A wide variety of animals, both wild and domestic, will bite or sting to ward off

enemies or kill prey, posing a common cause for visits to the emergency
department. Arthropod, reptile, fish, jellyfish, and mollusk stings and bites generally
cause little mechanical trauma to humans, but they can cause potentially severe local
and/or systemic damage if they deliver venom. Clinically significant venomous
animals include various species of spiders (e.g., black widow and recluse spiders),
scorpions (e.g., Arizona bark scorpion), hymenoptera (esp. bees and wasps), snakes
(e.g., rattlesnakes), fish (e.g., scorpionfish, stonefish), mollusks (e.g., blue-ringed
octopus, cone snails), and jellyfish (box jellyfish). While venomous mammals exist
(e.g., shrews, slow lorises, platypuses), attacks on humans are rare. Mammal bites are
instead clinically relevant for the mechanical trauma they cause (esp. with larger
mammals, such as dogs) and the risk of infection (e.g., rabies, rat-bite fever).
Diagnosis involves wound assessment, ruling out hypersensitivity reactions, and
identifying the animal responsible to determine the risk of infection and/or
envenomation. Symptoms of envenomation depend on the species of animal and
may involve local pain, swelling, and paresthesia; hypersensitivity reactions up
to anaphylaxis; nonspecific symptoms (e.g., nausea and vomiting); and, in severe
cases, neurotoxicity, autonomic dysfunction, and shock. Treatment depends on the
severity of the bite or sting and the animal responsible, potentially involving trauma
care up to surgery, hypersensitivity management up to epinephrine, care
with antibiotics, and the administration of antivenom.

For the general management of animal bites, see ”Bite wounds.” and “Rabies risk
assessment.”
NOTES
FEEDBACK

Dog bites
 Epidemiology
o Account for 1% of injury-related emergency department visits in the United
States  [1]

o Account for 60–90% of animal bites  [2]

o Children are more likely to be attacked and their injuries will be more severe
than in adults  [3]

 Clinical features
o Erythema, swelling, and possibly pus in the case of infection
o Depending on the size of the dog, injuries include puncture
wounds, superficial abrasions, lacerations, and/or crush injuries.
o In adults, the extremities are most commonly affected, and in children < 5
years of age, head and neck injuries are more common.
 Diagnostics
o Wound exploration for tendon or bone involvement and foreign bodies (e.g.,
broken off tooth)
o Radiography in the case of bone involvement
 Treatment   [3]

o Clean wound and irrigate with water, normal saline, or dilute povidone-

iodine solution
o Dog bite wounds should generally be left open to prevent infection, if feasible.
 Wounds with a low risk of infection may be closed after cleaning if the patient
wishes (e.g., for cosmetic reasons).
 Wounds with a high risk of infection (e.g., hand wounds, delayed presentation,
puncture wounds) should always be left open.
o Antibiotic treatment and prophylaxis
 Should be used for high-risk bite wounds (e.g., wounds to the hand, delayed
presentation, puncture wounds) and for wounds requiring closure
 First-line therapy is amoxicillin/clavulanate
o Prophylactic vaccination
 Rabies: indicated if there is suspicion or evidence of animal infection (see
“Rabies post-exposure prophylaxis”)
 Tetanus: recommended if the last vaccination was ≥ 5 years ago (see “Tetanus
prophylaxis” for more details)
 Complications  [4]

o Wound infection (risk is higher for deep and destructive bites)

o Arterial/neurological damage
o Arthritis, osteomyelitis, sepsis
o Cat scratch disease
 Reporting  [3]

o The reporting of dog bites is mandatory in most states.

o Rabies in animals as well as in humans is a notifiable disease. 

NOTES
FEEDBACK

Domestic cat bites

 Epidemiology: 5–20% of all animal bites  [2]
 Clinical features
o Typically a single puncture wound
o Most commonly on the hand or arm
o Erythema, swelling, lymphangitis, and possibly pus in the case of infection 
 Diagnostics: wound exploration to estimate depth and extend of injury and for
foreign bodies (e.g., broken off tooth)
 Treatment  [3]

o Clean wound and irrigate with water, normal saline, or dilute povidone-

iodine solution
o Wound closure: All cat bites are considered high risk for infection and should be
left open to prevent secondary infection. 
o Antibiotic prophylaxis: amoxicillin/clavulanate is first-line
o Vaccination: Tetanus vaccination is recommended if the last vaccination was ≥ 5
years ago (see “Tetanus prophylaxis” for more details).
o Rabies: See “Rabies post-exposure prophylaxis.”
 Complications  [4]

o Wound infection (risk is higher for deeper and more destructive bites)
o Arthritis, osteomyelitis, sepsis
 Reporting: Rabies in animals as well as in humans is a notifiable disease. 
NOTES
FEEDBACK

