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Do you know him?
Steve Irwin

―The Crocodile Hunter‖
Stingray Barb
Bites
Epidemiology
1% of ED visits
 80-90% are from dogs
 5-15% are from cats

Human Deaths from Animal Attacks
Humans – 200,000
 Snake – 60,000
 Crocodile– 1000
 Tiger – 800-1600
 Lion –60-200
 Leopard—30-125
 Hippopotamus 200-300

Any guesses about the animal?
It’s a Human Bite
Human Bites

Open Mouth
Microbiology






80% S. aureus
Mouth Anaerobes
Group A β-hemolytic Strep
Eikenella
Dog/Cat Bites

Cat Bite

Pit Bull Bite
Dog Bite






4.7 million bits annually
750,000 visits
66% of bites are not reported
59 per 10,000 incidence
250 per 10,000 in India


96% percent of rabies cases

Chhabra M. Humna rabies in Delhi, Indian Journal of Peds, 2004;
71;217-220
CDC, US, 2001. MMWR 2003;52:605-610
Cat Bites
400,000 bits annually
 Mostly female cats
 Mostly female victims


Smith Treating Mammalian bite wounds,
J Clinical Pharm , 2000; 25:85-99
Microbiology
Pasteurella multocida –60%
 S. aureus
 Cynocatophagia
 Anaerobes
 The average dog has 64 different bacterial
isolates in mouth

Most poisonous snakes have the
following characteristics:







Large fangs
Vertical slits for pupils, much like those of a cat
A heat-sensitive pit between the eye and the nostril
on each side of the head
A variety of differently shaped blotches on a
background of pink, yellow, olive, tan, gray, or
brown skin
The triangular head is larger than the neck

22
23
Severity of Snakebite







The location of the bite (fatty tissue absorbs the
venom more slowly than muscle tissue)
Whether disease-causing organisms are in the
venom
The size and weight of the victim
The general health and condition of the victim
How much physical activity the victim engaged in
immediately following the bite (physical activity
helps spread venom)

24
Signs and Symptoms of Snakebite







Two distinct fang marks about half an inch apart at the bite
site, which may or may not bleed (in some cases there may
be only one fang mark)
Immediate and severe burning pain and swelling around the
fang marks, usually within 5 minutes but sometimes taking
as long as 4 hours to develop (swelling may affect the entire
arm or leg)
Purplish discoloration and blood-filled blisters around the
bite, usually within 2 to 10 hours
Numbness around the bite

25
First Aid Care for Snakebite
Regardless of the type of snakebite, never
 Cut the skin, which can cause infection
 Use suction of any kind
 Use a tourniquet, which can result in loss of
a limb
 Apply ice, which causes more rapid
absorption of the venom
 Use electric shock, which can cause severe
injury
26
First Aid Care for Snakebite
Instead, do the following:
1. Treat a nonpoisonous snakebite as you would any minor wound; clean with soap and
water, cover with a dry sterile dressing, and seek medical advice.
2. For pit viper bite, move the victim away from the snake (they will bite more than once,
and can strike half their body length). Keep the victim calm and quiet; if possible, the
victim should not walk. Clean the bite with soap and water, then splint the affected
extremity. Seek medical attention immediately; antivenim is available only in
hospitals (partly because of its short shelf life) and must be administered within 4
hours.
3. For coral snake bite, gently wash the bite with soap and water and wrap the entire
extremity with several elastic bandages, exerting moderate pressure to slow the
spread of venom. Use overlapping turns to keep the pressure from the bandage firm,
beginning at the end of the limb farthest from the heart; gently stretch the bandage
as you wrap. Use figure-eight turns around the knee or elbow. When you have
finished, the bandage should be firm, but you should be able to slip your finger under
the bandage. Leave the toes or fingers exposed so you can check for any kind of
discoloration, which would indicate that the bandage is wrapped too
tightly;
the victim should also stay alert for numbness or tingling in the
fingers or toes,
which also indicate that the bandage is too tight.
Seek medical
attention immediately: an effective antivenin is available.
27
Marine Bites
Shark, fish, eel
 Vibrio(cirrhotics)
 Aeromonas(GNR)

Evaluation
Provoked or unprovoked?
 Penicillin allergy
 Tetanus status
 Evaluate for injury below the skin

Treatment
Aggressive debridement and wound
lavage
 Closure of lacerations within 24 hours
 May avoid antibiotics in superficial dermis
non-extremity wounds(scalp)
 All hand bites get prophylactic antibiotics
 ABX may be warranted in immunocompromised hosts

Antibiotic Selection
Amoxicillin/Clavulanate
 Azithromycin
 Cipro

Rabies Prophylaxis
Live captured animal is best
 Need the head
 Keep it in the frig until it can be analyzed
 Unprovoked aggression
 Lack of fear of humans
 Daylight attacks

