Sunday, November 18, 2018
CCH_emergency_Bites, Human
Bites, Human
- Kenneth Maniscalco
- Mary Ann Edens
- Mitchell FarrellBrian Froelke
- Frank SmeeksScott DulebohnErin HughesPritesh ShethMark PellegriniJames HughesRichard CiresiPhillip Hynes
- 11/15/2018 3:58:32 PM
Introduction
Human bites account for a relatively low percentage (3%) of the total bites encountered in the ED, but they have the potential for severe morbidity due to challenges in identifying the injuries and late presentations complicated by established infection. The greater cost of care in these injuries is from infection and post-infection treatment, and therefore all efforts should be made to make the diagnosis early and prevent further deterioration. [1][2]
Etiology
Unlike other animal bites, human bites are commonly acquired as a closed-fist injury where one individual punches another in the face and lacerates their hand on the other’s teeth. Occlusion bites have the same risk profile as closed-fist injuries but are more easily recognized and have less prevalence of skin penetration over areas with structures directly below the skin. [3]
Epidemiology
Human bites represent about 3% of the total bite injuries seen in the emergency department and are most commonly closed-fist injuries. Bites in children are most often occlusion bites to the face and upper body from rough playing, while bites in the other age ranges are commonly at the metacarpal-phalangeal joint from striking another individual in the face or contact with another person’s teeth. These wounds are most typically found on the third, fourth, and fifth fingers at the MCP-joint. Occlusion bites predominate in presentation though this distribution may be skewed due to occlusion bites presenting as a known bite while closed-fist injuries (fight bites) typically present under altercation, assault, or other complaints that do not lend themselves to data collection and may only be incidentally found amongst other injuries. Fight bites are most commonly found in the teenage to young adult males. [4]
Pathophysiology
The physical trauma from a human bite is rarely spectacular with relatively minor lacerations and occlusion bruising being the main initial findings. Human oral flora and contagious disease spread to account for the greater amount of morbidity with human bites. Eikenella corrodens, as well as more common aerobic and anaerobic bacteria, are normal human flora. Herpes, hepatitis, and human immunodeficiency viruses are all transmissible through bite injuries. Closed-fist injuries show a predication for infection due to the injury overlying the joint capsule of the MCP and the extensor tendon sheath. Direct joint and tendon sheath inoculation after the fist is relaxed allow bacteria deep penetration to normally sterile anaerobic environments. Local infection, disseminated infection, tenosynovitis, and septic arthritis are all possible complications from human bite wounds.
History and Physical
Focused H&P should determine the circumstances surrounding the bite, location of the bite, whether the bite was contaminated with blood, the infectious state of both individuals involved, time since the occurrence, whether the patient has been febrile, local erythema, swelling, warmth, or purulent drainage from the bite site. Careful examination and measurement of occlusion bites in children are important as any bite with an intra-canine distance great than 3cm most likely came from an adult and should raise suspicion of abuse. Any patient arriving after or due to an altercation should have his or her hands examined for possible fight bites. Conversely, anyone with lacerations on their hands, or especially over the MCP joint should be questioned about the source of the injuries and educated on the danger of not having human bites treated as some patients are apprehensive to admit to the altercation. Immunization status of the person with an injury is important in cases where transmission of disease is a concern.
Evaluation
Wounds that were recently acquired are usually minor, less than 2cm long, and rather superficial which makes them easy to overlook or dismiss especially in light of other injuries or complaints. Contaminated or otherwise obscured skin on hands should be cleaned thoroughly to evaluate for a possible fight bite especially in intoxicated individuals who cannot provide a reliable history. Infected joints or tendon sheaths are more apparent but also warrant surgical consultation and IV antibiotics. If a bite in a child is suspicious for abuse a thorough exam should be performed, a broadened history should be taken, and CPS should be contacted.[1][3]
Treatment / Management
All wounds should be extensively irrigated and the patient’s tetanus status updated if necessary. Provide appropriate pain management before exploration, irrigation, or debridement of the wounds. All human bite wounds that pierce the skin should receive amoxicillin-clavulanate prophylaxis for a week, and the patient is given strict wound care precautions. The patient's TDaP status should be updated if necessary. Any laceration to the MCP-joint is a closed-fist injury until proven otherwise. If signs or symptoms of infection in a joint space or tendon sheath are present orthopedics should be consulted for evaluation for surgical washout and inpatient treatment with IV antibiotics. Repair of lacerations from human bites should follow the same principles as that of other bites and in most cases should be left to heal by secondary intention to prevent providing a more hospitable environment for bacteria to reproduce. [5][6]
Complications
- Cosmetic deformity
- Loss of function
- Infectious tenosynovitis
- Necrotizing fasciitis
- Abscess formation
- Amputation
- Osteomyelitis
- Septic joint
Consultations
- Hand Surgeon
- Plastic surgeon
- Infectious disease consult
Pearls and Other Issues
The transmission of HIV through bite wounds is concerning though exceedingly rare. HIV prophylaxis is only indicated if the wound is percutaneous and the mouth was contaminated with blood. Otherwise, the side effect profile of prophylaxis is more dangerous than the risk of transmission. A thorough discussion with the patient about the risks and benefits is warranted and should be documented with the appropriate outpatient follow up recommended/referred. For medical professionals, there has been no reported transmission of HIV from any occupational exposure.
