Introduction to Animal Bites in ED CRASH in to Emergency Medicine

1. Introduction to Animal Bites in EDCRASH in to Emergency Medicine Frank LoVecchio, DO, MPH, FACEP, ABMT Co-Medical Director, Banner Good Samaritan Poison and Drug Information Center Maricopa Medical Center, Research Director Vice-Chair, Department of Emergency Medicine Professor University of AZ College of Medicine Phoenix, AZ

2. DISCLOSURE Relevant Financial Relationship(s) I am a principle investigator for various research projects, including NIH funding involving antibiotics, antivenoms, heparins, asthma and acute coronary syndromes They pay the hospital and occasionally patients. I receive no money directly. Off Label Usage None

3. Goals • To discuss presentation animals bites and some stings encountered in the ED • To discuss the treatment of animal bites and stings • Occasionally laugh

4. Dog bites • low risk for infection (5%-10%) unless hand involved (13%-30%); well vascularized areas at low risk • most wounds that do become infected usually easily treated with first-generation cephalosporin on outpatient basis; only 1% of patients hospitalized usually for cosmetic surgery • 1986 study showed most infected dog bite wounds healed with cephalexin (Keflex), suggesting that in multiorganism infections, only predominant organisms need be treated

5. Cat Bites • 75% of cat bites have Pasteurella, mostly pathogenic species, eg, Pasteurella multocida

6. Dog & Cat Bite Wound Infections Microbiology Cat Dog Pasteurella sp. 75% 50% Streptococcus sp. 46% 46% Staphylococcus sp. 35% 46% Fusobacterium sp. 33% 32% Bacteroides sp. 28% 30% Porphyromonas sp. 30% 28% Prevotella sp. 19% 28% Talan DA, Citron DM, Abrahamian FM, Moran GM, Goldstein EJC. NEJM 1999;340:85.

7. Dog & Cat Bite Wound InfectionsMicrobiology Dog Cat Aerobic/anaerobic 48% 63% Aerobes only 42% 32% Anaerobes only 1% 0% No growth 8% 5% Talan DA, Citron DM, Abrahamian FM, Moran GM, Goldstein EJC. NEJM 1999;340:85.

8. Cat bites • Infection rate 30- 50%; greater morbidity in local and systemic infection • Cats have sharp teeth that often penetrate to bone, tendon, and joint; cat biting owner on hand most common; patients generally delay treatment when bitten by own cat (present only if bite becomes infected) • 70% of cats have Pasteurella in their saliva (50% of dogs); when Pasteurella present, likely to be sole pathogen

9. What Works on Pasteurella * TMP/SMX: Trimethoprim/sulfamethoxazole Goldstein EJC. Antimicrob Agents Chemother 1998;41:391. Goldstein EJC. Antimicrob Agents Chemother 1997;41:1552.

10. Prophylaxis for Dog BitesFavors Antibiotic Favors Placebo (n = 62) (46) (55) (33) (113) (96) (39) (185) Summary Relative risk 0.56 0.1 0.125 0.25 0.5 1 2 4 8 10 Cummings P. Ann Emerg Med 1994;23:535.

11. Human Bite InfectionsMicrobiology ß-lactamase producer Streptococcus sp. 84% Staphylococcus sp. 54% >80% Eikenella corrodens 30% Haemophilus sp. 22% Prevotella sp. 36% >50% Fusobacterium sp. 34% Veillonella sp. 24% ~10% Talan DA, Abrahamian FM, Moran GJ, et al. Clin Infec Dis 2003:37:1481-89.

12. What Works on E corrodens * TMP/SMX: Trimethoprim/sulfamethoxazole Griego RD, et al. J Am AcadDermatol 1995;33:1019.

13. Human Bite Infections Antimicrobial Therapy EikenellaStaph.Anaerobes Amoxicillin/clav. + + + Ampicillin/sulbac. + + + Cefoxitin + + +/- Azithromycin + + +/- Levofloxacin + + +/- Moxifloxacin + + + Pen/cephalexin + + +/- Clindamycin + Cipro. + + +

14. http://www.youtube.com/watch?v=SUNmLuNdiL8&feature=related • <iframe title="YouTube video player" width="480" height="390" src="http://www.youtube.com/embed/SUNmLuNdiL8?rel=0" frameborder="0" allowfullscreen></iframe> • YouTube - Probably the Funniest Cat Video You'll Ever See

