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Terrestrial Bites and Stings: Brian Costello, MD Department of Pediatric Emergency Medicine June 24, 2010
Terrestrial Bites and Stings: Brian Costello, MD Department of Pediatric Emergency Medicine June 24, 2010
Stings
Brian Costello, MD
Department of Pediatric
Emergency Medicine
June 24, 2010
Objectives
3
Identifying Poisonous Snakes
4
Crotalids
Pre-Hospital
• ABCs
• Rest
• Take off jewelry and clothing from affected
extremity
• Immobilize extremity and keep below level of
heart
• Keep warm
• NPO
• Constriction band (experienced hands only)
• Incision and Suction kit if available (must use
within 5-10 minutes of bite)
• Rapid transport to medical facility
8
Snake Bite Kits
9
Crotalid - Management
ED
• IV access, fluids, (central line & CVP?), morphine
• If snake is brought to ED, treat it with respect
Many people bitten by “dead” snake
Decapitated snakes bite reflexively for up to 1
hour
• Measure circumference of extremity at leading
point of edema and 10 cm proximal Q30min X 6
hours, then Q4 for 24 hours
• CBC with platelets, coags, type and cross, U/A
• If moderate or severe poisoning, then also get
BMP, fibrinogen and ABG
• Repeat labs Q4-6 hours
10
Crotalid Antivenin
CroFAB
• Initial dose is 4-6 vials
• Repeat initial dose if there is progression of
symptoms
• Once there is no progression, then give either:
2 vials Q6h for 3 doses OR
2-6 vials if progression of symptoms recur
• Admit to PICU
• All patients must be reexamined in 2-5 days after
bite
• Watch for serum sickness up to 3 weeks out
12
Crotalid - Management
14
Elapids
17
Georgia Venomous Snakes
Georgia
Carolina Pygmy Rattlesnake - Sistrurus miliarius miliarius
Dusky Pygmy Rattlesnake - Sistrurus miliarius barbouri
Eastern Coral Snake - Micrurus fulvius
Eastern Cottonmouth - Agkistrodon piscivorus piscivorus
Eastern Diamondback Rattlesnake - Crotalus adamanteus
Florida Cottonmouth - Agkistrodon piscivorus conanti
Northern Copperhead - Agkistrodon contortrix mokasen
Southern Copperhead - Agkistrodon contortrix contortrix
Timber Rattlesnake - Crotalus horridus
Western Cottonmouth - Agkistrodon piscivorus leucostoma
18
Exotic Snakes
19
Arthropods (“Bugs”)
24
Brown Recluse – Clinical Signs
2-8 hours
• Local reaction with mild-moderate pain
• Erythema, central blister or pustule
24 hours
• Fever, chills, malaise weakness, N/V, rash with
petechiae, joint pain, DIC, hematuria, renal
failure, hemolysis, respiratory failure
• Subcutaneous discoloration that spreads over
3-4 days
• Spreads to 10-15 cm
• Pustule drains leaving ulcerated crater that scars
Scar formation is rare if no necrosis after 72 hrs
Reaction varies according to amount of
25 envenomation
Brown Recluse Bite Mimics in Children
It's really BIG! The size of the body, not including legs, of a
recluse is smaller than a dime.
It's really HAIRY! Brown recluses have only very fine hairs
that are invisible to the naked eye.
It JUMPS! Jumping spiders live up to their name, and some
other spiders including wolf spiders occasionally jump, but
recluses don't.
I found it in a WEB! Brown recluses don't spin a web to
catch prey; they spin silk retreats and egg cases, but don't
form a typical recognizable web.
It has DISTINCT MARKINGS VISIBLE TO THE NAKED
EYE, such as stripes, diamonds, chevrons, spots, etc. that
are easily seen! The "violin" is very small and located on the
front half of the body. The violin is also indistinct in some,
especially young spiders. They're really pretty dull looking.
28 http://department.monm.edu/biology/recluse-project/identify.htm
Quiz: Indentify 2 Brown Recluses…
29
Brown Recluse - Management
No local symptoms
1-8 hours after bite
• Generalized pain and muscle rigidity
Cramping pain to abdomen, flanks, thighs,
chest – “rigid abdomen”
• Chills, N/V
• HTN, Tachycardia
• Respiratory distress
• Urinary retention
• Priapism
• Death from cardiovascular collapse
32 Mortality 50% in young children
Black Widow - Management
Tarantulas
• Do not bite unless provoked
• Venom is mild and not a problem
Wolf Spider and Jumping spider
• Mild venom only causes local reaction
Treatment is good local wound care
34
Centipede/Millipede
Centipedes
• Bites with jaws that act like stinging pincers
• Extremely painful
• Toxin is innocuous – local reaction only
Millipedes - harmless
Treatment
• Local anesthetic at wound site
• Local wound care
35
Ticks
37
Bees, Hornets, Yellow Jackets, &
Wasps
40
Insects - Management
Wingless member of
Hymenoptera
Bites with jaws and pivots
head to give multiple stings
Venom is an alkaloid with
direct effect on mast cell
membranes
Solenopsis richteri
and Solenopsis invicta
43
Red Imported Fire Ant (RIFA)
44
Fire Ants – Clinical Presentation
45
Fire Ants - Treatment
Symptomatic care
• Ice
• Cleansing
• Antihistamines for itching
• Steroids, antibiotics and antihistamines don’t
have an effect on the lesions
Occasional systemic reactions (hives, anaphylaxis)
46
Mammalian Bites
47
Mammal Bites
49
Cat Bites
51
Rodent Bites and Other Mammals
52
Mammal Bites - Treatment
Antibiotic prophylaxis
• No perfect drug, but Augmentin is close
• If allergic, then a combination of clindamycin
PLUS a 2nd or 3rd gen cephalosporin OR Bactrim
• First dose should be given in the ED
Infected bites require aggressive drainage and
debridement
• Obtain aerobic and anaerobic deep would
cultures
• Leading edge would culture for cellulitis
• Admit for IV antibiotics
Tetanus prophylaxis
54
Rabies
Rabies virus
• Virus transmitted through scratches, abrasions
and animal saliva contact with mucous
membranes
• Causes an progressive, irreversible
encephalopathy traveling up peripheral nerves to
the brain
Anxiety, insomnia, confusion, agitation,
hypersalivation, hydrophobia
• Unprovoked attacks
• Wild carnivorous animals, BATS
• Rodents, squirrels and rabbits are considered
no-risk
55
Rabies
57