Julio Bites and Stings

Bites and Stings:

Bites and Stings Julio Diaz Training Officer Gwinnett County Fire and Emergency Services

Bites and Stings:

Bites and Stings Arthropods Insects Spiders Scorpions Ticks Reptiles Pit Vipers Coral Snakes Dog Bites

Insects (Hymenoptera) :

Insects (Hymenoptera) 50% insect sting 30% snake bite 14% spider bite 6% other Venomous Bites and Stings

Class: Insecta Order: Hymenoptera:

Class : Insecta Order : Hymenoptera Bees, wasps, ants Account for more envenomation deaths than anything else! 10 million stings/year 40-150 deaths/year Death usually due to immunologically medicated mechanism

Insects (Hymenoptera) :

Insects (Hymenoptera) Yellow jackets, white- and yellow-faced hornets, wasps, and domestic honeybees are found throughout the United States, whereas fire ants and African honeybees are indigenous to the southern and southwestern regions. African honeybees ( Apis mellifera Scutellata) have more defensive and hostile behavior and will attack in swarms without provocation. Yellow jackets are scavengers and are also aggressive. Imported fire ants (IFAs) anchor themselves by their mandibles and deliver multiple stings in a semicircular pattern.

Hymenoptera:

Hymenoptera Problems Allergic reactions Anaphylaxis Toxic venom effects (rare) About 40-150 deaths/year Honeybees 50% Yellow jackets and other wasps 50% 0.4% of population at risk for serious allergic reaction Most give history of progressive severity of response Some deny prior stings or report only normal reactions 50% of 2006 sting patients experiencing allergic reaction had NO previous warning symptoms!

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Local reaction (wheal/urticaria) Sharp, burning pain Pruritis Edema Extensive reactions may involve entire extremity Stings to tongue/throat may cause loss of airway Systemic reactions Mild: Diffuse itching, urticaria, swelling distant from sting site, flushing Severe: Laryngeal edema, severe bronchospasms, profound hypotension Most deaths (75%) occur within 4 hours of the sting

Hymenoptera:

Hymenoptera Treatment of Severe Reactions Treatment Local Reactions Remove retained stinger (flick) Ice to site Oral antihistamines Mild analgesics (Anaphylaxis) Activate EMS Airway management Epinephrine (0.3 cc of 1:1,000 q15 min) SQ or IM Fluids Antihistamines

Medications for Anaphylaxis:

Medications for Anaphylaxis Diphenhydramine 50 mg PO/IM q4-6h (may also give IV) Epinephrine (1:1,000) 0.3 cc of 1:1,000 solution q 15 min Avoid IV, but if necessary use 1: 10,000 soln Cimetidine 300-800 mg IV q6h (may also use ranitidine) Methylprednisolone 125mg IV load, 40mg q6h Albuterol (for bronchospasm)

Spiders:

Spiders 50,000 species 50 U.S. species can bite humans 15 U.S. species will produce symptoms Two are particularly dangerous Black widow ( Latrodectus mactans ) Brown recluse ( Loxosceles reclusa

Black Widow (Lactrodectus):

Black Widow ( Lactrodectus) Throughout U.S. As far north as Oregon, New York Common in South, Southwest Irregular webs in wood piles, under rocks, in trash dumps, in outdoor structures Occasionally in houses Females rarely leave web Only females can bite humans

Black Widow:

Black Widow Neurotoxic venom (alpha- latrotoxin ) Binds to nerve-ending calcium channels Triggers neurotransmitter release Blocks neurotransmitter re-uptake Inhibits normal nerve impulse transmission Produces low serum calcium

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Local discomfort (bite site) Systemic Symptoms Wound care Ice Analgesia Observe for progression Neuromuscular twitching, cramping Calcium gluconate infusion Diazepam 5-10 mg IV Methocarbamol 10 mg Severe pain Codeine Morphine Hypertension Pain control/sedation Nitroprusside (rarely)

Black Widow:

Black Widow Symptoms peak in a few hours, then diminish Usually last < 24 hours Some symptomatic up to 4 days 5% have delayed hypersensitivity 2 to 3 days post-bite Mortality rate unknown Most recover completely Antivenin indicated for : Very young Very old Hypertensive reactions Acute respiratory distress Horse serum based antivenin (Merck) 1-2 vials

Brown Recluse (Loxosceles):

Brown Recluse ( Loxosceles) Southeast and South Central U.S. Related species in desert Southwest Shy, nocturnal Dark closets, basements May live on floors, behind furniture in houses Venom damages endothelial cells

Brown Recluse:

Brown Recluse Local effects Tissue necrosis Edema Hemorrhage Thrombosis

Brown Recluse:

Brown Recluse Systemic effects Due to hemolytic effects of toxin Anemia/DIC/renal failure Systemic hemolysis , though rare, may be rapidly progressive and severe, especially in children. Symptoms generally start 24 to 72 hours after the bite and may include fever, chills, headache, malaise, weakness, nausea, vomiting, myalgias , and arthralgias .Severe anemia, consumptive coagulopathy , renal failure, shock, seizures, and coma have been reported.