Herpetic whitlow is caused by transmission of the herpes virus to the finger and appears as painful grouped vesicles on an erythematous base. It is most typically from a child sticking fingers into adults’ mouths and should be considered whenever a child presents with lesions on the distal fingers.
There is no post-exposure prophylaxis for Hepatitis C exposure, simply monitoring for signs of infection with outpatient follow-up. Hepatitis B exposure requires immune globulin only if the person bitten by an infected individual has never been immunized or is a known non-responder to the vaccine. Anyone who has never had their response to the vaccine measured and is exposed should be tested for the anti-HBs response and treated if negative.
Enhancing Healthcare Team Outcomes
Human bites can be very serious and are best managed by a team of healthcare professionals. Loss of function and cosmetic deformity are very common complications. All patients should be educated on signs of an infection following a human bite and when to seek treatment. Patients need to understand that long-term follow-up is necessary to prevent loss of function of the hand or fingers. In addition, the pharmacist should emphasize the importance of antibiotic compliance. Finally, all patients must be told that they may require a plastic surgery procedure later to improve function or cosmesis.[7]
Outcomes
Patients who seek immediate care after a human bite have excellent outcomes. However, patients who delay treatment tend to have adverse outcomes. In most cases, a florid infection develops which can involve the entire hand. In delayed cases, not only is there is a significant cosmetic deformity, but there is also a functional loss of the hand and fingers. Human bites on the nose, ear, or tips of the finger are difficult to cure and often require extensive plastic surgery. Scarring is another major complication of a human bite.
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Bites, Human - Questions
Take a quiz of the questions on this article.
Take Quiz
A patient complains of pain and swelling over the third metacarpophalangeal joint. She reports she was in a fight and hit her opponent, knocking out a couple of teeth. The area is swollen and red with decreased range of motion secondary to pain. Which of the following would not be appropriate management?
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What is the most appropriate choice for antibiotic prophylaxis after a human bite wound?
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A 56-year-old diabetic was injured in a bar argument. He had several cuts on his left hand when he punched someone in the mouth. Which antibiotic is indicated to prevent infection in this patient?
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In the treatment of a human bite, what is the first critical step?
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Which one of the following is most likely to get infected?
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Which is not true of human bite wounds?
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A child with significant developmental disabilities bites others. Select the best intervention.
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A 3 year-old male presents with his mother who reports that he came home from visiting their next door neighbor and playing with the two children with a bruise on his shoulder that looked like teeth marks. The child has no significant previous medical history, takes no medications, and has no allergies. On examination there is a small, raised, bruised area on the child's left shoulder with apparent teeth marks and an intercanine distance of 3.1cm. There is no bleeding or break in the skin. Otherwise the child is well and the mother has no other complaints. She has heard that human bites are dangerous and they need antibiotic treatment. What is the most appropriate next step in treatment?
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A 28 year-old man, his 6 year-old son, and wife present to the emergency department after the father was tossing the child in the air thirty minutes ago and the child slipped while being caught. The father is adamant the child did not his the ground, his head, or lose consciousness, simply that he was caught awkwardly. The child has a small laceration on the mucosa of his upper lip which is oozing blood, the lip is swollen, and the child is crying. The father has a small wound to the distal aspect of his radial styloid which is hemostatic and well approximated. Neither father nor son have any known medical history, allergies, or other injuries, though the wife has implied this isn't the last trauma which will occur today. Which of the following actions is most critical to proper patient care?
