toxoid and tetanus immune globulin </li></ul></ul><ul><ul><li>Broad spectrum antibiotic (3-5days) </li></ul></ul><ul><li>Fasciotomy: </li></ul><ul><ul><li>Done only if compartment pressure are over 30mmhg. </li></ul></ul><ul><ul><li>Routine fasciotomies to prevent compartment syndrome have not proved to be beneficial. </li></ul></ul>
    38. 38. Management <ul><li>Hospital Management: </li></ul><ul><li>Degree of Envenomation: </li></ul><ul><li>Grade 0: No envenomation </li></ul><ul><ul><li>Minimal pain in wound, <1 inch of edema & erythema, no systemic symptoms </li></ul></ul><ul><li>Grade I: Minimal </li></ul><ul><ul><li>Moderate to severe pain </li></ul></ul><ul><ul><li>1-5inches edema & erythema at 12hrs. </li></ul></ul><ul><ul><li>No systemic symptoms </li></ul></ul>
    39. 39. Management <ul><li>Hospital Management: </li></ul><ul><li>Degree of Envenomation: </li></ul><ul><li>Grade II: Moderate </li></ul><ul><ul><li>Severe pain </li></ul></ul><ul><ul><li>6-12inches of edema & erythema at 12hrs. </li></ul></ul><ul><ul><li>N/V, shock or neurotoxic symptoms </li></ul></ul><ul><li>Grade III: Severe </li></ul><ul><ul><li>Severe pain, >12 inches edema/erythema at 12hrs </li></ul></ul><ul><ul><li>Grade II plus generalized petechia and ecchymosis </li></ul></ul>
    40. 40. Management <ul><li>Hospital Management: </li></ul><ul><li>Degree of Envenomation: </li></ul><ul><li>Grade IV: Very Severe </li></ul><ul><ul><li>Renal failure/blood tinged secretions </li></ul></ul><ul><ul><li>Coma and death </li></ul></ul><ul><ul><li>Local edema extend beyond involved extremity </li></ul></ul>
    41. 41. Antivenin Therapy <ul><li>Most important tx </li></ul><ul><li>Horse serum; skin testing (0.02ml of 1:10 dilution of antivenum w/ 0.9% NaCl intradermally). </li></ul><ul><ul><li>(+) allergy ----> premedication w/ diphenhydramine HCL 25-50ug IV and an epinephrine drip (2-20ug/min) during antivenin administration. </li></ul></ul>
    42. 42. Antivenin Therapy <ul><li>Antivenin dose depends on the severity of envenomation and administered over 2-4hrs. </li></ul><ul><ul><li>Grade I = No antivenin </li></ul></ul><ul><ul><li>Grade II = 3-4 amp. in 500ml NSS </li></ul></ul><ul><ul><li>Grade III = 5-15amp. in 500ml NSS </li></ul></ul><ul><li>Pt re-evaluated every 2hrs and if necessary a repeat dose of ativenin shld be evaluated and given. </li></ul>
    43. 43. Antivenin Therapy <ul><li>Children: antivenin be increased by 50% bec. of higher rate of venom to body mass. </li></ul><ul><li>Pregnancy is not contraindicated </li></ul><ul><li>Antivenin for coral snake bite should be initiated even if envenomation is only suspected for there are frequently no local manifestation </li></ul>
    44. 44. Antivenin Therapy <ul><li>King cobra & Black mamba snake bites (Quick acting venom) </li></ul><ul><ul><li>The initial dose of antivenin is part of it’s first aid tx. </li></ul></ul>
    45. 45. Other form of Management <ul><li>Need for respirator ---> for respiratory failure </li></ul><ul><li>Dialysis ----> for renal failure </li></ul><ul><li>CNS Decompression </li></ul><ul><li>Transfusion of blood and its derivatives </li></ul><ul><li>Nutrition </li></ul>
    46. 46. ARTHROPOD BITE
    47. 47. Hymenoptera <ul><li>BEES (Honeybee/bumble bee/ black hornet), </li></ul><ul><ul><li>Venom: drop by drop similar to rattle snake </li></ul></ul><ul><ul><li>Bees has a barb-shaped stinger </li></ul></ul><ul><ul><li>Venom: </li></ul></ul><ul><ul><ul><li>H istamine/serotonin (local rxn & pain) </li></ul></ul></ul><ul><ul><ul><ul><li>Causes tissue necrosis </li></ul></ul></ul></ul><ul><ul><ul><li>Phospholipase/hyaluronidase </li></ul></ul></ul><ul><ul><ul><ul><li>Destroy collagen </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Allergen – can elicit IgE mediated response </li></ul></ul></ul></ul>
