Poisonous and

Animal Bite Management

Animal Bites

Animal
Bites
Introduction
Animal bites are not uncommon occurrences.

However, victims who are treated in

emergency centers represent only a small
percentage of all bite victims
The majority dog bites (80-90%). Cat & other

bites 10%, Most animal bites occur on the

extremities, but the head and neck region is
also often affected

Animal
Bites
Mortality/Morbidity

Animal bites infection, and, if treated appropriately,

patients can avoid this risk

Other complications: sepsis, osteomyelitis, septic

arthritis, and even death

Hasan Sadikin Hospital: 240 animal bites in 2003

10-15 deaths occur following dog bites each year in

the United States

Most of these fatalities are children who sustain bites

to the head and neck region. Even a minor bite to a
major vessel can lead to hemorrhage in a small child

Animal
Bites
History
Although the incidence of infection

transmission is quite low, the risk of rabies is

probably the best reason for investigating
animal bite injuries

When evaluating a patient following an

animal bite, the nature of the injury is

pertinent, including whether or not the animal
was known to the victim

The time of injury

may have implications for

treating potential wound infections or for
addressing avulsed appendages

Animal
Bites
Physical Examination

Following an animal bite, patients require a full

physical examination to address all bite wounds

Adults are injured most often in the extremities.

Children are injured more often in the head and neck
region compared with adults

The degree of injury is important. Some patients can

be managed with local wound care or simple suturing
by emergency department staff. Others require a
consultation with a specialist or a trip to the operating
room to address their wounds.

Animal
Bites
Physical Examination

Animal
Bites
Laboratory Studies
Routine laboratory studies are not

mandatory in the workup following an

animal bite

Risk of infection or sepsis

a complete
blood cell count and cultures may
provide useful information for treatment

Animal
Bites
Imaging Studies
Imaging studies are not routinely

performed, except for possible fractures

May be helpful to identify the presence

of a foreign body (eg, a tooth)

Animal
Bites
Medical Care

Thorough cleansing is adequate for contused, intact

skin. If the skin is penetrated, copious irrigation is
warranted. Debridement in crush injury

Head and neck region: vital structures and cosmesis

region. May require consultation with a specialist

Basic wound management debridement, antibiotic

therapy, supportive care, and, possibly, primary
suturing or hospitalization with operative debridement

Wound severity dictates surgical management

Tetanus toxoid & Anti rabies vaccine if necessary

Animal
Bites
Surgical Care
Debridement

of devitalized tissues in the head

and neck region is performed with care
Surgical management can be immediate or
delayed
Laceration injuries can be closed primarily, but
avulsion injuries may benefit from delayed
treatment
Injuries with significant tissue loss may require
local flap treatment, composite grafts, or even
vascularized flaps

Animal
Bites
Consultations
Injuries to the head and neck region can be

especially complex
Involvement of vital structures may require

consultation with a head and neck surgeon

Because of cosmesis issues, consultation

with a facial plastic surgeon may be required

to ensure proper closure of a complex bite, to
a repair fracture, or for reconstruction

Snake Bites

Snake
Bites
Epidemiology :
Incidence :

USA : 8000 cases/year, 98% at extremities,

etiology : 70% rattlesnake.
Indonesia : ?, common.
5 million snakebites occur worldwide

each year, causing about 125,000

deaths

Snake
Bites
Snakes
Despite their sinister reputation, snakes are

almost always more scared of you than you

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

Snake
Bites
Snakes
Only about 400 of 3000 snake species

worldwide inject venom

Many snakes catch their prey by
constriction
Snakes do not kill by crushing prey
Some snakes grab prey with their teeth
and then swallow it whole

Snake
Bites
Poisonous Snakes
In Indonesia :
Trimeresurus albolaris (Green Snake)
poison : hematotoxic

Ankistrodon rhodostoma (Rattle Snake)

poison : hematotoxic

Bungarus fasciatus (Welang snake ?)

poison : neurotoxic

Naya Sputatrix (Cobra)

poison : neurotoxic

In Papua : species = in Australia

Snake
Bites
Snake
characteristics

Poisonous snake :
triangular shaped
head
two retractable
fangs at the maxilla
fang marks : two
well distinguished
marks

Harmless snake :
square head
small fangs
fang marks : smooth
wound in a curved
row

Snake
Bites
Teeth Pattern

Snake
Bites
Snakes

Milk snake (Lampropeltis triangulum)

Black mamba (Dendraspis polylepis)

Diamondback rattlesnake (Crotalus atrox)

Timber rattlesnake (Crotalus horridus)

King cobra (Ophiophagus hannah)
Cottonmouth (Agkistrodon piscivorous)

Coral snake (Micrurus fulvius)

N copperhead (Agkistrodon contortrix)

Snake
Enzymes Bites
of Snake
Venoms

Snake venoms :

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

Effect :
neurotoxic, hemorrhagic, thrombogenic,hemolityc,
cytotoxic, antifibrin, anticoagulant, cardiotoxic, vascular
disturbance : destroying intimal layer.

Symptoms & signs:

Local : edema, pain, tenderness, ecchymosis (within 30
minutes - 24 hours ).

Snake
Clinical Bites
Manifestations
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

Snake
Bites
Clinical signs

Tissue necrosis
Soft tissue damage
Echymosis
Compartment syndrome
Swelling

Snake
Bites
What to do
Even a bite from

a nonvenomous snake
requires excellent wound care
The victim needs a tetanus booster if he
or she has not had one within 5 years
Wash the wound with large amounts of
soap and water. Inspect the wound for
broken teeth or dirt.

Snake
Bites
Degree of snake bites
Degree enveno- wound
mation

pain

O
I
II

O
+/+

+
+
+

+/+
+++

III

+++

IV

+++

+++

edema
/erythema
<3cm/12 hrs
3-12cm/12 hrs
>12-25cm/12hrs

>25cm/12hrs

> extremity

systemic

O
O
+, neurotoxic
nausea,
dizziness
++, petechiae
shock,
ecchymosis
++, ARF,coma
bleeding

Snake
Bites
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 minutes)
Calm the patient
Torniquet ? (controversy)
Incision & suction ( 1 hour 11% removed)
Excision
Monitoring vital signs and be prepared for supportive therapy

Snake
Bites
First Aid

Snake
Bites
Management
Supportive treatments :

Respiratory problems : Oxygen, endotracheal intubation,

tracheostomy
Shock : Crystalloid solutions/blood transfusion, if bleeding
occurs.
Compartment syndrome : Fasciotomy
Neurotoxic signs : neostigmine (acethylcholinesterase) with
Athropine sulphate.
Hemorrhage :Fresh Whole Blood, vitamin K, fibrinogen,
blood products.

Snake
Bites
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

Snake
Bites
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

Snake
Bites
Management
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

Snake
Bites
Management
Prophylactic treatment :

Broad spectrum antibiotics

The commonest : P. aeruginosa, Proteus sp.
Clostridium sp., & B. fragilis.
Tetanus Toxoid
Antitetanus serum (as indicated)

Snake
Bites
Conclusions
Snake bite by poisonous snake commonly occurs

at the extremities
The degree of clinical manifestations of

poisonous snake is determined by the dose of

envenomation
The management of snake bite depends on the

degree of envenomation