Animal And Insect Bites
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Animal And Insect Bites

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Animal And Insect Bites Animal And Insect Bites Presentation Transcript

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