Arsenic toxicology. “The King of Poisons” “The Poison of Kings”
Adam Algren, MD Medical Toxicology Fellow Georgia Poison Center Clinical Instructor
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Transcript of Adam Algren, MD Medical Toxicology Fellow Georgia Poison Center Clinical Instructor
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Adam Algren, MDAdam Algren, MDMedical Toxicology FellowMedical Toxicology Fellow
Georgia Poison CenterGeorgia Poison CenterClinical InstructorClinical Instructor
Emory University Dept. of Emergency MedicineEmory University Dept. of Emergency Medicine
Snakes, Spiders, and Creatures from the Sea
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ObjectivesObjectives
Review clinical manifestations of North Review clinical manifestations of North American snake envenomationsAmerican snake envenomations
Review presentation and management of Review presentation and management of black widow and brown recluse spider black widow and brown recluse spider bitesbites
Discuss the indications for the use of Discuss the indications for the use of antivenoms: CroFab and Lactrodectusantivenoms: CroFab and Lactrodectus
Discuss common marine envenomationsDiscuss common marine envenomations
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Snake EnvenomationsSnake Envenomations
CrotalidsCrotalids Pit VipersPit Vipers Found in every state except Alaska, Hawaii, Found in every state except Alaska, Hawaii,
MaineMaine 6000-8000 bites/yearly6000-8000 bites/yearly 5-10 deaths/yearly 5-10 deaths/yearly
ElapidsElapids Coral SnakeCoral Snake 69 Bites reported in 200069 Bites reported in 2000
64% Florida64% Florida
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NEJM 2002;347:350
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CrotalidsCrotalids
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CrotalidsCrotalids
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CrotalidsCrotalids CrotalusCrotalus
C. adamanteusC. adamanteus Eastern Diamondback Eastern Diamondback rattlesnakerattlesnake
C. atroxC. atrox Western Diamondback rattlesnakeWestern Diamondback rattlesnake C. horridus horridusC. horridus horridus Timber rattlesnakeTimber rattlesnake C. horridus atricaudatusC. horridus atricaudatus Canebrake rattlesnakeCanebrake rattlesnake C. scutulatusC. scutulatus Mojave rattlesnakeMojave rattlesnake C. viridis viridisC. viridis viridis Prairie rattlesnakePrairie rattlesnake C. cerastesC. cerastes Sidewinder rattlesnakeSidewinder rattlesnake
SistrurusSistrurus S. milariusS. milarius Pigmy rattlesnakePigmy rattlesnake S. catenatus spp.S. catenatus spp. Massasauga rattlesnakeMassasauga rattlesnake
AgkistrodonAgkistrodon A. contortixA. contortix CopperheadsCopperheads A. piscivorusA. piscivorus CottonmouthsCottonmouths
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Eastern Diamondback RattlesnakeEastern Diamondback RattlesnakeCrotalus adamanteusCrotalus adamanteus
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CrotalidsCrotalids
Majority of victims are maleMajority of victims are male Majority of bites occur May-OctoberMajority of bites occur May-October >50% victims of provoked bites are >50% victims of provoked bites are
intoxicatedintoxicated ¾ bites occur to upper extremities¾ bites occur to upper extremities 0-75% of snake’s venom is discharged0-75% of snake’s venom is discharged
Venom replenished within 1 monthVenom replenished within 1 month 5-20% of bites are “dry bites”5-20% of bites are “dry bites”
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CrotalidsCrotalids VenomVenom
Components Components MetalloproteinasesMetalloproteinases CollagenasesCollagenases HyaluronidasesHyaluronidases ProteasesProteases
Composition/Composition/potency variespotency varies
SnakeSnake SpeciesSpecies AgeAge SeasonSeason
NEJM 2002;347:351
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Western Diamondback rattlesnakeWestern Diamondback rattlesnakeCrotalus atroxCrotalus atrox
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Crotalid EnvenomationsCrotalid Envenomations PathophysiologyPathophysiology
Local EffectsLocal Effects Most commonMost common Metalloproteinases and other components damage Metalloproteinases and other components damage
vascular endothelium and basement membranesvascular endothelium and basement membranes Edema, ecchymosis, blisteringEdema, ecchymosis, blistering