    48. 48. Manifestation <ul><li>Local rxn: </li></ul><ul><ul><li>Sting produced localize pain, </li></ul></ul><ul><ul><li>wheal --> pustule </li></ul></ul><ul><ul><li>20% produced large local rxn as erythematous, edematous, painful and pruritic areas larger than 10cm. For 2-5 days </li></ul></ul><ul><ul><ul><li>Represents combination of IgE mediated, cell mediated </li></ul></ul></ul>
    49. 49. Manifestation <ul><li>Systemic rxn: </li></ul><ul><ul><li>Multiple stings can produced toxic rxns. </li></ul></ul><ul><ul><ul><li>Vomiting, diarrhea, generalized edema </li></ul></ul></ul><ul><ul><ul><li>Cardiovascular collapse </li></ul></ul></ul><ul><ul><ul><li>Hemolysis </li></ul></ul></ul><ul><ul><li>3% causes death due to anaphylaxis w/in 1 hr. </li></ul></ul><ul><ul><ul><li>Starts as urticaria ----> angioedema , respiratory arrest 2 nd to airway edema and cardiovascular collapse </li></ul></ul></ul>
    50. 50. Treatment <ul><li>Local therapy: </li></ul><ul><ul><li>Removal of sting (gentle scraping) </li></ul></ul><ul><ul><li>Clean the site </li></ul></ul><ul><ul><li>Pain: - apply ice </li></ul></ul><ul><ul><li>- vinegar </li></ul></ul><ul><ul><li>- topical or injected lidocaine </li></ul></ul><ul><ul><li>Pruritus: - antihistamine </li></ul></ul><ul><ul><li>Larger area: – elevate the site </li></ul></ul><ul><ul><li> - analgesia </li></ul></ul><ul><ul><li> - prednisone (1mg/k/day) </li></ul></ul>
    51. 51. Treatment <ul><li>Systemic therapy: </li></ul><ul><li>Mild anaphylaxis : </li></ul><ul><ul><li>0.3 ml of 1:1000 epinephrine subQ (children – 0.01ml/kg) </li></ul></ul><ul><ul><li>Oral or IV antihistamine </li></ul></ul><ul><li>Severe anaphylaxis: </li></ul><ul><ul><li>IVF - endotracheal intubation </li></ul></ul><ul><ul><li>Vasopressor - steroid </li></ul></ul><ul><ul><li>Bronchodilator - ICU monitoring </li></ul></ul>
    52. 52. Spiders <ul><li>Lactrodectus spiders (Black Widow) </li></ul><ul><ul><li>Worldwide </li></ul></ul><ul><ul><li>female: black color w/ a distinctive red ventral marking w/ hourglass shape </li></ul></ul><ul><ul><li>Nocturnal spider; bites defensively </li></ul></ul><ul><ul><li>Has neurotoxic venom </li></ul></ul><ul><ul><ul><li>Act at presynaptic terminal </li></ul></ul></ul><ul><ul><ul><li>Enhance neurotransmitter release </li></ul></ul></ul><ul><ul><ul><ul><li>Acetylcholine = neuromuscular junction (muscle spasm) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Norepinephrine = produces adrenergic stimulation </li></ul></ul></ul></ul>
    53. 53. Spiders <ul><li>Lactrodectus spiders ( Black Widow) </li></ul><ul><ul><li>Manifestation: </li></ul></ul><ul><ul><ul><li>Erythema & pain at bite site </li></ul></ul></ul><ul><ul><ul><li>Neuromuscular symptoms (30mins) </li></ul></ul></ul><ul><ul><ul><ul><li>Severe pain & spasm of large muscle grp </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Abdominal cramps (like acute abd) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Dyspnea (chest tightness) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Adrenergic stimulation: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>HPN / diaphoresis / tachycardia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fasciculation / Nausea/vomiting </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Headache / paresthesia / fatigue / salivation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Acute symptoms peak several hours & resolve in 1-2 days </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Death unusual </li></ul></ul></ul></ul>
