Pediatric Residents International Track Seminar

1. Pediatric Infectious Diseases Division Pediatric Residents International Track Seminar Animal Bites By Hossam M. Al-Tatari, M.D. Hossam M.Al-Tatari, M.D.

2. What are we going to talk about today? • Animal bites in U.S. • How to manage an animal bite in general. • Some weared animal bite mainly for the international travelers • Actually……even for non travelers!!! Hossam M.Al-Tatari, M.D.

3. Introduction • 1% of all visits to pediatric emergency centers • 4.7 million dog bites, 400 000 cat bites, and 250 000 human bites occur annually in the United States. • The incidence of infection • cat bites:50% • dog or human bites:15% to 20% Hossam M.Al-Tatari, M.D.

4. Etiologic agents • More than 50% are mixed. • CatsPasteurella multocida • DogsPasteurella Canis • HumansEikenella corrodens,Streptococcus pyogenes • HorsesActinobacillus species • FishHalomonas vensuta, Aeromonas hydrophilia, Psuedomonas species and Vibrio species. Hossam M.Al-Tatari, M.D.

5. Clinical approach • Questions to be asked • Home pet or a wild animal? • Would the animal be available for observation over the next 10days? • Provoked or not? • How long ago was the bite? • Assess tetanus immunization status. • In case of human bite assess the risk of Hep B and HIV in the offender. • Careful exam: e.g.: Clenched-Fist injuries. Hossam M.Al-Tatari, M.D.

6. Laboratory testing • Wound cultures: • Both aerobic and anaerobic • Inform the lab • If the wound is contaminated with soil, consider Mycobacteria and fungal cultures • Blood cultures • Imaging Hossam M.Al-Tatari, M.D.

7. Management, wound Hossam M.Al-Tatari, M.D.

8. Management, wound Hossam M.Al-Tatari, M.D.

9. Management, wound Hossam M.Al-Tatari, M.D.

10. Management, wound Hossam M.Al-Tatari, M.D.

11. Management, wound Hossam M.Al-Tatari, M.D.

12. Management, antibiotics prophylaxis • Indications for antibiotics prophylaxis: • Moderate or severe bite wounds, especially if edema or crush injury is present • Puncture wounds, especially if bone, tendon sheath, or joint penetration may have occurred • Facial bites • Hand and foot bites • Genital area bites • Wounds in immunocompromised and in asplenic persons Hossam M.Al-Tatari, M.D.

13. Management, antibiotics prophylaxis Hossam M.Al-Tatari, M.D.

14. Management, antibiotics prophylaxis Hossam M.Al-Tatari, M.D.

15. Management, tetanus Clean, minor wound All other wounds Hossam M.Al-Tatari, M.D.

16. Management, tetanus • Tetanus Immune Globulin (human) (TIG) :3000 to 6000 U IM for children and adults. • In tetanus neonatorum: smaller doses (as small as 500 U) • Some recommend infiltration around the wound. The efficacy has not been proven. • Where TIG is not available, equine tetanus antitoxin may be available. It is administered as a single dose of 50 000 to 100 000 U after testing for sensitivity.Part of this dose (20 000 U) should be given intravenously. • Intravenous Immune Globulin contains antibodies to tetanus and can be considered for treatment if TIG is not available. Hossam M.Al-Tatari, M.D.

17. Management, rabies Hossam M.Al-Tatari, M.D.

18. Management, rabies • Passive post-exposure prophylaxis • Human RIG should be used concomitantly with the first dose of vaccine. • Dose of RIG is 20 IU/kg of body weight. • As much of the dose as possible should be used to infiltrate the wound(s). Dilute if needed for large wounds. • The remainder is given intramuscularly using a separate syringe and needle. • Vaccine should be administered in a different site. • Purified equine RIG or antisera containing rabies antibodies is available outside the United States Hossam M.Al-Tatari, M.D.

19. Management, rabies • Active Immunization (Postexposure). • A 1.0-mL dose of any of the 3 vaccines is given intramuscularly in the deltoid area or anterolateral aspect of the thigh on the first day of post-exposure prophylaxis, and repeated doses are given on days 3, 7, 14, and 28 after the first dose. • An immunization series should be initiated and completed with 1 vaccine product. • Serologic testing to document seroconversion after administration is advised occasionally only for recipients who may be immunocompromised. Hossam M.Al-Tatari, M.D.

20. Complications • Cellulitis and soft tissue necrosis. • Pyogenic arthritis. • Osteomyelitis. • Septicemia. • Meningitis. • Brain abscess. Hossam M.Al-Tatari, M.D.

21. Weared Bites Hossam M.Al-Tatari, M.D.

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24. Snake bites • 45000 reported annually in US • Only 8000 are venomous • Toxins are species specific • Nuerotoxic: Death results from respiratory suppression • Cytolytic: Death results from hemorrhagic shock, adult respiratory distress syndrome or renal failure. • Antivenins should be administered within <4 hours when indicated and before the presence of any symptoms. • They pose a small but significant risk of immediate hypersensitivity reaction. Hossam M.Al-Tatari, M.D.

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26. Alligator bites Hossam M.Al-Tatari, M.D.

27. Alligator bites • Open thumb fracture resulting from an alligator bite became infected with Aeromonas hydrophila, Enterobacter agglomerans, and Citrobacter diversus. • Cultures obtained from the mouth of ten alligators !!! • Initial empiric therapy after alligator bites should be directed at gram-negative species, Initial antibiotic therapy for alligator bites: characterization of the oral flora of Alligator mississippiensis.Flandry F, et alDepartment of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, La. Hossam M.Al-Tatari, M.D.

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29. Alligator bites • 16 reported crocodile attacks in Northern Australia (1981-1991) • Four of these were fatal. • Most attacks resulted from swimming or wading in shallow water (13/16) • Half the victims were known to be affected by alcohol. • The majority of attacks occurred in failing light or at night (10/16). • Injuries in survivors ranged from minor lacerations and puncture wounds to major abdominal, chest and limb trauma. • Death in fatal attacks was caused by transection of the torso or decapitation. • Microorganisms isolated from wound swabs included Pseudomonas, Enterococcus, Aeromonas and Clostridium species. Hossam M.Al-Tatari, M.D.

30. Camel bites • In western countries are mostly inflicted by zoo or circus camels. • Highest risk during the mating season between December and March • Cause significant injuries by biting, throwing the victim, kicking in any direction (forward, sideways, and backwards), trampling, or squeezing with their whole body (weight, 450–690 kg) . • Nigeria: 32 patients with facial animal bites • Cows (n=14) • Camels (n=9) • Donkeys (n=6) • Dog (n=3) Hossam M.Al-Tatari, M.D.

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32. Lion bites • Big cats attack at the nape of the neck. By Loefler IJ. in journal of trauma 1996. • Reviewed 20 cases of lion bites • “Wild cats” bite the neck • “Domestic large animals” bite the peripheral limbs • Main organisms are Pasteurella multocida and septica • In a case report from Kansas: the arm was found to be unsuitable for reimplantation because of the near complete soft tissue loss while in possession of the lion. Hossam M.Al-Tatari, M.D.

33. Lion bites Hossam M.Al-Tatari, M.D.

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