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GEMC - Mammal and Human Bite Injuries

This document discusses mammal and human bite injuries, outlining their epidemiology, mechanisms of injury, and associated risks, including infection rates from various species. It provides guidelines on prophylactic antibiotic use, wound management, and treatment strategies for bites, emphasizing the need for careful evaluation of injuries and appropriate medical intervention. The information is intended to educate and inform, underlining that it is not a substitute for professional medical advice.

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Project: Ghana Emergency Medicine Collaborative Document Title: Mammal and Human Bite Injuries Author(s): Jim Holliman, M.D., F.A.C.E.P., Uniformed Services University, 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
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Mammal and Human Bite Injuries Jim Holliman, M.D., F.A.C.E.P. Program Manager, Afghanistan Health Care Sector Reconstruction Project Center for Disaster and Humanitarian Assistance Medicine Professor of Military and Emergency Medicine Uniformed Services University Bethesda, Maryland, U.S.A. 3
Mammal Bite Injuries Lecture Outline •  Non-bite injuries from animals •  Dog, cat, & rodent bites •  Human bites •  Rabies •  Tetanus 4
Relative Annual Death Rates (Worldwide) •  Suicides : 400,000 •  Murders : 200,000 •  Snakebites : 60,000 •  Crocodiles : 1,000 •  Farm animals : 800 (mostly from kick injuries) •  Tigers : 500 (?) •  1 million people eaten over last 5 centuries •  Lions : 400 •  Leopards : 300 •  Hippos : 300 •  Elephants : 200 5
North American Large Wild Mammals Attack Risks •  Grizzly bears : 6 deaths in Yellowstone since 1900 ; 7 deaths in Glacier N.P. since 1907 ; maybe average of one death per year in Alaska •  Black bears : almost no reports of attacks •  Polar bears : very rare attacks •  Moose : some injuries but very rare deaths •  Jaguar , mountain lion : only one case each •  Bison : about one death per year •  Musk, ox, mountain sheep and goats : almost none •  Coyotes, wolves : almost none 6
The most dangerous mammal in North America Averette, Wikimedia Commons 7
The Most Dangerous U.S. Big Game Mammals : Deer & Moose •  Kill over 100 people per year in car vs. animal collisions •  1994 review of moose vs. car incidents in Maine : •  658 collisions •  70 % of vehicle occupants hospitalized •  17 % had cervical spine injuries •  9 % died 8
Averater, Wikimedia Commons 9
Mammal Bites : Epidemiology •  > 50 million pet cats & dogs in U.S. •  > 1,000,000 bites / year in U.S. •  200 to 800 bites / 100,000 people per year •  80 to 90 % of bites due to dogs •  1 to 2 % of bites need admission •  10 to 12 deaths from dog bites per year •  Tremendous economic cost 10
Venomous Mammals (medical trivia) •  Only 3 known : •  Short-tailed shrew (Blarina brevicauda) in northeastern U.S. •  Secretes protein venom from maxillary glands •  Injects venom with lower incisors •  Venom causes edema, pain up to 2 weeks duration •  No specific treatment •  Male platypus (Ornithorhynchus anatinus) in Australia •  Injects venom from hollow spur in hind leg •  Causes pain, edema, lymphangitis •  Spiny anteater (echidna) in Africa •  Similar spur and venom •  No reported human injuries 11
Mechanisms of Injury From Animals •  Horses •  Bite frequently •  Kick backward with both feet •  Cattle •  Bite rarely •  Kick forward with one foot •  Camels •  Bite and kick •  Ostriches : kick & attempt to disembowel 12
Diseases Transmissable From Mammals to Humans (By Bite, Scratch, or Lick) •  Brucellosis •  Melioidosis •  Glanders •  Pasteurellosis •  Plague •  Yersiniosis •  Tularemia •  Rat-bite fever •  Tetanus •  Erysipeloid •  Staph Toxic Shock •  Tuberculosis •  Q fever •  Murine typhus •  Leptospirosis •  Simian herpes •  Foot and mouth disease •  Rabies •  Cat scratch disease •  Lymphocytic choriomeningitis •  Simian hepatitis •  Rio Bravo infection •  Sporotrichosis •  Blastomycosis 13
Mammal Bites By Species •  New York City •  Dogs : 89 % •  Cats : 4.6 % •  Rodents : 2.2 % •  Humans : 3.6 % ! •  Ohio •  Dogs : 91.6 % •  Cats : 4.5 % •  Rodents : 3 % •  Humans : 0.03 % 14
Average Infection Rates From Mammal Bites Dogs : 2 to 5 % Cats : 30 to 50 % Rats : 2to10% Monkeys : 25% Humans : 13to50%* *Higher rates reported mainly from delayed presentations15
Mammal Bites : Etiologic Agents for Wound Infections •  Dogs •  Staph. aureus : 10 to 30 % •  Strep species : 30 to 50 % •  Pasteurella multocida : 0 to 30 % •  Corynebacterium species : 10 to 30 % •  Cats •  Pasteurella multocida : 60 to 80 % •  Rodents •  Strep species : 30 to 70 % 16
Mammal Bites : Increased Infection Risk Factors •  Age < 2 or > 50 years •  Diabetes •  Immunosuppressive illness •  Chronic alcoholism •  Puncture wounds •  Large wounds •  Extremities •  Delayed (> 4 to 24 hrs.) presentation 17
Mammal Bites : Use of Wound Cultures •  Initial (fresh) animal bite wound cultures : •  Not recommended •  Initial culture results do not correlate with later proven infecting organisms •  However if the patient presents delayed, with signs of infection, then wound cultures are useful 18
Dog Bite Infections •  Overall infection rates are 2 to 5 % (however up to 20 % of hand bites) •  fortuitum80 % of these infections are aerobes : •  Pasteurella multocida ( zero to 1/3) •  Staph. aureus •  Strep •  Corynebacterium •  Uncommon: •  Fungi •  Clostridia •  Rabies •  Mycobacteria 19
Incidence of Dog Bites (By Breed) Decreasing German Shepherd : most common Incidence Pit Bull : most fatal bites Mixed Breeds Doberman St. Bernard Great Dane Rotweiler Collie 20
Fatal Dog Bites •  Injuries concentrated about head and neck (injuries only on limbs in most non-fatal bites) •  Fatal attacks cannot be predicted from the dog's prior behavior •  Most offending dogs revert to normal friendly behavior after the attack •  Therefore infants and disabled should never be left alone with a large dog 21
Considerations About Radiographs for Dog Bite Cases •  Large dogs can generate forces > 500 foot- pounds per square inch with their jaws •  Therefore can cause extremity long bone fractures •  Also can cause dural penetration from scalp bites in small children (this can lead to fatal meningitis if missed in the E.D.) •  So skull films may be needed to see if there is inner table penetration from teeth 22