Bees/Wasps

Paper wasp
Bumble bee

Honey bee

Yellow jacket
Bee Stings


Local edema
Prednisone—for local edema
 H1 blockade –for urticaria
 Epinephrine-laryngeal edema

Flea Bites
Chiggers
Tick Line Up
Eyrthema Chronica Migrans
Prophylaxis
Routine use of antibiotics or serologic
testing after tic bite
 Remove attached tic ASAP
 Treatment with ticks attached longer than
48 hours (C-III)

Who to Treat
All Patients with ECM(A-I)
 All patients who develop a rash or high
fever (>100F) within 30 days of bite (A-II)






Erlichiciosis or Babesiosis

All patients with positive ELISA(A-1)
Spiders
Spiders-Brown Recluse
Brown Recluse Bite
Harmless

Daddy Long Legs

House Spider
Black widow
•Found in every state in US
•Usually warmer climates
•Highly venomous
•Have them bring in the
spider
Yellow Sac
•Bites feel like bee sting
•Serum Sickness
•Eschar not always present
Scabies
Treatment
Permethrin (A)
 Launder clothing and sheets
 Launder the kids, spouse
 Zoloft may be necessary

Insect Bites and Stings
Signs and Symptoms include:
 A mark from the bite or sting
 Pain or tenderness at and surrounding the bite or sting
 Redness at and surrounding the bite or sting
 Swelling around the bite or sting
 A venom sac, stinger, tentacle, or other remnant of the insect at
the bite or sting
Medical help is necessary if:
 Itching lasts longer than 2 days.
 Signs of infection develop.
 Signs of an allergic reaction develop.
 The insect is poisonous, most often black widow or
brown recluse spiders (which can be fatal).
50
First Aid for Bites and Stings
1. If the stinger is still present, remove it by gently scraping against it with
the edge of your fingernail.
2. Wash the area around the bite or sting gently with a soap solution
3. Remove any jewelry or other constricting objects as soon as possible—
ideally, before any swelling begins.
4. Lower the site of the bite or sting slightly below the level of the victim’s
heart.
5. Apply a cold compress to the site of an insect bite or scorpion sting to
relieve pain and swelling
6. Apply a paste of baking soda and water to relieve the pain of bee sting
7. Observe the victim carefully for at least 30 minutes to determine whether
he or she is developing the signs and symptoms of an allergic reaction
8. Keep the victim calm, limit physical activity, and keep the victim
warm; arrange for transport as soon as possible

