2025 – PAGE 214 – EMERGENCY MEDICINE & TOXICOLOGY
SHARP OBJECT INGESTION
Sharp objects noted to be in the stomach or proximal duodenum should be removed with a flexible endoscope immediately. Once the object is beyond the reach of a flexible endoscope, SURGICAL removal is indicated for SYMPTOMS (pain, vomiting, fever or evidence of bleeding) or if the object FAILS TO PROGRESS on imaging over 3 consecutive days.
(DOUBLE TAKE) RABIES VIRUS
Rabies is caused by a VIRAL infection in which the virus is transmitted through bites, scratches, and contact with mucous membranes of infected animals, such as BATS, dogs, cats, foxes, RACCOONS (most common in the U.S.), skunks, and WOODCHUCKS. If the history suggests a possible exposure to a wild/aggressive animal, treat with standard wound care PLUS Human Rabies Immunoglobulin (HRIG) PLUS the four vaccine doses. If the animal is a pet, observation of the patient and animal is allowed without giving HRIG or vaccine.
PEARL: Rabbits, rats, and squirrels (rodents) are NOT associated with rabies.
PEARL: For the boards, if the word “BAT” is mentioned (alive, escaped, whatever!), treat as an exposure!
BROWN RECLUSE SPIDER
The brown recluse is a small spider. The bite is usually painless. Symptom onset is usually within hours, but most bites are minor. Some can result in a hemorrhagic blister, a necrotic ulcer, or a TARGET LESION. The spider does carry a potentially deadly toxin, but systemic symptoms are rare. Discharge from ER if there are no systemic symptoms. For minor bites, treatment is supportive.
MNEMONICS: RECLUse. RECLU spelled backwards spells ULCER! See below for a visual mnemonic to remind you of the potential target lesion.
BLACK WIDOW
If a black widow spider bite is suspected, look for a single, small puncture wound. There is a quick onset of symptoms (by 6–8 hours), which may include HTN and generalized muscular pain (abdomen, back, chest). Treat with antihypertensives and pain medications.
COMMON BITES
Common bite marks can be differentiated by shape and depth of a wound. A half-moon or semicircular lesion is likely a HUMAN bite, a tear-lesion is likely from a DOG, and PUNCTURE wounds are likely from a CAT. Cat bites carry the worst prognosis due to the deepest penetration. Amoxicillin-clavulanate provides adequate coverage for Staph and Pasteurella.