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A medical student is working in the emergency department one night when a patient she is examining grabs her arm and bites her. The patient is immediately restrained and the emergency department staff promptly examines the student. She has an occlusion wound with two epidermal punctures 3.3 cm apart in the soft tissue of her dorsal arm. She has a history of type 1 diabetes mellitus managed with an insulin pump and sliding scale boluses, and her tetanus vaccination status is current. A review of the patient's chart reveals he is HIV-positive. There was no blood in the patient's mouth when he bit the student, and the student immediately flushed the wounds with a liter of normal saline. What is the most appropriate management of her wounds?
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Bites, Human - References
References
| Bula-Rudas FJ,Olcott JL, Human and Animal Bites. Pediatrics in review. 2018 Oct [PubMed] |
| Saul D,Dresing K, [Surgical treatment of bites]. Operative Orthopadie und Traumatologie. 2018 Oct [PubMed] |
| Ng D,Chan T,Pothiawala S, A Human Bite on the Scrotum: Case Report and Review of Management in the Emergency Department. The Journal of emergency medicine. 2018 Apr [PubMed] |
| Contreras-Marín M,Sandoval-Rodríguez JI,García-Ramírez R,Morales-Yépez HA, [Mammal bite management]. Cirugia y cirujanos. 2016 Nov - Dec [PubMed] |
| Jenkins GW,Isaac R,Mustafa S, Human bite injuries to the head and neck: current trends and management protocols in England and Wales. Oral and maxillofacial surgery. 2018 Mar [PubMed] |
| Fisher-Owens SA,Lukefahr JL,Tate AR, Oral and Dental Aspects of Child Abuse and Neglect. Pediatric dentistry. 2017 Jul 15 [PubMed] |
| Oladokun R,Brown BJ,Osinusi K,Akingbola TS,Ajayi SO,Omigbodun OO, A case of human bite by an 11-year old HIV positive girl in a paediatrics ward. African journal of medicine and medical sciences. 2008 Mar [PubMed] |
CCh_EMT_Bag Mask Ventilation (Bag Valve Mask, BVM)
Bag Mask Ventilation (Bag Valve Mask, BVM)
- Joshua Bucher
- Jeffrey Cooper
- Mitchell FarrellBrian Froelke
- Frank SmeeksScott DulebohnErin HughesPritesh ShethMark PellegriniJames HughesRichard CiresiPhillip Hynes
- 10/27/2018 12:31:24 PM
Introduction
Bag valve mask ventilation is a skill of utmost important for emergency providers. It is not easy and requires practice to master as it will be utilized in emergent settings. Proper patient positioning is critical to the procedure. The tongue often falls to the back of the pharynx which can occlude the airway. The appropriate head tilt, chin lift maneuver or a jaw thrust helps to keep the airway open. The "sniffing" position is achieved with forward flexion of the neck and equilibrating the sternal notch and angle of the mandible. An oropharyngeal or nasopharyngeal may be utilized to maintain an open airway. Not only does the sniffing position assist with opening the airway as needed, but it can also help visualize the glottis opening as well as the vocal cords, improving your ability for first pass success during endotracheal intubation. Many BVMs are augmented by a one-way valve or a pressure valve. They require an oxygen supply to adequately deliver oxygen to the patient.
Anatomy
A review of oropharyngeal anatomy is important to understand the implications of BVMBVM ventilation. Anatomy may cause difficulty with ventilation.
It is important to predict which patients may be difficult to ventilate. Several acronyms have been formed to help predict who will be difficult to ventilate. MOANS stands for "mask seal, obesity, age (elderly), no teeth, stiffness." BONES stands for "beard, obese, no teeth, elderly, sleep apnea/snoring." These patients may be particularly difficult to ventilate and may require the use of a supraglottic airway to improve chances of ventilation. Likewise, several studies have identified factors that are associated with difficulty ventilating patients. These include the presence of a beard, obesity, lack of teeth, snoring, older age, and limited jaw protrusion. Leaving the patient’s dentures in, if applicable, helps create a better seal for the mask. A beard or significant facial hair can make it difficult to ventilate; the use of a water-soluble lubricant can improve the ability to create a seal.
Indications
The indications for performing BVM ventilation are a hypercapnic respiratory failure, hypoxic respiratory failure, apnea, or altered mental status with the inability to protect the airway. Also, patients who are undergoing anesthesia for elective surgical procedures may require BVM ventilation.