    54. 54. Spiders <ul><li>Lactrodectus spiders (Black Widow) </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><li>Mild envenomation </li></ul></ul><ul><ul><ul><li>Local wound care: </li></ul></ul></ul><ul><ul><ul><ul><li>Clean the site </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Apply ice – to alleviate pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>tetanus prophylaxis </li></ul></ul></ul></ul><ul><ul><li>Severe envenomation </li></ul></ul><ul><ul><ul><li>IV calcium gluconate (transient effect) </li></ul></ul></ul><ul><ul><ul><li>Narcotic & benzodiazepine - relieve muscle pain </li></ul></ul></ul><ul><ul><ul><li>Antivenin (horse serum) – reserve for severe envenomation due to anaphylaxis & serum sickness (side effect) </li></ul></ul></ul>
    55. 55. Spiders <ul><li>Lactrodectus spiders (Black Widow) </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><li>Severe envenomation </li></ul></ul><ul><ul><ul><li>Antivenum is recommended: </li></ul></ul></ul><ul><ul><ul><ul><li>Pregnant women </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Children under 16 yrs </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Patients w/ severe reaction: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Uncontrolled HPN </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Respiratory distress </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Seizures </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Skin testing = if (+) shd. Receive pretx w/ diphenhydramine. </li></ul></ul></ul><ul><ul><ul><li>Recommended antivenin dose = 1 vial, repeated as necessary </li></ul></ul></ul>
    56. 56. Spiders <ul><li>Brown Recluse (loxosceles): </li></ul><ul><ul><li>Necrotic arachnidism / loxoscelism </li></ul></ul><ul><ul><li>North & South America, Africa & Europe </li></ul></ul><ul><ul><li>Char. = dark brown violin shape marking over the cephalothorax </li></ul></ul><ul><ul><ul><li>Has 3 pairs of eye </li></ul></ul></ul><ul><ul><ul><li>Both male & female bites when threatened </li></ul></ul></ul>
    57. 57. Spiders <ul><li>Brown Recluse (loxosceles): </li></ul><ul><ul><li>Toxicology: </li></ul></ul><ul><ul><li>Sphingomyelinase (phospholipase) </li></ul></ul><ul><ul><ul><li>Dermonecrotic factor </li></ul></ul></ul><ul><ul><ul><li>Destroy cell membrane or RBC ---> hemolysis </li></ul></ul></ul><ul><ul><ul><li>Destroy endothelial cells ---> coagulation </li></ul></ul></ul><ul><ul><ul><li>Interact w/ platelets ----> platelet </li></ul></ul></ul><ul><ul><ul><li> aggregation </li></ul></ul></ul><ul><ul><ul><li>Necrosis – most severe in fatty areas </li></ul></ul></ul><ul><ul><ul><li>(abdomen & thigh) </li></ul></ul></ul>
    58. 58. Spiders <ul><li>Brown Recluse (loxosceles): </li></ul><ul><ul><li>Manifestation: </li></ul></ul><ul><ul><li>Local: </li></ul></ul><ul><ul><ul><li>Mild irritation to severe necrosis w/ ulceration </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Ischemia (pain, itching, swelling & erythema) ---> blister ----> central area turns purple and peripheral becomes pale due to vasoconstriction ----> necrosis ---> replaced by eschar that separates producing ----> large ulcer that heals w/in 2 months. </li></ul></ul></ul></ul></ul>
    59. 59. Spiders <ul><li>Brown Recluse (loxosceles): </li></ul><ul><ul><li>Manifestation: </li></ul></ul><ul><ul><li>Systemic: </li></ul></ul><ul><ul><ul><ul><li>N/V, headache, fever, malaise, arthralgia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Maculopapular rash </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thrombocytopenia / Disseminated intravascular coagulation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hemolytic anemia </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Coma and rarely death </li></ul></ul></ul></ul></ul>
