GME Surgery

Bites and Stings

August 22, 2017
SNAKES
Crotalinae
Crotalinae
Subfamily of Viperidae, more
commonly known as pit vipers

Include rattlesnakes, copperheads,

and cottonmouths/water moccasins

Cause 95% of venomous snakebites

in the United States

Contiguous US, except for Maine

Crotalinae can be found in...

All contiguous states...except for Maine.

Venom deposited in Rare: initial nausea, perioral ↑ PTT, PT, FSP, Cr,
subcutaneous tissue paresthesias, metallic taste, CPK, proteinuria,
and, rarely, IM or IV muscle twitching hematuria, anemia

Crotalinae
Pathophysiology Local signs
Systemic
symptoms
Systemic
signs
Abnormalities

Signs
Tissue necrosis, swelling,
pain, ecchymosis, bullae that
follow lymphatic path (now
rare with antivenin use)
Rare: diffuse capillary leakage,
pulmonary edema, circulatory
collapse in minutes
Red on yellow, kill a fellow.
Red on black, venom lack.
Coral Snakes
Part of the Elapidae family

Venom usually has a systemic effect;

bites have minimal or no local findings

Rounded heads, circular pupils, no fangs

The above image demonstrates the folk rhyme “red on yellow, kill
a fellow; red on black, venom lack.”
Venom contains α CN dysfunction, loss of Minimal or no local
neurotoxin deep tendon reflexes findings

Venom
Coral snake
Pathophysiology
Systemic
symptoms
Systemic signs Local signs

Signs
Toxin affects presynaptic and May progress to
postsynaptic receptors, results respiratory depression,
in direct neurotoxic effect neurogenic shock - high
mortality
 Snakebite
Management
BMP, CBC, UA, coags, X-cut aspiration, freshly Crotalinae: 4-6 vials
fibrinogen and split killed bird, cryotherapy, CroFab, repeat until
products, type & cross, suction, tourniquets, signs/symptoms stabilize,
ABG/LA (if systemic) electrical shock therapy then 2 vials every 6 hours

Snakebite
for 3 doses

Initial
Labs Studies DON’T DO Antivenin
Management

Management
CXR, EKG for older adults
or patients w/ systemic
Remove from danger, clean Coral snake antivenin is in
wound locally, elevate area to low supply, contact hospital
signs level of heart, hospital, ATLS, pharmacy and local poison
mark area of bite control office
MAMMALS
A 15 year-old girl is brought to the emergency department around 6:30 P.M. by her parents
after being bitten by her older brother’s pit bull. Her parent’s report she was outside playing
with the dog when it nipped at her, biting her on the right ear. They add that the dog also
jerked it’s head away while biting her, leaving a 2-3 centimeter open laceration over the
anterior cartilaginous portion of the ear. They state the incident occurred that morning and
that they initially washed it off and placed a small bandage over the wound. However, they
became concerned after their neighbor, who is an emergency medicine physician, told them
the infection rate of dog bites can be as high as 18%. The wound appears clean and without
bleeding. After irrigating it with dilute povidone-iodine, flushing with normal saline, and
administering a Tdap booster injection, what is the next best step?

A. Repair the laceration with suture and send the patient home with antibiotics
B. Prescribe antibiotics and leave the laceration open to heal by secondary intention
C. Reassure them and advise they can see their PCP for antibiotics if it becomes infected
D. Send the patient home with antibiotics and have her return to the hospital wound care
clinic in two days to have it repaired by delayed primary closure
E. Admit her and start intravenous antibiotics
What is the first-line antibiotic prescribed for most bite wounds?

A. Cefoxitin
B. Penicillin and cephalexin
C. Trimethoprim-sulfamethoxazole
D. Ciprofloxacin
E. Piperacillin-tazobactam
F. Amoxicillin-clavulanate
 Animal bites Dog (80-90% of bites)

Cat
Usually to the extremities of
adults and the scalp, face, and
neck of children Human
Human bites
All injuries over the dorsum of the MCP
joint are treated as clenched fist injuries.

Often result in serious injury to the

extensor tendon or joint capsule with
oral bacterial contamination.

Minor injuries irrigated, débrided, and left

open. Deeper injuries and infected bites
explored and débrided in the OR and IV
antibiotics given.

All bite injuries are reevaluated in 1 or 2

days to rule out secondary infection.
Hematocrit with blood loss, Primary closure for wounds of Hand and foot wounds high
cultures with infection, head and neck seen <24 infection risk - explore,
radiographs, tetanus hours and arms, legs, and irrigate, débride, wrap,
immunization as appropriate trunk seen with 6-12 hours elevate - heal by secondary

Animal Bites
Workup Cleaning
Low-risk
wounds wounds
intention

High-risk Very high-risk

wounds

Surrounding areas with 1% Delayed primary closure for

povidone-iodine, dirty wounds wounds seen after 24 hours
cleaned with gauze and sharply (or >6 hours if ear/nose
débrided, may require OR cartilage involved)
A 21 year-old male presents to the emergency department with a swollen right hand and you are
consulted to evaluate him. He states that he dropped a box on his hand while moving packages
during his shift at Fedex five days ago. He adds he was tired because he and his friends had
gone out to celebrate his 21st birthday the night before. Examination of his right hand reveals
that the area over the second, third, and fourth metacarpophalangeal joints is significantly
swollen with marked erythema and two small lacerations in the center. There is also a small
focal point along one of the lacerations that appears open and is oozing a white, milky exudate.
CBC reveals WBC 15.7, HGB 14.3, HCT 39.6, and PLT 425. T is 100.1, HR 89, RR 14, and BP
113/74. You decide to culture the wound. What microbe(s) would you expect to identify?

