EM - Bites, Stings, Marine things

What are some factors that increase susceptibility to infection after an animal bite?

- full thickness puncture

- hand/lower extremity wounds

- wounds requiring debridement

- wounds involving joints, ligaments, tendons, fx

- wounds in high risk hosts

- delayed tx

All animal bites should be considered ___ prone

tetanus

Which labs/diagnostics should be ordered for a patient with an animal bite?

- X-ray (r/o fx, fb)

- wound cultures (anaerobic and aerobic)

- consider abx and rabies prophylaxis

Which organisms are often misidentified after an animal bite?

- eikenella

- pasteurella

What domestic animal is most often infected with rabies?

cat

Tx of possible rabies exposure?

- HRIG (0, 3, 7, and 14 days)

- if symptoms present, rabies is almost always fatal

Which microbes are often found in dog bite wounds?

- alpha hemolytic strep

- staph aureus

- pasturella multocida

- staph intermedius

Tx of dog bites?

- trim devitalized tissue

- remove any foreign bodies/grass

- avoid high pressure irrigation

- consider soaking puncture wounds in betadine

- do not suture wounds <1/2cm

- do not use skin glue

- rabies/tetanus prophylaxis

- augmentin/clindamycin

Which is more likely to get infected: a cat or dog bite?

Cat

What is the major pathogen found in infected cat bites?

Pasturella multocida

Tx of cat bite?

- standard wound care, avoid high pressure irrigation

- do not suture wounds <1/2cm

- do not use skin clue

- augmentin tx of choice, or cefuroxime, doxy

- update tetanus/rabies

- wound cultures

Which antibiotics should not be used for cat bites due to resistance?

- keflex

- dicloxacillin

- clindamycin

Tx of monkey bites?

acyclovir/valacyclovir

Patients presenting with fight bites are at an increased risk of which complications?

- deep tendon laceration

- extensor tenosynovitis

- osteomyelitis

- septic arthritis

What are the most common infective organisms from fight bites?

- Staph aureus

- strep

- eikenella

Tx of fight bites?

- no sutures

- tetanus update

- Xray

- wound culture/care

- abx (augmentin/PCN)

- close follow up

Human bite tx?

- oral: augmentin, clindamycin

- IV: ampicillin-silbactam, zosyn, ticarcillin-clavulanate

When is primary closure indicated in a bite wound?

- clinically uninfected

- <12 hours old (<24 hours for face)

- not on hand or foot

- bite located on face

When is primary closure of a wound contraindicated?

- crush injuries

- puncture wounds

- bites involving the hands/feet

- wounds >12h old

- cat or human bites (except on face)

- bites in immunocompromised hosts

When should surgery be consulted for a wound?

- deep wounds penetrating bone, tendons, joints

- complex facial lacerations

- wounds w/ neurovascular compromise

- wounds w/ complex infections

When should abx be used with a bite wound?

- deep puncture wounds

- crush injuries

- wounds in area of underlying venous/lymphatic compromise

- bite wounds requiring closure

- wounds of the hands in close proximity to bones/joints

- bite wounds in compromised hosts

Which types of ticks are responsible for which types of diseases?

- deer: lyme and babesiosis

- wood: RMSF and Colorado tick fever

- lone star: Lyme disease and ehrlichiosis

___ can develop 5-6 days after a tick attaches to a host causing ascending symptoms like flaccid paralysis with the absence of fever

Tick paralysis

Tx of tick paralysis?

- remove the tick

- supportive care

- consider abx

S/sx of ___ include fever, rigors, headaches, myalgias and a petechial/purpuric rash

RMSF

tx of RMSF?

tetracycline or chloramphenicol

What are the stages of Lyme disease?

- I: erythema migrans

- II: neuro/cardiac complications

- III: arthritis

Tx of localized vs anaphylactic Hymenoptera stings?

- localized: ice, steroids, oral antihistamines

- anaphylactic: SQ epi, Benadryl, IV steroids, H2 blocker

S/Sx of ___ include intense pain, anxiety, restlessness, N/V, muscle cramps and symptoms of shock

wooly slug sting

tx of wooly slug sting?

- removal of spines

- supportive, analgesics

- antihistamines

Shark wound tx?

- ABCDs

- large bore IV

- Xrays

- beware of bleeding, tissue loss, FBs, fxs, infections

S/Sx of ___ include N/V/D, diaphoresis, muscle cramping, fasciculation, weakness, vertigo, paralysis, seizures, hypotension, and death

stingray envenomation

Tx of stingray envenomation?

- immersion in hot water

- IV narcotics

- debridement/check for FB

- Xray

- prophylactic abx/tetanus update

- discharge home if no systemic s/sx

Which abx should be given for stingray envenomation?

- coverage for vibrio and aeromonas

- quinolones

- doxy, bactrim, cefuroxime

What causes a sea bather's eruption?

thimble jellyfish larvae

What makes sea bathers eruption worse?

- wearing the bathing suit

- showering in fresh water

- mechanical stimulation

Tx of sea bathers eruption?

- take off the bathing suit

- diluted vinegar to neutralize

- 1% hydrocortisone lotion x10d

- topical calamine

- NSAIDs/antihistamines

Which types of fish can cause scombroid poisoning?

- tuna

- mackerel

- mahi mahi

- bonito

What causes scombroid fish poisoning?

improper preservation/refrigeration of fish

What causes the symptoms of scombroid poisoning?

histamine

S/Sx of ___ are similar to an allergic reaction and are accompanied by a metallic or peppery taste

scombroid poisoning

Tx of scombroid poisoning?

- parenteral antihistamines (Benadryl and Tagamet)

- epinephrine, albuterol if needed

Which fish can give you ciguatera fish poisoning?

- barracuda

- amberjack

- grouper

- snapper

What is thought to cause toxicity in ciguatoxin poisoning?

inhibition of calcium regulation

How do symptoms evolve in ciguatera fish poisoning?

- GI first then neuro

- N/V/D, diaphoresis, abdominal pain

- ataxia, burning feet, 'loose' teeth, confusion, weakness, sensory reversal dysesthesia

Tx of ciguatera fish poisoning?

- supportive

- isotonic crystalloid fluids

- antiemetics

- antihistamines

- atropine/dopamine for brady

S/sx of ___ include lip/tongue paresthesia, facial paresthesia, abdominal pain, N/V/D, bradycardia, hypotension, and ascending paralysis

Tetrodotoxin poisoning

What causes symptoms in tetrodotoxin poisoning?

- inhibition of voltage-gated sodium channels = inhibition of depolarization in the nerve/muscle cells

Tx of tetrodotoxin poisoning?

- ABCx

- IV fluids, pressors, antiarrhythmics

- activated charcoal

- no specific antidote