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

4. MARINE BITES AND STINGS:

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