McCubbins - treating the ouchies oct 24.pptx

Treating the Ouchies
MaryAlice McCubbins, RN, MSN, CPNP-PC, TNS,
LtCol,USAF(ret)
Trauma Nurse Practitioner
Disclosures
•  None
Objectives
•  Review trauma as a disease process
•  Recognize complexities of dog bite injury
in children
•  Summarize the appropriate protocols for
Rabies vaccination and immune globulin
post exposure prophylaxis
•  Explore treatment strategies for specific
injuries
So what
•  4.5 million treated annually in US
•  Half are children
–  Highest rate in age 5-9 yr olds
•  885,000 have significant injury
•  27,000 underwent reconstructive surgery (2012)
•  23,000 exposed to potentially rabid animals or
received post exposure prophylaxis (PEP)
Most Dangerous Breeds
4
3
Husky/Malamute
German Shepherd
American Kennel Association
American Veterinary Medical Association
Most Dangerous Breeds
•  4
•  3
•  2
Husky/Malamute
German Shepherd
Rottweiler
American Kennel Association
American Veterinary Medical Association
Most Dangerous Breeds
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4
3
2
1
Husky/Malamute
German Shepherd
Rottweiler
Pit Bull Terrier
Caucasian Ovcharka
•  Doberman, Chow Chow and Boxer
American Kennel Association
American Veterinary Medical Association
Chow Chow
Caucasian Ovcharka
Doberman pinscher
Boxer
Case Studies
•  8yo male presents to EU after being bit by
Pitbull
•  Rabies status unknown
•  Child’s immunizations UTD per mom
•  T 37.5, HR 98, rr 20, bp 107/48, 23.6kg
•  Xray femur neg for fracture
Pit Bull Terrier
Pit Bull Characteristics
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Trained to fight
Exploited for strengths
“locking jaw” theory
“Hold and shake”
Don’t release naturally
Often require prying open with object
Frequently shot
TF
anterior right thigh 9cm
Medial thigh 2cm
Rabies guidelines
•  Zoonotic disease by RNA viruses
–  F. Rhabdoviridae, G. Lyssavirus
•  Transmitted in saliva
•  Enters CNS
–  Acute, progressive encephalomyelitis
•  Incubation 1-3 month
–  Range days to years
What do we do?
•  HRIG (Human rabies immune globulin )
–  20IU/kg
–  Administered once
–  Directly around and into wound site
–  Any remaining volume given IM away from
vaccine site
Human diploid cell rabies vaccine HDCV
•  4 1ml IM vaccine dose schedule
–  First dose give as soon as possible after exposure
–  Followed by additional doses day 3, 7, and 14
–  Adults deltoid
–  Kids anterolateral thigh
–  Do not use gluteal area
•  Postexposure (Previously Immunized)
•  1 mL IM (deltoid region) x2
•  One injection each on days 0 and 3
•  Immunosuppressed patients
–  1 mL IM x5 doses on days 0, 3, 7, 14, and 28 with
HRIG
What to do with dog
•  If pet quarantine for 10 days
•  If unknown status
–  Euthenize
–  Necropsie tests
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If however the animal is
not available for
examination or the
status is unknown…
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Administer vaccine And
RIG according to ACIP
recommendations
MMWR
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Initially dog was apprehended then released
PEP started but…
Discharge with home care
Missed day 3
–  Children’s division
–  EU visit
•  Received day 7 and 14 without difficulty
–  Vessel loops removed at 1 week
•  Healed
Points to consider
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Scene size up
Scene safety
Additional patients
Gun violence
Options
Is there child endangerment issues
Meredith Reed
•  3yo female presents to EU after family
Australian Shepherd attacked her
–  Dog’s shots UTD
•  Presented initially to OSH and then transferred
to SLCH
•  PMHx: congenital hypothyroid
•  98.6, 140, 24, 98/65,
•  IV, 250mg bolus, Morphine, Zofran
•  Ancef OSH, Clindamycin upon arrival SLCH
Australian Shepherd
MR
anterior
posterior
MR
MR cont
Right posterior thigh left
medial thigh
Right buttock and superior
thigh
Hospital Course
•  Unasyn IV (Augmentin po to complete 7 days)
•  PAWS daily
•  Discharged home 10-6
–  Daily bath
–  Dressing change
•  Suture removal 10/10 Nitrous
•  No Rabies PEP d/t known dog status
CD
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8yo male with hx of NF1 and neuroblastoma
Mauled by family dog, American Bulldog
AOx3, t. 35.9, HR 114, RR 20, BP 102/79
CT head neg, head hematoma
Morphine, Zofran, Clindamycin
Hgb 13.5
American Bulldog
CD
•  Multiple trips to PAWS for wound care
•  Increased pain and disability related to comorbid condition
•  Family issues
CJ
•  7yo male presented to EU after being attacked
by the neighbor’s dog while playing football in
the neighbor’s yard
•  Multiple lacerations to LLE
•  Dog with history or previous bites
•  Animal control called
•  Animal’s immunization status reported UTD
•  PMHx: seizure disorder, last Td 1 yr ago
Medial calf
Anterior LLE
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To OR for initial débridement and assessment
IV antibiotics (ampicillin sulbactam)
Great saphenous vein ligated
Ortho consult in OR
–  Soleus and gastrocnemius muscles injury
–  Tibia exposure, no violation of cortex
•  Plastic Surgery
–  Débridement
–  Flap graft
–  STSG
Summary
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Reviewed incidence of animal bite injury
Introduced specific dog breed of concern
Described process for Rabies PEP
Explored case studies to demonstrate variable
injury patterns
questions
Right posterior thigh
•  Presents to EU 9/9
•  4yo female bitten by pitbull
•  Child reportedly entered
neighbor's house and dog
came up and attacked
her
•  dog’s Immunizations
UTD