Snake, Dog, Cat and other Bites

Bite Me
By:Howard J. McGowan, Maj, USAF, MC

Objectives
* Discuss general wound care principles
* Determine high risk vs low risk bites as related to antibiotic prophylaxis
* Determine need for tetanus prophylaxis
* Determine need for rabies prophylaxis
* Review common biting animals to include dogs, cats, humans, snakes, spiders, and ticks

General Wound Care
* Cleanse and debride wound
* Liberal application of ice or other cold packs
* Pressure to control bleeding
* Sterile dressing
* Hand and foot wounds require immobilization
* If wound high risk antibiotics should be started
* Consider need for tetanus/rabies

High Risk Wounds
o Location
+ Hand, wrist, foot
+ Scalp or face in infants (risk of cranial perforation)
+ Over a major joint (risk of perforation)
+ Through and through bite of cheek

o Biting species
+ Human (hand wound)
+ Cat (hand and lower extremity wounds)
+ Pig
o Type of wound
+ Puncture (impossible to irrigate)
+ Tissue crushing that cannot be debrided (typical of herbivore)
+ Carnivore bite over vital structure (artery, nerve, joint)
o Patient factors
+ Older than 50 years of age
+ Asplenia
+ Chronic alcoholic
+ Altered immune status (chemotherapy, AIDS, immune defects)
+ Diabetes
+ Peripheral vascular insufficiency
+ Chronic corticosteroid therapy
+ Prosthetic or diseased cardiac valve
+ Prosthetic or seriously diseased joint

Low Risk Wounds
* Face, scalp, ears, mouth
* Self-bite of buccal mucosa (not through and through)
* Large clean lacerations that can be thoroughly cleansed
* Partial thickness lacerations and abrasions

Antibiotics
To Close or Not
* Wound closure
o Puncture wounds, wounds that appear clinically infected, and wounds more than 24 hours old may have a better outcome with delayed primary closure
o May consider early primary closure if less than 8 hours old or located on face

Tetanus Prophylaxis
Rabies
Dog Bites
Cat Bites
Human Bites
Snake Bites
* Hemotoxic symptoms
* Intense pain
* Edema
* Weakness
* Swelling
* Numbness/Tingling
* Rapid pulse
* Ecchymoses
* Muscle fasciculation
* Unusual metallic taste
* Vomiting
* Confusion
* Bleeding disorders
* Neurotoxic symptoms
* Minimal pain
* Ptosis
* Weakness
* Paresthesia/Numbness at bite
* Diplopia
* Dysphagia
* Sweating
* Salivation
* Diaphoresis
* Hyporeflexia
* Respiratory depression
* Paralysis
* Evaluation/Treatment
Antivenoms
Spider Bites
Tick Bites
Summary
* Discussed general wound care principles
* Reviewed high risk vs low risk bites as related to antibiotic prophylaxis
* Reviewed need for tetanus prophylaxis
* Reviewed need for rabies prophylaxis
* Reviewed common biting animals to include dogs, cats, humans, snakes, spiders, and ticks

Bite Me.ppt

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Systematic Approach in Anemia Evaluation

Systematic Approach in Anemia Evaluation and Review of Peripheral Smears
By:Jun W. Kim, MD
Family Medicine Residency
Dewitt Army Community Hospital

Objective
* Recognize abnormal peripheral blood smear
* Review differentials through systematic approach

Approach to Dx
Basic Labs to Start
Reticulocyte count
Reticulocyte Correction
Reticulocyte Production Index
- Hemolytic disease
- Hemoglobinopathy (including thalassemia)
Peripheral smear
* Optimal area for review
* RBC morphology, WBC differential, PLT (clumping?)
RBC morphology
Basophilic stippling
Burr cells
Elliptocytes/ovalocytes
Howell Jolly body
Schistocyte/helmet cells
Sickle cells
NRBC
Spherocyte
Stomatocyte
Target cells
Tear drop cells
Differentials
MCV/smear
Micro
Normo
Macro
Iron panel
Retic
Iron/B12/Folate
*Occult Blood Loss
Bone Marrow Bx
Anemia of Chronic Dis.
Anemia Differential Dx by Flow Chart
First use size (MCV) to sort the Differential Dx
Microcytic anemia
Iron def. Anemia
Thalassemia
Alpha-thalassemia
Beta-thalassemia
Sideroblastic anemia
Sample questions
Macrocytic anemia
Megaloblastic Anemia
B12
Folate
Aplastic Anemia
Occult Blood Loss?
Hemolytic Anemia
Other Lab Characteristics
* RBC morphology
* Serum haptoglobin
* Serum LDH
* Unconjugated bilirubin
* Hemoglobinuria
* Hemosiderinuria

