Poisonous and Poisonous and Animal Bite ManagementAnimal Bite ManagementPoisonous and Poisonous and Animal Bite ManagementAnimal Bite Management

Animal BitesAnimal Bites

Animal bites are not uncommon occurrences. Animal bites are not uncommon occurrences. However, victims who are treated in However, victims who are treated in emergency centers represent only a small emergency centers represent only a small percentage of all bite victimspercentage of all bite victims

The majority dog bites (80-90%). Cat & other The majority dog bites (80-90%). Cat & other bites 10%, Most animal bites occur on the bites 10%, Most animal bites occur on the extremities, but the head and neck region is extremities, but the head and neck region is also often affectedalso often affected

Animal BitesAnimal BitesIntroductionIntroduction

Animal BitesAnimal BitesMortality/MorbidityMortality/Morbidity

Animal bites Animal bites infectioninfection, and, if treated appropriately, , and, if treated appropriately, patients can avoid this riskpatients can avoid this risk

Other complications: sepsis, osteomyelitis, septic Other complications: sepsis, osteomyelitis, septic arthritis, and even death arthritis, and even death

Hasan Sadikin Hospital: 240 animal bites in 2003Hasan Sadikin Hospital: 240 animal bites in 2003

10-15 deaths occur following dog bites each year in 10-15 deaths occur following dog bites each year in the United Statesthe United States

Most of these fatalities are children who sustain bites Most of these fatalities are children who sustain bites to the head and neck region. Even a minor bite to a to the head and neck region. Even a minor bite to a major vessel can lead to hemorrhage in a small childmajor vessel can lead to hemorrhage in a small child

Animal BitesAnimal BitesHistoryHistory

Although the incidence of infection Although the incidence of infection transmission is quite low, the transmission is quite low, the risk of rabiesrisk of rabies is is probably the best reason for investigating probably the best reason for investigating animal bite injuriesanimal bite injuries

When evaluating a patient following an When evaluating a patient following an animal bite, the animal bite, the nature of the injurynature of the injury is is pertinent, including whether or not the animal pertinent, including whether or not the animal was known to the victimwas known to the victim

The The time of injurytime of injury may have implications for may have implications for treating potential wound infections or for treating potential wound infections or for addressing avulsed appendagesaddressing avulsed appendages

Animal BitesAnimal BitesPhysical ExaminationPhysical Examination

Following an animal bite, patients require a full Following an animal bite, patients require a full physical examinationphysical examination to address all bite wounds to address all bite wounds

Adults are injured most often in the Adults are injured most often in the extremitiesextremities. . Children are injured more often in the Children are injured more often in the head and neckhead and neck region compared with adultsregion compared with adults

The The degree of injurydegree of injury is important. Some patients can is important. Some patients can be managed with local wound care or simple suturing be managed with local wound care or simple suturing by emergency department staff. Others require a by emergency department staff. Others require a consultation with a specialist or a trip to the operating consultation with a specialist or a trip to the operating room to address their wounds.room to address their wounds.

Animal BitesAnimal BitesPhysical ExaminationPhysical Examination

Animal BitesAnimal BitesLaboratory StudiesLaboratory Studies

Routine laboratory studies are not Routine laboratory studies are not mandatory in the workup following an mandatory in the workup following an animal biteanimal bite

Risk of infection or sepsis Risk of infection or sepsis a complete a complete blood cell count and cultures may blood cell count and cultures may provide useful information for treatmentprovide useful information for treatment

Animal BitesAnimal BitesImaging StudiesImaging Studies

Imaging studies are not routinely Imaging studies are not routinely performed, except for possible fracturesperformed, except for possible fractures

May be helpful to identify the presence May be helpful to identify the presence of a foreign body (eg, a tooth)of a foreign body (eg, a tooth)

Thorough cleansingThorough cleansing is adequate for contused, intact is adequate for contused, intact skin. If the skin is penetrated, copious irrigation is skin. If the skin is penetrated, copious irrigation is warranted. Debridement in crush injurywarranted. Debridement in crush injury

Head and neck region: Head and neck region: vital structures and cosmesisvital structures and cosmesis region. May require consultation with a specialistregion. May require consultation with a specialist

Basic wound managementBasic wound management debridement, antibiotic debridement, antibiotic therapy, supportive care, and, possibly, primary therapy, supportive care, and, possibly, primary suturing or hospitalization with operative debridementsuturing or hospitalization with operative debridement

Wound severityWound severity dictates surgical management dictates surgical management

Tetanus toxoid & Anti rabies vaccine if necessaryTetanus toxoid & Anti rabies vaccine if necessary

