Transcript Bites-animal, insects, poisoning Dr. J Frank 2012

That Bites!
Back to Basics
Review
Jason R. Frank
MD MA(Ed) FRCPC
Dept of Emergency Medicine
Bites & the MCC
• According to the MCC, what are the bites that every
doctor should know something about?
Important Medical Bites
MCC List:
Other list:
1. Dog bites
2. Cat bites
3. Human bites
4. Insect stings
5. Snake bites
1. Spider bites
2. Jellyfish stings
3. Scorpion stings
4. Tick bites
5. Bat bites
Case 1
Case 1
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A 20 woman presents with this bite
Delivering fliers
Neighbourhood dog
Unsure of owner
12 hours ago
Case 1
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Diagnostic issues?
Management issues?
Plan for this case?
Epidemiology?
Medicolegal?
Dog Bites
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Many MD visits (12,000 bites/day US)
Usually child <5
10-20 deaths per year US
Dx Issues:
– 6 incisors, straight, large deep punctures
– Circumstances; dog ownership; safety
– Nature of each wound
– r/o rabies
– Bacteria: anaerobes, Strep, Staph, etc
• 5-6% dog bites get infected
• Rare sepsis: Capnocytophaga canimorus
Dog Bites
• Tx
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issues:
Abx: Clavulin; Clinda + Cipro
Tetanus (Td)
Wound management
?Closure
Pain management
Rabies prophylaxis
Public health reporting
Safety for all
• Medicolegal
– Documentation
– Testimony
Case 1 – Your Management?
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A 20 woman presents with this bite
Delivering fliers
Neighbourhood dog
Unsure of owner
12 hours ago
Case 2
Case 2
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75 F
Her cat startled watching Senators lose on CBC
Bit her forearm
3 hours ago
Pain worse
What should she do?
Cat Bites
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Diagnostic issues?
Management issues?
Plan for this case?
Epidemiology?
Medicolegal?
Cat Bites
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Similar to dog bites
60-80% infection rate
Bacteria: esp Pasturella multocida
Very rapid cellulitis
Cat-scratch LN: Bartonella
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Rx Clavulin, doxycyline, or cefuroxime
Splint
Re-check
r/o osteomyelitis
Case 2 – Your Plan?
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75 F
Her cat startled watching Senators loss on CBC
Bit her forearm
3 hours ago
Pain worse
What should she do?
Case 3
Case 3
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19 male, HBD
“Minding his own business” at a bar
Assaulted
He “won”
Punched in face
Punched the other guy – cut his knuckle on tooth
Feeling hung over
Wants to leave, tired of waiting
Case 3
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Diagnostic issues?
Management issues?
Plan for this case?
Epidemiology?
Medicolegal?
Human Bites
• Bacterial Infections
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mouth bugs, including anaerobes, Staph, Strep
Eikenella
Rx Clavulin; Pip-tazo
Rx Clindamycin + Cipro
Tetanus
• Viral infections
– HIV, Hep B, Hep C; HSV
– PEP
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Wound management
“Closed fist injuries” / “Fight bites”
Other sites: ears, etc
Four incisors, oval
Case 3 – What is Your Plan?
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19 male, HBD
“Minding his own business” at a bar
Assaulted
He “won”
Punched in face
Punched the other guy – cut his knuckle on tooth
Feeling hung over
Wants to leave
Case 4
Case 4
• Bad field trip to woods
• Multiple kids with “bug bites”
Case 4 continued
• Hymenoptera (honeybees, bumblebees, wasps, ants)
– Anaphylaxis (IgE, non)
– Remove stinger
– 2’ infections (Staph, Strep)
• Tick bites
– Ixodes  Lyme disease (Borrelia burgdorferi)
– RMSF, Ehrichiosis, babesiosis, tularemia, etc
– Rx Doxycycline
• Mosquito bites
– Symptomatic (NSAIDS, antihistamines)
– West Nile Virus
Case 4 continued - Spiders
• Black widow spider
– Aggressive females
– Rare systemic
– Rx antivenom if severe
• Brown Recluse / “Fiddleback”
– More common
– Necrotic arachnism
– DIC, death
– Supportive
Case 5
Case 5
• 50 diabetic man bit by a snake at a petting zoo
Case 5
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Diagnostic issues?
Management issues?
Plan for this case?
Epidemiology?
Medicolegal?
Case 5 – Snake Bites
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Wound care
Identify snake
In Canada: Massasauga rattler
Antivenom (Rx CroFab)
That Bites! - Summary
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Clear history of events, timing
Identify all wounds
Wound care
Punctures
Foreign bodies
Tetanus
Abx
Other PEP: HIV, Hep B, Hep C, Rabies
Public health
Documentation
That Bites! - Summary
MCC List:
• Other list:
1. Dog bites
2. Cat bites
3. Human bites
4. Insect stings
1. Spider bites
1. Hymenoptera
2. Mosquitoes
5. Snake bites
1. Black widow
2. Brown recluse
2. Tick bites
1. Lyme disease
That Bites!
Back to Basics
Review
Jason R. Frank
MD MA(Ed) FRCPC
Dept of Emergency Medicine