Systemic EffectsSystemic Effects CoagulopathyCoagulopathy HypotensionHypotension
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Crotalid EnvenomationsCrotalid Envenomations
Pre-hospital ManagementPre-hospital Management Avoid exertionAvoid exertion Immobilize the extremity at or below level of Immobilize the extremity at or below level of
heartheart Rapid transport to nearest emergency dept.Rapid transport to nearest emergency dept. Consider constriction band if there is going to Consider constriction band if there is going to
be a prolonged transport timebe a prolonged transport time Extractor devices probably not helpfulExtractor devices probably not helpful Avoid tourniquet, cryotherapy, electric shock, Avoid tourniquet, cryotherapy, electric shock,
excision, and incisionexcision, and incision McKinney. Ann Emerg Med. 2001;37:168-74.McKinney. Ann Emerg Med. 2001;37:168-74. Alberts. Ann Emerg Med. 2004;43:181-6.Alberts. Ann Emerg Med. 2004;43:181-6.
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Crotalid EnvenomationsCrotalid Envenomations HistoryHistory
Circumstance of biteCircumstance of bite Type of snakeType of snake Number of bitesNumber of bites Time since envenomationTime since envenomation First aid providedFirst aid provided Previous history of snake Previous history of snake
envenomation/antivenom treatmentenvenomation/antivenom treatment Sensitivity to horse/sheep seraSensitivity to horse/sheep sera Be cautious with any snakes brought to the EDBe cautious with any snakes brought to the ED
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CopperheadCopperheadAkistrodon contortixAkistrodon contortix
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Crotalid EnvenomationsCrotalid Envenomations
Clinical ManifestationsClinical Manifestations LocalLocal
Fang marksFang marks Number of fang Number of fang
marks helpful, but not marks helpful, but not definitivedefinitive
EdemaEdema EcchymosisEcchymosis BullaeBullae
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Crotalid EnvenomationsCrotalid Envenomations
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Crotalid EnvenomationsCrotalid Envenomations
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Crotalid EnvenomationsCrotalid Envenomations Clinical ManifestationsClinical Manifestations
SystemicSystemic AnaphylaxisAnaphylaxis Nausea, vomiting, diaphoresis, metallic tasteNausea, vomiting, diaphoresis, metallic taste HypotensionHypotension CoagulopathyCoagulopathy ThrombocytopeniaThrombocytopenia RhabdomyolysisRhabdomyolysis Neurologic EffectsNeurologic Effects
Mojave rattlesnakeMojave rattlesnake
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NEJM 2002;347:351
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Timber rattlesnakeTimber rattlesnakeCrotalus horridus horridusCrotalus horridus horridus
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Canebrake rattlesnakeCanebrake rattlesnake Crotalus horridus atricaudatusCrotalus horridus atricaudatus
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Mojave rattlesnakeMojave rattlesnakeCrotalus scutulatusCrotalus scutulatus
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Crotalid EnvenomationsCrotalid Envenomations TreatmentTreatment
Remove any constriction band slowlyRemove any constriction band slowly TetanusTetanus Prophylactic antibiotics unnecessary Prophylactic antibiotics unnecessary Consult poison centerConsult poison center Determine antivenom supplies Determine antivenom supplies Document neurovascular exam for extremity Document neurovascular exam for extremity
bitesbites Measure limb circumference every 15 minutesMeasure limb circumference every 15 minutes Labs- CBC, chemistries, PT, PTT, Fibrinogen, CK Labs- CBC, chemistries, PT, PTT, Fibrinogen, CK
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CottonmouthsCottonmouths Agkistrodon piscivorusAgkistrodon piscivorus
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Crotalid EnvenomationsCrotalid Envenomations
TreatmentTreatment Surgical treatmentSurgical treatment
Routine surgical treatment not recommendedRoutine surgical treatment not recommended Measure compartment pressures if there is concernMeasure compartment pressures if there is concern Digit dermotomyDigit dermotomy
Hall E. Ann Emerg Med. 2001;37:175-180.Hall E. Ann Emerg Med. 2001;37:175-180.