Animal BitesAnimal BitesMedical CareMedical Care

DebridementDebridement of devitalized tissues in the of devitalized tissues in the head and neck region is performed with carehead and neck region is performed with care

Surgical managementSurgical management can be immediate or can be immediate or delayeddelayed

Laceration injuries can be closed primarily, Laceration injuries can be closed primarily, but avulsion injuries may benefit from delayed but avulsion injuries may benefit from delayed treatmenttreatment

Injuries with significant tissue loss may Injuries with significant tissue loss may require local flap treatment, composite grafts, require local flap treatment, composite grafts, or even vascularized flapsor even vascularized flaps

Animal BitesAnimal BitesSurgical CareSurgical Care

Injuries to the head and neck region can be Injuries to the head and neck region can be especially complexespecially complex

Involvement of vital structures may require Involvement of vital structures may require consultation with a consultation with a head and neck surgeonhead and neck surgeon

Because of Because of cosmesis issuescosmesis issues, consultation , consultation with a facial plastic surgeon may be required with a facial plastic surgeon may be required to ensure proper closure of a complex bite, to to ensure proper closure of a complex bite, to a repair fracture, or for reconstructiona repair fracture, or for reconstruction

Animal BitesAnimal BitesConsultationsConsultations

Snake BitesSnake Bites

Snake BitesSnake BitesEpidemiology :Epidemiology :

Incidence :Incidence :– USA : 8000 cases/year, 98% at USA : 8000 cases/year, 98% at

extremities, etiology : 70% rattlesnake.extremities, etiology : 70% rattlesnake.– Indonesia : ?, common.Indonesia : ?, common.

5 million snakebites occur worldwide 5 million snakebites occur worldwide each year, causing about 125,000 each year, causing about 125,000 deaths deaths

Snake BitesSnake BitesSnakesSnakes

Despite their sinister reputation, snakes are Despite their sinister reputation, snakes are almost always more scared of you than you almost always more scared of you than you are of themare of them

Few snakes, with the occasional exception of Few snakes, with the occasional exception of king cobras (king cobras (Ophiophagus hannahOphiophagus hannah) or black ) or black mambas (mambas (Dendroaspis polylepisDendroaspis polylepis), act ), act aggressively toward a human without aggressively toward a human without provocation provocation

Snake BitesSnake BitesSnakesSnakes

Only about 400 of 3000 snake species Only about 400 of 3000 snake species worldwide inject venomworldwide inject venom

Many snakes catch their prey by Many snakes catch their prey by constrictionconstriction

Snakes do not kill by crushing preySnakes do not kill by crushing preySome snakes grab prey with their teeth Some snakes grab prey with their teeth

and then swallow it whole and then swallow it whole

Snake BitesSnake BitesPoisonous SnakesPoisonous Snakes

– In Indonesia :In Indonesia :• Trimeresurus albolaris (Green Snake)Trimeresurus albolaris (Green Snake)

– poison : hematotoxic poison : hematotoxic

• Ankistrodon rhodostoma (Rattle Snake)Ankistrodon rhodostoma (Rattle Snake)– poison : hematotoxicpoison : hematotoxic

• Bungarus fasciatus (Welang snake ?)Bungarus fasciatus (Welang snake ?)– poison : neurotoxicpoison : neurotoxic

• Naya Sputatrix (Cobra)Naya Sputatrix (Cobra)– poison : neurotoxic poison : neurotoxic

• In Papua : species = in Australia In Papua : species = in Australia

Snake BitesSnake BitesSnake Snake characteristicscharacteristics Poisonous snake :Poisonous snake :

– triangular shaped triangular shaped headhead

– two retractable two retractable fangs at the maxillafangs at the maxilla

– fang marks : two fang marks : two well distinguished well distinguished marksmarks

Harmless snake :Harmless snake :

– square head square head

– small fangs small fangs

– fang marks : smooth fang marks : smooth wound in a curved wound in a curved row row

Snake BitesSnake BitesTeeth PatternTeeth Pattern

Snake BitesSnake Bites

King cobra (King cobra (Ophiophagus hannahOphiophagus hannah))

Black mamba (Black mamba (Dendraspis polylepisDendraspis polylepis) )

Coral snake (Coral snake (Micrurus fulviusMicrurus fulvius) )

Milk snake (Milk snake (Lampropeltis triangulumLampropeltis triangulum) )

Diamondback rattlesnake (Diamondback rattlesnake (Crotalus atroxCrotalus atrox) )