Cat Bite Infections •  30 to 50 % become infected •  These infection rates can still occur despite appropriate initial wound care •  Claw scratches also have high infection rates if not quickly cleansed (due to cat licking paws often) 23
Cat Bite Wounds Complications •  Wound cellulitis •  Septic arthritis •  Septic tendonitis •  Meningitis •  Disseminated pasteurellosis •  Tetanus •  Rabies •  Cat Scratch Fever •  Cosmetic defects, scarring 24
Pasteurella multocida •  Culturable in 75 % of cats (including large cats such as lions & tigers) •  Causes 3 types of disease : •  Local soft tissue infection •  Pneumonia / pulmonary abscess in immunocompromised patient : rare •  Disseminated pasteurellosis : in patient with liver disease 25
Complications of Pasteurella Infection (in 40 %) •  Local septic arthritis •  Osteomyelitis •  Tenosynovitis •  Bacteremia 26
Cat-bite wound infection of second proximal interphalangeal joint due to Pasteurella multocida. Failure of cephalexin therapy resulted in septic arthritis. Source Undetermined 27
Dog bite wound infected due to Pasteurella multocida and anaerobic bacteria. Source Undetermined 28
Hershey 1994 Study of Cat Bite Cases Seen in the E.D. •  30 cases •  40 % developed cellulitis •  14 % required hospital admission •  Majority of wounds were on upper extremities •  Only empiric Rx failures were in cases treated with Augmentin (amoxicillin- clavulanate) 29
Cat Scratch Fever •  Caused by bite or scratch •  Due to pleomorphic bacterium : Bartonella henselae •  Does not take up gram stain well (best seen with silver stains) •  Usually benign and self-limited illness •  Same bacteria associated with bacillary angiomatosis in immunocompromised patients •  Encephalitis can occur in 1 to 7 % of cases 30
Cat Scratch Fever : Syndrome Progression •  Local lymphodenopathy next to bite or scratch site •  Red papule leads to pustule at bite or scratch site : heals in 1 to 4 weeks •  Regional lymphodenopathy / malaise / fever up to 3 months •  Rare progression to pneumonia or encephalitis or endocarditis •  Can be part of differential of FUO 31
High magnification micrograph of Cat Scratch Disease. Nephron, Wikimedia Commons 32
Source Undetermined 33
Axillary lymphadenitis from Cat Scratch Disease Source Undetermined 34
Fundoscopic view of patient with choreoretinitis from Cat Scratch Disease (vision returned in 3 months) Source Undetermined 35
Cat Scratch Fever Treatment •  Prior reports indicated that usual antibiotics were ineffective •  Two reports indicated success in hospitalized patients with gentamicin •  One recent small case number report found good response to oral ciprofloxacin 36
Rat Bite Infections •  Rat bite fever (classic) •  Due to Streptobacillus moniliformis •  Rash : may involve palms & soles, high fever, polyarthritis •  Sodoku (spirillary rat bite fever) •  Due to Spirillum minus (a spirochete) •  Regional lymphodenopathy, rash, fever •  Either type could be cause of FUO (fever of unknown origin) 37
Rat Bite Fever : Treatment •  PCN 500 mg QID x 7 days or Erythromycin or Tetracycline (same dose) •  Usually PO antibiotics are sufficient (occasionally relative PCN resistance is encountered) 38
Mammal Bites : Rules for Prophylactic Antibiotics •  Yes for all bites of the hands •  Yes for all human bites with significant skin penetration •  Yes for almost all cat bites •  Yes if any question of bite fascial penetration •  Probably not needed for simple, smaller dog or rodent bites, especially of the face or scalp 39
Prophylactic Antibiotic Choices for Mammal Bites •  Dogs : need to cover for Staph. aureus •  Dicloxacillin or cephalexin 500 mg PO qid x 7 days •  Erythromycin or azithromycin if patient PCN allergic •  Cats : need to cover Pasteurella multocida •  Penicillin V potassium 500 mg PO qid x 7 days •  Ciprofloxacin or azithromycin if PCN allergic (Rx failures reported for tetracycline, erythromycin, & cephalosporins) •  Ciprofloxacin 500 mg PO qid x 7 days for cat scratch fever •  Rodents : Penicillin V potassium 500 mg PO qid x 7 days •  Note : Amoxicillin / clavulanate often touted as antibiotic of choice for bites but no good controlled study yet done to demonstrate this (is expensive & has high % side effects) 40
Mammal Bite : Wound Closure Rules •  Never suture human bites of the hands •  Never suture cat bites of the hands •  Never suture deep cat bite puncture wounds •  Seldom suture dog bites of the hands •  Usually OK to suture bites of the face or scalp •  Usually OK to suture rodent bites 41
Dog bite lacerations of the face Source Undetermined 42
Same patient after primary suture repair Source Undetermined 43
Same patient after healing, with good cosmetic outcome Source Undetermined 44
Mammal Bites Criteria for Hospital Admission •  Admit to hospital if : •  Patient presents with deep established infection •  Possible penetration of joint capsule •  Surgical (Operating Room) repair required •  Associated fracture present 45
Dog bite of the neck that caused intimal disruption of the vertebral artery. Source Undetermined 46
Child bitten by a ferret Source Undetermined 47
Another child bitten by a ferret Source Undetermined 48
All these should have primary suture repair Source Undetermined 49
Facial lacerations from dog bite before and after repair Sources Undetermined 50
Infections Transmitted By Human Bites •  Streptococci : 50 % •  Staph. aureus : 38 % •  Eikenella corrodens : 29 % •  Actinomycosis •  Syphillis •  Tuberculosis •  Hepatitis B •  ? AIDS ( no cases proven yet ) 51
Human Bite Wounds : Treatment Sequence •  Culture the wound ( + anerobes) •  Wound cleansing / opening •  Debridement / irrigation •  PO or IV cephalosporin for 5 to 7 days •  Add gentamicin if Eikenella corrodens is cultured •  Splint / elevation of limb •  Change bandage at least daily 52
Human Bite Wounds : Treatment Based on Anatomic Site •  Hickeys (skin abrasion only) : cleansing, consider tetanus immunization, apply topical antibiotic creme •  Face : irrigate, consider tetanus, OK to suture, give PO antibiotic •  Trunk or breast : same as face (some may need delayed closure) •  Hand : do not suture ; often need admission ; If discharged, F/U in 24 hours 53
Human Bite Wounds of the Hand : Indications for Admission •  Presentation > 24 hours from injury •  Any degree of infection beyond local wound cellulitis •  Lymphangitis or any purulent drainage •  Pain on passive ROM of fingers •  Questionable tendon or joint space involvement •  Immunocompromised •  Unable to follow outpatient instructions 54