Contraindications
There are no contraindications for BVM ventilation.
Equipment
The equipment required includes a bag valve mask, oxygen source, oxygen tubing, a PEEP valve, and simple airway adjuncts such as an oropharyngeal airway and nasopharyngeal airway.
Personnel
In general, bag valve mask ventilation only requires one provider. A second provider can help squeeze the bag while the primary provider holds the mask seal.
Preparation
An oropharyngeal airway may be inserted in order to displace the tongue forward. This prevents the occlusion of the airway when the patient is laying supine. The only true contraindication to using it is if the patient has a gag reflex. The airway can be inserted directly or rotated 90 or 180 degrees in order to facilitate placement behind the tongue.
A nasopharyngeal airway can be inserted to enable ventilation via BVM to reach the posterior pharynx in the case of a large tongue or other obstruction. It is contraindicated in the case of facial trauma where there is a concern for a facial fracture due to the possibility of it violating the intracranial space. The airway can be inserted with the bevel towards the septum, after appropriate lubrication, and rotated as needed to extend to the posterior pharynx. The use of either of these basic airway adjuncts facilitates ventilating a patient by maintaining a patent airway.
The rescuer should be positioned at the patient’s head. A good face seal must be achieved with the mask over the face, the pointed end of the mask over the nose, and the curved end below the lower lip. A one-person technique involves the "E-C seal" in which your first and second digits form a "C" over the mask with your thumb pressing down by the nasal bridge, your second digit over the bottom of the mask by the mouth, and your third through fifth digits forming an "E" and applying pressure to the mandible to hold the mask tight. There should be no gaps between the mask and the skin. You can also tilt the head backward in a “head-tilt chin lift” maneuver or can displace the jaw forward to do a “jaw-thurst” if indicated to open the airway. This often provides for easier ventilation.
In a two-person technique, someone else squeezes the bag while the rescuer uses the same E-C technique with both hands. This has been shown to deliver a higher tidal volume in simulations and also allows for a better seal to be created. One must be careful to ensure that the soft tissue of the neck is not compressed by the rescuer's fingers.
Positioning the patient can improve the ability to ventilate. Utilizing the sniffing position, with the ear to sternal notch aligned in the same plane, optimizes conditions for airflow. Utilizing a mask a size larger than expected may help create a seal, but a smaller mask is more likely to lead to a leak.
Technique
An adult BVM with oxygen supplied at a minimum of 15 liters per minute and a full reservoir can provide up to 1.5 liters of oxygen delivered per breath. Ventilating should be done with caution and only until chest rise is appreciated to reduce the risk of gastric insufflation, possibly causing vomiting and barotrauma from overdistention.
Complications
The complications include barotrauma from too much lung inflation and gastric insufflation which can lead to vomiting and aspiration.
Clinical Significance
Advanced Clinical Applications
The routine use of cricoid pressure during BVM ventilation and endotracheal intubation was initially standard practice but has never routinely been shown to improve patient-oriented outcomes. Its original purpose was to occlude the esophagus and prevent gastric regurgitation and thus aspiration. Some studies have shown it has displaced the esophagus, rather than occluding it. Others have shown that it is incompletely occluded depending on the amount of force applied. Further studies have shown it inhibits laryngeal view during intubation.
BVM ventilation can be aided by the use of a positive end-expiratory pressure (PEEP) valve attached and titrated from 5 to 15 cm H2O in order to improve oxygenation prior to intubation in patients who are unable to be appropriately pre-oxygenated with standard therapy. Do not exceed a PEEP of 20 cm H2O on a BVM as this pressure can open the lower esophageal sphincter and cause gastric insufflation and vomiting.
Low pressure, low volume insufflation can help prevent gastric distention.
Some BVMs have the ability to attach a filter for pathogens. However, these devices are not foolproof, and personal protective equipment is required for every patient contact.
Likewise, the adapter for the BVM can fit an end-tidal monitor or a nebulizer reservoir. This allows additional functioning of the BVM. If the seal with the face is inadequate, this does limit the utility of these devices, as the end-tidal reading will be inaccurate and the nebulized medications may leak out.
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Attributed To: Contributed by the Public Domain
Interested in Participating?
We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE courses, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.
Improve Content - Become an Author or Editor
This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.
Bag Mask Ventilation (Bag Valve Mask, BVM) - Questions
Take a quiz of the questions on this article.