Coombs’ positive with Spherocytes Autoimmune hemolytic anemia
Warm AIHA
Cold AIHA
Coombs’ positive with Spherocytes Other immune hemolytic anemia
Alloantibody hemolytic anemia
* Transfusion reaction
* Feto-maternal incompatibility (Kleihauer-Betke test)

Drug related Hemolytic anemia
* Toxic immune complex (drug+Ab+C3)
- Quinine, Quinidine, Rifampin, INH, Sulfonamides,
* Hapten formation (anti-IgG)
- PCN, methicillin, ampicillin

Coombs’ Negative Hemolytic anemia
Membrane Defects
Spherocytosis
Elliptocytosis
Coombs’ Negative Hemolytic Anemia Deficiency of RBC Enzymes
Pyruvate Kinase Def.
Coombs’ Negative Hemolytic Anemia Hemoglobinopathy
HbS disease
HbC disease
HbSC disease
Coombs’ Negative Hemolytic Anemia Paroxysmal Nocturnal Hemoglobinuria
Coombs’ Negative Hemolytic Anemia Fragmented RBC’s & Thrombocytopenia
Normocytic Anemia

Anemia Evaluation.ppt

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Asthma

ASTHMA
By:Rochelle M. Nolte, MD
CDR USPHS, Family Medicine

Objectives
* At the conclusion of the presentation, participants should be able to:
o ID signs and symptoms consistent with asthma and allergic rhinitis
o Differentiate the various severities of asthma
o Summarize an appropriate treatment regimen for asthma of various severities

Allergic Rhinitis
* Symptoms: sneezing, itching, rhinorrhea, and congestion
* Nasal smear with >10% eosinophils suggestive
* Dx can be confirmed by allergen-specific Ig-E
* Classification
* Affects 15%-50% of world-wide population
* Affects 40 million people in the US
* Prevalence increasing
* Associated with asthma

Management of Allergic Rhinitis
* Identification of allergens
* Avoid or minimize exposure to allergens
* Patient education
* Pharmacotherapy
* Allergen Immunotherapy

Definition of Asthma
* Chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are associated with widespread but variable airflow obstruction that is reversible either spontaneously, or with treatment.

Asthma
Asthma Triggers
* Allergens
* Pharmacologic agents (ASA, beta-blockers)
* Physical triggers (exercise, cold air)
* Physiologic factors

Diagnostic Testing
* Peak expiratory flow (PEF)
* Spirometry
* Methacholine challenge
* Diagnostic trial of anti-inflammatory medication (preferably corticosteroids) or an inhaled bronchodilator

Goals of Asthma Treatment
* Control chronic and nocturnal symptoms
* Maintain normal activity, including exercise
* Prevent acute episodes of asthma
* Minimize ER visits and hospitalizations
* Minimize need for reliever medications
* Maintain near-normal pulmonary function
* Avoid adverse effects of asthma medications

Treatment of Asthma
Written Action Plans
* Written action plans for patients to follow during exacerbations have been shown to:
o (Cochrane review of 25 studies)
o Decrease emergency department visits
o Decrease hospitalizations
o Improve lung function
o Decrease mortality in patients presenting with an acute asthma exacerbation
o NAEPP recommends a written action plan*







Pharmacotherapy

* Long-acting beta2-agonists (LABA)
o Beta2-receptors are the predominant receptors in bronchial smooth muscle
o Stimulate ATP-cAMP which leads to relaxation of bronchial smooth muscle and inhibition of release of mediators of immediate hypersensitivity
o Inhibits release of mast cell mediators such as histamine, leukotrienes, and prostaglandin-D2
o Beta1-receptors are predominant receptors in heart, but up to 10-50% can be beta2-receptors

Pharmacotherapy
* Long-acting beta2-agonists (LABA)
* Albuterol
* Inhaled Corticosteroids
* Mast cell stabilizers (cromolyn/nedocromil)
* Leukotriene receptor antagonists
* Theophylline

Various severities of asthma
* Step-wise pharmacotherapy treatment program for varying severities of asthma
* Patient fits into the highest category that they meet one of the criteria for

Mild Intermittent Asthma
Moderate Persistent Asthma
Severe Persistent Asthma

Pharmacotherapy for Adults and Children Over the Age of 5 Years
* Step 1 to 4
Pharmacotherapy for Infants and Young Children (<5 years)
* Step 1to 4
Acute Exacerbations
* Beneficial
* Likely to be beneficial
Exercise-induced Bronchospasm
* Evaluate for underlying asthma and treat
* SABA are best pre-treatment
* Mast cell stabilizers less effective than SABA
* Anticholinergics less effective than mast cell stabilizers
* SABA + mast cell stabilizer not better than SABA alone

Questions &Answers

ASTHMA.ppt

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