Timber rattlesnake (Timber rattlesnake (Crotalus horridusCrotalus horridus) )

Cottonmouth (Cottonmouth (Agkistrodon piscivorousAgkistrodon piscivorous) )

N copperhead (N copperhead (Agkistrodon contortrixAgkistrodon contortrix) )

SnakesSnakes

Snake BitesSnake BitesEnzymes of Snake Enzymes of Snake VenomsVenoms

Snake venoms :Snake venoms :– Polypeptide :Polypeptide :

• Phospholipase A, hyaluronidase, ATP-ase, 5-Phospholipase A, hyaluronidase, ATP-ase, 5-nucleotidase, cholinesterase, protease, nucleotidase, cholinesterase, protease, phosphomonoesterase, RNA-se, & DNA-se.phosphomonoesterase, RNA-se, & DNA-se.

– Effect :Effect :• neurotoxic, hemorrhagic, thrombogenic,hemolityc, neurotoxic, hemorrhagic, thrombogenic,hemolityc,

cytotoxic, antifibrin, anticoagulant, cardiotoxic, vascular cytotoxic, antifibrin, anticoagulant, cardiotoxic, vascular disturbance : destroying intimal layer.disturbance : destroying intimal layer.

– Symptoms & signs: Symptoms & signs: • Local : edema, pain, tenderness, ecchymosis (within 30 Local : edema, pain, tenderness, ecchymosis (within 30

minutes - 24 hours ).minutes - 24 hours ).

Snake BitesSnake Bites Clinical Clinical ManifestationsManifestations

• Systemic signsSystemic signs : :

– Hypotension, weakness, sweating, chills, nausea, Hypotension, weakness, sweating, chills, nausea, vomiting, headache.vomiting, headache.

• Specific signsSpecific signs : :

– HematotoxicHematotoxic : bleeding at the wound site, lungs, kidney, : bleeding at the wound site, lungs, kidney, heart, peritoneum, gum, brain, skin (petechiae, heart, peritoneum, gum, brain, skin (petechiae, ecchymosis), melena, hematemesis, hemoptoe, ecchymosis), melena, hematemesis, hemoptoe, hematuria.hematuria.

– NeurotoxicNeurotoxic : hipertonic, fasciculation, pareses, : hipertonic, fasciculation, pareses, respiratory paralysis, ptosis, opthalmoplegia, laryngeal respiratory paralysis, ptosis, opthalmoplegia, laryngeal muscles paralysis, abnormal reflex, convulsion, coma.muscles paralysis, abnormal reflex, convulsion, coma.

– Cardiotoxic Cardiotoxic : hypotension, “cardiac arrest”, coma: hypotension, “cardiac arrest”, coma

Snake BitesSnake BitesClinical signsClinical signs

Tissue necrosisTissue necrosis Soft tissue damageSoft tissue damage EchymosisEchymosis Compartment syndromeCompartment syndrome SwellingSwelling

Snake BitesSnake BitesWhat to doWhat to do

Even a bite from a nonvenomous snake Even a bite from a nonvenomous snake requires excellent wound carerequires excellent wound care

The victim needs a tetanus booster if he The victim needs a tetanus booster if he or she has not had one within 5 yearsor she has not had one within 5 years

Wash the wound with large amounts of Wash the wound with large amounts of soap and water. Inspect the wound for soap and water. Inspect the wound for broken teeth or dirt. broken teeth or dirt.

Snake BitesSnake BitesDegree of snake bites Degree of snake bites

Degree enveno- wound pain edema Degree enveno- wound pain edema systemicsystemic

mation mation /erythema /erythema

O OO O + +/- <3cm/12 hrs O + +/- <3cm/12 hrs O

I +/- + + 3-12cm/12 hrs OI +/- + + 3-12cm/12 hrs O

II + + II + + +++ >12-25cm/12hrs +, neurotoxic +++ >12-25cm/12hrs +, neurotoxic nausea, nausea, dizziness dizziness

IIIIII + + + + +++ +++ >25cm/12hrs >25cm/12hrs ++, petechiae ++, petechiae

shock, shock, ecchymosis ecchymosis

IV +++ + +++ > extremityIV +++ + +++ > extremity ++, ARF,coma ++, ARF,coma bleeding bleeding

Snake BitesSnake BitesManagementManagement

Objectives : Objectives : • To block / decrease the absorption of venom To block / decrease the absorption of venom • To neutralize venom in circulationTo neutralize venom in circulation• To treat local and systemic effectsTo treat local and systemic effects

Treatment:Treatment:• First Aids : (First 30 - 60 minutes)First Aids : (First 30 - 60 minutes)

