Emergency Care for MO-Bites and Stings.pdf

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1. Bites and Stings
For MO

2. DOMESTIC PERIDOMESTIC
COMMON ANIMAL
BITES IN INDIA
•Cats
•Rats
•Cows
•Buffaloes
•Sheep
•Goats
•Pigs
•Donkeys
•Horses
•Camels

3. WILD
RARELY
REPORTED
WILD ANIMAL BITES
IN INDIA
•Foxes&Jackals
•Monkeys
•Mongoose
•Bears
•Bats
•Rodents
•Birds
•Squirrel
** ALL WILD ANIMAL BITES ARE CONSIDERED AS CATEGORY III EXPOSURES.

4. RABID CAT
RABID SHEEP: HEAD-
BUTTING
RABID HORSE
RABID GOAT

5. COMMON RARE
MODE OF TRANSMISSION
•Bitesfrominfectedanimals
•LicksonBrokenSkin/Mucous
Membranes
•Scratches
•Inhalation
•Organtransplantation
•Ingestion
•Sexual

6. PATHOGENESIS OF RABIES

7. ANIMAL BITE
MANAGEMENT
Medical
Emergency

8. •Mechanical
⚬Washthewoundwithrunningtapwater
•Chemical
⚬Washthewoundwithsoapandwater
⚬Applydisinfectants
•Biological
⚬InfiltrateImmunoglobulinsinthedepthandaroundthewoundin
category-IIIexposures
Suturingonlyifrequired(1-2loosesutures)andonlyafter
administrationofRIGs.
WOUND MANAGEMENT -
DOs

9. •Povidone-iodine
•Alcohol
•Chloroxylenol(Dettol)
•Chlorhexidinegluconate
•Cetrimidesolution(savlon)
APPLICATION OF
ANTISEPTICS

10. •Donottouchthewoundwithbarehands
•Donotapplyirritantslikesoil,chilies,chalk,betelleaves,
CowDung,etc.
•Suturing
•Cauterise
WOUND MANAGEMENT -
DON’Ts

11. Typeofcontact
•Touchingorfeedingofanimals
•Licksonintactskin
Recommended PEP
•Noneifreliablecasehistoryisavailable
CATEGORY I -NO EXPOSURE

12. Typeofcontact
•Nibblingofuncoveredskin
•Minorscratchesorabrasionswithoutbleeding
Recommended PEP
•Woundmanagement
•AntiRabiesVaccine
CATEGORY II-MINOR EXPOSURE

13. Typeofcontact
•Singleormultipletransdermalbitesorscratches
•Licksonbrokenskin
•Contaminationofmucousmembranewithsalivai.e.licks
Recommended PEP
•Woundmanagement
•Rabiesimmunoglobulin
•AntiRabiesVaccine
CATEGORY III-SEVERE EXPOSURE

14. •BitesontheHead,Face,Hands,Genitalia
•Multiplebites
•Extensivelacerations
•Bitesby:
⚬provenrabidanimals
⚬animalsnotavailableforobservation
⚬morethanoneanimal
⚬wildanimals
SERIOUS EXPOSURES

15. Transdermal injury on the back
Extensive lacerated bites on the
face
Bites on the face of a
child
Lacerations on the scalp

16. Multiple bites on the face of a child
Multiple bites by many dogs
Bite on the face in an adult

17. SEVERE LACERATION CAUSED BY DOG BITE
Bite on the genitalia
Extensive laceration of the foot

18. •Managementofanimalbitewound
•PassiveImmunization:RabiesImmunoglobulin(RIG)
•ActiveImmunization-Anti-RabiesVaccines(ARV)
APPROACH TO POST -EXPOSURE
PROPHYLAXIS

19. •InjectRIGsintoallwounds(anatomicallyfeasible).
•IfRIGsareinsufficient(byvolume)dilutethemwithsterilenormalsaline
(uptoequalvolume).
•Presentlyavailablepreparationsareverysafe.However,theequine
serummustbeadministeredwithfullprecautions.
INFILTRATION OF RIG IN WOUNDS

20. RIG INFILTRATION

21. INTRADERMAL ARV

22. INTRA DERMAL REGIMENS FOR
POST EXPOSURE TREATMENT
•ApprovedbytheWHO.
•Costeffective.
•ViablealternativetoreplaceNerveTissueVaccineinIndia.
•StudiesinIndiaconfirmsafetyandefficacy.
•ApprovedbyDCGIforuseinIndia.

23. Dose
•0.1ml/IDSite
•injectionof0.1mlofreconstitutedvaccineperIDsiteandon
twosuchIDsites
Site
•UpperarmovereachDeltoidarea,aninchabovethe
insertionofdeltoidmuscle
UPDATED THAI RED CROSS
SCHEDULE(2-2-2-0-2)

24. SCHEDULE (2-2-2-0-2)
Day 0
Day 3
Day 7
Day 28

25. INTRA DERMAL
ADMINISTRATION OF ARV

26. Correct technique
for ID injection

27. GENERAL GUIDELINES FOR IDRV
•Mustbeadministeredbytrainedstaff
•Reconstitutedvaccineshouldbeusedassoonaspossibleoratleast
within6-8hours
•Vaccinewhengivenintra-dermallyshouldraiseavisibleandpalpable
blebintheskin
•Intheeventthatthedoseisgiveninadvertentlygivensubcutaneouslyor
intramuscularlyorintheeventofspillage,anewdoseshouldbegiven
intradermallyatanearbysite
•AnimalbitevictimsonchloroquinetherapyshouldbegivenARVbyIM
route