Human Bite Wounds : Closed-fist Injuries •  Get X-rays of hand ; look for : •  Foreign bodies (tooth chips) •  Fractures (boxer's fracture common) •  Air in joint or tendon space •  Defects in subchondral bone plate •  Irrigate •  IV antibiotics (best choice debatable) •  PCN + cephalosporin •  ? gentamicin, ? ceftriaxone •  Splint These are all indications for surgical exploration 55
Human bite wound with early cellulitis Berteun, Wikimedia Commons 56
Septic arthritis from human bite resulting in digit amputation Source Undetermined 57
Osteomyelitis of distal phalanx from human bite Source Undetermined 58
Osteomyelitis of proximal phalanx from human bite Source Undetermined 59
Typical “occult” human tooth bite mark over metacarpal head ; note early edema and cellulitis Evilgurl, Flickr 60
Mixed bacterial infection from human bite, 6 hours after time of injury Source undetermined 61
Unfortunate outcome for the same patient on the prior slide Source undetermined 62
Cost Comparisons of Some Rx Items for Animal Bites (Pennsylvania, 2005) •  Penicillin VK 500 mg PO qid for 7 days : $ 4.20 •  Dicloxacillin 500 mg PO qid for 7 days : $ 11.76 •  Cefalexin 500 mg PO qid for 7 days : $ 6.44 •  Augmentin 500 mg PO tid for 7 days : $ 40.32 •  Cefazolin 1 gram IV : $ 0.89 •  Nafcillin 1 gram IV : $ 5.83 •  Ceftriaxone 1 gram IV : $ 32.21 •  5 cc. Rabies Immune Globulin IM : $ 302.85 •  5 one cc. doses HDCV : $ 517.80 •  Wound culture / sensitivity : $ 66.00 Note : the IV costs listed do not include the nursing administration fees 63
Rabies •  Caused by an RNA rhabdovirus •  Transmitted by inoculation of infectious saliva •  Rarely can be transmitted by inhalation (from bats in caves) •  Causes a severe, uniformly fatal encephalitis •  Only 4 documented survivors worldwide so far 64
Electron micrograph of the rabies virus, demonstrating the bullet shape and capsular spikes. Sanofi Pasteur, Flickr 65
Dog with rabies. There is a ferocious appearance, excess salivation and anisocoria. State Farm, Flickr 66
Rabies Prophylaxis for Mammal Bite Wounds •  Pennsylvania currently has second highest state rate in U.S. of wild animal rabies •  Raccoon - based epidemic in eastern U.S. since late 1970's •  State Public Health Laboratories will do exams of sacrificed animals for rabies •  HDCV is current agent of choice (replaces DEV) •  Followup antibody titer after completion of series no longer recommended 67
Rabies Incidence in U.S.A. •  4,000 proven domestic animals / year •  Predominately dogs, cats, cattle •  15,000 proven wild animals / year •  Represents sampling by state labs so true incidence is much higher •  Average 1 U.S. human death / year (about 800 worldwide human deaths reported per year) 68
Rabies : Clinical Progression •  Bite •  Incubation period : weeks to months (no symptoms) ; shorter for head or neck bites •  Prodromal phase : 2 days to 2 weeks •  Neurologic symptoms : one week or more •  Paralytic phase : several weeks to months 69
Rabies : Symptom Progression •  Prodrome phase : fever, malaise, headache, sore throat •  Neurologic phase : paresthesias at bite site, anxiety, restlessness, insomnia, dysphagia, hydrophobia (from fear of painful esophageal spasms), spasms, seizures •  Flaccid paralysis : leads to coma •  Cardiovascular collapse •  Supportive treatment uniformly ineffective to date 70
Risk of Rabies Transmission from Animal Bite High Risk Bats Raccoons Foxes Coyotes / bobcats Other carnivores Intermediate Risk "Outdoor" cats and dogs Cattle in Midwest USA Low Risk Rodents Lagomorphs (hares & rabbits) Farm animals Indoor cats and dogs 71
Protocol for Starting Rabies Prophylaxis •  High risk bite & animal escapes : give prophylaxis •  High risk bite & animal captured : send animal's head to State Health Lab for path exam ; treat only if lab confirms rabid animal (brain sections show Negri bodies) •  Low risk animal & animal escapes : consider prophylaxis only if bite clearly unprovoked •  Low risk animal & animal captured : keep animal under reliable observation one week ; if animal gets sick : immediate check by veterinarian or State Health Lab ; if animal remains well 7 days : no Rx needed 72
Mammal Bites : Rabies Prophylaxis Summary •  If animal cannot be recovered : •  Dog / Cat / Cattle : yes •  Foxes / Skunks / Raccoons : yes •  Bats / Bears : yes •  Rodents / Rabbits : no •  ( ? if unprovoked squirrel ; due to one case report of rabid squirrel) •  Deer / Elk / Moose : no 73
Rabies Prophylaxis •  Post-exposure : •  HDCV 1.0 ml IM on days 0, 3, 7, 14, 28 •  Plus RIG 20 IU / kg IM on day 0 •  Pre-exposure : •  HDCV 1.0 ml IM on days 0, 7, 21 •  This is utilized for forest rangers, veterinarians, & others who have higher risk of encountering rabies •  Still requires booster dose after each exposure 74
Countries Without Animal Rabies •  Pacific Islands •  Caribbean Islands •  United Kingdom •  Iceland •  Singapore •  Australia •  Portugal •  Spain •  Sweden •  Japan •  Taiwan 75
Tetanus : Etiology •  Clostridium tetani (gram positive bacillus) spores enter wound, replicate, and produce toxins ; anerobic environment required •  Causative toxins •  Tetanospasmin : causes tetanus •  Tetanolysin : reduces tissue redux potential ; promotes bacterial replication 76
Micrograph of Clostridium tetani Centers for Disease Control and Prevention, Wikimedia Commons 77
Mechanism of Action of Toxicity from Clostridium tetani •  Bacteria release tetanospasmin toxin •  Tetanospasmin then : •  Travels via lymphatics and retrograde up neuronal axons •  Blocks inhibitory neurotransmitter release (glycine, GABA) •  Results in hyperactivity (disinhibition) of motor neurons 78
Autonomic Nervous System Effects of Tetanus •  Disinhibition of sympathetic nervous system results in elevated catechol secretion by the adrenals, causing : •  High blood pressure / hypertensive crisis •  Tachycardia •  Fever 79
Tetanus : Epidemiology •  90 U.S. cases reported / year ; case incidence 0.04 / 100,000 per year •  ? 1,000,000 deaths / year world-wide ; 90 % due to neonatal tetanus (often due to soil contamination of umbilical stump) 80
Classification of Tetanus •  Generalized : most common type •  Localized (These may progress to •  Cephalic generalized) •  Neonatal 81
