ANIMAL BITES, ANIMAL BITES, TETANUS, TETANUS, GAS GANGRENEGAS GANGRENE

By : Hayana By : Hayana

Species of Poisonous Species of Poisonous snakesnake

– 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

VENOMOUS SNAKE VS NON VENOMOUS SNAKE VS NON VENOMOUS SNAKEVENOMOUS SNAKE

Snake venomSnake venomComponents and their effectComponents and their effect

Severity GradingSeverity Grading

CLINICAL MANIFESTATIONCLINICAL MANIFESTATION

• 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, : bleeding at the wound site, lungs,

kidney, heart, peritoneum, gum, brain, skin kidney, heart, peritoneum, gum, brain, skin (petechiae, ecchymosis), melena, hematemesis, (petechiae, ecchymosis), melena, hematemesis, hemoptoe, hematuria.hemoptoe, 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

Complication of local Complication of local swelling : Compartment swelling : Compartment syndromesyndrome

Management :Management :

• 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 minutesI)First Aids : (First 30 - 60 minutesI)

– 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 bites

Management Management

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

tracheostomytracheostomy– Shock : Crystalloidsolutions/blood transfusion, if Shock : Crystalloidsolutions/blood transfusion, if

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

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

blood products. blood products.

ManagementManagement

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

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

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

• Radiology : Chest - X-ray Radiology : Chest - X-ray

Management :Management :• Immunotherapy : Antivenin (Immunotherapy : 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

Management :Management :• Indications : Indications : • Symptoms of systemic envenomation.Symptoms of systemic envenomation.• Severe edema at the wound.Severe edema at the wound.

– 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 within 12 hours, but increasing severity mandates the administration of antiveninmandates the 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

ManagementManagement

• 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 )

Dog BitesDog Bites

Epidemiology:Epidemiology:

Dog bites account for majority(80%-90%) Dog bites account for majority(80%-90%) of animal bite wounds treated in the ED, of animal bite wounds treated in the ED, followed by cat bites (10%) and human followed by cat bites (10%) and human bites (3%)bites (3%)

PathophysiologyPathophysiology

• Dogs and cats have prominent Dogs and cats have prominent canine teeth; canine teeth;

• Dogs have wider canines, while Dogs have wider canines, while cats have thinner canines. cats have thinner canines.

• Dogs are capable of exerting Dogs are capable of exerting enormous pressure when biting.enormous pressure when biting.

PathophysiologyPathophysiology

• Such extreme pressure may Such extreme pressure may damage deeper structures such as damage deeper structures such as bones, vessels, tendons, muscle, bones, vessels, tendons, muscle, and nerves. and nerves.

PathophysiologyPathophysiology

• Puncture wounds, perhaps because Puncture wounds, perhaps because of their deep inoculation of bacteria of their deep inoculation of bacteria into the tissue, are at higher risk into the tissue, are at higher risk for infection as compared with for infection as compared with other types of bites.other types of bites.

Prehospital care:Prehospital care:

• With the exception of bites causing only With the exception of bites causing only superficial abrasions, all dog, cat, and superficial abrasions, all dog, cat, and human bites should receive medical human bites should receive medical evaluation.evaluation.

• A sterile dressing should be applied to A sterile dressing should be applied to all open wounds and direct pressure all open wounds and direct pressure should be used to control bleeding. should be used to control bleeding.

• Intravenous access is suggested when a Intravenous access is suggested when a significant amount of blood loss has significant amount of blood loss has occurred.occurred.

• Victims presenting to the ED can be Victims presenting to the ED can be divided into two groups: divided into two groups:

1.1.Within 8-12 hrs of injury who are Within 8-12 hrs of injury who are primarily concerned about wound primarily concerned about wound management and rabies, management and rabies,

2.2.After 12 hrs with signs and symptoms of After 12 hrs with signs and symptoms of infection. infection.

ED Evaluation:ED Evaluation:

• The bite was provoked or unprovoked? The bite was provoked or unprovoked? influence influence rabies prophylaxis. rabies prophylaxis.

• Information about the bite source, Information about the bite source, ownership and immunization status, as ownership and immunization status, as well as the current location of the well as the current location of the animal.animal.

Physical Examination:Physical Examination:

• Vital signs often give valuable clues Vital signs often give valuable clues to bite-related pathology.to bite-related pathology.