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Crotalid EnvenomationsCrotalid Envenomations AntivenomAntivenom
Wyeth polyvalent antivenomWyeth polyvalent antivenom CroFabCroFab Indications:Indications:
Rapid progression of local effectsRapid progression of local effects Compartment syndromeCompartment syndrome Coagulopathy, ThrombocytopeniaCoagulopathy, Thrombocytopenia Neurologic SymptomsNeurologic Symptoms ShockShock
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Crotalid EnvenomationsCrotalid Envenomations
CroFabCroFab FDA approved in 2000FDA approved in 2000 Sheep derived FabSheep derived Fab IgGIgG Less immunogenicLess immunogenic Eastern/Western Diamondback rattlesnake, Eastern/Western Diamondback rattlesnake,
Mojave rattlesnake, Cottonmouth Mojave rattlesnake, Cottonmouth Skin testing not requiredSkin testing not required 0-14% incidence of immediate hypersensitivity0-14% incidence of immediate hypersensitivity <5% incidence of serum sickness<5% incidence of serum sickness
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Crotalid EnvenomationsCrotalid Envenomations Dart et al. Arch Intern Med. 2001;161:2030-Dart et al. Arch Intern Med. 2001;161:2030-
6.6. 31 patients31 patients 6 or 12 vials CroFab initially6 or 12 vials CroFab initially 16 patients PRN, 15 scheduled16 patients PRN, 15 scheduled
8 patients in PRN group required additional CroFab8 patients in PRN group required additional CroFab 0 patients in scheduled group0 patients in scheduled group
All patients had significant improvement in All patients had significant improvement in snakebite severity scoressnakebite severity scores
6 allergic reactions6 allergic reactions 4 urticaria, 1 urticaria/cough, 1 4 urticaria, 1 urticaria/cough, 1
urticaria/dyspnea/wheezingurticaria/dyspnea/wheezing
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In fuse Additional 2 Via ls Dosesat 6, 12, and 18 hours After In itia l Control
Yes
In itia l Contro l Achieved?
NoAdm inister Additional 4 - 6 Via ls o f CroFab(TM)
In itia l Contro l Achieved?
Establish Initial Control o f Envenom ationBy Adm inistering 4 - 6 V ials of CroFab(TM)
Patient with Ind ication forCroFab(TM ) Adm inistration
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Crotalid EnvenomationsCrotalid Envenomations
CroFab for Copperhead envenomationsCroFab for Copperhead envenomations 32 cases 32 cases 25 (78%) were moderate severity25 (78%) were moderate severity 7 had mild laboratory abnormalities7 had mild laboratory abnormalities 23 (72%) achieved control with 4 vials23 (72%) achieved control with 4 vials 4 cases progressed following CroFab4 cases progressed following CroFab No allergic reactionsNo allergic reactions 1 mild case serum sickness1 mild case serum sickness
Lavonas et al. Ann Emerg Med. 2004;43:200-6.Lavonas et al. Ann Emerg Med. 2004;43:200-6.