Tetanus : Clinical Course •  Incubation period = time from inoculation to appearance of first symptoms •  Period of onset = from first symptom to time of first reflex spasm 82
Progression of Symptoms in Generalized Tetanus Trismus neck stiffness risus sardonicus opisthotonus rigid abdomen spasms 83
Tetanus : Differential Diagnosis •  Oral or Dental or Temporomandibular joint pathology •  Acute dystonic reaction •  Strychnine ingestion •  Stiff-man syndrome •  Rabies •  Black widow spider bites •  Hypocalcemic tetany •  Meningoencephalitis or CNS metastases •  Trichinosis •  Hepatic encephalopathy •  Cocaine abuse 84
Causes of Tetanus in 239 Patients from One Review Etiologic factor Number of patients Neonatal tetanus 3 (1.1%) Acute injury Puncture Laceration 166 (69.5%) 85 81 Circumstances - Indoor activity Gardening related activity Animal related Major trauma Other 68 65 7 7 19 Other identified condition Chronic wound, abscess, etc. Parenteral drug use No apparent source 53 (22.2%) 48 5 17 (7.2%) 85
•  *The case of tetanus in the Navy occurred in an individual who was circumcised several days before enlisting and who then developed tetanus despite post-enlistment immunization Reported Cases of Tetanus in the U.S. Armed Forces U.S. Armed Forces Unit Period No. of cases Army 1956 to 1977 0 Navy / Marine Corps 1946 to 1977 1* Air Force 1958 to 1977 2 86
Classification of the Severity of Tetanus Severity Incubation period (d) Period of Onset (d) Associated findings Mild 10 or more 4 to 7 Local rigidity, mild trismus Moderate 7 to 10 3 to 6 Severe trismus dysphagia, spasms Severe Less than 7 Less than 3 Severe spasms, diffuse rigidity, autonomic dysfunction (“d” = “days”) 87
Tetanus Mortality •  1982 to 1984 overall mortality 26 % •  All patients < 30 years old survived •  52 % of patients > 60 years old died •  Some reports : > 90 % mortality for neonatal tetanus 88
•  A measurable titer of anti-tetanus antibody excludes the diagnosis •  This test seldom would be available acutely however •  Prior episode of tetanus does not confer immunity (toxin dose too low to stimulate antibodies) •  Diagnosis cannot be excluded just because no wound present Diagnostic Confirmation of Tetanus 89
Tetanus : Treatment •  Admit to ICU •  Limit exams & consults on patient (they trigger spasms) •  Intubation & mechanical ventilation •  High-dose benzodiazepines •  Diazepam : up to 500 mg/day may be needed (IV) •  Lorazepam : up to 80 mg/day in 2 mg IV increments •  Methocarbamol 3 to 4 g IV q6h if unable to take benzodiazepines, or Dantrolene 1 to 2 mg/kg q 4h as an adjunctive agent •  Pancuronium (paralysis) : may be necessary to control severe spasms and prevent fracture (2 mg IV increments) 90
Tetanus : Additional Treatment Measures •  Human tetanus immune globulin (binds unbound toxin) 500 to 5000 units IM •  Labetolol : 0.25 to 1.0 mg / min. constant infusion or morphine 0.5 to 1.0 mg / kg / 6 h IV •  Temporary cardiac pacing for bradyarrhythmias •  "Prophylactic" SQ heparin 5000 units q 12 h •  Metronidazole 500 mg IV q 6 h •  Wound debridement •  Enteral hyperalimentation •  Supportive psychotherapy •  Active immunization at follow-up (3 doses of toxoid) 91
Complications of Tetanus •  Rhabdomyolysis : leads to renal failure •  Respiratory failure •  Negative nitrogen balance •  Fractures, tendon separations •  Ectopic calcification •  Autonomic instability (like "pheochromocytoma crisis") 92
A child suffering from tetanus in opisthotonos Centers for Disease Control and Prevention, Wikimedia Commons 93
Compression fractures of upper mid-thoracic vertebral bodies in a case of tetanus. Source undetermined 94
Routine Diphtheria, Tetanus, and Pertussis Immunization Schedule Summary for Children Dose Age / Interval Product Primary 1 6 weeks or older DTP Primary 2 4 to 8 weeks after first dose DTP Primary 3 4 to 8 weeks after second dose DTP Primary 4 6 to12 months after third dose DTP Booster 4 to 6 years old, before entering DTP elementary school (not necessary if 4th primary immunizing dose administered on or after 4th birthday) Additional boosters Every 10 years after last dose Td 95
Considerations for Use of Tetanus Immune Globulin (Hypertet) •  Immunodeficient patient : Check serum antitetanus antibody levels and give passive immunization (Hypertet 250 u IM) for any wound if patient is antibody deficient and cannot mount antibody response to Td •  Also give Hypertet 250 u IM to any patient with a highly tetanus prone wound who has lapsed immunity (> 10 years since last Td immunization) 96
Tetanus - Prone Wounds •  Deep punctures •  Large, deep lacerations •  Imbedded foreign body •  Stool or soil contamination •  Delayed presentation •  Deep burns 97
Tetanus Immunization General Guidelines •  Standard dose is 0.5 cc for both dT and TT (tetanus toxoid without diptheria booster) •  Good general rule for most wound cases is to administer it if > 5 years since last dose (even for minimal skin injuries) •  Also give TIG (Hypertet) if : •  Patient never immunized •  Immunosuppressed •  Allergic or severe local reaction to toxoid •  Highly tetanus prone wound & > 10 years since last dose 98
Mammal and Human Bites Lecture Summary •  Consider need for radiographs •  Always perform careful wound cleansing & irrigation •  Decide if antibiotics & suture closure are indicated •  Assess for risk of rabies & tetanus •  Assure close followup 99

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GEMC - Mammal and Human Bite Injuries

  • 1.
    Project: Ghana EmergencyMedicine Collaborative Document Title: Mammal and Human Bite Injuries Author(s): Jim Holliman, M.D., F.A.C.E.P., Uniformed Services University, 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  • 2.
    Attribution Key for moreinformation see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt Make Your Own Assessment Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Creative Commons – Zero Waiver Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. { Content the copyright holder, author, or law permits you to use, share and adapt. } { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } { Content Open.Michigan has used under a Fair Use determination. } 2
  • 3.
    Mammal and Human BiteInjuries Jim Holliman, M.D., F.A.C.E.P. Program Manager, Afghanistan Health Care Sector Reconstruction Project Center for Disaster and Humanitarian Assistance Medicine Professor of Military and Emergency Medicine Uniformed Services University Bethesda, Maryland, U.S.A. 3
  • 4.