• Hypotension with tachycardia Hypotension with tachycardia suggests hemorrhagic shock when suggests hemorrhagic shock when significant blood loss has occurred.significant blood loss has occurred.

• Fever is often associated with Fever is often associated with systemic infection. systemic infection.

Physical Examination:Physical Examination:

• Note the location, size, and depth of all Note the location, size, and depth of all wounds and carefully assess the wounds and carefully assess the vascular status distal to all extremity vascular status distal to all extremity bites.bites.

• Check motor and sensory function of all Check motor and sensory function of all nerves distal to the wound; specifically, nerves distal to the wound; specifically, the median, radial, and ulnar nerve in the median, radial, and ulnar nerve in the hand and the tibial and deep and the hand and the tibial and deep and superficial peroneal nerves in the foot. superficial peroneal nerves in the foot.

Diagnostic Studies:Diagnostic Studies:

• Obtain radiographs if there is a Obtain radiographs if there is a considerable amount of edema and considerable amount of edema and tenderness around the wound, or if tenderness around the wound, or if there is any possibility of bony damage there is any possibility of bony damage or a foreign body.or a foreign body.

• Teeth and tooth fragments can be Teeth and tooth fragments can be ““left left behindbehind”” in bite wounds, with resultant in bite wounds, with resultant infectious complications.infectious complications.

Diagnostic Studies:Diagnostic Studies:

• When reviewing x-rays, look for air in When reviewing x-rays, look for air in the joint, which indicates penetration of the joint, which indicates penetration of the capsule. With older infected wounds, the capsule. With older infected wounds, assess for osteomyelitis and soft-tissue assess for osteomyelitis and soft-tissue gas.gas.

• Angiography is indicated if the bite is Angiography is indicated if the bite is near a major artery and there is near a major artery and there is evidence of vascular injury(e.g., evidence of vascular injury(e.g., expanding hematoma, pulsatile mass or expanding hematoma, pulsatile mass or diminished peripheral pulses)diminished peripheral pulses)

MEDICAL CAREMEDICAL CARE

• Address ABCs immediately in the Address ABCs immediately in the event of facial and neck wounds.event of facial and neck wounds.

• Wounds Wounds irrigated (isotonic irrigated (isotonic sodium chloride solution),18- or 19-sodium chloride solution),18- or 19-gauge needle or angiocatheter. gauge needle or angiocatheter.

MEDICAL CAREMEDICAL CARE

• Polymicrobial Polymicrobial antibiotic for antibiotic for staphylococci and anaerobes is staphylococci and anaerobes is necessary.necessary.

• Consider tetanus prophylaxis.Consider tetanus prophylaxis.• Consider rabies prophylaxis Consider rabies prophylaxis

RABIESRABIES

• Postexposure treatment includes Postexposure treatment includes administration of rabies immune administration of rabies immune globulin (RIG) or human diploid cell globulin (RIG) or human diploid cell vaccine (HDCV).vaccine (HDCV).

• HDCV can be administered prior to HDCV can be administered prior to exposure if people are traveling to exposure if people are traveling to endemic areas or working with endemic areas or working with rabid animals.rabid animals.

Surgical CareSurgical Care

• DebridementDebridement• Careful wound excisionCareful wound excision• Perform primary closure in certain Perform primary closure in certain

wounds. wounds. – Facial wounds rarely become infected Facial wounds rarely become infected

because the face is well vascularized. because the face is well vascularized. – Clean wounds can also be closed. Clean wounds can also be closed.

Surgical CareSurgical Care

• Wounds on the hands or lower Wounds on the hands or lower extremities should be left open. extremities should be left open.

• Patients who have a wound older than 6 Patients who have a wound older than 6 hours are best treated using delayed hours are best treated using delayed primary closureprimary closure

TETANUSTETANUS

Clostridium TetaniClostridium Tetani

ToxinsToxins

• Tetanolysin Tetanolysin - heat and oxygen - heat and oxygen labile/lyse RBC/labile/lyse RBC/

• TetanospasminTetanospasmin - heat and - heat and oxygen stable/highly lethal (for oxygen stable/highly lethal (for mice 0.0000001 mg) dies within 1 - mice 0.0000001 mg) dies within 1 - 2 days2 days

