ANIMAL BITES, TETANUS, GAS GANGRENE

By : Hayana

Species of Poisonous snake

In Indonesia :
Trimeresurus albolaris ( green Snake) Ankistrodon rhodostoma (rattle snake) Bungarus fasciatus (welang snake ?) Naya Sputatrix ( Cobra ) In Papua : species = in Australia
poison : neurotoxic
poison : neurotoxic poison : hematotoxic

poison : hematotoxic

VENOMOUS SNAKE VS NON VENOMOUS SNAKE

Components and their effect

Snake venom

Severity Grading

CLINICAL MANIFESTATION
Systemic signs :
Hypotension, weakness, sweating, chills, nausea, vomiting, headache.

Specific signs :
Hematotoxic : bleeding at the wound site, lungs, kidney, heart, peritoneum, gum, brain, skin (petechiae, ecchymosis), melena, hematemesis, hemoptoe, hematuria. Neurotoxic : hipertonic, fasciculation, pareses, respiratory paralysis, ptosis, opthalmoplegia, laryngeal muscles paralysis, abnormal reflex, convulsion, coma. Cardiotoxic : hypotension, cardiac arrest, coma

Complication of local swelling : Compartment syndrome

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

Treatment:
First Aids : (First 30 - 60 minutesI) Calm the patient Torniquet ? (controversy) Incision & suction ( 1 hour 11% removed) Excision Monitoring vital signs and be prepared for supportive therapy

Snake bites

Management
Supportive treatments :
Respiratory problems : Oxygen, endotracheal intubation, tracheostomy Shock : Crystalloidsolutions/blood transfusion, if bleeding occurs. Compartment syndrome : Fasciotomy Neurotoxic signs : neostigmine (acethylcholinesterase) with Athropine sulphate. Hemorrhage :Fresh Whole Blood, vitamine K, fibrinogen, blood products.

Management
Laboratory examinations
Blood : routine, urea-N, creatinine, electrolyte, BT, CT, PT, APTT, thrombocyte , D-dimer, Liver Function Tests, blood typing & cross match. Urinalysis : hematuria, glycosuria & proteinuria. ECG

Radiology : Chest - X-ray

Management :
Immunotherapy : Antivenin (SABU) Hyperimmune equine serum : polyvalene, & 1 ml dose containing : 10 - 50 LD50 Ankystrodon venom , 25 - 50 LD50 Bungarus venom, 25 - 50 LD50 Naya Sputatrix, Phenol 0,25 % v/v. Administration :
2 vials (@ 5 ml) i.v. In 500 cc NaCl 0,9% / Dextrose 5% Rate of infusion : 40 - 80 dps/m. Max :100 mls
Local infiltration not recommended

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

Guidelines for treatment :

Degree O & I : antivenin not required , observe within 12 hours, but increasing severity mandates the administration of antivenin Degree II : 3-4 vials of antivenin Degree III : 5 - 15 vials of antivenin Degree IV : Add 6-8 vials if necessary

Management
Prophylactic treatment :
Broad spectrum antibiotics The commonest : P. aeruginosa, Proteus sp. Clostridium sp., & B. fragilis. Tetanus Toxoid Antitetanus serum (as indicated )

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

Pathophysiology
Dogs and cats have prominent canine teeth; Dogs have wider canines, while cats have thinner canines. Dogs are capable of exerting enormous pressure when biting.

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

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

Prehospital care:
With the exception of bites causing only superficial abrasions, all dog, cat, and human bites should receive medical evaluation. A sterile dressing should be applied to all open wounds and direct pressure should be used to control bleeding. Intravenous access is suggested when a significant amount of blood loss has occurred.

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

1. Within 8-12 hrs of injury who are primarily concerned about wound management and rabies, 2. After 12 hrs with signs and symptoms of infection.

ED Evaluation:
The bite was provoked or unprovoked? influence rabies prophylaxis.
Information about the bite source, ownership and immunization status, as well as the current location of the animal.

Physical Examination:
Vital signs often give valuable clues to bite-related pathology. Hypotension with tachycardia suggests hemorrhagic shock when significant blood loss has occurred. Fever is often associated with systemic infection.