Rodent bites
 Examples: rats, mice, squirrels
 Clinical features: Rodent bites generally carry a low risk of infection.
o Local inflammation: cardinal signs of inflammation
o Local and systemic infection: purulent secretion, fever, and arthritis
o May cause:
 Leptospirosis
 Lassa fever
 Rat-bite fever
 Transmitted by Streptobacillus moniliformis
 Characterized by fever, rigors, and polyarthralgia
 Can cause severe organ damage (e.g., hepatosplenomegaly, interstitial
pneumonia, endocarditis).
 Small rodents have not been known to transmit rabies to humans.
 Treatment
o General: dirty wound treatment
o Leptospirosis: aminopenicillins, doxycycline, penicillin G
 Rat-bite fever: penicillin G
o
References: [5]

NOTES
FEEDBACK

Bat bites
[6]

 Epidemiology: the leading cause of rabies transmission in the US (70% of cases)   [6]

 Pathophysiology: Bats transmit rabies through infected saliva, but their bites can

be very small, painless, and difficult to identify.
 Treatment
o Clean wound.
o Irrigate wound with water, normal saline, or dilute povidone-iodine solution.
o Rabies prophylaxis should be administered:
 In the case of any bite or scratch, even if through clothing
If a child is left unattended in a room where a bat is found

 If an individual wakes up to find a bat in their room
 For further information, see “Rabies post-exposure prophylaxis.”
o Tetanus: recommended if the last vaccination was ≥ 5 years ago (for further
information see “Tetanus prophylaxis”)
NOTES
FEEDBACK
Snakebites
 Epidemiology  [7]

o ∼ 5000 venomous snakebites per year in the US

o Crotaline snakes (pit vipers, e.g., rattlesnakes, copperheads, cottonmouths) are
responsible for the majority of snakebites in the US.
 Clinical features
o Dry bites (bites without envenomation): minor local symptoms
Envenomation leads to varying degrees of local and systemic symptoms that
o
depend on the amount and toxicity of the venom (see table below).
MAXIMIZE TABLETABLE QUIZ

Common snakebites  [8][9]

Rattlesnakes Coral snakes

Distinguishing features  Subtle earth-tone colored skin with  Alternating red, yellow, and black color bands 

rattle tail, triangular head, and

 Common snakebites  [8][9]

Rattlesnakes Coral snakes

vertical pupils 

 All US states except Maine, Hawaii,

Distribution  Southern US and northern Mexico
and Alaska

 Cytohemoneurotoxic

 Increases permeability of the  Neurotoxin 

Venom cell membrane  Causes competitive inhibition of presynaptic

 Fibrinolytic and protein C- and postsynaptic muscarinic AChR

activation effect

 Severely painful bite

 Bite painless or mildly painful
Local  Swelling, ecchymoses, erythema
 Swelling and paresthesia
 Tissue necrosis

 Nausea, vomiting

 Coagulopathy: can lead to DIC and  Nausea, vomiting, abdominal pain

Clinical

features of bleeding  Neurotoxicity

envenomatio  Thrombocytopenia o Descending paralysis: e.g., bulbar

n Systemi  Hemodynamic instability: paralysis, ophthalmoplegia, dysphagia, dysar

c e.g., tachycardia, hypotension, distribu thria

tive shock o Respiratory depression 

 Neurotoxicity: e.g.,  Autonomic symptoms:

paresthesias, altered mental e.g., hypersalivation, miosis

status, seizures
 Diagnostics: usually based on history (description of possible identifying features
of the snake) and clinical features
MAXIMIZE TABLETABLE QUIZ

Grading scale for snakebite severity  [10][11]

Degree of severity Clinical features

 Asymptomatic

Asymptomatic  Punctures or abrasions

 Minimal edema and/or erythema

 Painful bite
Mild
 Localized erythema and edema

 Painful bite

 Tenderness, erythema, edema beyond the bite area

Moderate
 Systemic features (e.g., tachycardia, tachypnea, nausea, vomiting)

 Signs of coagulopathy (e.g., abnormal coagulation parameters)

 Severely painful bite

 Swelling of the entire affected extremity

Severe
 Severe systemic features (e.g., hypotension, paresthesia)

 Signs of coagulopathy (e.g., hemorrhage)

 Abnormal systemic features (e.g., seizures, altered mental status, respiratory failure, shock)

Life-threatening
 Severe coagulopathy (e.g., DIC)

 Management  [8]

o Antivenom administration
 Can slow or halt the progression of poisoning and is most effective when
administered within 4–6 hours of the snakebite  [10]

 Should only be given to patients with clear symptoms of envenomation and in

whom the benefits are likely to exceed the risks of adverse
reaction to antivenom
 For pit viper bites: crotalidae polyvalent immune fab
 Adverse effects: hypersensitivity, serum sickness
 o Pressure immobilization and/or tourniquets are not recommended as part of
routine management in the US.   [12]

o Patients must be monitored closely for signs of cardiovascular instability and

respiratory compromise.

