This document discusses the management of common emergencies including insect bites, anaphylaxis, heat stroke, snake bites, and scorpion stings. It provides guidance on treating animal bites, administering antibiotics, tetanus vaccines, and rabies prophylaxis when needed. For snake bites, recommendations include reassuring the patient, checking coagulation, giving antivenom, and immobilizing the area. Anaphylaxis requires epinephrine, IV fluids, oxygen, and monitoring for biphasic reactions. Heat stroke and exhaustion are also outlined, with cooling methods like cold water immersion and lavage to rapidly lower core body temperature.

1. Common emergencies in
PMH
Insect bite , anaphylaxis, heat stroke
Dr Habiba AL Harthi
R3 ,Famco resident

2. Objectives
• Cat and dog bite (rabies )(anti rabies )
• Tetanus vaccination
• Snake bite
• Scorpion bite
• Insect bite
• Anaphylaxis
• Heat stroke

3. Case 1
• 3 years old child brought by his mother after ho scratch by un
provoked domestic cat in his hand
• Vitals
• Weight 14
• Temp:36.8
• Superficial cat scratch marks seen on his hand
• Next step ??

4. Cat bite
• Cat bites account for 5% to 10% of animal bite wounds.
• Cat bites occur most often in adult women, usually on the
extremities.
• Almost all of these bites are self-reported as provoked.

5. Dog bite
• Most dog bite victims are children, and these bites usually involve the
head and neck.
• Adolescents and adults tend to have more bite wounds to the
extremities.
• More than 70% of bites are from a dog that is known to the victim,
and about 50% are self-reported as unprovoked

6. • The wound should be carefully explored for tendon or bone
involvement and foreign bodies, such as teeth fragments.
• Older dogs and cats often have significant periodontal disease,
increasing the risk that a tooth will break off during a bite.
• Radiography is indicated if a foreign body or bone involvement is
suspected.
• Tendon ruptures should be evident on examination, but identifying a
partial tendon rupture requires careful exploration of the wound.
Observing the tendon throughout the joint's full extension and full
flexion can reveal small or partially torn tendons, which warrant
referral for repair.

7. • In a study of 145 bite wounds that were primarily closed, only 5.5%
became infected, including bites from dogs (61%), cats (31%), and
humans (8%).
• Both of these studies are small and have design limitations; therefore,
wounds may be primarily closed if desired for cosmetic reasons.
• However, allowing a wound to close by secondary intention should
be considered if there is a higher risk of infection , such as wounds to
the hand.
• The safety and effectiveness of skin adhesives have not been studied
in animal bite wounds.

9. • Antibiotic prophylaxis should be used for high-risk bite wounds
• considered in average-risk wounds
• Meta analysis showed no difference except for hand wounds
• All cat bites are considered high risk for infection because they tend
to cause deep puncture wounds.

10. • Antibiotic prophylaxis should be considered in :
1-a high risk of infection, such as with cat bites,
2-puncture wounds,
3-wounds to the hand,
4-immunosuppressed.
• Amoxicillin/clavulanate is the first-line prophylactic antibiotic.

13. RABIES
• Rabies is a virus that can infect any mammal.
• cats are the most commonly infected domesticated animal, whereas
raccoons, bats, and skunks are the most commonly infected wild
animals.

14. • Post exposure rabies prophylaxis consists of :
• immune globulin at presentation
• vaccination on days 0, 3, 7, and 14.
• The need for rabies prophylaxis should be addressed with any
animal bite because even domestic animals are often unvaccinated.

15. • The immune globulin is infiltrated around the bite wound, and any
additional volume is administered at a site distant to the vaccination
site, usually the opposite arm as the rabies vaccine.
• If the patient had already received pre exposure prophylaxis before
the animal bite, no immune globulin is needed, and the rabies vaccine
is administered only on days 0 and 3.

16. • Counseling patients and families about animal safety may help
decrease animal bites.
• In most states, physicians are required by law to report animal bites.

18. aafp
• Postexposure prophylaxis is generally not needed in patients with a
dog or cat bite as long as the animal is not showing signs of rabies,
such as inappetence, dysphagia, abnormal behavior, ataxia, paralysis,
altered vocalization, or seizures; however, the animal should be
monitored for at least 10 days.
• if the animal shows signs of rabies, becomes sick, or dies, immediate
post exposure prophylaxis is recommended.

19. • Pre exposure prophylaxis should be considered in persons with higher
risk of rabies exposure, such as certain laboratory workers,
veterinarians, spelunkers, and certain international travelers.

20. • Tetanus vaccination is recommended after an animal bite if it has
been more than five years since the patient has been immunized

23. Case 2
• 60 years old American tourist was brought to your local health center
with h/o snake bite while he was in camping tour at the desert in his
left shin
• On ex
• Snake bite marks noted in his left shin
• Vitals within normal range
• How to proceed ??

