1. This PowerPoint file is a supplement to the video presentation. Some of the educational content of this program is not available solely through the PowerPoint file. Participants should use all materials to enhance the value of this continuing education program.

2. Snake, Spider, and Insect Bites Paul R. Lockman, BSN, PhD Assistant Professor, Pharmaceutical Sciences TTUHSC School of Pharmacy Amarillo, Texas EMS/Nursing 80112/ 30312

3. Objectives 1.Identify venomous bites associated with Crotalidae and Micrurus snakes. EMS/Nursing 80112/ 30312

4. Objectives 2.Identify signs, symptoms, and treatment options for envenomations. EMS/Nursing 80112/ 30312

5. Objectives 3.Recognize clinical symptoms associated with envenomations from a brown recluse, black widow, tarantula, scorpion, and fire ant bite. EMS/Nursing 80112/ 30312

6. Snakes 1.Be familiar with the various types of Crotalidae snakes that are present in our region 2.Discuss the primary signs and symptoms of Crotalidae envenomation

7. Snakes 3.Develop a treatment plan, for both stabilization and treatment of Crotalidae envenomations

8. Snakes 4.Be familiar with the various types of Micrurus snakes that are present in our region 5.Discuss the primary signs and symptoms of Micrurus envenomation

9. Snakes 6.Develop a treatment plan, for both stabilization and treatment of Micrurus envenomation

10. Snakebites Snakes in Texas – 155 species altogether – 15 species are venomous (10-15% of snakes) – deaths in Texas from snakebites = 2-3/year

11. Snakebites Snakes in Texas – compare to insect bites: 5-7/year – compare to lightning strikes: ~8/year

14. Snakebites Venomous snakes bite 7000- 8000 people annually – occurred while snake handling = ~3000 – accidental = 4000-5000

15. Snakebites Venomous snakes bite 7000- 8000 people annually – 85% of natural bites are below the knee

16. Snakebites Epidemiology – male > female by 9:1 – average age = 24 Significant rates of intoxication at time of bites (28%)

17. General Principles Most bites aren’t lethal!! Be concerned about: – very old – very young – very sick – very pregnant

18. General Principles Anaphylaxis risk Good first aid/wound care avoid: ice, shock, cowboy treatment, and tourniquet Remain calm and seek medical attention

19. Good vs. Bad ???

20. Crotalus : true rattlers Pit Vipers: Crotalidae

21. Crotalidae Sistrurus – massasauga – pygmy rattler

22. Crotalidae Agkistrodon : Copperhead

23. Agkistrodon : Cottonmouth Crotalidae

24. Usually rattle before biting but not always Rattles can fall off with trauma, so may not be present Rattle done to give warning; may be startled

25. Crotalidae Accounts for average of 5.5 deaths/year in US 50% of all bites occur in 18- 28-year-old group; young males most common

26. Venom Modified saliva: digests the tissue in the affected area – 90% water – 5-15 enzymes – 3-12 proteins

27. Venom Potency and effects vary by species and individual snake: ~25% of bites are “dry”

28. Symptoms Local symptoms – skin necrosis – tissue sloughing

29. Symptoms Histotoxic – hyaluronidase – collagenase – metalloproteinase Edema: stimulation of the inflammatory cascade

30. Crotalidae Hematologic mediators – main one is fibrinolysis – defibrination, without DIC (disseminated intravascular coagulation)

31. Crotalidae Hematologic mediators – thrombocytopenia (unknown mechanism) – uncommonly may cause generalized bleeding

32. Crotalidae – labs: abnormal for up to a week; reports of relapse elevated fibrin split products elevated PT (prothrombin time) low fibrinogen

33. Crotalidae – DIC is uncommon – if it occurs it is the primary reason for mortality

34. Crotalidae Local mediators – VMPs (venom metalloproteinases): cleave/activate TNF (tumor necrosis factor) alpha,…

35. Crotalidae Local mediators – …which then cleaves endogenous metalloproteinases = amplification

36. Crotalidae Local mediators – myotoxin A necrosis of skeletal muscle may cause distant rhabdomyolysis

37. Crotalidae Local mediators – pain and edema rapid edema indicative of severe envenomation bullae formation/blebs not uncommon

