1. Bites Dr. Stella Yiu Staff Emergency Physician

2. Insect bites: LMCC Objectives Determine what complications they caused List critical investigations Construct management plan 2

3. Complications 3

4. 3 complications in insect bites 1.Local reaction/ Allergic reaction 2.Toxins 3.Infection 4

5. Complications -1. Local reaction 5

6. Complications - 1. Allergic reaction 6

7. CDMQ: Treat anaphylaxis to bee sting (7) 7

8. Airway: im Epi, intubate if needed Breathing: Ventolin Circulation: iv fluids, iv epi Antihistamines (H1, H2) Steroids Remove stinger 8

9. Complications - 2. Toxins 9

10. Brown recluse spider: in SE Ont and S Quebec 10

11. Brown recluse spider: Necrosis + Systemic collapse 11 Venom digests tissues Systemic: Fever DIC Renal failure Seizures, Coma

12. Black widow spider: Neuro + Autonomic Muscle cramping/rigid (large muscle) N/v, headache HR , BP  12

13. Treatment: Supportive & Specific Iv fluids, pressors, Benzo (GABA) Surgical debridement (Brown recluse) Specific: Antivenom (Black widow spider) 13

14. Complications - 3. Infections 14

15. Ticks 15

16. 16

17. Lyme disease Early (weeks) Rash, bell’s palsy, joint pain Late (months) Joint pain, Neuro symptoms Treatment? 17

18. Mosquito Malaria West Nile 18

19. Malaria = Flu like illness form endemic area Cough Fatigue, malaise Arthalgia/Myalgia 19

20. Severe malaria = Systemic involvment Brain: Coma Hem: Severe anemia, thrombocytopenia Resp: Pulmonary edema 20

21. MCQ 6: Pt returned from Congo with fever q48h. What is the most life-threatening infection that need to be ruled-out? A.Plasmodium Ovale B.Plasmodium Vivax C.Salmonella Typhi D.Dengue Fever E.Plasmodium Falciparum 21

22. CDMQ: Order bloodwork (5) 22

23. CDMQ: List bloodwork to be ordered Hb, platelet Liver function, Creatinine, Lytes (Na) Hemolysis screen (LDH, haptoglobin) Malaria screen Thick and thin smear 23

24. 1 negative smear does not rule out malaria (repeat) 24

25. West Nile encephalitis Similar investigations to other encephalitis 25

26. Insect bites: LMCC Objectives Determine what complications they caused - Allergy, toxins, infections List critical investigations Construct management plan 26

27. Animal bites: LMCC objectives Risk of transmissible infection from bites Manage animal bites including reporting 27

28. MCQ 7: Who does not need antibiotic? A.35 yo hx of splenectomy with dog bite to face B.7 yo with dog bite to face C.15 yo with cat bite to foot D.25 yo asthmatic with fight bite to hand E.40 yo DM with cat bite to face 28

29. Dog Cat Human Needlestick 29

30. Dog bites – Wound management Do we treat with antibiotics? Do we close? 30

31. Dog bites - Infections Bacteria: Anaerobes, Strep, Staph (5% infected) 31

32. 32 Dog bite = No antibiotics except

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35. Dog bite – What wound to close? 35

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37. Dog bites – Deciding rabies risk Rabies vaccine status (stray, unknown) Behavior 37

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39. Dog bites – Deciding rabies risk Observe animal x 10 days If treat: Rabies Immunoglobulin + Rabies vaccine 39

40. Cat bite What infections do we worry about? What is the risk of infection? 40

41. 41 Cat bite: Pasturella, 80% infection rate

42. Cat bite = Abx + immobilize Prophylaxis: Clavulin, cefuroxime Treat: iv Ceftriaxone Splint Frequent reassessments, r/o osteomyelitis 42

43. What other animals do we worry about rabies? Fox Raccoon Skunk Bat Needs bites, contact with open wound or mucous membrane 43

44. 44 Patient presents with this. List your mgt steps (7).

45. 1.Rule out foreign body (teeth) 2.Irrigation ++ 3.Abx 4.Rule out fracture or tendon injury 5.Tetanus 6.Discuss HIV prophylaxis + Hep B imm 7.Do not close, repeated assessments 8.(Splint) 45

46. 46 Rule out Tendon Injury

47. Human bites: Dirty! 50% infection rate: Bacteria: Staph, Strep, Eikenella 47

48. Human bites: Dirty! 50% infection rate: Bacteria: Staph, Strep, Eikenella Prophylaxis: Clavulin, Cefuroxime, Cellulitis: iv Ceftriaxone + flagyl Close wound? 48

49. Viruses from human bites: Hep B, Hep C, HIV 49

50. Hep B If primary series done: Check immunity (anti-HBsAgAb): give HBIg + booster if low If no primary series: HBIg + HBV vaccines 50

51. Hep C No Prophylaxis Follow up with serology 51

52. PEP Determine risk 52

53. Needlestick Injury: PEP Baseline risk: 0.3% 53

54. Risk increases if: 54

55. Animal bites: LMCC objectives Risk of transmissible infection from bites - Abx: Clavulin, Cefuroxime, Ceftriaxone Manage animal bites including reporting 55