– Calm the patientCalm the patient– Torniquet ? (controversy)Torniquet ? (controversy)– Incision & suction ( 1 hour Incision & suction ( 1 hour 11% removed) 11% removed)– ExcisionExcision

• Monitoring vital signs and be prepared for supportive therapyMonitoring vital signs and be prepared for supportive therapy

Snake BitesSnake BitesFirst AidFirst Aid

Snake BitesSnake BitesManagement Management

Supportive treatments :Supportive treatments :– Respiratory problems : Oxygen, endotracheal intubation, Respiratory problems : Oxygen, endotracheal intubation,

tracheostomytracheostomy– Shock : Crystalloid solutions/blood transfusion, if bleeding Shock : Crystalloid solutions/blood transfusion, if bleeding

occurs.occurs.– Compartment syndrome : FasciotomyCompartment syndrome : Fasciotomy– Neurotoxic signs : neostigmine (acethylcholinesterase) with Neurotoxic signs : neostigmine (acethylcholinesterase) with

Athropine sulphate. Athropine sulphate. – Hemorrhage :Fresh Whole Blood, vitamin K, fibrinogen, Hemorrhage :Fresh Whole Blood, vitamin K, fibrinogen,

blood products. blood products.

Snake BitesSnake BitesManagementManagement

Laboratory examinationsLaboratory examinations– Blood : routine, urea-N, creatinine, electrolyte, BT, CT, PT, Blood : routine, urea-N, creatinine, electrolyte, BT, CT, PT,

APTT, thrombocyte , D-dimer, Liver Function Tests, blood APTT, thrombocyte , D-dimer, Liver Function Tests, blood typing & cross match.typing & cross match.

– Urinalysis : hematuria, glycosuria & proteinuria.Urinalysis : hematuria, glycosuria & proteinuria.– ECGECG

RadiologyRadiology : Chest - X-ray : Chest - X-ray

Snake BitesSnake Bites ManagementManagement

Immunotherapy :Immunotherapy : Antivenin ( Antivenin (SABUSABU))• Hyperimmune equine serum : polyvalene, & 1 ml dose Hyperimmune equine serum : polyvalene, & 1 ml dose

containing :containing :– 10 - 50 LD50 Ankystrodon venom , 10 - 50 LD50 Ankystrodon venom , – 25 - 50 LD50 Bungarus venom, 25 - 50 LD50 Bungarus venom, – 25 - 50 LD50 Naya Sputatrix, 25 - 50 LD50 Naya Sputatrix, – Phenol 0,25 % v/v.Phenol 0,25 % v/v.

• Administration : Administration : – 2 vials (@ 5 ml) i.v. In 500 cc NaCl 0,9% / Dextrose 5% 2 vials (@ 5 ml) i.v. In 500 cc NaCl 0,9% / Dextrose 5% – Rate of infusion : 40 - 80 dps/m. Max :100 mlsRate of infusion : 40 - 80 dps/m. Max :100 mls– Local infiltration not recommendedLocal infiltration not recommended

Snake BitesSnake Bites ManagementManagement

– Guidelines for treatment :Guidelines for treatment :• Degree O & I : antivenin not required , observe Degree O & I : antivenin not required , observe

within 12 hours, but increasing severity mandates within 12 hours, but increasing severity mandates the administration of antiveninthe administration of antivenin

• Degree II : 3-4 vials of antivenin Degree II : 3-4 vials of antivenin • Degree III : 5 - 15 vials of antivenin Degree III : 5 - 15 vials of antivenin • Degree IV : Add 6-8 vials if necessary Degree IV : Add 6-8 vials if necessary

Snake BitesSnake BitesManagementManagement

Prophylactic treatment :Prophylactic treatment :

– Broad spectrum antibiotics Broad spectrum antibiotics • The commonest : P. aeruginosa, Proteus sp. The commonest : P. aeruginosa, Proteus sp.

Clostridium sp., & B. fragilis.Clostridium sp., & B. fragilis.– Tetanus ToxoidTetanus Toxoid– Antitetanus serum (as indicated)Antitetanus serum (as indicated)

Snake BitesSnake Bites

Snake bite by poisonous snake commonly occurs Snake bite by poisonous snake commonly occurs at the extremitiesat the extremities

The degree of clinical manifestations of The degree of clinical manifestations of poisonous snake is determined by the dose of poisonous snake is determined by the dose of envenomationenvenomation

The management of snake bite depends on the The management of snake bite depends on the degree of envenomationdegree of envenomation

ConclusionsConclusions