38. General Treatment Do nothing that delays getting to ED (emergency department)

39. General Treatment Basic and advanced life support Mark border of advancing edema with pen every 15 minutes

40. General Treatment No benefit with negative pressure venom extraction device

41. General Treatment Fang marks not recommended Mouth suction contraindicated

42. General Treatment Constriction and pressure immobilization: may help impede spread of venom Tourniquets not recommended Keep in neutral position

43. General Treatment Do not give antivenom in field secondary to anaphylaxis risk

44. General Treatment Do not try and find snake – may result in more bites – may delay ED arrival

45. Crotalidae Bite Severity Grading based on clinical presentation Dry bite – puncture wound only – no systemic effect – normal labs

46. Crotalidae Bite Severity Mild – local effects at bite site only – no systemic effects – normal labs

47. Crotalidae Bite Severity Moderate – local effects beyond immediate bite area – vomiting, metallic taste, fasciculation

48. Crotalidae Bite Severity Moderate – platelets <90,000, fibrinogen <90-100 mg/dl – PT >14 seconds – CPK (creatine phosphokinase) >500-1,000 U/L

49. Crotalidae Bite Severity Severe – rapid involvement of entire area near bite – compartment syndrome – systemic shock – severe bleeding

50. Crotalidae Bite Severity Severe – renal failure – respiratory difficulty – altered mental status – platelets <20,000 – rhabdomyolysis

51. Polyvalent Antivenin Derived from horse serum immunized with venom from various species

52. Polyvalent Antivenin Used for moderate to severe symptoms – test dose for anaphylaxis – skin testing

53. Polyvalent Antivenin Used for moderate to severe symptoms – start with 10 vials (average 10-15 for moderate bite) – can go up to 25-30 vials

54. Polyvalent Antivenin

55. Used for moderate to severe symptoms – ~80% develop serum sickness

56. 0-3 minimal severity 4-7 moderate severity 8-20 severe Severity Score

57. Serum Sickness

58. Fever Redness of joints Skin rash Itching Swollen glands Malaise Anorexia

59. Serum Sickness Patient has to be hospitalized to treat

60. Crofab ® Sheep-derived antivenin – venom-specific Fab fragment of immunoglobulin G (IgG) – binds and neutralizes venom toxins

61. Crofab ® Because the antibodies are raised in sheep there is minimal to no serum sickness Start with 4-6 vials

62. Crofab ® Administer 4-6 more vials every hour until coagulopathies and edema have been controlled After initial control, provide 2 vials every 6 hours for 18 hours

63. Crofab ®

64. Compartment Syndrome Increased pressure within the fixed compartment of the limb muscle fascia

65. Compartment Syndrome Symptoms – skin is taught, warm, blanched – distal to the swelling may have numbness, loss of blood supply

66. Compartment Syndrome Diagnosis: made by percutaneous insertion of needle with measurement of internal pressure

67. Compartment Syndrome Treatment – surgical release – fasciotomy

68. Compartment Syndrome With antivenin, may have some disfigurement, rare functional impairment, and even rarer loss of a limb

69. Fasciotomy

70. Mexican Milk Snake

71. Red touches yellow: kill a fellow Red touches black: a friend of Jack

72. Coral Snake

73. Micrurus sp. Moderate to severe neurologic symptoms usually seen with envenomation Systemic effects may be delayed >12 hours May require antivenin!!

74. Coral Snake Bite Neurotoxic, neuromuscular dysfunction Little enzymatic activity, low necrotic potential Little venom delivered per bite

75. Coral Snake Bite Primitive delivery system – small mouth – pair of small, fixed hollow fangs on anterior mouth

76. Coral Snake Bite Primitive delivery system – venom released via chewing motion – must bite and temporarily hold and “chew” to get venom out

77. Coral Snake Bite Respiratory distress – pharyngeal spasm – hypersalivation – cyanosis – trismus

78. Coral Snake Bite Cardiovascular collapse – hypotension – tachycardia Onset: symptoms may be delayed up to 12 hours

79. Coral Snake Bite Bite site: paucity of complaints – little pain – no necrosis – paresthesias – swelling usually mild

80. Coral Snake Bite Neurotoxic – altered mental status can occur – diplopia, ptosis – generalized weakness – muscle fasciculations