24. Snake venom
• Venom is a complex of mixture of poisonous toxins ,proteolytic
,enzymes ,and different proteins
• Amount and degree of poisoning differ from one snake to another
depending on several factors
• Type of snake
• Age ,sex
• Geographical , seasonal variation

25. • Severity depends on amount of venom injected in to the victim
• Varies from one person to another
• Usual appearance of a bite of a non-venomous species or by a
venomous snake without a venom injection is two or more fang
(tooth) marks ,mild local tenderness , some swelling ,but no bruising

26. Types of enovenomation
• Haemotoxic(vipers )—(Dhofar )local pain , swelling ,petachia and co
agulopathy ,,bleeding , acute renal failure ,cardiovascular collapse

27. • Myotoxin sea snake muscle damage ,rhabdomolisis ,weakness
of the limb ,respiratory muscle and swallowing muscles can be
affected ,
• No ASV available

28. • Neurotoxic cobras (Naja haja Arabica )
• Affect nervous system , ptosis can be early sign ,systemic effect can be
delayed up to 12 hours , nausea , vomiting ,confusion , dysarthia
,muscle fasciculations , respiratory arrest

29. • Re assure the pt
• Perform WBCT , send for urgent coagulation profile ,INR , cbc ,RFT,LFT
, DIC ,blood group ,save serum ,
• Give ASV
• Give tetanus toxoid injection intramascular or sc if severe
coagulopathy
• Immobilize the bitten area , clean it with saline
• Observe patient during ASV , infusion for 1-2 hours

30. 20 minutes WBCT
• Place few ml of freshly sampled venous blood in a small ,glass vessel.
• Leave undisturbed for 20 minutes at ambient temperature
• Tip the vessel once
• If the blood still liquid (un clotted )and runs out , the patient has
hypofibrinogenaemia(incoagulable blood) as a result of venom-
induced consumption coagulopathy

31. First aid in management of snake bite
• Avoid walking in darkness
• Don’t disturb snakes
• Don’t handle snakes , beware if a snake has recently died or been
killed its head can still bite even few hours after its death
• Remove the wounded person from dangerous place
• Do not mobilize the bitten area
• Apply a splint or a sling to immobilize the affected area
• Don’t apply hot or cold water over the bitten area
• Don’t try to suck out the venom

32. • Don’t apply a tight bandage or tourniquet
• Re assure the victim
• Transport victim to nearest HLC as soon as possible with the affected
site immobilized
• If transport of the patient is expected to be delayed , give the patein
AVS , can be given even im if iv acsses not available , but make sure
that epinephrine is there (in case of anaphylaxis )

34. • Contraindication of ASV
• NO absolute contraindication , but in patient with ho anaphylaxis
should be given with caution and pre treatment should be given ,
epinephrine and other measures

35. Case 3
17 years old male , not kwon to have chronic medical problem
Presented to LHC with ho scorpion sting at his right big toe
Patient is screaming from pain
On ex:
BP :128/70
A febrile
Local erythema noted in right big toe
What is your next step??

38. Case 4
• 30 year old Indian house made bought by her madam with ho sob ,
swollen lips and flush over her face after bee sting
• On ex:
• Patient is tachypnea
• BP :90/50
• Pulse :110
• Chest :bl wheezes

40. anaphylaxis
• Anaphylaxis is a severe, life-threatening, systemic allergic reaction
that is almost always unanticipated and may lead to death by
airway obstruction or vascular collapse.
• Anaphylaxis occurs as the result of an allergen response, usually
immunoglobulin E–mediated, which leads to mast cell and basophil
activation and a combination of dermatologic, respiratory,
cardiovascular, gastrointestinal, and neurologic symptoms.

41. • The incidence of anaphylaxis in the United States is 49.8 cases per
100,000 person-years

42. • Dermatologic and respiratory symptoms are most common, occurring
in 90 and 70 percent of episodes, respectively.
• The three most common triggers are food, insect stings, and
medications.
• Food-related reactions are most common in children up to four years
of age, and medication reactions are most common in patients older
than 55 years.

44. • The diagnosis of anaphylaxis is typically made when symptoms
occur within one hour of exposure to a specific antigen.

45. • A biphasic reaction is a second acute anaphylactic reaction occurring
hours after the first response and without further exposure to the
allergen.
• One to 20 percent of patients with anaphylaxis experience biphasic
reactions, which usually occur within eight hours of the initial
reaction, but may occur as late as 24 to 72 hours after exposure

46. • Compared with that of the general population, the risk of anaphylaxis
is doubled in patients with mild asthma and tripled in those with
severe disease.