Take Quiz
In which patient is bag mask ventilation LEAST difficult?
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A bag-mask device is most useful if employing what technique?
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A 42-year-old bearded male presents unresponsive. Apparently, he complained of a severe headache and collapsed. On arrival, his vitals are 192/100, HR 85, RR 4, Sp02 78% and Temp 98.6 deg Fahrenheit. On exam, he is not protecting his airway. Which of these exam findings would cause difficulty with ideal pre-oxygenation?
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Which of the following levels of training is necessary for the skill of bag valve mask ventilation?
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What is the next step if in a situation in which one cannot ventilate with a bag-valve mask or intubate?
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Bag Mask Ventilation (Bag Valve Mask, BVM) - References
References
| Effect of general anaesthesia on the pharynx., Nandi PR,Charlesworth CH,Taylor SJ,Nunn JF,Doré CJ,, British journal of anaesthesia, 1991 Feb [PubMed] |
| A comparison of direct laryngoscopic views in different head and neck positions in edentulous patients., Kim H,Chang JE,Min SW,Lee JM,Ji S,Hwang JY,, The American journal of emergency medicine, 2016 Sep [PubMed] |
| Comparison of bag-valve-mask hand-sealing techniques in a simulated model., Braude DA,Tawil I,Gerstein NS,Carey MC,Petersen TR,, Annals of emergency medicine, 2014 Jun [PubMed] |
| Predictive factors for difficult mask ventilation in the obese surgical population., Cattano D,Katsiampoura A,Corso RM,Killoran PV,Cai C,Hagberg CA,, F1000Research, 2014 [PubMed] |
| Incidence and predictors of difficult mask ventilation and intubation., Shah PN,Sundaram V,, Journal of anaesthesiology, clinical pharmacology, 2012 Oct [PubMed] |
| Difficult mask ventilation., El-Orbany M,Woehlck HJ,, Anesthesia and analgesia, 2009 Dec [PubMed] |
| Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics., Kheterpal S,Martin L,Shanks AM,Tremper KK,, Anesthesiology, 2009 Apr [PubMed] |
| Comparative evaluation of the sniffing position with simple head extension for laryngoscopic view and intubation difficulty in adults undergoing elective surgery., Prakash S,Rapsang AG,Mahajan S,Bhattacharjee S,Singh R,Gogia AR,, Anesthesiology research and practice, 2011 [PubMed] |
| A comparison of direct laryngoscopic views in different head and neck positions in edentulous patients., Kim H,Chang JE,Min SW,Lee JM,Ji S,Hwang JY,, The American journal of emergency medicine, 2016 Sep [PubMed] |
| Comparison of sniffing position and simple head extension for visualization of glottis during direct laryngoscopy., Bhattarai B,Shrestha SK,Kandel S,, Kathmandu University medical journal (KUMJ), 2011 Jan-Mar [PubMed] |
| Incidence and predictors of difficult and impossible mask ventilation., Kheterpal S,Han R,Tremper KK,Shanks A,Tait AR,O'Reilly M,Ludwig TA,, Anesthesiology, 2006 Nov [PubMed] |
| Cricoid pressure: Where do we stand?, Bhatia N,Bhagat H,Sen I,, Journal of anaesthesiology, clinical pharmacology, 2014 Jan [PubMed] |
| Cricoid pressure provides incomplete esophageal occlusion associated with lateral deviation: a magnetic resonance imaging study., Boet S,Duttchen K,Chan J,Chan AW,Morrish W,Ferland A,Hare GM,Hong AP,, The Journal of emergency medicine, 2012 May [PubMed] |
| Cricoid pressure and laryngeal manipulation in 402 pre-hospital emergency anaesthetics: essential safety measure or a hindrance to rapid safe intubation?, Harris T,Ellis DY,Foster L,Lockey D,, Resuscitation, 2010 Jul [PubMed] |
| Incidence and predictors of difficult mask ventilation and intubation., Shah PN,Sundaram V,, Journal of anaesthesiology, clinical pharmacology, 2012 Oct [PubMed] |
| Difficult mask ventilation., El-Orbany M,Woehlck HJ,, Anesthesia and analgesia, 2009 Dec [PubMed] |
| Incidence and predictors of difficult and impossible mask ventilation., Kheterpal S,Han R,Tremper KK,Shanks A,Tait AR,O'Reilly M,Ludwig TA,, Anesthesiology, 2006 Nov [PubMed] |
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