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Primary closure:
Appropriate for most bites
1. MAMMALIAN BITES: Optimize the aesthetic and
Epidemiology: functional outcome
Incidence Head and neck wounds seen within
Most patients -> Minor wounds 24hours. Bec head and neck area is
Dogs -> 80-90% very vascular
followed by cats and humans Aesthetic results are important and
majority -> family or infection rates are low
neighbourhood pets Low-risk wounds to the arms, legs
Treatment: and trunk if seen within 6-12hours
Evaluation of the bite
Risk of blunt and penetrating Wounds prone to the development
trauma of infection ( read Box 23-1), such
Animals produce blunt injuries by as those initially seen longer than
striking and crushing 24hours after the bite (or longer
Teeth and claws can puncture than 6hours if ear or nose cartilage
Patients with serious injuries are is involved)
managed -> Polytrauma Suture. Pwedei isara pag mababa
Attention given to wound infection rate otherwise, pag
management severely infected, isinara mo, mag
Laboratory test -> Hematocrit spread and abscess.
Cultures when infection is present Bites ->Hands/Feet have increase chance of
Radiographs ->Fractures being infected and left open
tetanus immunization updated The primary goal hand bites -> to
Wound care: maximize functional outcome
Local wound management reduces Healing by secondary intention for
risk for infection most hand lacerations
Early wound cleansing -> Prevent Hand is immobilized, wrapped in a
infection and zoonotic diseases bulky dressing and elevated
Intact skin surrounding dirty Clenched fist injury (fight bite) ->High
wounds -> 1% povidone-Iodine Morbidity
solution Injuries over the dorsum of the
Copious high-pressure irrigation metacarpophalangeal joints are
1% povidone-iodine solution can treated as clenched-fist injuries
be used for irrigation (wound is Minor-appearing wounds -> Serious injury
flushed afterward) to the extensor tendon or joint capsule +
Dirty wounds or devitalized tissue oral bacterial contam
are cleansed lightly with gauze or Minor injuries are irrigated,
debrided debrided, and left open
Options for wound repair include: Deeper injuries and infected bites require
Primary closure exploration and debridement. IV antibiotics
Delayed primary closure All bite injuries are re-evaluated in 1 or
Secondary closure 2days to rule out secondary infection
Location, source and the type of
injury Microbiology:
Large variety and concentration of Prophylactic -> with high-risk bites
bacteria in mouths antibiotic choice and route ->type of
Wound infection -> main animal, severity and location of bite
complication Cat bites often cause puncture wounds that
3% to 18% of dog bite wounds and require antibiotics
50% of cat bite wounds Low-risk dog and human bites -> NO benefit
Aerobic and anaerobic bacteria from prophylactic antibiotics unless the
and yield an average of five hand or foot is involved
isolates per culture 24hours after a bite w/o signs of infection
Staphylococcus and Streptococcus -> NO need prophylactic
species and anaerobes Routine cultures of uninfected wounds is
Pasteurella species most common not needed
pathogen (found in 50% of dog Initial antibiotic selection covers
bites and 75% of cat bites) >Staphylococcus and
Human bite wounds are frequently Streptococcus species
contaminated with Eikenella >Anaerobes
corrodens in addition to the >Pasteurella species for dog
microorganisms found after dog and cat bites
and cat bites >E.corrodens for human bites
Pls read Box 23-2(Common Amoxicillin-clavulanate
Bacteria found in animals’ mouth) Alternatives:
Systemic Disease (animal bites): >Second-generation
Rabies cephalosporins
Cat-scratch disease >combination of penicillin and a 1st
Cowpox gen
Tularemia >clindamycin + ciprofloxacin (or
Leptospirosis trimethoprim-sulfamethoxazole if
Brucellosis pregnant or a child)
Human bites have transmitted: >Moxifloxacin
Hepatitis B and C Serious infection -> Hospital admission and
Tuberculosis parental antibiotics
Syphilis >Ampicillin-subactam
Human Immunodeficiency Virus >Cefoxitin
(HIV) >Ticarcillin-clavulanate
>Clindamycin + fluoroquinolone or
HIV transmission from human bites trimethoprin-sulfamethoxazole
is rare, seroconversion is possible
Seroconversion is when an open Rabies:
wound-> exposed to saliva Dog bites or scratches ->Major source
containing HIV-positive blood US -> wildlife, raccoons (primary), skunks,
Baseline and 6-month bats and foxes
postexposure HIV testing Cats and dogs -> Less then 5%of cases
Prophylactic treatment with anti- (rabies control programs)
HIV drugs Rhabdovirus (cause of rabies) is found in
the saliva of animals and transmitted
Antibiotics: bites/scratches
acute encephalitis develops -> die Active immunization consists of
begins with a prodromal phase of administering 1ml of human diploid cell
nonspecific complaints and paresthesias, (+) vaccine, purified chick embryo cell vaccine,
itching/burning at bite site spreading to the or rabies vaccine
entire bitten extremity IM in to the deltoid (adults)
progresses to acute neurologic phase anterolateral aspect of the thigh in
This phase generally takes one of two forms (children)
The more common encephalitic or furious Prophylaxis given days 0, 3, 7, 14 and 28
form -> fever and hypersensitivity, Patients with pre-exposure immunization
stimulated by internal or external factors do not require passive immunization and