    Mammal Bite Injuries LectureOutline •  Non-bite injuries from animals •  Dog, cat, & rodent bites •  Human bites •  Rabies •  Tetanus 4
  • 5.
    Relative Annual DeathRates (Worldwide) •  Suicides : 400,000 •  Murders : 200,000 •  Snakebites : 60,000 •  Crocodiles : 1,000 •  Farm animals : 800 (mostly from kick injuries) •  Tigers : 500 (?) •  1 million people eaten over last 5 centuries •  Lions : 400 •  Leopards : 300 •  Hippos : 300 •  Elephants : 200 5
  • 6.
    North American LargeWild Mammals Attack Risks •  Grizzly bears : 6 deaths in Yellowstone since 1900 ; 7 deaths in Glacier N.P. since 1907 ; maybe average of one death per year in Alaska •  Black bears : almost no reports of attacks •  Polar bears : very rare attacks •  Moose : some injuries but very rare deaths •  Jaguar , mountain lion : only one case each •  Bison : about one death per year •  Musk, ox, mountain sheep and goats : almost none •  Coyotes, wolves : almost none 6
  • 7.
    The most dangerousmammal in North America Averette, Wikimedia Commons 7
  • 8.
    The Most DangerousU.S. Big Game Mammals : Deer & Moose •  Kill over 100 people per year in car vs. animal collisions •  1994 review of moose vs. car incidents in Maine : •  658 collisions •  70 % of vehicle occupants hospitalized •  17 % had cervical spine injuries •  9 % died 8
  • 9.
  • 10.
    Mammal Bites :Epidemiology •  > 50 million pet cats & dogs in U.S. •  > 1,000,000 bites / year in U.S. •  200 to 800 bites / 100,000 people per year •  80 to 90 % of bites due to dogs •  1 to 2 % of bites need admission •  10 to 12 deaths from dog bites per year •  Tremendous economic cost 10
  • 11.
    Venomous Mammals (medical trivia) • Only 3 known : •  Short-tailed shrew (Blarina brevicauda) in northeastern U.S. •  Secretes protein venom from maxillary glands •  Injects venom with lower incisors •  Venom causes edema, pain up to 2 weeks duration •  No specific treatment •  Male platypus (Ornithorhynchus anatinus) in Australia •  Injects venom from hollow spur in hind leg •  Causes pain, edema, lymphangitis •  Spiny anteater (echidna) in Africa •  Similar spur and venom •  No reported human injuries 11
  • 12.
    Mechanisms of InjuryFrom Animals •  Horses •  Bite frequently •  Kick backward with both feet •  Cattle •  Bite rarely •  Kick forward with one foot •  Camels •  Bite and kick •  Ostriches : kick & attempt to disembowel 12
  • 13.
    Diseases Transmissable FromMammals to Humans (By Bite, Scratch, or Lick) •  Brucellosis •  Melioidosis •  Glanders •  Pasteurellosis •  Plague •  Yersiniosis •  Tularemia •  Rat-bite fever •  Tetanus •  Erysipeloid •  Staph Toxic Shock •  Tuberculosis •  Q fever •  Murine typhus •  Leptospirosis •  Simian herpes •  Foot and mouth disease •  Rabies •  Cat scratch disease •  Lymphocytic choriomeningitis •  Simian hepatitis •  Rio Bravo infection •  Sporotrichosis •  Blastomycosis 13
  • 14.
    Mammal Bites BySpecies •  New York City •  Dogs : 89 % •  Cats : 4.6 % •  Rodents : 2.2 % •  Humans : 3.6 % ! •  Ohio •  Dogs : 91.6 % •  Cats : 4.5 % •  Rodents : 3 % •  Humans : 0.03 % 14
  • 15.
    Average Infection RatesFrom Mammal Bites Dogs : 2 to 5 % Cats : 30 to 50 % Rats : 2to10% Monkeys : 25% Humans : 13to50%* *Higher rates reported mainly from delayed presentations15
  • 16.
    Mammal Bites : EtiologicAgents for Wound Infections •  Dogs •  Staph. aureus : 10 to 30 % •  Strep species : 30 to 50 % •  Pasteurella multocida : 0 to 30 % •  Corynebacterium species : 10 to 30 % •  Cats •  Pasteurella multocida : 60 to 80 % •  Rodents •  Strep species : 30 to 70 % 16
  • 17.
    Mammal Bites : IncreasedInfection Risk Factors •  Age < 2 or > 50 years •  Diabetes •  Immunosuppressive illness •  Chronic alcoholism •  Puncture wounds •  Large wounds •  Extremities •  Delayed (> 4 to 24 hrs.) presentation 17
  • 18.
    Mammal Bites : Useof Wound Cultures •  Initial (fresh) animal bite wound cultures : •  Not recommended •  Initial culture results do not correlate with later proven infecting organisms •  However if the patient presents delayed, with signs of infection, then wound cultures are useful 18
  • 19.
    Dog Bite Infections • Overall infection rates are 2 to 5 % (however up to 20 % of hand bites) •  fortuitum80 % of these infections are aerobes : •  Pasteurella multocida ( zero to 1/3) •  Staph. aureus •  Strep •  Corynebacterium •  Uncommon: •  Fungi •  Clostridia •  Rabies •  Mycobacteria 19
  • 20.
    Incidence of DogBites (By Breed) Decreasing German Shepherd : most common Incidence Pit Bull : most fatal bites Mixed Breeds Doberman St. Bernard Great Dane Rotweiler Collie 20
  • 21.
    Fatal Dog Bites • Injuries concentrated about head and neck (injuries only on limbs in most non-fatal bites) •  Fatal attacks cannot be predicted from the dog's prior behavior •  Most offending dogs revert to normal friendly behavior after the attack •  Therefore infants and disabled should never be left alone with a large dog 21
  • 22.
    Considerations About Radiographs forDog Bite Cases •  Large dogs can generate forces > 500 foot- pounds per square inch with their jaws •  Therefore can cause extremity long bone fractures •  Also can cause dural penetration from scalp bites in small children (this can lead to fatal meningitis if missed in the E.D.) •  So skull films may be needed to see if there is inner table penetration from teeth 22
  • 23.
    Cat Bite Infections • 30 to 50 % become infected •  These infection rates can still occur despite appropriate initial wound care •  Claw scratches also have high infection rates if not quickly cleansed (due to cat licking paws often) 23
  • 24.
    Cat Bite Wounds Complications • Wound cellulitis •  Septic arthritis •  Septic tendonitis •  Meningitis •  Disseminated pasteurellosis •  Tetanus •  Rabies •  Cat Scratch Fever •  Cosmetic defects, scarring 24
  • 25.
