Venomous arthropod handbook

by Terry L. Biery

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.

[BLACK WIDOW SPIDER]

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])

[BROWN RECLUSE SPIDER]

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

[CENTIPEDES]

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

[TRUE BUGS (KISSING BUGS)]

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])

[ANTS]

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])

[BEES AND WASPS]

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

[SCORPIONS]

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])

[URTICATING CATERPILLARS]

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
	GENERIC NAMES		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