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Crotalid EnvenomationsCrotalid Envenomations Safety and Efficacy of CroFab for Pediatric Safety and Efficacy of CroFab for Pediatric
EnvenomationsEnvenomations 24 patients24 patients Mean age 7.3 (range 1.9-13)Mean age 7.3 (range 1.9-13) All had local swellingAll had local swelling 14 (58%) PT >13sec14 (58%) PT >13sec 3 (12.5%) platelets <150,0003 (12.5%) platelets <150,000 2 (8.3%) fibrinogen <150 mg/dl2 (8.3%) fibrinogen <150 mg/dl Mean number of CroFab vials used 12.3 (4-24)Mean number of CroFab vials used 12.3 (4-24) 5 patients progressive thrombocytopenia5 patients progressive thrombocytopenia ? 1 allergic reaction? 1 allergic reaction
Pizon et al. Acad. Emerg Med. 2007;14:373-6.Pizon et al. Acad. Emerg Med. 2007;14:373-6.
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Crotalid EnvenomationsCrotalid Envenomations Recurrence- Local or systemicRecurrence- Local or systemic
Possible explanationsPossible explanations Pharmacokinetic/pharmacodynamic mismatch of Pharmacokinetic/pharmacodynamic mismatch of
venom/antivenomvenom/antivenom CroFab elimination ½ life 15-20 hoursCroFab elimination ½ life 15-20 hours
Late onset of venom effectsLate onset of venom effects Prolonged absorption of venom from woundProlonged absorption of venom from wound
Dissociation of venom/antivenom complexDissociation of venom/antivenom complex Development of host anti-antivenom responseDevelopment of host anti-antivenom response
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Crotalid EnvenomationsCrotalid Envenomations
Post-marketing study of CroFab for Post-marketing study of CroFab for rattlesnakesrattlesnakes 28 patients (3 children)28 patients (3 children) 16/28 achieved local control with 4-6 vials16/28 achieved local control with 4-6 vials 20/28 elevated PT, 6/28 thrombocytopenia, 20/28 elevated PT, 6/28 thrombocytopenia,
12/28 hypofibrinogenemia12/28 hypofibrinogenemia Control achieved in all, 67-80% required >10 vialsControl achieved in all, 67-80% required >10 vials
6/21 had systemic recurrence6/21 had systemic recurrence No significant bleedingNo significant bleeding
No anaphylactic reactionsNo anaphylactic reactions Ruha et al. Ann Emerg Med. 2002;39:609-615 Ruha et al. Ann Emerg Med. 2002;39:609-615
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Ann Emerg Med 2001;37:2
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Ann Emerg Med 2001;37:2
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Crotalid EnvenomationCrotalid Envenomation DispositionDisposition
Observe for 6-8 hours if asymptomaticObserve for 6-8 hours if asymptomatic May discharge if asymptomatic with normal May discharge if asymptomatic with normal
labslabs Admit all suspected Mojave rattlesnake Admit all suspected Mojave rattlesnake
envenomations for 24 hoursenvenomations for 24 hours Admit for significant local effects or if labs Admit for significant local effects or if labs
abnormalabnormal
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Which snake is poisonous?Which snake is poisonous? King snake
Lampropeltis getulus
Coral Snake
Micrurus fulvius
“Red on yellow, kill a fellow”
“Red on black, venom lack”
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Coral Snake EnvenomationsCoral Snake Envenomations
UncommonUncommon Florida, GeorgiaFlorida, Georgia Eastern, Texas, SonoranEastern, Texas, Sonoran Small, ~40 inches full grown, small teethSmall, ~40 inches full grown, small teeth 25% of bites are “dry bites”25% of bites are “dry bites” VenomVenom
Components not well understoodComponents not well understood Zinc dependent acetylcholinesteraseZinc dependent acetylcholinesterase
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Coral Snake EnvenomationsCoral Snake Envenomations
Clinical PresentationClinical Presentation 1/3 have mild local swelling1/3 have mild local swelling Mild systemic symptomsMild systemic symptoms May develop localized pain or fasciculationsMay develop localized pain or fasciculations Neurologic symptomsNeurologic symptoms
Normal mental statusNormal mental status CN palsies, weakness/paralysis, respiratory failureCN palsies, weakness/paralysis, respiratory failure
Avg. delay to symptom onset is ~ 2 hoursAvg. delay to symptom onset is ~ 2 hours May be delayed up to 13 hoursMay be delayed up to 13 hours
Kitchens et al. JAMA. 1987;258:1615-8. Kitchens et al. JAMA. 1987;258:1615-8.