    60. 60. Spiders <ul><li>Brown Recluse (loxosceles): </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><li>Bite site elevated </li></ul></ul><ul><ul><li>Cold compress: Cold can </li></ul></ul><ul><ul><ul><li>Inhibits venom </li></ul></ul></ul><ul><ul><ul><li>Decrease inflammation & ulcer formation </li></ul></ul></ul><ul><ul><li>Dapson = reduces local inflammation by inhibiting neutrophil function. (100mg/d) </li></ul></ul><ul><ul><li>Debridement is recommended be done 1-2 wks after the margin are defined </li></ul></ul><ul><ul><li>Split thickness skin grafting done while dapsone is being continued </li></ul></ul><ul><ul><li>No antivenin </li></ul></ul>
    61. 61. Scorpion <ul><li>Worldwide / Buthidae family </li></ul><ul><li>Has neurotoxin that prevent sodium channel closure </li></ul><ul><li>Manifestation: </li></ul><ul><ul><li>Local paresthesia & burning symptoms </li></ul></ul><ul><ul><li>Cranial nerves & neuromuscular dysfunction ----> respiratory distress </li></ul></ul>
    62. 62. Scorpion <ul><li>Treatment: </li></ul><ul><li>Local: </li></ul><ul><ul><li>Ice pack therapy / analgesic -> for pain </li></ul></ul><ul><ul><li>Tetanus prophylaxis </li></ul></ul><ul><li>Systemic: </li></ul><ul><ul><li>Monitor closely cardiovascular & respiratory status in ICU </li></ul></ul><ul><ul><li>Antivenin can reverses cranial nerve & neuromuscular symptoms but can cause anaphylaxis & delayed serum sickness </li></ul></ul><ul><ul><li>Dose = 1 vial; if sensitive (diphenhydramine) </li></ul></ul>
    63. 63. Marine Trauma & Envenomation <ul><li>Considerations: </li></ul><ul><ul><li>Hypothermia </li></ul></ul><ul><ul><li>Drowning </li></ul></ul><ul><ul><li>Decompression syndrome (air embolism) </li></ul></ul><ul><ul><li>Follow ABC </li></ul></ul><ul><ul><li>Bacterial isolates: C/S impt. </li></ul></ul><ul><ul><ul><li>Gram (-) rods (vibrio sp.) </li></ul></ul></ul><ul><ul><ul><li>Staph / strep </li></ul></ul></ul><ul><ul><li>Tetanus vaccine </li></ul></ul>
    64. 64. Marine Trauma & Envenomation <ul><li>Considerations: </li></ul><ul><ul><li>Antibiotics: </li></ul></ul><ul><ul><ul><li>3 rd generation cephalosphorin </li></ul></ul></ul><ul><ul><ul><li>Quinolones </li></ul></ul></ul><ul><ul><ul><li>Gentamicin </li></ul></ul></ul><ul><ul><ul><li>Trimethoprin-sulfamethoxazole </li></ul></ul></ul><ul><ul><li>Debridement = to lower infection & promote healing </li></ul></ul><ul><ul><li>Wound are loosely closed & drained; primary closure of distal extremity are avoided. </li></ul></ul><ul><ul><li>Antivenin if available is given after skin testing </li></ul></ul>
    65. 65. Injuries from Nonvenous Aquatic Animals: <ul><li>SHARK: </li></ul><ul><ul><li>tiger / great white / bull shark </li></ul></ul><ul><ul><li>Most injuries are lower extremities </li></ul></ul><ul><ul><li>Powerful jaws & sharp teeth produces crushing & tearing injuries </li></ul></ul><ul><ul><li>Causes of death: </li></ul></ul><ul><ul><ul><li>hypovolemic shock </li></ul></ul></ul><ul><ul><ul><li>drowning </li></ul></ul></ul>
    66. 66. Injuries from Nonvenous Aquatic Animals: <ul><li>Moray Eels: </li></ul><ul><ul><li>Residing in holes or crevices at the floor of the sea </li></ul></ul><ul><ul><li>Bites and produces multiple puncture wounds </li></ul></ul><ul><ul><li>Hands is the most frequently bitten </li></ul></ul><ul><li>Alligators / Crocodile </li></ul><ul><ul><li>Similar to shark bites </li></ul></ul>
    67. 67. Injuries from Venomous Aquatic Invertebrates Animals: <ul><li>Coelenterates: (Jelly fish) </li></ul><ul><ul><li>Venomous stinging cells called nematocyte </li></ul></ul><ul><ul><li>Mild envenomation: </li></ul></ul><ul><ul><ul><li>Sting produces skin irritation </li></ul></ul></ul><ul><ul><ul><ul><li>Pruritus, paresthesia & throbbing pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Edema and erythema ----> blisters & petechia ----> local infection & ulceration. </li></ul></ul></ul></ul>
