Bites and Stings

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Bites and Stings

• B.W. BLOUNT, M.D., MPH
• Professor, Family Medicine
  
• Emory University School of Medicine

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WHATS BITING IN GEORGIA?

• B. Wayne Blount, MD, MPH
• Professor, Family Medicine

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Case 1

• 22 yr WM positive 5 T sign
• Arrives in back of pickup driven by others
  directly into the front lobby at the hospital

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5 Ts

• Has more tattoos than teeth
• Drives truck with loaded gun in rack
• Lives in trailer tied down by tires on top
• Always tanked Friday through Monday
• More Testosterone than Betz cells

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Case 1 (contd)

• Patient has extremely swollen shoulder with two
  puncture marks clearly visible with surrounding
  ecchymosis hemorrhagic blebs.

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Case 1

• He states his group was trying to protect the
  neighborhood from dangerous pests and after
  deliberation at the local bar had sought out the
  snakes at the local quarry.

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Case 1 (contd)

• The patient was trying to crack the
  whip with the snake when he was instead bitten.
  He now complains of great terrible pain he
  regrets his past and asks for a priest.

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Case 1 (contd)

• His VS are steady
• AF, 110/85,20,105,95
• No wheezing, but pt. crying
• Some nausea and paresthesias

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Case 1 (contd)

• What should be done next?

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Snake Bite Rx- late 19th century

• The Cottage physician
• String
• Bleed
• Cauterize or cut out
• Leeches
• Tincture of arsenic
• Keep thoroughly saturated with hot brandy, gin,
  or whiskey

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Snake Bite Rx-1950

• Tourniquet, bleed
• Cauterize hot iron or coals
• Oxidize area (H2O2)
• Antidote
• NS after some blood withdrawn
• Keep patient quiet

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Snake Bite Rx

• Whats new in 2004?

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Review

• Venom-neuromuscular blocker and tissue emulsifier
• Bites are categorized as minimal, moderate, and
  severe.

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Grades of envenomation,symptoms and signs within
2 to 5 hours

• Minimal- moderate pain, edema 2.5-15 cm,
  erythema, no systemic symptoms
• Moderate- severe pain, tenderness, edema 25-40
  cm, erythema, petechiae, vomiting, fever,
  weakness
• Widespread pain, tenderness, edema 40-50 cm,
  ecchymosis, systemic signs, vertigo
• Rapid swelling, ecchymosis, CNS symptoms, visual
  disturbance, shock, convulsions

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• If severe ? Antivenom
• If moderate ? Antivenom
• If minimal ? nothing
• Many are dry bites

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Other treatments of unproved value

• Cutting and suction
• Vacuum kits
• Ice, electricity
• Tourniquets, etc.

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• Immobilize patient with
• bitten area at level of heart.
• Horse based serum causes serum sickness.
• Therefore, plan on 10 vials or
  nothing.

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• Insert is your best guide
• Takes long time to mix (30 min)
• and to administrate ( gt1 hour)
• Pretest for reactions?

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• Rattlesnakes worst
• Water moccasin next
• Copperheads least
• New goat antivenom out but no
  experience yet

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• Reactions to Crotalidae antivenom frequent
• Give epi/H 1-2 blockers/steroids
• End point is ? symptoms signs
• Measure part involved

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• Lab Q4 for coagulopathy
• Transfusions may be needed
• Fasciotomy may be needed (not routine)
• for compartment syndrome
• No routine Abx or Steroids

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Case 2

• 49 yr Arizona male up to use toilet during the
  night, stepped on something in hall. Immediate
  sensation of red hot poker being shoved up leg to
  chest.

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Case 2 (contd)

• On arrival to ED, patient was drooling and
  exhibiting roving eye movements, and muscle
  spasms were extremely uncomfortable.

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Case 2 (contd)

• His wife asks you
• What was it doc, and what can we do?
• Answer

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Review

• Scorpion ? venom opens sodium
  channels
• Leading to prolonged firing of
  nerves.
• Rx Morphine
• Valium
• Resolves over 24-48

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Tip

• They fluoresce, so take your UV/Woods lamp on
  your campout

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Case 3

• 38 yr female cleaning attic
• Felt pin prick on the forearm and brushed off
  unknown assailant, then squashed it.

