HEART OF THE MATTER"
a special program of the National Emergency Medicine Association (NEMA)
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Week: 570.7 Guest: Dr. Ron Charles, Asst. Prof. Emergency Medicine, U of Texas Med. Sch. Topic: Animal bites/Nose bleeds Producer/Host: Steve Girard
NEMA: Everyone has an animal bite story. I've been bitten by a dog ... when I was younger, a German Shepherd grabbed my right side, right above my waist and kind of shook me around a bit, and everybody has little stories like that. My aim is to find out what people can do to stay away from getting bitten first of all, if that's possible, and find out what kinds of things they should do after they are bitten. So, the first thing - do you have any words of wisdom as to how to avoid being bitten by a dog or cat or animal?
CHARLES: Right. The first thing is, you don't ever want to go near a dog that you don't know. Especially any wild animals or dogs that don't have any owners, just running about, there's a very high likelihood that they're scared of you and when you reach out there's a good chance that they'll bite you. Even your pets that love you, you need to be careful when they're eating. When they're in the trash trying to get food or their bone, sometimes they'll take that the wrong way and snap at you. So when... even with pets... when animals are eating, you need to be very careful so that they don't bite you.
NEMA: Now when an animal bites you, for instance a dog bite, that's the most prevalent type of bite....
CHARLES: Dog bites are the most common. Out of all emergency visits, about 1 percent occur, about 1 percent of patients come to the emergency department because of animal bites. Dog bites are the most common because they are the most common pet. We don't know how many people get bit that don't come to the emergency department, which could also be a fairly high number. But the estimate is about 1.5 million animal bites each year.
NEMA: Now everybody should be able to look at the bite and figure out what to do. Are there some parameters... that they can look at the wound and say, "well what should I do with this?".
CHARLES: Well even before you look at the wound you have to know what bit you. If it's a known pet, then the chance of getting rabies is very small and there are some precautions you'll take... as long as the dog continues to act normally you're okay. But if it's a dog that's wild, a dog that you don't know, then you need to take precautions. Call the county health department or local health department see about the prevalence of rabies. There're certain animals that give you a higher chance of getting rabies. Those are foxes, bats, raccoons, those types of things that can give you rabies. If you get bitten by a squirrel or a rat they don't give you rabies, because they get killed by... any animal that gives them rabies will kill them while they are giving them the rabies, so they're not vectors, they don't transmit rabies. So the first question you have to ask is, "is this a rabies prone wound or not"? Then you look at the wound and you look at where it is and you look at the type of wound. Certain areas need antibiotics even if they can't do anything else. Cat bites generally themselves need antibiotics because of the type of wound, their teeth are long and thin, and when they bite you, they produce a puncture wound injury. And at the bottom of the end of their teeth is where they will inoculate you with bacteria that will cause infection. And so, any cat bite generally needs antibiotics. Dog bites less so, but still might, depending on where you're bitten. If you're bitten on the hands where the blood supply is not as great, then you probably should be put on antibiotics to prevent infection. So the location is important, and the type of injury, type of bite. The puncture wounds carry a greater likelihood that you need antibiotics. If it's a slash wound, those can be cleaned out, irrigated and you might not need antibiotics, that's up to the doctor that treats you. How quickly you come to see him and how quickly he can get it. But those are wounds that might need suturing or that might need other things to improve the cosmetic affects.
NEMA: A friend of mine spent thousands of dollars on a cat bite he didn't take seriously... and still has some problems with that hand today, several years later.
CHARLES: When you have a puncture wound, what that does is that deposits the bacteria down deep and then the skin will close over that. So it leaves a pocket of bacteria. The dog bites generally will be a slashing or tearing, so it's easier to clean out ...its got an open area that you can clean out, wash out, and so you don't have as great a chance of infection. The worst, though, is human bites. Those are the worst. Dog bites have 64 organisms, human bites can approach 250 different organisms in your mouth. So I think it's an old wives tale that if a dog licks a wound that that's going to help it heal faster, I haven't seen any scientific data to support that. But its not going to cause an infection by licking a normal skin. Skin is very protective, it's the largest organ we have and it's very protective.
NEMA: So the general rule would be if you're bitten by a cat you pretty much should go see your doctor and get it taken care of.
CHARLES: If it's just that friendly... certain cats that know you will just sorta' put their teeth on you, you've encroached on their territory and they're not happy or whatever. But if it breaks the skin, and looks at all deep, antibiotics are needed. There are some other reasons why that's important, usually you'll get bitten, especially by cats, around the hand. The hand has a very poor blood supply. The blood supply brings what the body produces to fight infection. So if the blood, there's not enough blood supply to bring those things that fight infection, there's also a greater chance for infection. So bites to the hand, whether it's a human bite, a dog bite or animal bite can really become infected... and very quickly. And a lot of times you need to go to the operating room to be cleaned, in order to treat the infection, and try to make sure that hands going to recover. Infections of the hands are bad and cause irreparable damage to jobs and income.