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Coral Snake EnvenomationsCoral Snake Envenomations TreatmentTreatment
Supportive CareSupportive Care Aggressive airway management, monitor NIFAggressive airway management, monitor NIF Consult poison center, determine antivenom suppliesConsult poison center, determine antivenom supplies Consider NeostigmineConsider Neostigmine Early antivenom administration even if asymptomaticEarly antivenom administration even if asymptomatic
Equine derivedEquine derived 3-5 vials initially, redose additional 5 vials in symptomatic pts3-5 vials initially, redose additional 5 vials in symptomatic pts Reconstitution 15-30 minutesReconstitution 15-30 minutes Immediate hypersenitivity- 6/17 urticaria, 1/39 anaphylaxis Immediate hypersenitivity- 6/17 urticaria, 1/39 anaphylaxis Serum sickness- 4/39 patientsSerum sickness- 4/39 patients
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Coral Snake EnvenomationsCoral Snake Envenomations DispositionDisposition
Admit all suspected Coral snake bites for at Admit all suspected Coral snake bites for at least 24 hoursleast 24 hours
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Black Widow EnvenomationsBlack Widow Envenomations
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Black Widow EnvenomationsBlack Widow Envenomations Latrodectus mactansLatrodectus mactans ~2500 bites/year~2500 bites/year
300-400 severe300-400 severe Prefer dry, dark environmentsPrefer dry, dark environments Only females envenomateOnly females envenomate No deaths in US in past 20 yearsNo deaths in US in past 20 years αα-lactrotoxin-lactrotoxin
Stimulates release of acetylcholine and Stimulates release of acetylcholine and catecholaminescatecholamines
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Black Widow EnvenomationsBlack Widow Envenomations Non-specific symptoms can make diagnosis difficultNon-specific symptoms can make diagnosis difficult Bite is not always feltBite is not always felt Pain within 10-60 min, but may be delayedPain within 10-60 min, but may be delayed 75% will only have local symptoms75% will only have local symptoms
Pain, diaphoresis, piloerectionPain, diaphoresis, piloerection Systemic symptoms may develop over several Systemic symptoms may develop over several
hourshours Generalized pain, abdominal pain, priapism, Generalized pain, abdominal pain, priapism,
diaphoresis, tachycardia, hypertension, headache, diaphoresis, tachycardia, hypertension, headache, vomiting, tremorvomiting, tremor
Symptoms peak within 12-24 hoursSymptoms peak within 12-24 hours Typically resolves over 24-72 hoursTypically resolves over 24-72 hours
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Black Widow EnvenomationsBlack Widow Envenomations TreatmentTreatment
Opiates, benzodiazepinesOpiates, benzodiazepines 115/163 patients had resolution of pain115/163 patients had resolution of pain
No evidence to support calciumNo evidence to support calcium 23/24 no improvement23/24 no improvement
AntivenomAntivenom Severe/refractory pain, severe hypertension, Severe/refractory pain, severe hypertension,
threatened abortionthreatened abortion Equine IgGEquine IgG 58 patients received 1 vial; all had pain resolution <2 58 patients received 1 vial; all had pain resolution <2
hrshrs 4 urticaria, 1 analphylaxis death4 urticaria, 1 analphylaxis death
Clark et al. Ann Emerg Med. 1992;21:782-7.Clark et al. Ann Emerg Med. 1992;21:782-7.
