Bites and Stings Temple College EMS Professions

Bites and Stings l Arthropods – Insects – Spiders – Scorpions l Reptiles – Pit Vipers – Coral Snakes l Venomous Marine Life

Bite & Sting Deaths l 50% insects l 30% snakes l 14% spiders l 6% other

Hymenoptera l Bees, wasps, hornets, yellow-jackets, ants l About 25 deaths/year – Honeybees 50% – Yellow-jackets, other wasps 50% l Problems – Allergic reactions – Anaphylaxis – Toxic venom effects (rare)

Local Reactions l Sharp, burning pain l Itching l Edema – Extensive reactions may involve entire extremity – Tongue/throat stings may cause airway loss

Systemic Reactions l Mild – Diffuse itching – Urticaria – Swelling distant from sting site – Flushing

Systemic Reactions l Severe – Laryngeal edema, upper airway obstruction – Severe bronchospasm, difficulty breathing – Profound hypotension Anaphylaxis

Anaphylaxis Management l Remove stinger (scrape) l Manage airway l Oxygen, assist ventilations l Shock position l Epinephrine Auto-Injector l Consider ALS back-up

Epi Auto-Injector l Actions – Dilates airways – Constricts blood vessels – Raises peripheral resistance, BP

Epi Auto-Injector l Supplied as solution in auto-injector unit

Epi Auto-Injector l Indication – Allergic reaction with: Respiratory compromise: Rapid, labored breathing; chest, throat tightness; hoarseness, stridor; wheezing Hypoperfusion: Rapid, weak pulse; altered level of consciousness; decreased BP

Epi Auto-Injector l No contraindications for severe allergic reactions

Epi Auto-Injector l Dosage – Adult system: 0.3 mg – Pediatric system: 0.15 mg

Epi Auto-Injector l Procedure – Expose, clean site if possible – Remove safety cap – 90 o to skin; lateral thigh midway between waist, knee – Push against thigh – Hold until medication injected (10 seconds)

Epi Auto-Injector l Side Effects – Rapid heart rate – Pale skin – Headache – Chest pain – Nausea, vomiting – Anxiety

Epi Auto-Injector l Precautions – Oxygen first – Monitor vital signs following use

Spiders l 37,000 species l All venomous l 50 U.S. species can bite humans l 15 U.S. species produce symptoms l Only two are dangerous – Black widow (Latrodectus mactans) – Brown recluse (Loxosceles reclusa)

Black Widow l As far north as Oregon, New York; Common in South, Southwest l Irregular webs in wood piles, trash dumps, outdoor structures, under rocks l Occasionally in houses l Females rarely leave web l Only females bite humans

Black Widow l Neurotoxic l Immediate sharp, stinging pain l Muscle cramps in 15 minutes to 2 hours – Upper extremity: pleuritic chest pain – Lower extremity/genitalia: abdominal pain, rigidity

Black Widow l Muscle twitching, weakness, paralysis, drooping eyelids l Sweating, tearing, salivation, increased bronchial secretions l Anxiety, headache, restlessness, dizziness, nausea, vomiting, hypertension l Edema, skin rash, conjunctivitis, itching l Shock, respiratory depression

Black Widow l Symptoms peak in few hours, diminish – Usually last < 24 hours – Some symptomatic up to 4 days l Mortality rate unknown l Most recover completely

Black Widow l Treatment – Local cold application – Symptomatic care – Antivenin available

Brown Recluse l Fiddle-back spider l Southeast, South Central U.S. l Related species in desert Southwest l Shy, nocturnal l Dark closets, basements l On floors, behind furniture in houses

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

Brown Recluse l Systemic signs, symptoms – Mild Fever, chills Malaise Nausea, vomiting Joint pain – Severe Bleeding disorders Renal failure Convulsions Heart failure Death

Brown Recluse l Prehospital management – Local cold application – Wound cleansing – Padded splint, bulky dressing

Scorpions l 40 U.S. species l Only one potentially lethal (Centuroides sculpturatus) – Primarily in Arizona – Occasionally in western New Mexico, southeast California, northern Mexico, far West Texas

Centuroides sculpturatus l Local signs, symptoms – No local swelling, inflammation – Local pain, hypersensitivity

Centuroides sculpturatus l Systemic signs, symptoms – Extreme restlessness, agitation – Roving eye movements – Poor coordination, slurred speech, difficulty swallowing – Salivation, wheezing, stridor – Tachycardia, tachypnea, hypertension, nausea, vomiting

Centuroides sculpturatus l Treatment – Symptomatic, non-specific – Antivenin available from Arizona State University (National Venomous Desert Animal Study Center)

Snakes l 45,000 bites per year in U.S. l 8,000 from venomous snakes l 10 deaths

U.S. Venomous Snakes l Pit vipers (Crotalidae) – Rattlesnakes – Copperheads – Water moccasins (cotton mouth) l Coral snakes (Elapidae)

Pit Vipers l Heavy bodies l Diamond-shaped heads l Vertical, elliptical pupil l Heat sensing pit on upper lip between eye. nostril l Erectile fangs l Hemotoxic, necrotoxic venom

Pit Vipers l Rattlesnakes – 13 Species – 7,000 bites/year – 9 to 10 fatalities – Most deaths from western diamondback, eastern diamondback

Pit Vipers l Copperhead – Deaths VERY rare – Minimal edema, pain

Pit Vipers l Water moccasin – Average of one death a year – Mild systemic symptoms – Potential for severe local tissue injury, necrosis

Pit Viper Bites l Pain, swelling l Progressive edema l Bruising l Blood-filled vesicles

Pit Viper Bites l Weakness, sweating, nausea, vomiting l Tachycardia, hypotension, shock l Prolonged clotting l Bleeding gums l Hematemesis, melena, hematuria l Numbness, tingling, neurological symptoms

Coral Snake l Thin-bodied l Small, rounded head l Brightly colored l Small, non-erectile fangs l Injects venom by chewing l Venom mostly neurotoxic Red on yellow, kill a fellow. Red on black, venom lack.

Coral Snake Bite l Little, no pain/ swelling l Tingling around bite l Muscular incoordination l Weakness l Increased salivation l Difficulty swallowing, talking l Visual disturbances l Respiratory distress, failure l Shock Most deaths occur from respiratory arrest within 36 hours

Snakebite Management l Calm victim l Oxygen l Proximal constricting band ( + ) l Clean, bandage wound l Immobilize bitten area, keep dependent l Watch constricting bands, bandages, splints carefully for edema l Transport

Snakebite Management l Do NOT – Apply ice – Apply arterial tourniquets – Cut and suck – Use electrical shock – Actively attempt to locate snake – Bring live venomous snake to hospital

Venomous Marine Life

Coelenterates l Jellyfish, Portuguese man-of-war l Stinging cells in tentacles – Intense, burning pain – Red, hemorrhagic lesions – Nausea, vomiting – Fever, chills – Dyspnea, wheezing, stridor – Hypotension, shock – Cardiovascular collapse l Kill stinging cells with alcohol, vinegar

Venomous Fish l Sting ray l Scorpionfish (Lion fish, Stonefish) l Immerse stung area in hot water

Sea Urchins l Immerse injured area in hot water l Use vinegar to dissolve embedded spines l Larger spines may require surgical removal