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Case 3 (contd)

• 24 later noted purple nodular area at site where
  surrounding pallor and erythema. Now at 48,
  complaining of an ulcerating lesion.

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Case 3 (contd)

• Dx?
• Rx?

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Review

• Brown Recluse Spider
• Most bites benign- no problem
• Few develop necrotic papule or blister
• Followed by blue/white/red pattern
• Necrosis from destruction of capillaries

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Symptoms

• Uncommon
• F/C, N/V, myalgia, hemolysis which ? renal
  failure, DIC, death
• Almost all deaths very young or old

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• Venom
• Not real clear
• Treatment
• Not very good
• No antivenom
• Tetanus, ice, antihistamine, analgesics

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• Dapsone-
• No proof
• Steroids, HBO, electricity, fumes, etc. also no
  benefit
• Revision-wait, wait, wait

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Case 4

• 63 yr WM in Acute Distress
• Brought by Wife via POV
• Bee stings approx 15 min pta
• While working in yard

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Case 4 (contd)

• Multiple stings all exposed areas gt30
• Some pain, much swelling periorbitally
• Lightheaded, wheezing
• No previous problem with stings
• Hx HTN and glaucoma

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Case 4 (contd)

• 100/60 80 16 AF
• Lungs scattered wheezing
• Heart RRR Ø murmur
• A O x 3

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Case 4 (contd)

• Dx
• Rx

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Review

• Hymenoptera
• Bumblebees
• Honey bees
• Hornets
• Fire Ants

• Sweat bees
• Wasps
• Yellow jackets
• Harvester Ants

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• Only sting once each (?only)
• Killer bees- same as honey bee, just
• an attitude problem (x 10)
• Membrane active polypeptide- 50 dry weight
• Cross reactivity- IgE

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Symptoms

• Local- pain, erythema, edema,
  pruritus,
• Toxic-N/V/D, lightheadedness, HA, fever, spasms,
  seizures, D/C,
• ARD, arrest

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Anaphylaxis

• Majority occur within 15 minutes, all within 6
  hours
• No correlation with of stings,
• Ac Airway Obstruction, ?BP,
• Urticaria, wheezing, N/V/D

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Delayed Reaction

• 10-14 days ? serum sickness like, fever, malaise,
  lymphadenopathy, polyarthritis, HA.
• Even encephalopathy
  Guillain-Barré

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Rx Epinephrine SQ/IV

• Antihistamine (H1 H2 blockers)
• Steroids
• Beta agonists
• IV
• Dopamine

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• What if patient (like this one) is on ß blocker?
  Not only will symptoms be blunted, but Rx
  compromised.

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• Glucagon/Atrovent
• might work

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• Kits/Pens
• Medic Alert tags
• Testing ----?
• Desensitization---?

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Fire Ants

• Venom-alkaloid (can cross react)
• Papule forms-sterile
• Same as bees Rx

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Case 5

• 14 yr male learning to scuba dive during 3 day
  family vacation in Florida

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Case 5 (contd)

• Day 1 brushes forearm on reef, notes burning
  sensation develops urticaria.
• Tells diving instructor who pours unknown liquid
  and mother puts Cortaid on it.

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Case 5 (contd)

• Day 2 Rash is gone. But winds blowing heavily
  and several on board begin wheezing, coughing,
  and develop runny eyes and noses.
• Dive captain cancels trip, group goes indoors and
  symptoms cease.

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Case 5 (contd)

• Day 3 While wading in shallows, youth steps on
  unknown object or animal. Severe pain ensues,
  wound bleeds freely.

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Case 5 (contd)

• Dive master rushes youth to local restaurant
  where he obtains tub of hot water and immerses
  foot. After an hour, visit local ED where
  fragments removed from wound. Placed on Abx.

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Day 1

• What was that?