Physical Examination:
Note the location, size, and depth of all wounds and carefully assess the vascular status distal to all extremity bites. Check motor and sensory function of all nerves distal to the wound; specifically, the median, radial, and ulnar nerve in the hand and the tibial and deep and superficial peroneal nerves in the foot.

Diagnostic Studies:
Obtain radiographs if there is a considerable amount of edema and tenderness around the wound, or if there is any possibility of bony damage or a foreign body. Teeth and tooth fragments can be left behind in bite wounds, with resultant infectious complications.

Diagnostic Studies:
When reviewing x-rays, look for air in the joint, which indicates penetration of the capsule. With older infected wounds, assess for osteomyelitis and soft-tissue gas. Angiography is indicated if the bite is near a major artery and there is evidence of vascular injury(e.g., expanding hematoma, pulsatile mass or diminished peripheral pulses)

MEDICAL CARE
Address ABCs immediately in the event of facial and neck wounds. Wounds irrigated (isotonic sodium chloride solution),18- or 19-gauge needle or angiocatheter.

MEDICAL CARE
Polymicrobial antibiotic for staphylococci and anaerobes is necessary. Consider tetanus prophylaxis. Consider rabies prophylaxis

RABIES
Postexposure treatment includes administration of rabies immune globulin (RIG) or human diploid cell vaccine (HDCV). HDCV can be administered prior to exposure if people are traveling to endemic areas or working with rabid animals.

Surgical Care
Debridement Careful wound excision Perform primary closure in certain wounds.
Facial wounds rarely become infected because the face is well vascularized. Clean wounds can also be closed.

Surgical Care
Wounds on the hands or lower extremities should be left open. Patients who have a wound older than 6 hours are best treated using delayed primary closure

TETANUS

Clostridium Tetani

Toxins
Tetanolysin - heat and oxygen labile/lyse RBC/ Tetanospasmin - heat and oxygen stable/highly lethal (for mice 0.0000001 mg) dies within 1 - 2 days get easily neutralize with antitoxin

EPIDEMIOLOGY

PATHOGENESIS

CLINICAL FEATURES

CLINICAL FEATURES
Early symptom is trismus (lock jaw) spasms of the masseter muscle
- difficulty in opening of the mouth and masticating - rigidity spreads to muscles of the face, neck and truck - risus sardonicus contraction of the frontails and muscles at the angle of the mouth - back is usually slightly curved (Opisthotonus) - Insevere cases violent spasms will last for few seconds to 3-4 mins.

CLINICAL FEATURES
- If convulsions appear soon after the initial symptoms, it is very serious. - The spasms gradually intensify and patient may die of exhaustion, asphyxia or aspiration peumonia - If local tetanus after a wound at the neck, you might think of tuberculous meningitis (irritation and paralysis is common).

NEONATAL TETANUS

MANAGEMENT

TETANUS TOXOID

GABA GLYCINE

GAS GANGRENE
Gas Gangrene
Bacteria Clostridium species

Gram-positive, spore-forming, anaerobic rods

Soil and the gastrointestinal tract of humans and animals

CLASSIFICATION
Gas Gangrene classification
Trauma Surgery

Spontaneously

Both traumatic gas gangrene and spontaneous gas gangrene

Dead tissue, blood clots, foreign matter aerobic organisms

In an injury DEVELOP ANAEROBIC CONDITION
(Exogenous infection)

Germination of spores Gas gangrene oedema, necrosis, gas production, toxaemia, myositis Crepitus

Gas composition

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

SIGN AND SYMPTOMS

severe pain and tenderness local swelling to massive edema skin discoloration with hemorrhagic blebs and bullae nonodorous or sweet odor crepitus fever relative tachycardia and altered mental status.

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

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

53

Specific gangrenes

Noma is a gangrene of the face.

Necrotizing fasciitis is attacking the deeper layers of the skin. Fournier gangrene usually affects the male genitals.

Treatment
An emergency operation to explore or remove dead tissue Amputating the affected body part Repeated operations to remove dead tissue (debridement) An operation to improve blood supply to the area Antibiotics Treatment in the intensive care unit (for severely ill patients) Hyperbaric oxygen therapy (HBOT)

END

Thank you