1. That Bites! Back to Basics Review Jason R. Frank MD MA(Ed) FRCPC Presented and modified by Avik Nath Dept of Emergency Medicine

2. Bites & the MCC According to the MCC, what are the bites that every doctor should know something about?

3. NEW SLIDE : MCC Objectives MCC Key Objectives: Examine the patient completely to document the presence/absence of more than one wound Search for evidence of infection (e.g., fever, cellulitis, discharge), or joint penetration.

4. NEW SLIDE – Animal Bites Microbiology COMMON BACTERIA IN ANIMAL BITES –Pasteurella species –Staphylococci –Streptococci –Anaerobic bacteria Dog bites –Capnocytophaga canimorsus –Causes sepsis (esp asplenic) Cat bites –Bartonella henselae (organism responsible for cat scratch disease) Human bites –Eikenella corrodens

5. Important Medical Bites MCC List: 1.Dog bites 2.Cat bites 3.Human bites 4.Insect stings 5.Snake bites Other list: 1.Spider bites 2.Jellyfish stings 3.Scorpion stings 4.Tick bites 5.Bat bites

6. Case 1 A 20 woman presents with this bite Delivering fliers Neighbourhood dog Unsure of owner 12 hours ago

7. Case 1 1.Diagnostic issues? 2.Management issues? 3.Plan for this case? 4.Epidemiology? 5.Medicolegal?

8. Dog Bites 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

9. Dog Bites Tx issues: –Abx: Clavulin; Clinda + Cipro –Tetanus –Wound management –?Closure –Pain management –Rabies prophylaxis –Public health reporting –Safety for all Medicolegal –Documentation –Testimony

10. NEW SLIDE - Dog Bites Primary Closure: –Clinically uninfected –Less than 12 hours old (24 hours on the face) –NOT located on the hand or foot Most cat and human bites leave open

11. NEW SLIDE - Dog Bites Wounds at high risk for the development of infection –Crush injuries –Puncture wounds (cats worse than dogs) –Bites involving the hands and feet –Wounds more than 12 hours old (24 hours old on face) –Cat or human bites, except those to the face –Bite wounds in compromised hosts (eg, immunocompromised, absent spleen or splenic dysfunction, venous stasis, diabetes mellitus [adults])

12. NEW SLIDE - Rabies Rabies: –animals uniformly begin to sicken and die within 10 days (usually five to seven days) of spread of rabies virus from the CNS to the salivary glands –a healthy domestic dog, cat, or ferret should be confined and observed for 10 days –If the animal remains healthy for the full 10 days, then it did not have rabies virus in its saliva at the time of exposure. –Post-exposure prophylaxis should be given immediately if an exposing animal is rabid or suspected to be rabid Passive immunization – rabies immune globulin Active immunization – rabies vaccination –Contact public health –Unprovoked attacks are more likely by rabid than non-rabid animals

13. NEW SLIDE - Rabies Rabies: –If the animal is available for observation, immediate prophylaxis is indicated when the animal develops clinical signs of illness. –In addition, prophylaxis should be started if the person's significant exposure is to the head or neck, since incubation periods as short as four days have been reported in bites this close to the central nervous system –If the animal remains well for 10 days, the regimen can be discontinued at that time.

14. Case 1 – Your Management? A 20 woman presents with this bite Delivering fliers Neighbourhood dog Unsure of owner 12 hours ago

15. Case 2 75 F Her cat startled watching Senators win on CBC Bit her forearm 3 hours ago Pain worse What should she do?

16. Cat Bites 1.Diagnostic issues? 2.Management issues? 3.Plan for this case? 4.Epidemiology? 5.Medicolegal?

17. Cat Bites Similar to dog bites 60-80% infection rate Bacteria: esp Pasturella multocida Very rapid cellulitis Cat-scratch LN: Bartonella Rx Clavulin or Doxycyline Splint Re-check

18. Case 2 – Your Plan? 75 F Her cat startled watching Senators loss on CBC Bit her forearm 3 hours ago Pain worse What should she do?

19. Case 3 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

20. Case 3 Diagnostic issues? Management issues? Plan for this case? Epidemiology? Medicolegal?

21. Human Bites Bacterial Infections –mouth bugs, including anaerobes, Staph, Strep –Eikenella –Rx Clavulin; Pip-tazo –Tetanus Viral infections –HIV, Hep B, Hep C; HSV –PEP Wound management “Closed fist injuries” / “Fight bites” Other sites: ears, etc Four incisors, oval

22. Case 3 – What is Your Plan? 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

23. Case 4 Bad field trip to woods Multiple kids with “bug bites”

24. 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

25. 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

26. Case 5 50 diabetic man bit by a snake at a petting zoo

27. Case 5 Diagnostic issues? Management issues? Plan for this case? Epidemiology? Medicolegal?

28. Case 5 – Snake Bites Wound care Identify snake In Canada: Massasauga rattler Antivenom (Rx CroFab)

29. That Bites! - Summary 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

30. That Bites! - Summary MCC List: 1.Dog bites 2.Cat bites 3.Human bites 4.Insect stings 1.Hymenoptera 2.Mosquitoes 5.Snake bites Other list: 1.Spider bites 1.Black widow 2.Brown recluse 2.Tick bites 1.Lyme disease

31. That Bites! Back to Basics Review Jason R. Frank MD MA(Ed) FRCPC Presented by Avik Nath Dept of Emergency Medicine