Envenomation

Question 1

What is the order of insects that includes ants, bees and wasps?

Answer 1

Hymenoptera

Question 2

(a) A local reaction is the most common reaction. It consists of a small red patch that burns and itches.
(b) The generalized reaction consists of diffuse red skin, hives, swelling of lips and tongue, wheezing, abdominal cramps and diarrhea.
(c) Stings to the mouth and throat are more serious, as they may cause airway swelling.
(d) Victims of multiple stings often experience:
1) Vomiting
2) Diarrhea
3) Dyspnea
4) Hypotension
5) Tachycardia
6) Syncope
7) Skin infections

Answer 2

Hymenoptera Sting

Question 3

In advanced stages of toxicity, the victim experiences
1) Increased muscle activity with hyperkalemia
2) Acute tubular necrosis
3) Renal failure
4) Pancreatitis
5) Coagulopathy
6) Heart attack
7) Stroke

Answer 3

Hymenoptera Sting

Question 4

Treatment of Hymenoptera Sting

Answer 4

(a) Remove the stinger
(b) Wash the site with soap and water.
(c) Place a cold compress or ice on the site to reduce inflammation.
(d) Give oral analgesics as needed for pain relief.
(e) Topical steroid cream can be helpful for swelling, as are oral antihistamines

Question 5

How should you remove a stinger

Answer 5

1) Scrape away the stinger in a horizontal fashion.
2) Try not to grasp the stinger sac.
3) However, if one is unable to remove the stinger in a horizontal fashion, it is most important to remove it as soon as possible by any available means

Question 6

Medications for Hymenoptera Sting

Answer 6

(1 Loratadine (Claritin) - 10mg orally once daily
(2 Desloratadine (Clarinex) - 5mg once daily
(3 Fexofenadine (Allegra) – 60mg twice daily or 120 mg once daily
(4 Cetirizine (Zyrtec) - 10 mg orally once daily
(5 Brompheniramine (Dimetapp) or chlorpheniramine (Chlor-Trimeton) - 4mg orally every 6-8 hours, or 8-12 mg orally every 8-12 hours as a sustained release tablet
(6 Clemastine - 1.34-2.68 mg orally twice daily

Question 7

If hives occur with wheezing and respiratory difficulty after a stinger, what should be given immediately

Answer 7

Epinephrine

Question 8

What can help with wheezing after stinger

Answer 8

Beta agonist inhalers (e.g., albuterol)

Question 9

What other medications should be used when epinephrine is used

Answer 9

oral steroids and antihistamines

Question 10

Ticks transmit many diseases, including

Answer 10

(a) Lyme Disease
(b) Rocky Mountain spotted fever (RMSF)
(c) Relapsing fever
(d) Colorado tick fever
(e) Ehrlichiosis
(f) Babesiosis
(g) Tularemia
(h) Southern Tick-Associated Rash Illness (STARI)

Question 11

A non-infectious ascending paralysis similar to Guillain- Barre syndrome, may occur within five days after the tick attaches. Removal of the tick is
curative.

Answer 11

Tick paralysis

Question 12

Where are ticks found

Answer 12

• areas replete with weeds, shrubs, and trails
• They will often be found at forest boundaries where deer and other mammals reside
• will sit on low-hanging shrubs with legs outstretched until an animal passes

Question 13

Tick treatment

Answer 13

1) Use thin-tipped tweezers or forceps to grasp the tick as close to the skin surface as possible.
2) Pull the tick straight upward with steady even pressure.
(b) Wash the bite with soap and water, then wash hands after the tick has been removed.
(c) Watch for local infection and symptoms of tick-borne illness (incubation period 3 to
30 days), especially headache, fever, and rash.

