Bee Scorpion Snake bite Bees venom Histamine most

■ Bee ■ Scorpion ■ Snake bite

Bees

venom ■ Histamine > most of reaction ■ Melittin > cause degranulation of basophils and mast cells

Clinical features ■ Pain, slight erythema, edema, pruritus ■ Reactions : – Severe local reactions – Toxic reactions – Anaphylactic reactions – Delayed reactions – Unusual reactions

Severe local reaction ■ In the mouth or throat: airway obstruction ■ Around the eye or on the lid: cataract, atrophy of the iris, lens abscess, perforation of the globe, glaucoma,

Toxic reaction ■ History of multiple stings >> venom toxicity >> usually subside in 48 hours ■ Common : Nausea, vomiting, diarrhea, light-head ness, syncope. ■ May be : Headache, fever, drowsiness, muscle spasm, edema, Convulsion. ■ Not seen : urticaria, bronchospasm ■ Respiratory insufficiency and arrest may occur ■ Renal failure, hepatic failure, DIC, rhabdomyolysis (CPK>100, 000) ■ Hospital admission : – with > 100 stings , comorbidity , extreme of age

Anaphylactic reaction ■ Generalized systemic allergic >> single or multiple stings ■ It is develop within 15 minutes to 6 hours ■ From mild to fetal ■ Initial symptoms : itching eyes, facial flashing, generalized urticaria, dry cough. ■ Then : wheezing, dyspnea, cyanosis, abdominal cramps, diarrhea, nausea, vomiting, vertigo, chills and fever, stridor, shock, syncope.

Delayed reaction ■ 5 to 14 days after sting ■ Serum sickness-like sign ■ Symptoms: fever, malaise, headache, urticaria, lymphadenopathy, poly arthritis.

Unusual reaction ■ Neurologic : encephalopathy, neuritis ■ Cardiovascular: vasculitis ■ Urologic: nephritis

Treatment ■ Remove the sting and Application of ice pack ■ The sting site should be washed with soap and water ■ Oral antihistamine and analgesic(NSAIDs) ■ If infection develop : antibiotic ■ In systemic reaction : – Epinephrine 0. 3 to 0. 5 mg in adult and 0. 01 mg/kg in children IM – Diphenhydramine 25 to 50 mg IV or IM or PO – Ranitidine 50 mg IV – Methylprednisolone 125 mg IV or Prednisone 60 mg PO – Bronchospasm : β agonist – Shock : crystalloid infusion >> dopamine infusion >> epinephrine infusion

Long term management

Scorpions

Clinical features ■ Pain, paresthesia ■ In severe case : – Cranial nerve and somatic motor dysfunction ■ Abnormal eye movement, blurred vision, drooling, respiratory compromise ■ Uncontrollable jerking in extremities ■ Nausea, vomiting, tachycardia ■ Cause of death : cardiogenic shock and pulmonary edema

Treatment ■ Initial treatment : supportive (analgesia + BNZ) ■ For hyper salivation and respiratory distress with Centruroides Scorpion in USA: – >>> Atropine – It is contraindicated in other scorpions ■ Scorpion Antivenom: controversial and vary widely in countries

Snake

Crotalinea ( Pit Viper ) ﺍﻓﻌی

Clinical features ■ 25% : dry bite ■ Fang marks ■ Localized Pain, progressive edema, ■ Nausea, vomiting, weakness, oral numbness, dizziness, muscle fasciculation, ■ Tachypnea, tachycardia, hypotension, altered level of conciseness, ■ Progressive ecchymosis,

Diagnosis ■ Fung marks + evidence of tissue injury : 1. Local injury : swelling, pain, ecchymosis 2. Hematologic abnormality : thrombocytopenia, elevated PT, hypofibrinogenity 3. Systemic effect : oral swelling or paresthesia, metallic taste in mouth, hypotension, tachycardia

Treatment (first aid) ■ Remain calm : movement will increase venom absorption ■ Immobilize the extremity in a neutral position below the level of the heart ■ Transport to a medical facility ■ Use Constriction bands – – – Do not capture the snake. should never delay the antivenom. Suction and incision should not be done. Electric shock of the bite site is dangerous. Ice water immersion worsen the venom injury. Use of tourniquet is contraindicated.

Treatment (prehospital management) ■ Immobilize the limb ■ IV access ■ Oxygen ■ Transport

Treatment (ED management) ■ Antivenom : Indication of antivenom : – Progressive of local injury (pain, ecchymosis, swelling ) – Abnormal lab test (PLT count, prolonged CT, … ) – Systemic manifestation (unstable V/S , abnormal mental status) ■ Fab antivenom : Skin testing is not required ■ Initial dose : 4 to 6 vial >>> then : 2 vial ■ Antivenom : should not injected to the digit or IM injection ■ Fab AV: is diluted in 250 cc crystalloid and infused over 1 hour ■ If an acute allergic reaction occurs : stop the infusion and treat the reaction ■ Lab test : every 4 hours (CBC, PTT, fibrinogen, FDP, BS, Electrolyte, BUN, PLT, CPK, ABG) ■ EKG

Treatment (ED management) ■ Tetanus immobilization ■ Antibiotic prophylaxis : controversial ■ Steroid : harmful ( only for the allergic reaction )

Disposition ■ Observe patient for at least 8 hours ■ Dry bite : after 8 hours >>> discharge ■ Patient with mild symptoms : admitted in general ward ■ Patient receive antivenom: admitted in ICU ■ Out patient follow up for : infection & serum sickness

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