51
Thank you

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Bites

  • 1. Do you know him?
  • 2.
  • 3.
  • 4.
  • 8. Epidemiology 1% of ED visits  80-90% are from dogs  5-15% are from cats 
  • 9. Human Deaths from Animal Attacks Humans – 200,000  Snake – 60,000  Crocodile– 1000  Tiger – 800-1600  Lion –60-200  Leopard—30-125  Hippopotamus 200-300 
  • 10.
  • 11.
  • 12.
  • 13.
  • 14. Any guesses about the animal?
  • 17. Microbiology     80% S. aureus Mouth Anaerobes Group A β-hemolytic Strep Eikenella
  • 19. Dog Bite      4.7 million bits annually 750,000 visits 66% of bites are not reported 59 per 10,000 incidence 250 per 10,000 in India  96% percent of rabies cases Chhabra M. Humna rabies in Delhi, Indian Journal of Peds, 2004; 71;217-220 CDC, US, 2001. MMWR 2003;52:605-610
  • 20. Cat Bites 400,000 bits annually  Mostly female cats  Mostly female victims  Smith Treating Mammalian bite wounds, J Clinical Pharm , 2000; 25:85-99
  • 21. Microbiology Pasteurella multocida –60%  S. aureus  Cynocatophagia  Anaerobes  The average dog has 64 different bacterial isolates in mouth 
  • 22. Most poisonous snakes have the following characteristics:      Large fangs Vertical slits for pupils, much like those of a cat A heat-sensitive pit between the eye and the nostril on each side of the head A variety of differently shaped blotches on a background of pink, yellow, olive, tan, gray, or brown skin The triangular head is larger than the neck 22
  • 23. 23
  • 24. Severity of Snakebite      The location of the bite (fatty tissue absorbs the venom more slowly than muscle tissue) Whether disease-causing organisms are in the venom The size and weight of the victim The general health and condition of the victim How much physical activity the victim engaged in immediately following the bite (physical activity helps spread venom) 24
  • 25. Signs and Symptoms of Snakebite     Two distinct fang marks about half an inch apart at the bite site, which may or may not bleed (in some cases there may be only one fang mark) Immediate and severe burning pain and swelling around the fang marks, usually within 5 minutes but sometimes taking as long as 4 hours to develop (swelling may affect the entire arm or leg) Purplish discoloration and blood-filled blisters around the bite, usually within 2 to 10 hours Numbness around the bite 25
  • 26. First Aid Care for Snakebite Regardless of the type of snakebite, never  Cut the skin, which can cause infection  Use suction of any kind  Use a tourniquet, which can result in loss of a limb  Apply ice, which causes more rapid absorption of the venom  Use electric shock, which can cause severe injury 26
  • 27. First Aid Care for Snakebite Instead, do the following: 1. Treat a nonpoisonous snakebite as you would any minor wound; clean with soap and water, cover with a dry sterile dressing, and seek medical advice. 2. For pit viper bite, move the victim away from the snake (they will bite more than once, and can strike half their body length). Keep the victim calm and quiet; if possible, the victim should not walk. Clean the bite with soap and water, then splint the affected extremity. Seek medical attention immediately; antivenim is available only in hospitals (partly because of its short shelf life) and must be administered within 4 hours. 3. For coral snake bite, gently wash the bite with soap and water and wrap the entire extremity with several elastic bandages, exerting moderate pressure to slow the spread of venom. Use overlapping turns to keep the pressure from the bandage firm, beginning at the end of the limb farthest from the heart; gently stretch the bandage as you wrap. Use figure-eight turns around the knee or elbow. When you have finished, the bandage should be firm, but you should be able to slip your finger under the bandage. Leave the toes or fingers exposed so you can check for any kind of discoloration, which would indicate that the bandage is wrapped too tightly; the victim should also stay alert for numbness or tingling in the fingers or toes, which also indicate that the bandage is too tight. Seek medical attention immediately: an effective antivenin is available. 27
  • 28. Marine Bites Shark, fish, eel  Vibrio(cirrhotics)  Aeromonas(GNR) 
  • 29. Evaluation Provoked or unprovoked?  Penicillin allergy  Tetanus status  Evaluate for injury below the skin 
  • 30. Treatment Aggressive debridement and wound lavage  Closure of lacerations within 24 hours  May avoid antibiotics in superficial dermis non-extremity wounds(scalp)  All hand bites get prophylactic antibiotics  ABX may be warranted in immunocompromised hosts 
  • 32. Rabies Prophylaxis Live captured animal is best  Need the head  Keep it in the frig until it can be analyzed  Unprovoked aggression  Lack of fear of humans  Daylight attacks 
  • 34. Bee Stings  Local edema Prednisone—for local edema  H1 blockade –for urticaria  Epinephrine-laryngeal edema 
  • 39. Prophylaxis Routine use of antibiotics or serologic testing after tic bite  Remove attached tic ASAP  Treatment with ticks attached longer than 48 hours (C-III) 
  • 40. Who to Treat All Patients with ECM(A-I)  All patients who develop a rash or high fever (>100F) within 30 days of bite (A-II)    Erlichiciosis or Babesiosis All patients with positive ELISA(A-1)
  • 44.
  • 46. Black widow •Found in every state in US •Usually warmer climates •Highly venomous •Have them bring in the spider
  • 47. Yellow Sac •Bites feel like bee sting •Serum Sickness •Eschar not always present
  • 49. Treatment Permethrin (A)  Launder clothing and sheets  Launder the kids, spouse  Zoloft may be necessary 
  • 50. Insect Bites and Stings Signs and Symptoms include:  A mark from the bite or sting  Pain or tenderness at and surrounding the bite or sting  Redness at and surrounding the bite or sting  Swelling around the bite or sting  A venom sac, stinger, tentacle, or other remnant of the insect at the bite or sting Medical help is necessary if:  Itching lasts longer than 2 days.  Signs of infection develop.  Signs of an allergic reaction develop.  The insect is poisonous, most often black widow or brown recluse spiders (which can be fatal). 50
  • 51. First Aid for Bites and Stings 1. If the stinger is still present, remove it by gently scraping against it with the edge of your fingernail. 2. Wash the area around the bite or sting gently with a soap solution 3. Remove any jewelry or other constricting objects as soon as possible— ideally, before any swelling begins. 4. Lower the site of the bite or sting slightly below the level of the victim’s heart. 5. Apply a cold compress to the site of an insect bite or scorpion sting to relieve pain and swelling 6. Apply a paste of baking soda and water to relieve the pain of bee sting 7. Observe the victim carefully for at least 30 minutes to determine whether he or she is developing the signs and symptoms of an allergic reaction 8. Keep the victim calm, limit physical activity, and keep the victim warm; arrange for transport as soon as possible 51