NOTES
FEEDBACK

Spider bites
 General treatment includes cleaning of the wound, cooling, and analgesia.
 They rarely require specific medical treatment.
MAXIMIZE TABLETABLE QUIZ

Common spider bites

Brown recluse spider Widow spider

 Black body with varying red marks

 Violin-shaped marking on its  North American species:

Distinguishing features
cephalothorax  characteristic red hourglass mark on

the ventral portion of the body 

 South and North America

 Found in many regions worldwide
Distribution  In the US, it is endemic to the
 In the US: Southwest
Southeast and Midwest.

 Necrotoxin  Neurotoxin (latrotoxin) 

Venom  Causes local destruction of tissue  Causes massive exocytosis

integrity, leading to tissue necrosis of ACh and norepinephrine

Clinical Local  Initially painless bite that develops  Painful bite that turns into a circular
features
into an erythematous, red macule and then a target-

painful blister within several hours. like lesion

 Bluish-black skin discoloration
 Common spider bites

Brown recluse spider Widow spider

usually seen within 24 hours

 Formation of a dark

black eschar by the end of the first

week

 Muscle pain and rigidity of the

 Uncommon extremities, abdomen, and back

Systemic
 Nausea, vomiting, fever, hemolysis  Autonomic neurologic symptoms

can occur.

 Tissue debridement for  Benzodiazepines for muscle rigidity

Specific treatment
severe necrotic lesions  Antivenom

NOTES
FEEDBACK
Scorpion stings
Bark scorpion sting
 Distribution: southwestern US 
 Pathophysiology: venom contains a neurotoxin that inhibits the inactivation of
the sodium channels → prolonged depolarization → neuronal membrane
hyperexcitability
 Clinical features
o Mild: local pain, swelling, and paresthesia at the sting site
o Severe: cranial nerve dysfunction, autonomic dysfunction, neuromuscular toxicity
(e.g., fasciculations, muscle jerks), rarely acute pancreatitis
 Diagnostics: based on history and clinical features
 Treatment: antivenom administration for severe cases
 NOTES
FEEDBACK

Hymenoptera stings
 Examples: bees, wasps, yellow jackets, hornets, fire ants
 Distribution: worldwide
 Pathophysiology: Insects from the Hymenoptera order release venom into tissue
when stinging, triggering a local skin reaction and potentially life-
threatening systemic reactions.
 Clinical features
o Local skin reaction at the site of the sting
 Initial pain
 Swelling and redness appear within minutes of the sting event.
 Usually resolves within hours
 Large local reactions (LLR): gradually extending area of swelling and redness
(typically > 10 cm) that lasts for days 
[13]

o Systemic allergic reactions, anaphylaxis are possible

 Diagnostics: primarily a clinical diagnosis
 Treatment
o Removal of the stinger if it is still lodged in the skin
o Cold compresses
o Analgesia (NSAIDs)
o Observation of patients with multiple stings or a history of systemic reactions or
other allergies
o Severe cases
 Oral prednisone for LLR to reduce significant swelling
 Systemic reactions (anaphylaxis): See ”Management of anaphylaxis.”
NOTES
FEEDBACK
Shellfish
 Example: oysters
 Distribution: worldwide in warm coastal waters
 Epidemiology: increased risk in individuals with immunodeficiency, diabetes,
or liver disease (e.g, hemochromatosis)
 Pathophysiology
o Consuming raw or undercooked shellfish → infection with Vibrio vulnificus
o Dermal injury exposed to contaminated marine water. Necrotizing wound
infections can occur.
 Clinical features
o Dermatologic
 Hemorrhagic bullous lesions
 Severe necrotizing fasciitis
o Gastrointestinal
 Diarrhea
 Vomiting
o Primary septicemia   [14]

 Diagnostics
o Laboratory: blood cultures
o Imaging methods of affected tissues (e.g., CT, MRI)
 Treatment
o Emergent surgical debridement
o Antibiotics: IV doxycycline and ceftriaxone
References: [14]