16. A sick patient after a dog bite • A 40 year old with sickle cell disease, is admitted for septic shock. • A history of a dog bite 5 days prior and the wound is mildly infected • Despite aggressive care dies on hospital day 3 • All blood cultures are negative

17. Capnocytophaga canimorsus (dysgonic fermenter-2; DF-2): • Gram-negative facultatively anaerobic rod that has caused sepsis in small number of people; can be fatal; 75% of victims immunosuppressed in unusual way (ie, but have no spleen, have lung disease, taking steroids, or alcoholic) • 25% have no apparent underlying illness; associated with contact with dog or cat; causes generalized sepsis with hypotension, petechiae, purpura, and adrenal hemorrhage; ≈25% mortality; susceptible to most drugs used for sepsis of unknown etiology and for prophylaxis of wounds (prophylaxis indicated in any immunosuppressed patient with dog bite) • Very slow growing (warn laboratory not to throw out blood culture too soon);

18. Summary • Dog bites low risk except for hands; Pasteurella multocida not major threat; patients with infections can generally be treated as outpatients; consider DF-2 in patients with risk factors • Cat bites are bad • Augmentin is your friend • No substitute for good wound care

20. Rodents • Wound infection rate 2%; bites usually cause local cellulitis that can be easily treated with first-generation cephalosporin or dicloxacillin • No cases of rodent transmission of rabies to humans in United States (bats are not rodents and have high risk for rabies)

22. Ferrets • Third most common pet in United States; members of skunk and weasel family; outlawed in California and Hawaii; 500,000 pet ferrets in California • Known for sudden, unprovoked, disfiguring attacks on infants (feed on suckling animals in wild); cage not protective (ferrets known to escape, hide for days, then attack) • Can carry and transmit rabies, although no cases in United States (rabies vaccine available for ferrets, even in states where ferrets outlawed)

25. Case: A new antidote for an old problem • A 30 year old man is envenomated by a rattlesnake. • He has no history or asthma and takes no meds • He has no allergies

30. RULE ONE: PLEASE DON’T KISS SNAKES

32. 34 5 patients 6 bites

33. CroFabTM Dose

34. Patient One

35. First Aid for Snakes • ABC’s • Analgesics • Volume Support • Don’t do anything stupid • Go to ER

36. Legitimacy of Snakebite • Legitimate Bite • did not recognize encounter with snake before being bitten • recognized encounter and immediately attempted to move away, but was bitten anyway • Illegitimate Bite • recognized encounter with snake, but did not try to immediately move away • pet snakes, moving snakes, killing snakes, kissing snakes, playing with snakes, feeding snakes

40. Compartment Syndrome • Other management options • Antivenom • Antivenom and mannitol

41. edema and ischemia inflammation ANTIVENOM NECROSIS venom ProTNFa + + ECM protein degradation VMPs TNFa only effective if antivenom infused within a few minutes of envenomation HMP activation

42. Types of Poisonous Snakes • 19 of 115 snake species in the U.S. are poisonous • Crotalidae are the pit vipers • Elapidae are the coral snakes

46. What Not To Do! • Don’t use ice as this may worsen the tissue damage • Doe not use the snakebite kits • Do not use electric shock treatment as it is ineffective & has resulted in electrical injuries • The Sawyer Extractor Vacuum Pump produces up to 750 mmHg of suction & may be helpful in theory

47. Emergency Care of Snakebites • Serial exams & lab evaluations are a must to follow envenomation & effectiveness of treatment • Measure limb circumference at several sites above & below the bite & reevaluate every 30 – 60 minutes • Repeat labs after each round of antivenin or every 4 hours, whichever is most current

48. Emergency Care of Snakebites • Wound care • Remember to clean the wound & update tetanus if needed • Antibiotics & steroids are not needed

50. Coral Snake Bites • There are three species • Eastern • Texas • Sonoran • Identification of a coral snake • “Red on yellow, kill a fellow; red on black, venom lack” (this is true on in the U.S.) • Coral snakes have short, fixed, anterior fangs & their venom is primarily neurotoxic