APPENDIX: ARTHROPOD ENVENOMIZATION REACTIONS AND TREATMENT |
The material presented in this appendix was prepared by Lt Col John C. Moseley, USAF, MC, Dermatologist, Wilford Hall USAF Medical Center, Lackland AFB, Texas. REACTIONS IMMEDIATE: Pinprick sensation from the bite LOCAL: Dull numbing pain; two red puncture marks at bite site. Pain peaks at 1-3 hours and persists 12-48 hours REGIONAL: - 1. Severe muscular pain and spasm
- 2. Rigid boardlike abdomen
- 3. Tightness in chest and pain on inspiration
GENERAL: - 1. Rigidity and spasm of all large muscle groups; excruciating abdominal pain
- 2. Convulsions, paralysis
- 3. Shock
DEATHS: 4-5% of untreated cases due to neurotoxic effect of the venom TREATMENT LOCAL FIRST AID: Ineffective and unnecessary SYSTEMIC: - 1. Antivenin—1 vial IM (carefully follow package insert instructions) after testing for horse-serum sensitivity
- 2. Calcium gluconate—10 ml of 10% solution given IV immediately and prn to control muscle pain
- 3. Muscle relaxants—Give continuously over 8-16-hr period to relieve intensity of muscle spasm and pain
- 4. Treat for shock as necessary (Chart 2)
REACTIONS IMMEDIATE: Very little pain, if any LOCAL: - 1. 2-8 Hours—Mild to severe pain with redness and vesiculation at bite site, followed by ischemia
- 2. 3-4 Days—Star-shaped firm area of deep-purple color with necrosis
- 3. 7-14 Days—Central area of depression and ulceration
- 4. 21 Days—Healing and scar formation. May not heal sufficiently and may require skin grafting
SYSTEMIC: - 1. Fever, chills, nausea, vomiting, weakness, joint pain
- 2. Morbilliform or petechial generalized eruption
- 3. Occasionally serious hematological disturbances—hemolytic anemia, thrombocytopenia
DEATHS: Reported; usually in children, due to renal failure and hematological abnormalities. TREATMENT LOCAL FIRST AID: None effective or necessary LOCAL: Within 4 hours of the bite, locally excise bite site SYSTEMIC: - 1. Systemic corticosteroids is the treatment of choice and must be administered immediately—methylprednisolone (Depo-Medrol) 80 mg IM, followed by prednisone 60 mg a day for 3 days and gradually tapered over a 10-14-day course of therapy
- 2. Heparin therapy may reduce the disseminated intravascular coagulation phenomenon
- 3. Analgesics for pain
REACTIONS IMMEDIATE: Pain, often intense LOCAL: 1-4 hours—A two-puncture wound at the site with redness, swelling, and a burning aching pain that subsides in 4-5 hours REGIONAL: Rare—Purpura of an entire limb ANAPHYLAXIS AND DEATH: None reported in the United States TREATMENT LOCAL FIRST AID: - 1. Wash with soap and water
- 2. Apply ammonia in 10% solution
- 3. Apply cool wet dressings of a saturated magnesium sulfate solution
SYSTEMIC: Analgesics for pain REACTIONS IMMEDIATE: Usually no sensation, occasionally mild pain LOCAL: (Four distinct reactions depending on degree of sensitivity): - 1. Papule with a central punctum
- 2. Small vesicles grouped around bite site with swelling and little redness
- 3. Giant urticarial lesion with central punctum and surrounding brawny edema
- 4. Hemorrhagic nodular-to-bullous lesions on hands and feet—the characteristic “kissing bug bites”
ANAPHYLACTIC SHOCK: Rare, but reported DEATHS: None reported TREATMENT LOCAL FIRST AID: Wash with soap and water SYSTEMIC: Oral antihistamines (Chart 1) REACTIONS IMMEDIATE: Fierce burning pain lasting minutes LOCAL: (Fire Ants) - Minutes—Wheal formation