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Black Widow EnvenomationsBlack Widow Envenomations DispositionDisposition
Discharge if symptoms improveDischarge if symptoms improve May discharge if antivenom givenMay discharge if antivenom given
Observe for 2 hours after completion of infusionObserve for 2 hours after completion of infusion
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Brown Recluse EnvenomationsBrown Recluse Envenomations
Loxosceles reclusaLoxosceles reclusa April-October ? more bites at night Prefers warm, dry environment Venom
Sphingomyelinase D, Sphingomyelinase D,
hyaluronidase, phosphohydrolaseshyaluronidase, phosphohydrolases
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Brown Recluse EnvenomationsBrown Recluse Envenomations
Most bites have a benign courseMost bites have a benign course May progress over several hoursMay progress over several hours Pain, induration, ecchymosisPain, induration, ecchymosis May develop serous/bloody blistersMay develop serous/bloody blisters GravitationalGravitational Necrosis at 2-4 days, heals over 6-8 Necrosis at 2-4 days, heals over 6-8
weeksweeks
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Brown Recluse EnvenomationsBrown Recluse Envenomations
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Brown Recluse EnvenomationsBrown Recluse Envenomations
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Brown Recluse EnvenomationsBrown Recluse Envenomations Bacterial InfectionsBacterial Infections
Orf, Anthrax, Orf, Anthrax, LeishmaniosisLeishmaniosis
Bee StingBee Sting Skin cancerSkin cancer Drug reactionsDrug reactions
Coumadin, TEN, SJSCoumadin, TEN, SJS Ecthyma gangrenosumEcthyma gangrenosum Erythema migransErythema migrans Erythema nodosumErythema nodosum Erythema multiformeErythema multiforme Emboli, septicEmboli, septic Fire antsFire ants FrostbiteFrostbite MitesMites
Necrotizing fascitisNecrotizing fascitis Polyarteritis nodosaPolyarteritis nodosa Purpura fulminansPurpura fulminans Pyoderma Pyoderma
gangrenosumgangrenosum ScrofulaScrofula SporotrichosisSporotrichosis Systemic gonorrheaSystemic gonorrhea SclerodermaScleroderma Tick bitesTick bites UlcersUlcers Viral infectionsViral infections VasculitisVasculitis
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Brown Recluse EnvenomationsBrown Recluse Envenomations
Systemic loxoscelismSystemic loxoscelism Not proportional to dermal findingsNot proportional to dermal findings
4/111 patients4/111 patients 6/546 pediatric series6/546 pediatric series
? More common in children? More common in children Develops within 72-96 hoursDevelops within 72-96 hours Fever, nausea, myalgias, arthralgias, headacheFever, nausea, myalgias, arthralgias, headache Jaundice, coagulopathy, hemolysis, renal Jaundice, coagulopathy, hemolysis, renal
failurefailure Mortality from hemolysis, DICMortality from hemolysis, DIC
Wright et al. Ann Emerg Med. 1997;30:28-32.Wright et al. Ann Emerg Med. 1997;30:28-32. Elbahlwan et al. Pediatr Emerg Care. 2005;21:177-Elbahlwan et al. Pediatr Emerg Care. 2005;21:177-
180.180.