A. Staphylococcus spp.
B. Eikenella corrodens
C. Pasteurella spp.
D. Streptococcus spp.
E. All of the above
F. A, B, and D
G. B only
 Microbiology of Bite Wounds
Dogs Cats Humans

Pasteurella spp. (50%) Pasteurella spp. (75%) Eikenella corrodens

Staphylococcus and Staphylococcus and Staphylococcus and

Streptococcus spp., and Streptococcus spp., and Streptococcus spp., and
anaerobes anaerobes anaerobes

Rabies, cat-scratch disease, Rabies, cat-scratch disease, Hepatitis B and C,

cowpox, cowpox, tuberculosis, syphillis, HIV
tularemia, leptospirosis, and tularemia, leptospirosis, and
brucellosis brucellosis
 Although HIV transmission from human bites
HIV
is rare, seroconversion is possible when a
seroconversion person with an open wound, either from a bite
or a preexisting injury, is exposed to saliva
containing HIV-positive blood.

In this scenario, baseline and 6-month

postexposure HIV testing is performed, and
prophylactic treatment with anti-HIV drugs is
considered.
RABIES
In the U.S., 8,000 infected animals/year.
Racoons most common source overall,
but also skunks, bats, foxes.
However, bats are the most
common source of human rabies
in the United States.

All wild carnivores must be

considered rabid, but birds and
reptiles do not contract or
transmit rabies.
Rabies
Rhabdovirus in saliva of animals

Transmitted through bites or scratches

Acute encephalitis develops

Patients almost invariably die

Prodromal phase

Acute neurologic phase (2 forms)

Coma/terminal phase
Prodromal
Nonspecific complaints and paresthesias,
with itching or burning at the bite site
spreading to the entire bitten extremity
Acute Neurologic
Furious form is typified by fever and hyperactivity
that can be stimulated by internal or external factors
such as thirst, fear, light, or noise, followed by
fluctuating levels of consciousness, aerophobia or
hydrophobia, inspiratory spasm, and abnormalities
of the autonomic nervous
Acute Neurologic
Paralytic form of rabies is manifested by
fever, progressive weakness, loss of deep
tendon reflexes, and urinary incontinence.
Terminal
Both forms progress to paralysis, coma,
circulatory collapse, and death
Wash & Irrigate the Wound

Wash with soap and water.

Irrigate with a virucidal agent such

as povidone-iodine solution.
Guidelines for administering rabies
prophylaxis can be obtained from local
public health agencies or from the
Advisory Committee on Immunization
Practices and the U.S. Centers for
Disease Control and Prevention.
Prophylaxis
Passive Immunity: 20 IU/kg body weight of rabies immune globulin.

As much of the dose as possible is infiltrated into and around the wound. The rest is given
intramuscularly at a site remote from where the vaccine was administered.

Active Immunity: 1 mL of human diploid cell vaccine or 1 mL of purified chick embryo cell vaccine
intramuscularly into the deltoid of adults and into the anterolateral aspect of the thigh in children on
days 0, 3, 7, and 14.

For immunocompromised patients, a five-dose schedule is recommended on days 0, 3, 7, 14, and 28.
Patients with pre-exposure immunization do not require passive immunization and need active
immunization only on days 0 and 3.
A bite from a healthy-appearing
domestic animal does not require
prophylaxis if the animal can be
observed for 10 days
ARTHROPODS
Many more people in the United States
die from insect bites and stings, most
often caused by anaphylaxis, than from
mammalian or reptilian bites.
Widow spider
Nonaggressive female widow
spider bites in defense.

Males are too small to bite

through human skin.
Widow spiders are found in every
US state except Alaska.
Neurotoxic venom with Bite may be painless or like a Conservative management
alpha-latrotoxin which pinprick, local findings are for mild bites; narcotics,
stimulates release of minimal benzodiazepines, and/or
neurotransmitters antivenin for severe bites

Widow Bites
Toxicology Pathophysiology Local signs
Systemic
symptoms
Management

Causes excess stimulation of Severe pain and spasms of large muscle

neuromuscular junctions as well groups after 30 minutes; abdominal cramps
as the sympathetic and and rigidity; dyspnea, hypertension,
parasympathetic nervous system tachycardia, diaphoresis; nausea, vomiting
Mild bites
Local wound care - cleansing, intermittent
application of ice, and tetanus prophylaxis
as needed.
Severe bites
Narcotics and benzodiazepines are more
effective agents to relieve muscular pain.
Antivenin has been shown to reduce or
eliminate symptoms of latrodectism.
 Antivenom is currently recommended
for pregnant women, children younger
than 16 years, adults older than 60
years, and patients with severe
envenomation and uncontrolled

Antivenin hypertension or respiratory distress.