    Pasteurella multocida •  Culturablein 75 % of cats (including large cats such as lions & tigers) •  Causes 3 types of disease : •  Local soft tissue infection •  Pneumonia / pulmonary abscess in immunocompromised patient : rare •  Disseminated pasteurellosis : in patient with liver disease 25
  • 26.
    Complications of Pasteurella Infection(in 40 %) •  Local septic arthritis •  Osteomyelitis •  Tenosynovitis •  Bacteremia 26
  • 27.
    Cat-bite wound infectionof second proximal interphalangeal joint due to Pasteurella multocida. Failure of cephalexin therapy resulted in septic arthritis. Source Undetermined 27
  • 28.
    Dog bite woundinfected due to Pasteurella multocida and anaerobic bacteria. Source Undetermined 28
  • 29.
    Hershey 1994 Studyof Cat Bite Cases Seen in the E.D. •  30 cases •  40 % developed cellulitis •  14 % required hospital admission •  Majority of wounds were on upper extremities •  Only empiric Rx failures were in cases treated with Augmentin (amoxicillin- clavulanate) 29
  • 30.
    Cat Scratch Fever • Caused by bite or scratch •  Due to pleomorphic bacterium : Bartonella henselae •  Does not take up gram stain well (best seen with silver stains) •  Usually benign and self-limited illness •  Same bacteria associated with bacillary angiomatosis in immunocompromised patients •  Encephalitis can occur in 1 to 7 % of cases 30
  • 31.
    Cat Scratch Fever: Syndrome Progression •  Local lymphodenopathy next to bite or scratch site •  Red papule leads to pustule at bite or scratch site : heals in 1 to 4 weeks •  Regional lymphodenopathy / malaise / fever up to 3 months •  Rare progression to pneumonia or encephalitis or endocarditis •  Can be part of differential of FUO 31
  • 32.
    High magnification micrographof Cat Scratch Disease. Nephron, Wikimedia Commons 32
  • 33.
  • 34.
    Axillary lymphadenitis fromCat Scratch Disease Source Undetermined 34
  • 35.
    Fundoscopic view ofpatient with choreoretinitis from Cat Scratch Disease (vision returned in 3 months) Source Undetermined 35
  • 36.
    Cat Scratch Fever Treatment • Prior reports indicated that usual antibiotics were ineffective •  Two reports indicated success in hospitalized patients with gentamicin •  One recent small case number report found good response to oral ciprofloxacin 36
  • 37.
    Rat Bite Infections • Rat bite fever (classic) •  Due to Streptobacillus moniliformis •  Rash : may involve palms & soles, high fever, polyarthritis •  Sodoku (spirillary rat bite fever) •  Due to Spirillum minus (a spirochete) •  Regional lymphodenopathy, rash, fever •  Either type could be cause of FUO (fever of unknown origin) 37
  • 38.
    Rat Bite Fever: Treatment •  PCN 500 mg QID x 7 days or Erythromycin or Tetracycline (same dose) •  Usually PO antibiotics are sufficient (occasionally relative PCN resistance is encountered) 38
  • 39.
    Mammal Bites : Rulesfor Prophylactic Antibiotics •  Yes for all bites of the hands •  Yes for all human bites with significant skin penetration •  Yes for almost all cat bites •  Yes if any question of bite fascial penetration •  Probably not needed for simple, smaller dog or rodent bites, especially of the face or scalp 39
  • 40.
    Prophylactic Antibiotic Choices forMammal Bites •  Dogs : need to cover for Staph. aureus •  Dicloxacillin or cephalexin 500 mg PO qid x 7 days •  Erythromycin or azithromycin if patient PCN allergic •  Cats : need to cover Pasteurella multocida •  Penicillin V potassium 500 mg PO qid x 7 days •  Ciprofloxacin or azithromycin if PCN allergic (Rx failures reported for tetracycline, erythromycin, & cephalosporins) •  Ciprofloxacin 500 mg PO qid x 7 days for cat scratch fever •  Rodents : Penicillin V potassium 500 mg PO qid x 7 days •  Note : Amoxicillin / clavulanate often touted as antibiotic of choice for bites but no good controlled study yet done to demonstrate this (is expensive & has high % side effects) 40
  • 41.
    Mammal Bite : WoundClosure Rules •  Never suture human bites of the hands •  Never suture cat bites of the hands •  Never suture deep cat bite puncture wounds •  Seldom suture dog bites of the hands •  Usually OK to suture bites of the face or scalp •  Usually OK to suture rodent bites 41
  • 42.
    Dog bite lacerationsof the face Source Undetermined 42
  • 43.
    Same patient afterprimary suture repair Source Undetermined 43
  • 44.
    Same patient afterhealing, with good cosmetic outcome Source Undetermined 44
  • 45.
    Mammal Bites Criteria forHospital Admission •  Admit to hospital if : •  Patient presents with deep established infection •  Possible penetration of joint capsule •  Surgical (Operating Room) repair required •  Associated fracture present 45
  • 46.
    Dog bite ofthe neck that caused intimal disruption of the vertebral artery. Source Undetermined 46
  • 47.
    Child bitten bya ferret Source Undetermined 47
  • 48.
    Another child bittenby a ferret Source Undetermined 48
  • 49.
    All these shouldhave primary suture repair Source Undetermined 49
  • 50.
    Facial lacerations from dog bitebefore and after repair Sources Undetermined 50
  • 51.
    Infections Transmitted By HumanBites •  Streptococci : 50 % •  Staph. aureus : 38 % •  Eikenella corrodens : 29 % •  Actinomycosis •  Syphillis •  Tuberculosis •  Hepatitis B •  ? AIDS ( no cases proven yet ) 51
  • 52.
    Human Bite Wounds: Treatment Sequence •  Culture the wound ( + anerobes) •  Wound cleansing / opening •  Debridement / irrigation •  PO or IV cephalosporin for 5 to 7 days •  Add gentamicin if Eikenella corrodens is cultured •  Splint / elevation of limb •  Change bandage at least daily 52
  • 53.
    Human Bite Wounds: Treatment Based on Anatomic Site •  Hickeys (skin abrasion only) : cleansing, consider tetanus immunization, apply topical antibiotic creme •  Face : irrigate, consider tetanus, OK to suture, give PO antibiotic •  Trunk or breast : same as face (some may need delayed closure) •  Hand : do not suture ; often need admission ; If discharged, F/U in 24 hours 53
  • 54.
    Human Bite Woundsof the Hand : Indications for Admission •  Presentation > 24 hours from injury •  Any degree of infection beyond local wound cellulitis •  Lymphangitis or any purulent drainage •  Pain on passive ROM of fingers •  Questionable tendon or joint space involvement •  Immunocompromised •  Unable to follow outpatient instructions 54
  • 55.