    68. 68. Injuries from Venous Aquatic Invertebrates Animals: <ul><li>Coelenterates: (Jelly fish) </li></ul><ul><ul><li>Systemic envenomation: </li></ul></ul><ul><ul><ul><li>Manifestation of anaphylactic rxn </li></ul></ul></ul><ul><ul><ul><ul><li>Fever, N/V, body malaise </li></ul></ul></ul></ul><ul><ul><ul><li>Death due to hypotension and cardio-respiratory arrest. </li></ul></ul></ul>
    69. 69. Injuries from Venous Aquatic Invertebrates Animals: <ul><li>Coelenterates: (Jelly fish) </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><li>Clean the wound w/ sea water </li></ul></ul><ul><ul><li>Apply diluted 5% acetic acid (vinegar) or baking soda; it can inactivate the toxin; applied for 30 mins or until the pain is relieved </li></ul></ul><ul><ul><li>After wound irrigation ---> remaining nematocyst are removed by applying shaving cream and shave the area w/ razor </li></ul></ul><ul><ul><li>Local anesthesia, atihistamine or steroids can relieve pain after the toxin is inactivated. </li></ul></ul><ul><ul><li>Prophylactic antibiotic are usually unnecessary </li></ul></ul>
    70. 70. Injuries from Venous Aquatic Invertebrates Animals: <ul><li>Echinodermata ( sea urchins & sea cucumber) </li></ul><ul><ul><li>Causes contact dermatitis </li></ul></ul><ul><ul><li>Sea cucumbers feeds on coelenterates and secrete nematocytes hence local therapy for coelenterates shd be done </li></ul></ul><ul><ul><li>Sea urchins – venomous spines causing local & systemic rxn like coelenterates </li></ul></ul>
    71. 71. Injuries from Venous Aquatic Invertebrates Animals: <ul><li>Echinodermata ( starfish, sea urchins & sea cucumber ) </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><li>Soak w/ hot water </li></ul></ul><ul><ul><li>Spines of the organism located w/ x-ray or MRI and shd be removed </li></ul></ul><ul><ul><li>Swelling alleviated w/ steroids </li></ul></ul>
    72. 72. Injuries from Venous Aquatic Invertebrates Animals: <ul><li>Mollusks ( octopus ): </li></ul><ul><ul><li>Can bite & inject tetrodoxine (paralytic agent) </li></ul></ul><ul><ul><li>Tx: </li></ul></ul><ul><ul><ul><li>pressure & immobilize to contain venom </li></ul></ul></ul><ul><ul><ul><li>Systemic complication --- supportive </li></ul></ul></ul>
    73. 73. Injuries from Venous Aquatic Vertebrates Animals: <ul><li>Stingrays: </li></ul><ul><ul><li>Whiplike appendages w/ spines at its end that can produce puncture wounds & lacerations </li></ul></ul><ul><ul><li>Venom = vasoconstrictions causing cyanosis of wound ----> myonecrosis </li></ul></ul><ul><ul><li>Systemic rxn: </li></ul></ul><ul><ul><ul><li>Cardiac arrhythmia </li></ul></ul></ul><ul><ul><ul><li>Respiratory arrest </li></ul></ul></ul><ul><ul><ul><li>seizures </li></ul></ul></ul>
    74. 74. Injuries from Venous Aquatic Vertebrates Animals: <ul><li>Stingrays: </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><li>Wound irrigated and soaked w/water for an hour </li></ul></ul><ul><ul><li>Debridement, exploration and removal of spines </li></ul></ul><ul><ul><li>Wound is elevated, dressed and not closed primarily </li></ul></ul><ul><ul><li>Pain relieved locally and systemically </li></ul></ul>
    75. 75. Injuries from Venous Aquatic Vertebrates Animals: <ul><li>Sea Snakes: ( Hydrophiidae ) </li></ul><ul><ul><li>neurologic sign and symptoms </li></ul></ul><ul><ul><li>Death is due to paralysis and resp. arrest </li></ul></ul><ul><ul><li>Tx similar to coral snake </li></ul></ul><ul><ul><ul><li>Pressure, immobilize technique </li></ul></ul></ul><ul><ul><ul><li>Antivenin administration 1 ampule initially then repeated as needed </li></ul></ul></ul>
    76. 76. THANK YOU

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