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Bites and Stings

Bites and Stings. B.W. BLOUNT, M.D., MPH Professor, Family Medicine Emory University School of Medicine. WHAT’S BITING IN GEORGIA?. B. Wayne Blount, MD, MPH Professor, Family Medicine. Case 1. 22 yr WM positive “5 T” sign

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Bites and Stings

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  1. Bites and Stings B.W. BLOUNT, M.D., MPH Professor, Family Medicine Emory University School of Medicine

  2. WHAT’S BITING IN GEORGIA? • B. Wayne Blount, MD, MPH • Professor, Family Medicine

  3. 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

  4. 5 T’s: • 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

  5. Case 1 (cont’d) Patient has extremely swollen shoulder with two puncture marks clearly visible with surrounding ecchymosis & hemorrhagic blebs.

  6. 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.

  7. Case 1 (cont’d) 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.

  8. Case 1 (cont’d) His VS are steady AF, 110/85,20,105,95% No wheezing, but pt. crying Some nausea and paresthesias

  9. Case 1 (cont’d) What should be done next?

  10. 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

  11. Snake Bite Rx-1950 • Tourniquet, bleed • Cauterize hot iron or coals • Oxidize area (H2O2) • Antidote • NS after some blood withdrawn • Keep patient quiet

  12. Snake Bite Rx What’s new in 2004?

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

  14. 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

  15. If severe  Antivenom If moderate  Antivenom If minimal  nothing Many are “dry” bites

  16. Other treatments of unproved value: Cutting and suction Vacuum kits Ice, electricity Tourniquets, etc.

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

  18. Insert is your best guide Takes long time to mix (30 min) and to administrate ( >1 hour) Pretest for reactions?

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

  20. Reactions to Crotalidae antivenom frequent Give epi/H 1-2 blockers/steroids End point is  symptoms & signs Measure part involved

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

  22. 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.

  23. Case 2 (cont’d) On arrival to ED, patient was drooling and exhibiting roving eye movements, and muscle spasms were extremely uncomfortable.

  24. Case 2 (cont’d) His wife asks you “What was it doc, and what can we do?” Answer…

  25. Review Scorpion  venom opens sodium channels Leading to prolonged firing of nerves. Rx: Morphine Valium Resolves over 24-48°

  26. Tip: They fluoresce, so take your UV/Woods lamp on your campout

  27. Case 3 38 yr female cleaning attic Felt pin prick on the forearm and brushed off unknown assailant, then squashed it.

  28. Case 3 (cont’d) 24° later noted purple nodular area at site where surrounding pallor and erythema. Now at 48°, complaining of an ulcerating lesion.

  29. Case 3 (cont’d) Dx? Rx?

  30. 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

  31. Symptoms: Uncommon F/C, N/V, myalgia, hemolysis which  renal failure, DIC, death Almost all deaths very young or old

  32. Venom: Not real clear Treatment: Not very good No antivenom Tetanus, ice, antihistamine, analgesics

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

  34. Case 4 63 yr WM in Acute Distress Brought by Wife via POV “Bee stings” approx 15 min pta While working in yard

  35. Case 4 (cont’d) Multiple stings all exposed areas >30# Some pain, much swelling periorbitally Lightheaded, wheezing No previous problem with stings Hx HTN and glaucoma

  36. Case 4 (cont’d) 100/60 80 16 AF Lungs: scattered wheezing Heart: RRR Ø murmur A & O x 3

  37. Case 4 (cont’d) Dx: Rx:

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