- 2-4 Hours—Clear fluid-filled vesicles
- 8-10 Hours—Cloudy fluid-filled vesicles
- 12-24 Hours—Umbilicated pustules on a red base, with pain and tenderness
- 3-8 Days—Lesions resolve; may leave scars
SYSTEMIC: Due to allergic sensitization; severity and speed of onset related to degree of sensitivity. May see wheezing, urticaria, abdominal cramps, generalized edema, nausea, vomiting, dizziness, confusion, shock ANAPHYLAXIS AND DEATH: Rare, but reported TREATMENT LOCAL FIRST AID: - 1. Wash sites with soap and water
- 2. Apply ice packs or cold compresses
- 3. Apply baking soda and water paste
SYSTEMIC: - 1. Epinephrine (1:1,000) subcutaneous injection (0.2-0.5 ml in adults and 0.1-0.3 in children). Repeat in 5-10 min if necessary
- 2. Antihistamine (Benadryl, 50 mg IM)—Adult
- 3. Oral antihistamines (Chart 1)
- 4. Treat for shock as necessary (Chart 2)
REACTIONS IMMEDIATE: Pain LOCAL: Within 1-4 hours—Appearance and subsidence of wheal and red flare; may see intense local swelling in region of sting SYSTEMIC: - 1. Mild reaction—Generalized urticaria, itching, malaise, anxiety
- 2. Moderate reaction—Any of the above plus generalized edema, tightness in the chest, wheezing, abdominal pain, nausea, vomiting, dizziness
- 3. Severe reaction—Any of the above plus labored breathing, difficulty in swallowing, hoarseness or thickened speech, marked weakness, confusion, feeling of impending disaster
- 4. Shock—Cyanosis, fall in BP, collapse, incontinence, unconsciousness
- 5. Delayed serum-sickness-like reaction (10-14 days after sting)—Fever, lymphadenopathy, malaise, headache, urticaria, polyarthritis
ANAPHYLAXIS AND SUDDEN DEATH: Many cases reported, usually in adults TREATMENT LOCAL FIRST AID: - 1. Remove bee stinger from sting site by gently scraping with fingernail or blade to prevent further venom injection from attached venom sac
- 2. Wash site with soap and water
- 3. Apply ice packs or ammonia in 10% solution
- 4. Apply baking soda and water paste
- 5. Elevate and rest involved limb
SYSTEMIC: - 1. Epinephrine (1:1,000) subcutaneous injection (0.2-0.5 ml in adults and 0.1-0.3 ml in children). Repeat in 5-10 min if necessary
- 2. Analgesics (ASA, Tylenol) for pain
- 3. Antihistamines (Chart 1)—Useful only for urticarial and pruritic reactions
- 4. Treat for shock as necessary (Chart 2)
LONG-TERM MANAGEMENT: (for hypersensitive patients) - 1. Medic-alert tag or bracelet
- 2. Emergency treatment kit and instructions for use
- 3. Program for desensitization
REACTIONS IMMEDIATE: Severe sharp pain LOCAL: - 1. Dangerous neurotoxic species—Pins-and-needles sensation with no local swelling or discoloration (found in Arizona only)
- 2. Comparatively harmless species (not neurotoxic)—Local swelling and discoloration at sting site
SYSTEMIC (neurotoxic species only—within 1-3 hours): - 1. Hypoesthesia and numbness or drowsiness
- 2. Itching of nose and throat
- 3. Impaired speech and tightness of jaw muscles
- 4. Restlessness and muscle twitching
- 5. Muscle spasms with pain, nausea, vomiting, incontinence, convulsions
- 6. Respiratory and/or circulatory distress
ANAPHYLAXIS: Rare, but reported with non-neurotoxic species DEATHS: Occasional; due to neurotoxic species TREATMENT LOCAL FIRST AID: - 1. Apply ice packs