Initial recommended dose is 1 vial

intravenously or intramuscularly,
repeated as necessary, although it is
exceedingly rare for more than 2 vials to
be required.
A 73 year-old female is admitted to the hospital for an elective right lower extremity angiogram for a history of unilateral
leg pain. She has a history of moderately controlled diabetes and poorly controlled hypertension up to SBP up to 190
SBP. In preop for same-day surgery she is found to have a wound superior to the left medial malleolus. It is 2.5 cm x 3
cm with an eschar covering the surface. It is also noted that she has some lower leg pigmentation. The patient is placed
inpatient due to concern that she needs to be stabilized medically before undergoing the procedure. On hospital day 3
she is taken for the angiogram which shows some mild stenosis in the right lower extremity that is successfully
ballooned. The wound is debrided during the same operation and found to have necrotic tissue and an ulcer underneath
the eschar. Both the surgeon and the patient’s primary inpatient physician feel that her vascular disease and diabetes are
not severe enough to cause a wound like this. What other etiologies should you consider?

A. Black widow bite

B. Bed bug bite
C. Brown recluse bite
D. Venous stasis
E. Cholesterol embolus
F. Recent tick “bite”
G. Chigger bite
H. A only
I. A and C only
J. C and D only
K. C only
L. D only
Bilateral venous duplex ultrasound is done and is significant only for mild venous stasis. What could
have been done to prevent the progression of this wound if it had been recognized early?

A. Washed with soap and water and irrigated with povidone-iodine solution
B. Tourniquet
C. Debrided and dressed with Dakin's solution, Kerlix, 4x4 gauze, and Medipore tape
D. Amoxicillin-clavulanate
E. X-cut aspiration
F. Cryotherapy
G. Amputation
Brown Recluse
Most significant bites in the United
States are by Loxosceles reclusa, the
brown recluse. The brown spiders are
varying shades of brownish gray, with a
characteristic dark brown, violin-shaped
marking over the cephalothorax - hence,
the name violin spider. Although most
spiders have four pairs of eyes, brown
spiders have only three pairs. Male and
female spiders can bite and may do so
when threatened.
Major deleterious factor is Pain, itching, swelling, and Splint, elevate, and cold
sphingomyelinase D, which erythema; may turn purple with compresses, tetanus PRN, no
causes dermonecrosis and pale border; eschar develops and antivenin in the US,
hemolysis separates leaving an ulcer debridement after eschar

Brown Recluse
Toxicology Pathophysiology Local signs
defined

Systemic
symptoms
Management

Bites
Interacts with cell membranes of
erythrocytes, platelets, and endothelial
cells causing hemolysis, coagulation,
and platelet aggregation
Headache, nausea, vomiting, fever, malaise,
arthralgia, and maculopapular rash;
thrombocytopenia, DIC, hemolytic anemia,
coma, and possibly death
Bites
Diagnosis can be very challenging because
skin lesions can resemble bites by other
arthropods, skin infections (including
MRSA), herpes zoster, dermatologic
manifestation of a systemic illness, or other
causes of dermatitis and vasculitis
Hymenoptera
1. Bee stingers are removed as quickly as possible to prevent the continued injection of venom. The
sting site of Hymenoptera is cleaned and locally cooled. Topical or injected lidocaine can help
decrease pain from the sting. Antihistamines administered orally or topically can decrease pruritus.
Patients with previous severe, systemic allergic reactions to Hymenoptera stings or in whom serum
sickness develops are referred to an allergist for possible immunotherapy. Referral is also
recommended for adults with purely generalized dermal reactions, such as diffuse hives.
2. Treatment of an exaggerated, local envenomation includes the aforementioned therapy in addition
to elevation of the extremity and analgesics. A 5-day course of oral prednisone (1 mg/kg/day) is
also recommended.
3. Mild anaphylaxis can be treated with 0.01 mg/kg (up to 0.5 mg) of 1 : 1000 (1 mg/mL, or 0.1%)
intramuscular (mid-anterolateral thigh) epinephrine and an oral or parenteral antihistamine.
4. Hymenoptera-associated fatalities occur most often in adults, usually within 1 hour of the sting.
Other high-yield facts
1. Most scorpion stings in the United States cause short-lived, searing
pain and mild, local irritation with slight swelling. All patients receive
tetanus prophylaxis if indicated, application of cold compresses to the
sting site, and analgesics for pain.
2. Ticks can be removed by gently tying a knot over the tick as close to
the skin as possible and gently pulling.
3. Sharks, in most cases, attack in shallow waters and only bite once.
THANK YOU