1. That Bites! Back to Basics Review Jason R. Frank MD MA(Ed) FRCPC Dept of Emergency Medicine

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

3. 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

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

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

6. 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

7. 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

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

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

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

11. 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

12. 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?

13. 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

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

15. 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

16. 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

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

18. 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

19. 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

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

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

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

23. 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

24. 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

25. That Bites! Back to Basics Review Jason R. Frank MD MA(Ed) FRCPC Dept of Emergency Medicine