    Human Bite Wounds: Closed-fist Injuries •  Get X-rays of hand ; look for : •  Foreign bodies (tooth chips) •  Fractures (boxer's fracture common) •  Air in joint or tendon space •  Defects in subchondral bone plate •  Irrigate •  IV antibiotics (best choice debatable) •  PCN + cephalosporin •  ? gentamicin, ? ceftriaxone •  Splint These are all indications for surgical exploration 55
  • 56.
    Human bite woundwith early cellulitis Berteun, Wikimedia Commons 56
  • 57.
    Septic arthritis fromhuman bite resulting in digit amputation Source Undetermined 57
  • 58.
    Osteomyelitis of distalphalanx from human bite Source Undetermined 58
  • 59.
    Osteomyelitis of proximalphalanx from human bite Source Undetermined 59
  • 60.
    Typical “occult” humantooth bite mark over metacarpal head ; note early edema and cellulitis Evilgurl, Flickr 60
  • 61.
    Mixed bacterial infectionfrom human bite, 6 hours after time of injury Source undetermined 61
  • 62.
    Unfortunate outcome for the same patienton the prior slide Source undetermined 62
  • 63.
    Cost Comparisons ofSome Rx Items for Animal Bites (Pennsylvania, 2005) •  Penicillin VK 500 mg PO qid for 7 days : $ 4.20 •  Dicloxacillin 500 mg PO qid for 7 days : $ 11.76 •  Cefalexin 500 mg PO qid for 7 days : $ 6.44 •  Augmentin 500 mg PO tid for 7 days : $ 40.32 •  Cefazolin 1 gram IV : $ 0.89 •  Nafcillin 1 gram IV : $ 5.83 •  Ceftriaxone 1 gram IV : $ 32.21 •  5 cc. Rabies Immune Globulin IM : $ 302.85 •  5 one cc. doses HDCV : $ 517.80 •  Wound culture / sensitivity : $ 66.00 Note : the IV costs listed do not include the nursing administration fees 63
  • 64.
    Rabies •  Caused byan RNA rhabdovirus •  Transmitted by inoculation of infectious saliva •  Rarely can be transmitted by inhalation (from bats in caves) •  Causes a severe, uniformly fatal encephalitis •  Only 4 documented survivors worldwide so far 64
  • 65.
    Electron micrograph ofthe rabies virus, demonstrating the bullet shape and capsular spikes. Sanofi Pasteur, Flickr 65
  • 66.
    Dog with rabies.There is a ferocious appearance, excess salivation and anisocoria. State Farm, Flickr 66
  • 67.
    Rabies Prophylaxis for MammalBite Wounds •  Pennsylvania currently has second highest state rate in U.S. of wild animal rabies •  Raccoon - based epidemic in eastern U.S. since late 1970's •  State Public Health Laboratories will do exams of sacrificed animals for rabies •  HDCV is current agent of choice (replaces DEV) •  Followup antibody titer after completion of series no longer recommended 67
  • 68.
    Rabies Incidence inU.S.A. •  4,000 proven domestic animals / year •  Predominately dogs, cats, cattle •  15,000 proven wild animals / year •  Represents sampling by state labs so true incidence is much higher •  Average 1 U.S. human death / year (about 800 worldwide human deaths reported per year) 68
  • 69.
    Rabies : ClinicalProgression •  Bite •  Incubation period : weeks to months (no symptoms) ; shorter for head or neck bites •  Prodromal phase : 2 days to 2 weeks •  Neurologic symptoms : one week or more •  Paralytic phase : several weeks to months 69
  • 70.
    Rabies : SymptomProgression •  Prodrome phase : fever, malaise, headache, sore throat •  Neurologic phase : paresthesias at bite site, anxiety, restlessness, insomnia, dysphagia, hydrophobia (from fear of painful esophageal spasms), spasms, seizures •  Flaccid paralysis : leads to coma •  Cardiovascular collapse •  Supportive treatment uniformly ineffective to date 70
  • 71.
    Risk of RabiesTransmission from Animal Bite High Risk Bats Raccoons Foxes Coyotes / bobcats Other carnivores Intermediate Risk "Outdoor" cats and dogs Cattle in Midwest USA Low Risk Rodents Lagomorphs (hares & rabbits) Farm animals Indoor cats and dogs 71
  • 72.
    Protocol for StartingRabies Prophylaxis •  High risk bite & animal escapes : give prophylaxis •  High risk bite & animal captured : send animal's head to State Health Lab for path exam ; treat only if lab confirms rabid animal (brain sections show Negri bodies) •  Low risk animal & animal escapes : consider prophylaxis only if bite clearly unprovoked •  Low risk animal & animal captured : keep animal under reliable observation one week ; if animal gets sick : immediate check by veterinarian or State Health Lab ; if animal remains well 7 days : no Rx needed 72
  • 73.
    Mammal Bites : RabiesProphylaxis Summary •  If animal cannot be recovered : •  Dog / Cat / Cattle : yes •  Foxes / Skunks / Raccoons : yes •  Bats / Bears : yes •  Rodents / Rabbits : no •  ( ? if unprovoked squirrel ; due to one case report of rabid squirrel) •  Deer / Elk / Moose : no 73
  • 74.
    Rabies Prophylaxis •  Post-exposure: •  HDCV 1.0 ml IM on days 0, 3, 7, 14, 28 •  Plus RIG 20 IU / kg IM on day 0 •  Pre-exposure : •  HDCV 1.0 ml IM on days 0, 7, 21 •  This is utilized for forest rangers, veterinarians, & others who have higher risk of encountering rabies •  Still requires booster dose after each exposure 74
  • 75.
    Countries Without Animal Rabies • Pacific Islands •  Caribbean Islands •  United Kingdom •  Iceland •  Singapore •  Australia •  Portugal •  Spain •  Sweden •  Japan •  Taiwan 75
  • 76.
    Tetanus : Etiology • Clostridium tetani (gram positive bacillus) spores enter wound, replicate, and produce toxins ; anerobic environment required •  Causative toxins •  Tetanospasmin : causes tetanus •  Tetanolysin : reduces tissue redux potential ; promotes bacterial replication 76
  • 77.
    Micrograph of Clostridiumtetani Centers for Disease Control and Prevention, Wikimedia Commons 77
  • 78.
    Mechanism of Actionof Toxicity from Clostridium tetani •  Bacteria release tetanospasmin toxin •  Tetanospasmin then : •  Travels via lymphatics and retrograde up neuronal axons •  Blocks inhibitory neurotransmitter release (glycine, GABA) •  Results in hyperactivity (disinhibition) of motor neurons 78
  • 79.