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Review

• Coelenterate (fire coral) predators that look
  like vegetation immobilize prey by toxins
  delivered by nematocyst.
• Often relieved by acetic acid, saline, steroids,
  and Benadryl.

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Day 2

• What was that?

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Review

• Dinoflagellates (algae bloom) derive toxin
  from red tide
• Aerosolized ? wheezing, etc.
• Go indoors.

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Day 3

• What was that?

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Review

• Sting ray probably (also cat, lion, scorpion,
  zebra, and stone fish or sea
  urchins)
• All cause pain from venom apparatus
• Usually denatured by heat 45 C x 1 Hr

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Review (contd)

• Fragments must be débrided
• Wounds warrant consideration for Vibrios,
  mycobacterium, E coli, as well as
  Staph/Strep/Salmonella Rx SMX-TMP, or
  floxins
• TCN usually works. Tetanus also.

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Jellys

• Not cute-
• Though Beautiful!

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• Nematocysts are the problem

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• Linear lesions-
• may cover entire body

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Treatment

• Acetic Acid followed by Benadryl, steroids,
  analgesics

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• Can get exposed just walking
  on the beach

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Case 6

• 16 yr Scout returns from camp. Parent finds tick
  embedded on occipital area. Tick is approximately
  1 cm2 and cannot be dislodged easily.

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Case 6 (contd)

• Scout is asymptomatic. Camp was in northern New
  Mexico. How do you advise the parents who are
  asking for tests and/or shots?

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Case 6 (contd)

• What diseases are likely?

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Case 6 (contd)

• Lyme- Possible, not likely
• RMSF- Possible, not likely

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Case 6 (contd)

• What is the CDC definition of Lyme Disease?
• History is everything

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Case 6 (contd)

• EM gt 5 cm or one
• MSK, Neuro, or CV late manifestation
• Plus lab confirmation
• No prophylactic treatment!
• JAMA 2/2/2000

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Case 6 (contd)

• What about RMSF?

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Case 6 (contd)

• Same thing
• No prophylaxis
• Wait for symptoms

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Case 6 (contd)

• Ehrlichiosis (2nd most common)
• STARI-spirochete
• Babesiosis-protozoa
• Relapsing Fever-spirochete
• Tularemia-bacteria
• Colorado Tick Fever-protozoa

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Case 6 (contd)

• How do you remove the tick?

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Case 6 (contd)

• Tweezers or forceps close to mouth
  parts
• Traction (local ok)
• May need to scrape
• Prevention/Inspection better

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Jeopardy Time!

• You are asked to present a talk to the residents
  on Bites and Stings. You also prepare a
  list of questions. The first is
• When good ole Aunt Mary gets bitten by her kitty
  cat, what is likely to happen?

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Answer

• She will not come in for at least 24, then will
  have swollen red painful hand from puncture
  wounds. You will give her Augmentin 875 mg BID
  and a Td.
• What organisms?

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Question 2

• 5 yr child bitten in tenement house by rat
  mother demands shot. What do you give, how, and
  why?

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Response

• DPT (its booster time anyway)
• No rabies- rodents dont carry it
• Neither do chickens, birds, gerbils, hamsters,
  iguanas, snakes, possum, rabbits, squirrels, or
  chipmunks

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Top candidates for rabies Bats

• Raccoons, skunks, foxes, dogs and cats
  (observation)
• Horses and mules, cattle
  (tops in Tennessee)

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Question 3

• Pursuit/interaction with what animal leads to
  the most US human deaths?

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Answer Deer

• 200 hunters per year killed

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Question 4

• What biting or stinging animal causes the most
  deaths worldwide?

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Answer- Mosquito

• Millions worldwide from malaria, dengue fever,
  encephalitis, etc.
• Dogs- 50/year in US
• Bees- a few dozen/year
• Snakes- dozen/year
• Sharks and Bears- 2-6/year

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Bibliography

• Clark, R., Emergency Medicine, Tintinalli, 2000.
• Crown, L., Text of Family Practice, Rakel, 2002
  (in print).