Brown Recluse:

Brown Recluse Local signs and symptoms No pain or only mild stinging Within 2 hours: Local pain, blue-gray constrictive halo 12 to 18 hours: Bleb formation, growing ischemic zone 5 to 7 days: Aseptic necrosis, eschar formation, necrotic ulcer Severe lesions up to 30 cm in diameter

Brown Recluse:

Brown Recluse Management of minor (local) bites Local cold application Wound cleansing Padded splint, bulky dressing Tetanus update Hospital management Supportive and symptomatic care Debride full thickness lesions with subsequent grafts Dapsone may improve outcomes Antivenin under development Outcomes NOT improved by Early excision Steroids

Lepidoptera:

Lepidoptera Pus caterpillar Larval form of the M. opercularis moth. Seasonal: one stage in June/July and one in October/November 1921 San Antonio , so abundant public schools were ordered to close while pest was brought under control.

Pus Caterpillar:

Pus Caterpillar Distribution: widely throughout Southern states. Host plants: Citrus trees, hackberry, elm, plum, sycamore and oak. Stages: Adult--yellowish brown, wings have long wavy hairs with white streaks Larva--5 or 6 instars (molts), ~1 inch. Cocoon--Larva sheds hairs as it spins and are interwoven with the silk.

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Life history: First generation--Max number of grown larvae in June and July Second generation--Max number of grown larvae in September and October Stings: Caused by inadvertently pressing caterpillar against exposed part of body Severity of reaction varies among individuals and also depends on amount of pressure applied Toxicology Poorly understood Never been extensively studied 6 rows of spines underneath long hairs Spines contain toxin that is secreted into victim upon touch

Clinical Presentation:

Clinical Presentation Intense local burning pain Erythema , swelling Severe proximally radiating pains Hemorrhagic lesion may develop forming grid-like pattern Swollen lymph nodes common Pain may last 24 hours to 5 days Allergic reactions unlikely

Treatment:

Treatment Application of adhesive tape is successful in removing spines Local wound care Intermittent ice application Morphine or meperidine may be required for pain control 10mL of 10% IV calcium gluconate was shone to provide pain relief in a small study. Hydrocortisone used empirically. Pruritus and urticaria -- Diphenhydramine

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Class : Reptilia Eastern D-Back Copperhead Coral Snake Timber

Snakes:

Snakes 45,000 bites per year in U.S. 8,000 bites from venomous snakes 25% are dry strikes 10 deaths

Venomous Snakes:

Venomous Snakes Types of U.S.venomous snakes Pit vipers (Crotalidae) Rattlesnakes Copperheads Water moccasins (cotton mouth) Coral snakes (Elapidae) Cobras, mambas, kraits (not in US)

Venomous Snakes:

Venomous Snakes Pit vipers Heavy bodies Diamond-shaped heads Vertical, elliptical pupil Heat sensing pit on upper lip between eye and nostril Moveable fangs Venom primarily hemotoxic , necrotoxic

Pit Vipers (Crotalidae):

Pit Vipers (Crotalidae) Rattlesnakes 13 Species 7,000 bites/year 9 to 10 fatalities Most deaths are from western diamondback or eastern diamondback

Pit Vipers (Crotalidae):

Pit Vipers (Crotalidae) Copperhead Agkistrodon contortrix Deaths VERY rare Minimal edema and pain

Pit Vipers (Crotalidae):

Pit Vipers (Crotalidae) Water moccasin Agkistrodon piscivorus leucostoma Causes an average of one death a year Produces mild systemic symptoms, potential for severe local tissue injury and necrosis

Epidemiology:

Epidemiology 25% are dry bites 25-75% of venom is discharged in a bite Replenished in 3 to 4 weeks Extremities are most common bite site Most common victims: Children Intoxicated adults Snake handlers and collectors

Pit Viper Envenomation:

Pit Viper Envenomation Pain, swelling at bite site Progressive edema of bitten extremity Bruising of bitten area Formation of blood-filled vesicles Weakness, sweating, nausea, vomiting Tachycardia Hypotension, shock Prolonged clotting times Bleeding gums Hematemesis , melena , hematuria

Snakebite Management:

Snakebite Management Calm victim Oxygen, monitor, IV Clean, bandage wound Immobilize bitten area, keep dependent Transport

Snakebite Management:

Snakebite Management Do NOT Apply ice Apply arterial tourniquet Cut and suck Use electrical shock Actively attempt to locate a venomous snake Bring a live venomous snake to the hospital

Dog Bites:

Dog Bites 60% of dog bite victims are children. According to the American Medical Association, dog bites form the second highest cause of childhood injuries, surpassing playground accidents. The majority of dog bites to adult humans are at the lower extremities followed by bites to the upper extremities including the head, face and neck. For children, 77% of dog bite injuries are to facial areas.

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Last but not least…….. They are coming!!!!!!

Anaphylaxis from a Africanized Honey Bee!!:

Anaphylaxis from a Africanized Honey Bee!!

Thank You!!!!!!!!:

Thank You!!!!!!!!