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Brown Recluse EnvenomationsBrown Recluse Envenomations TreatmentTreatment
Wound careWound care Prophylactic antibiotics unnecessaryProphylactic antibiotics unnecessary LabsLabs
CBC, chemistries, LDH, retic count, PT, PTT, CBC, chemistries, LDH, retic count, PT, PTT, fibrinogen, UA, plasma free hemoglobin, type & fibrinogen, UA, plasma free hemoglobin, type & screenscreen
Avoid dapsone/early surgical treatmentAvoid dapsone/early surgical treatment ? Early HBO? Early HBO Steroids for hemolysisSteroids for hemolysis
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Brown Recluse EnvenomationsBrown Recluse Envenomations
DispositionDisposition Admit for systemic complicationsAdmit for systemic complications ChildrenChildren
Consider daily out-patient labs for 96 hours Consider daily out-patient labs for 96 hours
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Marine EnvenomationsMarine Envenomations
JellyfishJellyfish Box JellyfishBox Jellyfish Portuguese man-of-warPortuguese man-of-war
StingraysStingrays ScorpaenidaeScorpaenidae
LionfishLionfish
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Box JellyfishBox Jellyfish Chironex fleckeriChironex fleckeri
15 tentacles up to 7 meters in length Found along northern coast of Australia Responsible for >60 deaths in past
century
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Box JellyfishBox Jellyfish Millions of nematocysts/jellyfish tentacleMillions of nematocysts/jellyfish tentacle VenomVenom
Cardiotoxic/myotoxicCardiotoxic/myotoxic Increases intracellular Na/CaIncreases intracellular Na/Ca
Most stings are minorMost stings are minor Death possible within minutesDeath possible within minutes
with severe envenomationswith severe envenomations
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Box jellyfishBox jellyfish Clinical ManifestationsClinical Manifestations
Immediate painImmediate pain Skin wheals/vesiclesSkin wheals/vesicles Delayed hypersensitivity reaction commonDelayed hypersensitivity reaction common Hypotension/cardiac arrestHypotension/cardiac arrest
O’Reilly. Med J Aust. 2001;175:652-5.O’Reilly. Med J Aust. 2001;175:652-5.
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Box jellyfishBox jellyfish
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Portuguese man-of-warPortuguese man-of-war
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Portuguese man-of-warPortuguese man-of-war
Physalia sp.Physalia sp. Responsible for thousands of stings in USResponsible for thousands of stings in US Found along Atlantic/Gulf coastsFound along Atlantic/Gulf coasts Tentacles may be up to 30 metersTentacles may be up to 30 meters Most envenomations minor, deaths rareMost envenomations minor, deaths rare Immediate pain/skin reactionImmediate pain/skin reaction
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Jellyfish TreatmentJellyfish Treatment Supportive careSupportive care Irrigate with 5% acetic acidIrrigate with 5% acetic acid Remove tentaclesRemove tentacles Wound careWound care Pain medsPain meds Consider prophylactic antibioticsConsider prophylactic antibiotics Monitor for delayed reactionsMonitor for delayed reactions
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StingraysStingrays
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StingraysStingrays Tropical/temperate environmentsTropical/temperate environments Shallow watersShallow waters Non-aggressiveNon-aggressive 1-4 spines1-4 spines 17 deaths reported worldwide17 deaths reported worldwide VenomVenom
Phosphodiesterases, serotonin,Phosphodiesterases, serotonin,
5’-nucleotidase5’-nucleotidase Immediate pain lasting 6-48 hrImmediate pain lasting 6-48 hr Vomiting, dizziness, weakness,Vomiting, dizziness, weakness,
syncope, cramps, arrhythmias, hypotensionsyncope, cramps, arrhythmias, hypotension
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StingraysStingrays
Immediate cold water irrigationImmediate cold water irrigation Then warm water (40-42Then warm water (40-42°) immersion°) immersion
Pain medsPain meds Wound managementWound management Consider prophylactic antibioticsConsider prophylactic antibiotics
Cook et al. J Emerg Med. 2006;30:345-7.Cook et al. J Emerg Med. 2006;30:345-7.
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LionfishLionfish
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LionfishLionfish Pterois sp.Pterois sp. Atlantic, Pacific, CaribbeanAtlantic, Pacific, Caribbean Popular aquarium fishPopular aquarium fish 12 or 13 dorsal spines with 12 or 13 dorsal spines with
venom glandsvenom glands Venom poorly characterizedVenom poorly characterized Severe pain lasting 6-12 hoursSevere pain lasting 6-12 hours Systemic effects rare Systemic effects rare
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LionfishLionfish
Warm water (45Warm water (45°) immersion for 30-90 °) immersion for 30-90 minmin
Pain medsPain meds Wound careWound care Consider prophylactic antibioticsConsider prophylactic antibiotics
Vetrano et al. J Emerg Med. 2002;23:379-382.Vetrano et al. J Emerg Med. 2002;23:379-382.
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Questions?Questions?