- 2. Apply tourniquet if possible and as near sting site as possible. Loosen briefly every 10-15 minutes
- WARNING: Do not use morphine or opiates since they increase toxic effects
SYSTEMIC: - 1. Specific antivenin available for many dangerous species; administered early, may be lifesaving
- 2. Calcium gluconate—10 ml of 10% solution IV immediately and prn to control muscle pain
- 3. Phenobarbital—30-60 mg orally for sedation and control of convulsions
- 4. Treat for shock as necessary (Chart 1)
REACTIONS IMMEDIATE: Severe burning pain LOCAL: - 1. Numbness and swelling of area inflicted with severe radiating pain
- 2. Possible double row of parallel red punctuate marks forming a gridlike tract along the path of the caterpillar
- 3. Swelling of regional lymph nodes
- 4. Late foreign-body reaction to unremoved spines
SYSTEMIC: - 1. Nausea, vomiting, fever
- 2. Headaches
- 3. Shock and convulsions (rare)
DEATHS: None reported TREATMENT LOCAL FIRST AID: - 1. Repeated stripping using adhesive or cellophane tape to remove spines
- 2. Apply ice packs
- 3. Apply baking soda and water paste
SYSTEMIC: - 1. For severe pain give meperidine hydrochloride (Demerol, 50-100 mg PO or IM), morphine sulfate (0.25 subcutaneous), codeine phosphate (0.5 g PO)
- NOTE: Aspirin is generally not effective
- 2. Shock (Chart 2)
CHART 1
ANTIHISTAMINES | GROUP | TRADE NAME | AVERAGE ORAL BASE | SEDATION | | GENERICNAMES | | ADULT | CHILD | | Ethanolamines | | diphenhydramine•HCl | Benadryl | 50 mg q 4-6h | 25 mg q 4-6h | ++++ | | diphenhydramine theophyllinate | Dramamine | 50 mg q 4h | 25 mg q 4h | ++++ | | Ethylenediamine | | tripelennamine | Pyribenzamine | 50 mg q 4-6h | 25 mg q 4-6h | +++ | | Alkylamines | | chlorpheniramine maleate | Chlor-Trimeton | 4 mg q 6h | 2 mg q 6h | ++ | | brompheniramine maleate | Dimetane | 8 mg q 6h | 4 mg q 6h | + | | triprolidine•HCl | Actidil | 2.5 mg q 8h | 1.25 mg q 8h | ++ | | Cyclizines | | hydroxyzine•HCl | Atarax | 25-100 mg q 6h | 10-25 mg q 6h | + | | Miscellaneous | | cyproheptadine•HCl | Periactin | 4 mg q 6h | 2 mg q 6h | +++ | | promethazine | Phenergan | 25-50 mg q 6-8h | 12.5-25 mg q 6-8h | ++++ | Chart 2
Treatment of Anaphylaxis—Shock | IMMEDIATE TREATMENT | MILD REACTION TREATMENT | SEVERE REACTION TREATMENT | | REACTION: Conjunctivitis, Rhinitis, Urticaria, Pruritus, Erythema | Epinephrine•HCl 0.3 ml (1:1,000) IM
Diphenhydramine•HCl 50 mg PO | Diphenhydramine•HCl 50 mg PO q 6h | | REACTION: Laryngeal edema | Epinephrine•HCl 0.3 ml (1:1,000) IM
Diphenhydramine•HCl 50 mg IV | Diphenhydramine•HCl 50 mg q 6h IM or PO
Ephedrine sulfate 25 mg q 6h | Oxygen
Diphenhydramine•HCl 50 mg q 6h
Ephedrine sulfate 25 mg q 6h
Monitor blood gases
Hydrocortisone
Tracheostomy | | REACTION: Bronchospasm | Epinephrine•HCl 0.3 ml (1:1,000) IM
Diphenhydramine•HCl 50 mg IV | Epinephrine•HCl 0.3 ml (1:1,000) IM
Aminophylline 250 mg IV over 10-min period of time | Oxygen
Aminophylline 500 mg IV q 6h
Hydrocortisone
IV fluids
Monitor blood gases
Observe for respiratory failure | | REACTION: Hypotension | Epinephrine•HCl 0.3 ml (1:1,000) IM
Diphenhydramine•HCl 50 mg IV | Metaraminol bitartrate, 100 mg in 1,000 ml 5% dextrose in water | Oxygen
Metaraminol bitartrate IV
IV fluids |
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