81. Coral Snake

82. No advantage for giving antivenom for other snake species

83. Coral Snake Wyeth ® Antivenin ( Micrurus fulvius ) – dose: 3-6 vials IV (intravenously) over 1-2 hours

84. Coral Snake Wyeth ® Antivenin ( Micrurus fulvius ) – if necessary, give extra 3-5 vials over 1-2 hours – rarely need >10 vials

85. Coral Snake Wyeth ® Antivenin ( Micrurus fulvius ) – must be started early – before any symptoms develop, as soon as they arrive at the ED

86. Crawlers 1.Be able to recognize the clinical symptoms associated with an envenomation from a brown recluse, black widow, tarantula, scorpion, and fire ant

87. Crawlers 2.Define a basic treatment plan for individuals who are bitten by the insects listed in the first objective

88. Crawlers 3.Recognize the clinical symptoms associated with insect bite-associated allergic reaction – be able to define a treatment plan for the individual undergoing anaphylaxis

89. Brown Recluse Characteristic fiddle pattern

90. Brown Recluse Loxosceles sp. Venom – digestive enzymes – sphingomyelinase D

91. Brown Recluse Proper wound care – +/- debridement – no prophylactic antibiotics No antidote – ??? early dapsone

92. Brown Recluse Symptoms Necrotic lesion Fever Rash Arthralgias

93. Brown Recluse Symptoms

95. Black Widow Characteristic hourglass pattern

96. Black Widow Latrodectus sp. Neurotoxic venom – increased calcium influx – increased acetylcholine

97. Black Widow Local pain Abdominal cramping Diaphoresis Nausea, vomiting, diarrhea

98. Black Widow Treatment – wound care – muscle relaxers – opiate analgesics – antivenin (rarely used)

99. There is little toxicity associated with North American tarantulas Tarantula

101. Hymenoptera

102. Apidae: honey bees Bombidae: bumble bees Vespidae: wasps, hornets, yellow jackets Formicoidea: ants

103. Hymenoptera Symptoms – local pain, itching, and swelling – multiple stings or stings to the face  risks

104. Hymenoptera Symptoms – vomiting, cyanosis, hypotension, syncope, dyspnea – anaphylaxis risk

105. Hymenoptera Treatment – wound care – remove stinger? – analgesics – antihistamines

106. Scorpion

107. Very painful sting Typically supportive care is all that is needed If numbness or paresthesias persist for >48 hours need medical evaluation

108. Fire ants

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111. This continuing education activity is approved by the Continuing Education Coordinating Board for Emergency Medical Services for 1.5 basic CEH. You have participated in a continuing education program that has received CECBEMS approval for continuing education credit. If you have any comments regarding the quality of this program and/or your satisfaction with it, please contact CECBEMS at: CECBEMS - 12200 Ford Road, Suite 478 Dallas, TX 75234 Phone: 972-247-4442 - lsibley@cecbems.com lsibley@cecbems.com EMS 80112

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115. Conflicts of Interest: Paul R. Lockman, BSN, PhD has disclosed that no financial interests, arrangements or affiliations with organization/s that could be perceived as a real or apparent conflict of interest in employment, leadership positions, research funding, paid consultants or member of an advisory board or review panel, speaker’s bureau, major stock or investment holder, or other remuneration. Commercial Support: There is no commercial support and/or relevant financial relationships related to this educational activity. Commercial support is defined as financial (or in-kind) contributions given by a commercial interest, which is used to pay all or part of the costs of a CNE activity. Relevant financial relationships are defined as financial relationships of any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner that could create a conflict of interest. Nursing 30312

116. Non-endorsement of Products: Paul R. Lockman, BSN, PhD has disclosed that no significant relationships with commercial companies whose products or services are discussed in educational presentations. For speakers, significant relationships include receiving from a commercial company research grants, consultancies, honoraria and travel, or other benefits or having a self-managed equity interest in a company. Disclosure of a relationship is not intended to suggest or condone bias in any presentation, but is made to provide participants with information that might be of potential importance to their evaluation of a presentation. Off-label Use: Paul R. Lockman, BSN, PhD has disclosed that no products with off-label or unapproved uses are discussed within this activity. Nursing 30312

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