NEMA: That means even the house cats?
CHARLES: Even, even if they're friendly cats. Even your confined cats that stay in the house still have organisms. The organism is called pasteurella, and its got a very high likelihood for infection and it sets up and produces a kind of grayish discharge and it gets the patient, gets the person infected very quickly.
NEMA: What to do in between the injury and going to see a doctor. Is there something you can do to help out?
CHARLES: Soap and water is a great thing. Just clean that bite as quickly as you can. So you want to clean it as quickly as you can. The other thing we really didn't talk about is tetanus and tetanus prone wounds. It's a slightly controversial debate for a doctor... it's five to ten years. You're generally covered for ten years unless you're elderly, or you're immuno-compromised. But if you have not had a tetanus shot in ten years, you definitely need to make sure you get one to keep everything up to date. And then those that are elderly, immuno-compromised - by immuno-compromised... you could be diabetic, you could be HIV positive, you could be anything that causes a decrease in your body's ability to fight infection, that puts you at a higher risk for infection for any bite.
NEMA: Dr. Charles, let's change gears. The nosebleed is a curious thing... sometimes it just happens... but what is the number one cause?
CHARLES: When you do this, you do this on TV, it's easy... but stick out your pointer finger. Now stick out the pointer finger on your other hand. Those are your number one and number two causes of nosebleeds, digital trauma, nose picking. Number one and number two causes of nosebleeds, your right and left hand.
NEMA: Wow, here I'm looking for something esoteric... you know....?
CHARLES: I have to do that on TV, and it's a lot of fun and, of course they fall for it hook, line and finger... sinker, but digital trauma or nose picking is the number one cause of nosebleeds. Other factors include high blood pressure, which could be associated... and the weather plays a factor if it's real dry outside and your nose gets real dry. Or you're blowing it a lot... there's a greater likelihood that you could get a nosebleed.
NEMA: Now I can understand that if you have a cold, kind of blowing all day and it gets kind of rough, but when it gets really dry what happens?
CHARLES: First of all, people are chronically dehydrated. We don't drink enough water, and so when it gets dry outside, our mucosa which is the pink stuff in the nose that's normally moist and collects stuff, the dust, as it goes in the hair, it gets dry and cracks and when you blow your nose or you stick your finger in there then it helps lead to bleeding.
NEMA: What would be some other reasons for nosebleeds that would be kind of unexpected. I've had this happen a couple of times where I'd get up quickly and I wouldn't know why but all of the sudden it would start to bleed.
CHARLES: Well nosebleeds, patients with high blood pressure if their blood pressure gets high can have nosebleeds. If you get any trauma, whether it be hit in the face or something, or spontaneous nosebleeds... you probably did something in the last short period of time, a day or two, that predisposed you, but along the flu and allergy season, it's real prone for nosebleeds. Unlikely are those who are on blood thinners, whether it be for heart attacks or strokes, they also... with very, very minor trauma can have spontaneous nosebleeds.
NEMA: So, what should you do when you get a nosebleed?
CHARLES: What we recommend for nosebleeds, now trauma nosebleeds are a little different because you have a set cause... once you stop the bleeding it will stop... generally. You might have a prolonged bleed if you got popped pretty good. But what you do when they come to visit us or if you are at home, what we recommend is you blow your nose. Because when a nosebleed starts, it could be a clot right at the spot of where it's bleeding, and that clot will stop that area from closing over... and it will continue to bleed. So you blow your nose, if you have some Afrin - it's a vaso- constrictor, constricts the blood vessels - you spray that in there and then you hold pressure for 10 minutes... then that should stop most nosebleeds. If that doesn't, then you need to come to the emergency department. But the thing that they talk about is tilting your head back. If you tilt your head back you swallow the blood. If you swallow the blood, it's very irritating to your stomach, which can cause you to vomit, which increases the pressure up top around your nose, and can increase your nose bleed. You also don't have any idea how much blood has been lost, so we always tell you to sit down, lean with your head forward and apply that pressure for 10 to 15 minutes.
NEMA: Our thanks to Dr. Ron Charles, Assistant Professor of emergency medicine at the University of Texas Medical School.
SPOT: 15 years in the prevention of heart disease, stroke and trauma - The National Emergency Medicine Association. This show is just part of what NEMA does. We send out millions of pieces of prevention information to people around the country, give grants to organizations in research, public information and emergency services, and have been instrumental in the creation and expansion of the Chest Pain Emergency Room movement. To play a role, call 800-332-6362.
NEMA: Thanks for joining us for today's program. If you have any comments or suggestions, contact this station. Or visit our home page at: www.NEMAhealth.org ...for a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I'm Steve Girard at The Heart of the Matter.
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