(thirst, light, or noise), need active immunization only on days 0
aerophobia/hydrophobia, inspiratory and 3
spasm, and abno of ANS
The paralytic form of rabies is manifested 2. SNAKE BITES:
by fever, progressive weakness, loss of deep Venomous:
tendon reflexes and urinary incontinence -relatively triangular heads, elliptical pupils,
Both forms progress to paralysis, coma, heat sensing facial pits, large retractable
circulatory collapse and death anterior fangs and a single row of subcaudal
Adequate wound care and postexposure scales
prophylaxis Nonvenomous Snakes:
Wounds -> washed with soap and water -more rounded heads, circular pupils, no
and irrigated with povidone-iodine solution fangs, and a double row of subcaudal scales
(virucidal)
rabies exposure -> strongly suspected, leave Local Symptoms:
the wound open puncture wounds/lacerations, minimal pain
The decision to administer rabies burning pain followed by edema/erythema
prophylaxis after an animal bite or scratch swelling progresses
depends on the offending species and the ecchymoses and hemorrhagic bullae may
nature of the event appear
Unprovoked attacks lymphangitis and lymphadenopathy
All wild carnivores must be considered rabid with delayed or inadequate treatment,
NOT birds/reptiles severe tissue necrosis can occur
bite from a healthy-appearing domestic
animal does not require prophylaxis if the Systemic Symptoms:
animal can be observed for 10days weakness, nausea, vomiting, perioral
paresthesias, a metallic taste and muscle
Rabies Prophylaxis: twitching
Passive and active immunization diffuse capillary leakage leads to pulmonary
Passive immunization consists of edema, hypotension and eventually, shock
administering 20 IU/kg body weight of multifactorial acute renal failure resulting
rabies immunoglobulin from direct nephrotoxins, circulatory
Infiltrated into and around the wound collapse, myoglobinuria and consumptive
Rest can be given IM at a site remote from coagulopathy is possible
where the vaccine was given
Fluid Treatment:
Wound is cleansed and immobilized at Fire ants -> multiple pustules from
approximately heart level repetitive stings at the same site
pressure immobilization technique (entire Multiple Hymenoptera stings can produce a
bitten extremity is snugly wrapped with a toxic reaction
bandage) -vomitting, diarrhea, generalized edema,
cardiovascular collapse and hemolysis, ->
Hospital Treatment: difficulty to distinguish from an acute,
Toxicologist or an envenomation specialist anaphylactic reaction
Wound care Large, exaggerated local reactions 17%
Fasciotomy, in venom-induced manifested as erythematous, edematous,
compartment syndrome painful and pruritic areas larger than 10cm
Compartment syndrome – immobilize extremity in diameter and may last 2 to 5 days
with negative pressure inside. To avoid vascular pathophysiology may, in part be IgE
compromise mediated
Bee sting anaphylaxis develops in 0.3% to
3. HYMENOPTERA: 3%
Most anthropod envenomation occurs by Fatalities occur most often in adults, usually
this species within 1 hour of the sting
Includes bees, wasps, yellow jackets, Symptoms within minutes ->mild urticaris
hornets and stinging ants and angioedema -> respiratory arrest
secondary to airways edema and
Toxicology: bronchospasm -> cardiovascular collapse
Hymenopterans sting defensively Unusual reactions include:
stingers are attached to venom sacs located - Late-onset allergic reactions (>5hours after
on the abdomen and can be used the sting)
repeatedly -Late serum sickness
Some bees ->barb-shaped stingers prevent -Renal disease
detachment capable of only a single sting -Neurologic disorders such as Guillain-Barre
Hymenoptera venom contains vasoactive syndrome
compounds -> histamine and serotonin
responsible for the local reaction and pain Treatment:
Venom also contain peptides If a stinger has been left -> remove as
-Melitin quickly as possible to prevent continued
-enzymes (phospholipases and injection of venom
hyaluronides) -> highly allergenic and elicit Sting site is cleansed and cooled
an Ig-E mediated response in some Topical or injected lidocaine
Fire ant venom consists primarily of Antihistamines -> orally or topically can
nonallergenic alkaloids that release decrease pruritus
histamine and cause mild, local necrosis Blisters and pustules (typically sterile) from
Allergenic proteins constitute only 0.1% of fire ant stings are left intact
fire ant venom 5-day course of oral prednisone (1mkd)
Mild anaphylaxis treated with 0.01ml/kg
Clinical Reactions: (up to 0.5ml) of 1:1000 IM epinephrine and
nonallergic individual produces immediate an oral or parenteral antihistamine
pain -> wheal ->flare reaction
Severe cases -> steroids and may require
O2, ET, IV epinephrine in fusion,
bronchodilators, IV fluids or vasopressors
observed for approximately 24hours in a
monitored environment for any recurrence
of severe symptoms
Patients with a history of systemic reactions
resulting from Hymenoptera stings need to
carry injectable epinephrine with them at
all times; they also need to wear an
identification medallion identifying their
medical condition
Initial Assessment:
Injuries range from mild to local irritant skin
reactions to systemic collapse
Immersion in cold water predisposes to
hypothermia
Air embolism or decompression illness
Microbiology:
Most marine isolates are gram-negative
rods
Management:
ABCs
Wound care
Radiographs, CT scans
Anti-tetanus, anti-venom
Antibiotics