47. • 90 % skin manifestation , urticarial , angioedam
• 70% respiratory manifestation
• 45% gastrointestinal system, cardiovascular
• 15 %neurological

48. • The clinical history is the most important tool to determine whether a
patient has had an anaphylactic reaction and the cause of the
episode.

51. DDX
• Any condition that may result in the sudden, dramatic collapse of the
patient such as
• myocardial ischemia
• pulmonary embolism
• foreign body aspiration
• acute poisoning
• hypoglycemia,
• seizure, can be confused with severe anaphylaxis.

52. • . However, a vasovagal event is the most common condition confused
with anaphylaxis.
• Bradycardia helps differentiate vasovagal events from anaphylaxis,
because tachycardia is typical in the latter.
• However, tachycardia can transition into bradycardia during the end
stages of a severe anaphylactic reaction when vascular collapse
occurs.

53. Management
• Securing the airway and providing 100 percent oxygen
• Intravenous fluid administration is critical for all patients whose
hypotension does not respond to epinephrine.
• In adults and adolescents, 2 L of normal saline are usually
administered initially; more may be required in severe cases.

54. • Children should receive boluses of 10 to 20 mL per kg until
hypotension is controlled.
• Even in the presence of upper airway obstruction, placing a patient in
the recumbent position with the lower extremities raised is preferred
over elevating the head of the patient's bed, because the vascular
collapse during anaphylaxis can be devastating.

55. • Administration of intramuscular epinephrine at the onset of
anaphylaxis, before respiratory failure or cardiovascular
compromise, is essential.
• Histamine H1 receptor antagonists and corticosteroids may be useful
adjuncts.

59. • All patients at risk of recurrent anaphylaxis should be educated
about the appropriate use of prescription epinephrine
autoinjectors.

60. • The preferred route of administration for epinephrine is
intramuscular injection because it provides more reliable and quicker
rise to effective plasma levels than the subcutaneous route.

64. Heat
Stroke
Exhaustion

65. • Heatstroke and heat exhaustion occur when the body’s
thermoregulatory responses are inadequate to preserve homeostasis.
This can result from extrinsic factors that make heat dissipation less
efficient, such as extremes of temperature, physical effort, and
environmental conditions.

66. • Classic heatstroke is caused by environmental exposure and results in
core hyperthermia above 40°C (104°F). This condition primarily occurs
in the elderly and those with chronic illness.
• These manifestations are thought to be an encephalopathic response
to a systemic inflammatory cascade

67. • Heat exhaustion is a more common and less extreme manifestation of
heat-related illness in which the core temperature is between 37°C
(98.6°F) and 40°C.
• Symptoms of heat exhaustion are milder than those of heatstroke,.
Patients with heat exhaustion lack the profound central nervous
system derangement found in those with heat stroke .
• Their symptoms typically resolve promptly with proper hydration and
cooling.

68. Heat
stroke
Heat
exhuastion

70. Cooling
external Internal

71. • External method
• A- evaporation
• In evaporative cooling, a mist of cool water (15°C [59°F]) is sprayed on
the patient’s skin, while warm air (45°C [113°F]) is fanned over the
body. Cooling rates with this technique have been measured at 0.31°C
(0.56°F) per minute.

73. • B-immersion
• Immersion cooling can be achieved with an ice bath, or by using
cooling blankets in conjunction with ice packs placed on the axilla,
groin, neck, and head
• Although immersion methods are thought to be less effective than
evaporative cooling, direct comparison studies are lacking.

74. • Internal method :
• Internal cooling methods are more effective in rapidly decreasing
temperature
• Gastric, bladder, and rectal cold-water lavage
• Peritoneal and thoracic lavage are performed only in extreme cases.
• Cardiopulmonary bypass also is a rare but effective cooling method.

76. Complications of Heatstroke
• Central nervous system injury is permanent in 20 percent of cases and
is associated with poor prognosis.
• Rhabdomyolysisincrease risk of renal injury
• Hepatocytes may be damaged, causing coagulopathy and hepatitis.
• Myocardial muscle may be damaged and result in arrhythmias or
even cardiac arrest.

77. Prevention
• Preparation for and understanding of heat-stroke can help prevent
much of its associated morbidity and mortality.
• Physicians should encourage their patients to protect themselves by
maintaining adequate hydration, avoiding heat exposure, wearing
loose, light clothing, and monitoring their exertion level.

78. • Athletes should be advised to acclimatize for at least three to four
days before exerting in the heat.
• Because a heat injury releases an inflammatory cascade that may
increase risk on subsequent days, patients should be protected from
exposure to heat for 24 to 48 hours following a mild injury.

80. Referance
• www.aafp.org
• Nationtal guidelines on poisoning management
• Clinical management of common emergency cases at PHC