28. INTRAMUSCULAR ARV

29. ESSEN REGIMEN
(INTRA-MUSCULAR)
•Day0:1stdose
•Day3:2nddose
•Day7:3rddose
•Day14:4thdose
•Day28:5thdose
•Day90:6thdose(optional)

30. POINTS TO REMEMBER
•Day0(D0)-Dayof1stdoseofvaccinegiven,notthedayofthe
bite
•AllmodernTissueCultureVaccines(TCVs)areequallyeffectiveandsafe
•Neverinjectthevaccinesintotheglutealregion.
•Interchangeofvaccinesacceptableinspecialcircumstancesbutnottobe
doneroutinely
•Reconstitutedvaccinetobeusedimmediatelywithin6hours
•Vaccinedosageisthesameforallagegroups

31. MEDICAL ADVICE TO VACCINEES
•Nodietaryrestriction.
•Norestrictiononphysicalexercise.
•Avoidimmunesuppressants(Steroids,anti-malarial)ifpossible.
•Besttoavoidconsumptionofalcoholduringthecourseoftreatment.
•Completethecourseofvaccination.
•Addressandcontactdetailsshouldbecollectedfromeveryclientand
followedup
•ClientshouldbeinformedthatInj.Tetanustoxoidshouldnotbecounted
asanARVdose

32. SNAKE BITE MANAGEMENT

33. •Allsnakebitesarenotpoisonous.
•Only30–40%arepoisonous(BigFour).
•DrybiteisalsoPossible
•Mostofthevictimsareanxiousandtheyneedre-assurance.
•Don’tthreatenthesnakes.
•Don’ttouchthesocalleddeadsnakes.
•Don’tkillthesnakes.(asperlawitispunishable)
•Neverignoreanysnakebites.
BASIC FACTS ON SNAKE BITES

34. MAJOR POISONOUS SNAKES IN INDIA

36. DOS IN A SNAKE BITE

37. DON’TS IN A SNAKE BITE
•Tourniquets
•CuttingandSuction
•Washingthewound
•Nativetreatment
•AvoidTraditionalhealers

41. RESPONSE TO INJ. NEOSTIGMINE
•Inj.Atropine0.6mgfollowedby
•Inj.Neostigmine1.5mgtobegivenIVstat
•Improvement inneurologicalweakness
indicatescobrabite.

42. 20 MIN WBCT

48. PREVENTION OF SNAKE BITE

49. SCORPION STING MANAGEMENT

51. Priapism Salivation

52. Shortactingmust
beused
Prazppress
Sustained acting
shouldbeavoided

53. SCORPION ANTIVENOMROLE?

54. MANAGEMENT OF
SCORPION STING
ASV: Antiscorpion Venom; SNP: Sodium Nitroprusside; NTG: Nitroglycerine;
NIV: Non-Invasive Ventilator; MV: Mechanical Ventilator

57. •Common-oedema,erythema,urticaria,pain
•GeneralizedreactionrareduetoIgEmediated
•Anaphylaxiscanoccur.
•Rarelytoxin-mediated-
⚬Rhabdomyolysis,
⚬Hemolysis,
⚬A.R.F.
⚬Hepaticdamage,
⚬CVSabnor.
⚬Neurodeficit.
⚬DICcanoccur
•Treatment–SymptomaticandSupportiveCare.
CLINICAL FEATURES

58. Animal Bite
Management
is Medical
Emergency
TO CONCLUDE

59. •A25-year-oldmanwhilecomingbackfromthefactoryhada?
Bitewithpaininhislegwhilewalkinginthefieldat4.00PM.
•Hewasnotsureofthenatureofthebiteandreportedhimselftothe
PHCat6.00PM
•Howwillproceedfurther?
CASE SCENARIO -1

60. Take-Home Message
•RIGHT
•He needs to be observed for early symptoms and signs of
envenomation for at least 24 hrs.
•If he shows either Neurotoxic or Hemotoxic features, 1st dose of ASV
(10 vials) can be started and completed before being referred.

61. •A50-year-oldmalewhilesleepingonthefloorathishomewas
bittenbyasnakeat2.00AM.
•HisfamilymemberskilledthesnakeandbroughtittothePHCalong
withthepatient.
•Onarrivalat5.00AMpatientisconsciousbutdrowsy,bilateralptosis+,
RR–10/min.,andcyanosed.
•Howwillproceedfurther?
CASE SCENARIO -2

62. Take-Home Message
•ABC
•Ensure either ET ventilation or AMBU BAG ventilation till he reaches
the higher center.
•Inj. Neostigmine can be given after one dose of Inj. Atropine
•Start the first dose of ASV and complete it before referral.
.

63. •A70-year-oldladyhascometothePHCwiththeh/oScorpion
Stingandseverepainintheleftindexfinger.
•Howwillproceedfurthertomanage?
CASE SCENARIO -3

64. Take-Home Message
•ABC
•Tab. Prazosin 30mic/kg provided systolic BP of more than 90mm of Hg
and hydration is adequate.
•If BP is <90mm Hg, adequately hydrate if there are signs of
dehydration and give Tab. Prazosin once the BP improves.
•Avoid Inj. Dexamethasone

65. •A10-year-oldboywhileplayingwiththeneighbours’petdoghada
scratchontherighthandwithbleeding.
•Howwillyouproceedtomanagethisboy?
CASE SCENARIO -4

66. Take-Home Message
•Thorough wound washing
•Categorization
•Immunoglobulin
•ARV
•Follow-up

67. Thank You