NOTES
FEEDBACK

Venomous aquatic animals

The following sections cover the venomous aquatic animals most commonly
responsible for hospital visits in the US. Included here are not only animals native to
US waters, but also animals popular among aquarists. Wounds caused by aquatic
animals are particularly susceptible to infection with Vibrio species, due to
contaminated seawater (see “Noncholera Vibrio infection” for more information).
NOTES
FEEDBACK
Jellyfish stings
 Distribution: Box jellyfish are most commonly found in Hawaii, Northern Australia,
and the tropical Atlantic.
 Pathophysiology: Jellyfish have tentacles with specialized capsules (nematocysts)
that attach to the skin and release venom. The toxicity of the venom depends on
the species.
 Clinical features
o Local envenomation
  Initial pain
 Sting develops into a linear urticarial lesion. 
 Severe stings can be complicated by skin necrosis.
o Systemic envenomation: anaphylaxis, cardiac arrest
 Diagnostics: based on history and clinical features
 Treatment: Routine management depends on the jellyfish species and the
geographic location. [15]

o Apply topical vinegar: recommended only for some jellyfish species (e.g., box
jellyfish) 
o Remove attached tentacles  and rinse the sting site with seawater. 
o Immerse in hot water for pain relief. 
o Administer antivenom in the case of severe stings (e.g., stings affecting large
areas, systemic symptoms). 

NOTES
FEEDBACK
Stingray stings
 Distribution: freshwater and coastal regions
 Epidemiology: 750–2000 stings reported annually in the US  [16]

 Clinical features
o Local: laceration or puncture wound, with severe pain that is disproportionate to
the injury
o Systemic:
 Headache, seizures, syncope
 Dyspnea
 Muscle cramps
 Hyperhidrosis
 Abdominal pain, nausea, vomiting
o Potential allergic reaction or anaphylaxis
 Diagnostics
o Imaging: x-ray to check for retained barb 
o Laboratory studies: swab sample for culture if signs of secondary infection
 Differential diagnosis: stonefish sting 
 Treatment
o Immerse injury in hot water (42–45°C) for 30–90 minutes (provides analgesia and
denatures the venom).
 o Administer NSAIDs or opioids if analgesia from hot water immersion is
insufficient.
o Wound treatment
 Clean puncture site.
 Check for retained barb under local anesthetic.
 Do not suture wound (due to risk of infection).
o Administer prophylactic antibiotics.
o Tetanus: recommended if the last vaccination was ≥ 5 years ago (for further
information see “Tetanus prophylaxis”)
 Complications
o Infection or necrosis (due to retained barb)
o Potentially lethal systemic poisoning in the event of penetrating trauma to
abdomen, chest, or neck
NOTES
FEEDBACK

Stonefish, scorpionfish, and lionfish stings

 Distribution
o Worldwide, mainly Indian and Pacific Oceans 
o Injuries not limited to coastal areas, due to inland aquarium trade
 Pathophysiology: Venom causes vasodilation, hypotension, neuromuscular
paralysis, arrhythmias, and myocardial ischemia.
 Clinical features [17]

o Local: intense burning sensation at the puncture site, which radiates proximally
o Systemic:
 Headache, syncope, weakness
 Chest pain, dyspnea (due to pulmonary edema)
 Hyperhidrosis
 Abdominal pain, nausea, vomiting
o Potential hypersensitivity reaction including anaphylaxis
 Diagnostics
o Primarily a clinical diagnosis
o Imaging: x-ray to exclude retained spines and foreign bodies 
o Laboratory studies: swab sample for culture if there are signs of secondary
infection
 Differential diagnosis
o Sea urchin sting: dark discoloration around the puncture site (due to pigment in
the spines)
o Stingray sting 
 Treatment
o Immerse the affected area in hot water at 42–45°C for 30–90
minutes (provides analgesia and denatures the fish venom).
o Administer NSAIDs or opioids if analgesia from hot water immersion is
insufficient.
o Wound treatment
 Clean puncture site.
 Check for retained spines under local anesthetic.
 Drain blisters, as they may contain venom.
o Administer antivenom if systemic symptoms occur.
 Complications: wound infection, necrotic ulcers, compartment syndrome, chronic
neuropathy
NOTES
FEEDBACK

Shark bites
 Examples: great white shark, tiger shark, bull shark
 Epidemiology
o Despite posing a relatively low public health risk, shark-related injuries often
generate a disproportionate amount of public and media attention.
o Annually, 70–80 unprovoked shark attacks occur worldwide   [18]

 Management
o In the rare event of a patient being admitted with shark-related injuries:
 Prioritize hemorrhage control
 Clean wounds thoroughly to prevent infection 
o For more information, see 'Management of trauma patients'
Approx. 7% of shark attacks are fatal.  [19]

NOTES
FEEDBACK
References
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