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Referral and warning signs
When to refer
Refer based on specific bite/sting type (see subsequent entries). General indications: Signs of systemic illness (anaphylaxis, envenomation), signs of severe infection, deep wounds involving underlying structures, heavily contaminated wounds, bites on face/hands/feet/genitalia, need for specific antidote/antivenom, need for surgical debridement/repair.
Red flags
- Signs of anaphylaxis (difficulty breathing, throat swelling, hypotension, collapse)
- Signs of severe systemic envenomation (e.g., paralysis, severe bleeding, shock - varies by source)
- Rapidly spreading redness, swelling, or severe pain (infection/necrosis)
- Inability to move digits/limb distal to bite (nerve/tendon injury)
Signs and symptoms
- Pain at the site
- Swelling
- Redness
- Bleeding
- Visible wound (puncture, laceration, teeth marks)
- Itching (esp. insects)
- Systemic symptoms (if venomous or allergic reaction): e.g., difficulty breathing, shock, generalized weakness (See specific entries)
Risk factors
- Encounter with animals (dogs, snakes, etc.)
- Encounter with humans (bites)
- Encounter with insects (bees, wasps, ants, spiders, scorpions)
Diagnosis
Clinical assessment
Based on history of the event (what bit/stung, when, circumstances) and clinical examination of the wound and patient's overall condition. Assess for local signs (wound type, contamination, swelling) and systemic signs (allergy/anaphylaxis, envenomation).
Investigations
- Wound inspection for depth, contamination, foreign bodies.
- Assessment of neurovascular status distal to the bite/sting (if applicable).
- Assessment for signs of anaphylaxis (see EM001).
- Consider X-ray if foreign body (e.g., tooth fragment) or underlying fracture suspected.
Diagnostic criteria
History of bite or sting with resultant skin wound or local/systemic reaction.
Management
Non-pharmacological management
- First Aid: Immediately clean the wound thoroughly with plenty of clean water and soap. Stop excessive bleeding by applying direct pressure.
- Rinse the wound and allow to dry.
- Apply an antiseptic: Chlorhexidine solution 0.05% or Povidone iodine solution 10%.
- Apply ice packs or cold compresses for significant swelling.
- Immobilize the affected part if necessary.
- Reassurance.
Pharmacological treatment
- Analgesics: Paracetamol or other simple analgesics as needed for pain.
- Tetanus Prophylaxis: Give Tetanus Toxoid (TT) 0.5 ml IM if not immunized within the last 10 years.
- Antibiotics: Generally NOT routine unless high-risk (see below/specific entries). Considerations for prophylaxis: Moderate/severe wounds with extensive tissue damage, heavy contamination, deep puncture wounds (esp. cats), wounds on hands/feet/genitalia/face, underlying structure involvement, immunocompromised host.
- Specific treatments (antivenom, epinephrine, specific antibiotics) depend on the type of bite/sting (See specific entries).
Monitoring
Monitor wound for signs of infection (increasing redness, swelling, pain, pus). Monitor for systemic symptoms.
Complications
- Wound infection (cellulitis, abscess)
- Tetanus
- Rabies (animal bites)
- Transmission of other infections (e.g., Hepatitis B/C, HIV from human bites)
- Tissue damage/necrosis
- Anaphylaxis (allergic reaction)
- Systemic envenomation (venomous bites/stings)
- Damage to underlying structures (nerves, tendons, bones)
Prevention
- Avoid provoking animals.
- Supervise children around animals.
- Wear protective clothing in areas with venomous creatures.
- Use insect repellent.
- Control pests around homes.
Patient education
- Explain proper wound care.
- Advise on signs of infection to watch for.
- Discuss tetanus prevention.
- Provide specific advice based on the type of bite/sting.
- Educate on prevention measures.
Uganda-specific notes
Tetanus and rabies are significant risks. Cleaning with soap and water is a crucial first step. Avoid traditional remedies on wounds. Be aware of common local venomous snakes and insects.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 1, Section 1.2.1 (General Management)