• get easily neutralize with get easily neutralize with antitoxin antitoxin

EPIDEMIOLOGYEPIDEMIOLOGY

PATHOGENESISPATHOGENESIS

CLINICAL FEATURESCLINICAL FEATURES

• Early symptom is trismus (lock jaw) – Early symptom is trismus (lock jaw) – spasms of the masseter musclespasms of the masseter muscle

- difficulty in opening of the mouth and masticating difficulty in opening of the mouth and masticating - rigidity spreads to muscles of the face, neck and rigidity spreads to muscles of the face, neck and

trucktruck- risus sardonicus – contraction of the frontails and risus sardonicus – contraction of the frontails and

muscles at the angle of the mouthmuscles at the angle of the mouth- back is usually slightly curved (Opisthotonus) back is usually slightly curved (Opisthotonus) - Insevere cases violent spasms will last for few Insevere cases violent spasms will last for few

seconds to 3-4 mins.seconds to 3-4 mins.

CLINICAL FEATURESCLINICAL FEATURES

CLINICAL FEATURESCLINICAL FEATURES

- If convulsions appear soon after the initial If convulsions appear soon after the initial symptoms, it is very serious.symptoms, it is very serious.

- The spasms gradually intensify and patient The spasms gradually intensify and patient may die of exhaustion, asphyxia or aspiration may die of exhaustion, asphyxia or aspiration peumoniapeumonia

- If local tetanus after a wound at the neck, you - If local tetanus after a wound at the neck, you might think of tuberculous meningitis (irritation might think of tuberculous meningitis (irritation and paralysis is common).and paralysis is common).

NEONATAL TETANUSNEONATAL TETANUS

MANAGEMENTMANAGEMENT

TETANUS TOXOIDTETANUS TOXOID

GABA GLYCINE

Gas Gangrene

Bacteria Clostridium species

Gram-positive, spore-forming, anaerobic rods

Soil and the gastrointestinal tract of humans and animals

GAS GANGRENEGAS GANGRENE

Gas Gangrene classification

Trauma

Surgery

Spontaneously

Both traumatic gas gangrene and spontaneous gas gangrene

CLASSIFICATIONCLASSIFICATION

Dead tissue, blood clots, foreign matter aerobic Dead tissue, blood clots, foreign matter aerobic organismsorganisms

In an injuryIn an injury

DEVELOP ANAEROBIC CONDITIONDEVELOP ANAEROBIC CONDITION

((Exogenous infectionExogenous infection) ) Germination of sporesGermination of spores

Gas gangreneGas gangrene

oedema, necrosis, gas production,oedema, necrosis, gas production,

toxaemia, myositistoxaemia, myositis

CrepitusCrepitus

Gas compositionGas composition

• A gas composition of 5.9% A gas composition of 5.9% hydrogen, 3.4% carbon dioxide, hydrogen, 3.4% carbon dioxide, 74.5% nitrogen and 16.1% oxygen. 74.5% nitrogen and 16.1% oxygen.

SIGN AND SYMPTOMSSIGN AND SYMPTOMS

• severe pain and tendernesssevere pain and tenderness• local swelling to massive edemalocal swelling to massive edema• skin discoloration with hemorrhagic blebs skin discoloration with hemorrhagic blebs

and bullaeand bullae• nonodorous or sweet odornonodorous or sweet odor• crepituscrepitus• feverfever• relative tachycardiarelative tachycardia• and altered mental status.and altered mental status.

An example of myonecrosis, where the necrosis has An example of myonecrosis, where the necrosis has spread to other areas of the bodyspread to other areas of the body

53The clinical appearance of myonecrosis in A compound fracture of the leg.

Specific gangrenesSpecific gangrenes

• Noma is a gangrene Noma is a gangrene of the face. of the face.

• Necrotizing fasciitis is is attacking the deeper attacking the deeper layers of the skin. layers of the skin.

• Fournier gangrene usually affects the usually affects the male genitals. male genitals.

TreatmentTreatment     

• An emergency operation to explore or An emergency operation to explore or remove dead tissue remove dead tissue

• Amputating the affected body part Amputating the affected body part • Repeated operations to remove dead Repeated operations to remove dead

tissue (debridement) tissue (debridement) • An operation to improve blood supply to An operation to improve blood supply to

the area the area • Antibiotics Antibiotics • Treatment in the intensive care unit (for Treatment in the intensive care unit (for

severely ill patients) severely ill patients) • Hyperbaric oxygen therapy (HBOT) (HBOT)

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