    Autonomic Nervous System Effectsof Tetanus •  Disinhibition of sympathetic nervous system results in elevated catechol secretion by the adrenals, causing : •  High blood pressure / hypertensive crisis •  Tachycardia •  Fever 79
  • 80.
    Tetanus : Epidemiology • 90 U.S. cases reported / year ; case incidence 0.04 / 100,000 per year •  ? 1,000,000 deaths / year world-wide ; 90 % due to neonatal tetanus (often due to soil contamination of umbilical stump) 80
  • 81.
    Classification of Tetanus • Generalized : most common type •  Localized (These may progress to •  Cephalic generalized) •  Neonatal 81
  • 82.
    Tetanus : ClinicalCourse •  Incubation period = time from inoculation to appearance of first symptoms •  Period of onset = from first symptom to time of first reflex spasm 82
  • 83.
    Progression of Symptomsin Generalized Tetanus Trismus neck stiffness risus sardonicus opisthotonus rigid abdomen spasms 83
  • 84.
    Tetanus : Differential Diagnosis • Oral or Dental or Temporomandibular joint pathology •  Acute dystonic reaction •  Strychnine ingestion •  Stiff-man syndrome •  Rabies •  Black widow spider bites •  Hypocalcemic tetany •  Meningoencephalitis or CNS metastases •  Trichinosis •  Hepatic encephalopathy •  Cocaine abuse 84
  • 85.
    Causes of Tetanusin 239 Patients from One Review Etiologic factor Number of patients Neonatal tetanus 3 (1.1%) Acute injury Puncture Laceration 166 (69.5%) 85 81 Circumstances - Indoor activity Gardening related activity Animal related Major trauma Other 68 65 7 7 19 Other identified condition Chronic wound, abscess, etc. Parenteral drug use No apparent source 53 (22.2%) 48 5 17 (7.2%) 85
  • 86.
    •  *The caseof tetanus in the Navy occurred in an individual who was circumcised several days before enlisting and who then developed tetanus despite post-enlistment immunization Reported Cases of Tetanus in the U.S. Armed Forces U.S. Armed Forces Unit Period No. of cases Army 1956 to 1977 0 Navy / Marine Corps 1946 to 1977 1* Air Force 1958 to 1977 2 86
  • 87.
    Classification of theSeverity of Tetanus Severity Incubation period (d) Period of Onset (d) Associated findings Mild 10 or more 4 to 7 Local rigidity, mild trismus Moderate 7 to 10 3 to 6 Severe trismus dysphagia, spasms Severe Less than 7 Less than 3 Severe spasms, diffuse rigidity, autonomic dysfunction (“d” = “days”) 87
  • 88.
    Tetanus Mortality •  1982to 1984 overall mortality 26 % •  All patients < 30 years old survived •  52 % of patients > 60 years old died •  Some reports : > 90 % mortality for neonatal tetanus 88
  • 89.
    •  A measurabletiter of anti-tetanus antibody excludes the diagnosis •  This test seldom would be available acutely however •  Prior episode of tetanus does not confer immunity (toxin dose too low to stimulate antibodies) •  Diagnosis cannot be excluded just because no wound present Diagnostic Confirmation of Tetanus 89
  • 90.
    Tetanus : Treatment • Admit to ICU •  Limit exams & consults on patient (they trigger spasms) •  Intubation & mechanical ventilation •  High-dose benzodiazepines •  Diazepam : up to 500 mg/day may be needed (IV) •  Lorazepam : up to 80 mg/day in 2 mg IV increments •  Methocarbamol 3 to 4 g IV q6h if unable to take benzodiazepines, or Dantrolene 1 to 2 mg/kg q 4h as an adjunctive agent •  Pancuronium (paralysis) : may be necessary to control severe spasms and prevent fracture (2 mg IV increments) 90
  • 91.
    Tetanus : AdditionalTreatment Measures •  Human tetanus immune globulin (binds unbound toxin) 500 to 5000 units IM •  Labetolol : 0.25 to 1.0 mg / min. constant infusion or morphine 0.5 to 1.0 mg / kg / 6 h IV •  Temporary cardiac pacing for bradyarrhythmias •  "Prophylactic" SQ heparin 5000 units q 12 h •  Metronidazole 500 mg IV q 6 h •  Wound debridement •  Enteral hyperalimentation •  Supportive psychotherapy •  Active immunization at follow-up (3 doses of toxoid) 91
  • 92.
    Complications of Tetanus • Rhabdomyolysis : leads to renal failure •  Respiratory failure •  Negative nitrogen balance •  Fractures, tendon separations •  Ectopic calcification •  Autonomic instability (like "pheochromocytoma crisis") 92
  • 93.
    A child sufferingfrom tetanus in opisthotonos Centers for Disease Control and Prevention, Wikimedia Commons 93
  • 94.
    Compression fractures ofupper mid-thoracic vertebral bodies in a case of tetanus. Source undetermined 94
  • 95.
    Routine Diphtheria, Tetanus,and Pertussis Immunization Schedule Summary for Children Dose Age / Interval Product Primary 1 6 weeks or older DTP Primary 2 4 to 8 weeks after first dose DTP Primary 3 4 to 8 weeks after second dose DTP Primary 4 6 to12 months after third dose DTP Booster 4 to 6 years old, before entering DTP elementary school (not necessary if 4th primary immunizing dose administered on or after 4th birthday) Additional boosters Every 10 years after last dose Td 95
  • 96.
    Considerations for Useof Tetanus Immune Globulin (Hypertet) •  Immunodeficient patient : Check serum antitetanus antibody levels and give passive immunization (Hypertet 250 u IM) for any wound if patient is antibody deficient and cannot mount antibody response to Td •  Also give Hypertet 250 u IM to any patient with a highly tetanus prone wound who has lapsed immunity (> 10 years since last Td immunization) 96
  • 97.
    Tetanus - ProneWounds •  Deep punctures •  Large, deep lacerations •  Imbedded foreign body •  Stool or soil contamination •  Delayed presentation •  Deep burns 97
  • 98.
    Tetanus Immunization General Guidelines • Standard dose is 0.5 cc for both dT and TT (tetanus toxoid without diptheria booster) •  Good general rule for most wound cases is to administer it if > 5 years since last dose (even for minimal skin injuries) •  Also give TIG (Hypertet) if : •  Patient never immunized •  Immunosuppressed •  Allergic or severe local reaction to toxoid •  Highly tetanus prone wound & > 10 years since last dose 98
  • 99.
    Mammal and HumanBites Lecture Summary •  Consider need for radiographs •  Always perform careful wound cleansing & irrigation •  Decide if antibiotics & suture closure are indicated •  Assess for risk of rabies & tetanus •  Assure close followup 99