Question 14

Lyme Disease, RMSF, Tularemia, or Ehrlichiosis is suspected, which medications should be initiated

Answer 14

• doxycycline

Question 15

Treatment for other tick-borne illnesses that are not Lyme Disease, RMSF, Tularemia, or Ehrlichiosis

Answer 15

Supportive

Question 16

Do nots of tick removal

Answer 16

1) Do not use petroleum jelly
2) Do not use fingernail polish
3) Do not use rubbing alcohol
4) Do not use a hot match
5) Do not use gasoline
6) Do not grab the rear end of the tick. This expels gastric contents and
increases the chances of infection
7) Do not twist or jerk the tick, as this will most likely cause incomplete removal of the tick

Question 17

Neurotoxins cause respiratory paralysis
(a) Signs and Symptoms: ptosis, dysphagia, diplopia, and respiratory arrest via diaphragmatic paralysis

Answer 17

Neurotoxic (coral snake)

Question 18

Cause tissue destruction by digestion and hemorrhage due to hemolysis and destruction of the endothelial lining of
the blood vessels.

Answer 18

Cytolytic (rattlesnakes, other pit vipers)

Question 19

Name the snake:
Red touches black your OK jack. Red touches yellow you’re dead fellow.

Answer 19

Coral snakes

Question 20

Name the snake:
(a) Triangular head
(b) Keeled scales
(c) Elliptical pupils
(d) Nostrils plus IR pit
(e) Single row of subcaudal scales

Answer 20

Venomous snakes

Question 21

Name the snake:
(a) Oval shaped head
(b) Round pupil
(c) No IR pit
(d) Double row of subcaudal scales

Answer 21

Nonvenomous snakes

Question 22

(a) Local pain
(b) Redness
(c) Swelling
(d) Extravasation of blood
(e) Perioral tingling
(f) Metallic taste
(g) Nausea and vomiting
(h) Hypotension
(i) Coagulopathy

Answer 22

Cytolitic snake bite

Question 23

Treatment of snake bites

Answer 23

(a) Remove from threat, try to ID snake
(b) Immobilize the patient and maintain the bitten part in a neutral position
(c) Remove jewelry
(d) DO NOT apply a tourniquet or attempt to extract venom!!!
(e) Irrigate and clean the bite
(f) Loose dressing if hemotoxic bite, expect swelling
(g) Do not let patient walk, limit exertion
(h) MEDEVAC

Question 24

Methods to avoid for removing venom

Answer 24

(a) Incision and oral suction
(b) Mechanical suction devices
(c) Cryotherapy
(d) Surgery
(e) Electric shock therapy
(f) Tourniquets

Question 25

Signs and Symptoms:
1) Generalized muscular pains
2) Muscle spasms,
3) Rigidity
4) Abdominal Pain

Answer 25

Black Widow Spiders

Question 26

Treatment of Black Widow Spider bite

Answer 26

Pain may be relieved with pain control and muscle relaxants (benzodiazepines and supportive care)

Question 27

Sign and Symptoms: Causes progressive local necrosis as well as hemolytic reactions (rare). Bite is usually painless

Answer 27

Brown Recluse Spider

Question 28

Treatment of Brown Recluse Spider bite

Answer 28

1) Pain management for secondary local necrosis and close monitoring initially.
2) Consider antibiotic prophylaxis in field setting
3) Bites occasionally progress to extensive local necrosis and may require excision of the bite site and oral corticosteroids.

Question 29

(1) Signs and Symptoms:
(a) Muscle cramps
(b) Twitching and jerking
(c) Occasionally hypertension
(d) Convulsions
(e) Pulmonary edema

Answer 29

Scorpion

Question 30

Treatment of Scorpion

Answer 30

(a) Supportive care is appropriate for North American species.
(b) Always review the threat of local species when operating OCONUS
(c) If severe neurologic or neuromuscular dysfunction consult poison control and discuss further management and anti-venom
(d) Suction oral secretions, airway management, cardiac monitoring, IV opioids preferably fentanyl due to no histamine release, benzo for spasms unless getting anti-venom