Wrap up of our conference day focused on pediatrics and environmental emergencies.
Dr. Subramaniam on Venomous Land Animals
SNAKES
- 9000 snake bites annually, with 1% mortality – highest in young children
- DO: remove constricting clothing, transport to hospital immediately, establish IV access, immobilize and raise limb, and mark the leading edge of erythema/edema
- DO NOT: incise the wound, use a venom suctioning kit, apply tourniquets, or apply ice or heat
- In addition to the localized effect of pain from a bite, systemic events include hematologic and neurologic problems.
- Cellulitis and compartment syndrome are rare
- Pain control with opiates
- Give tetanus if not up to date
- Venomous snakes in the US are either Crotalidae (“pit vipers”) or Elapidae (coral snakes).
- Crotalids, aka pit vipers, include rattlesnakes, copperheads, and cottonmouths
- Venomous crotalids have broad heads, elliptical pupils, pointy snouts, and heat-sensing pits on their face
- More common to have hematologic effects
- Can use Crofab antivenom for moderate to severe bites (use grading system)
- Coral snakes are found in the southeastern US
- “red on yellow kill a fellow” (these are venomous!)
- “red on black venom lack” (not so much)
- Crotalids, aka pit vipers, include rattlesnakes, copperheads, and cottonmouths
- Call the Poison center and your local zoo or snake center (in NYC this is Jacobi Hospital)
SCORPIONS
- Bark Scorpion in the Southwestern US and Mexico is venomous
- Effects:Local injury / pain, cranial nerve dysfunction, neuromuscular hyperactivity, dysautonomia, and rarely pancreatitis or rhabdomyolysis
- 20,000 bites per year, most lethal in children
- Antivenom was discontinued but now made by Mexico, however your best bet is supportive intensive care (intubation, benzodiazepines, etc)
Check out another of our blog posts on scorpions: Bored Review in the Sonoran
Dr. Fernando - Marine Envenomations
- Bites
- Blue-Ringed Octopus – tiny but deadly, uses tetrodotoxin
- Sea Snakes – 50 species: all are venomous, 7 are fatal.
- Nematocysts (Jellyfish and Portugese Man o’ War
- Use barb, spine, and thread to discharge into skin
- Management
- Remove nematocysts (shaving cream and credit card method) or warm saline water
- Consider oral antihistamines and oral corticosteroids
- Stings
- Sea urchin, sea cucumber and starfish – no venom but cause local irritation
- Stingrays – cause laceration and puncture envenomation – treat both!
- Severe local pain
- Syncope, weakness, nausea, vomiting, diarrhea, muscle fasciculations
- Treatment: salt water immersion / irrigation, remove stinger, explore wound
- Bony Fish – have spines with venom
- Scorpionfish, lionfish, stonefish, catfish
- Check out our own wilderness medicine post about scorpionfish envenomation
- Ciguatera Poisoning
- From large fish that eat smaller reef fish that feed off of coral that hosts bacteria
- Heat stabile, water soluble = you can’t cook it off
- Clinical manifestations are:
- GI (3-6 hours) – vomiting, diarrhea, abdominal pain
- Neurologic (3-72 hours) – paresthesias, tooth discomfort, blurred vision *these can lasts for weeks!
- Cardiovascular (hours) – bradycardia, heart block, hypotension
- Treatment is supportive care, mannitol for very severe symptoms
- Scromboid Poisoning
- From dark meat, large fish (tuna, mackerel, swordfish, mahi-mahi)
- Caused by bacterial overgrowth when fish is improperly stored (> 40° C) leading to production of histadine (converted to histamine)
- Clinical manifestations are flushing, rash, diarrhea, headache, numbness (think histamine reaction)
- Treatment is antihistamines and supportive care, most cases resolve within 12-48 hours
- Pufferfish Poisoning – Tetrodotoxin
- Not just pufferfish! Also found in frogs, salamanders, octopus, and crab eggs
- Sodium cannel blockade leads to weakness, hypotension, paralysis and ultimately respiratory failure
- Treatment is aggressive supportive care and GI decontamination
Lastly, check out this TOKC post reviewing fish-related poisoning.
Dr. Delgado Torres - Poisonous Plants
- Most poisonous plant exposures are unintentional, small, asymptomatic, and from household plants
- Get a thorough history including travel, time of exposure, quantity eaten and which part of plant
- Problems for medical providers include misidentification, scant literature, and variable xenobiotics within a plant. Best bet is to observe your patient!
- Types of Xenobiotics in plants, with examples
- Alkaloids
- Jimsonweed – anticholinergic toxicity through atropine
- Gylcosides
- Yellow oleander and foxglove – acts like digoxin toxicity
- Cassava (from improperly prepared yucca) is cyanogenic
- Terpenes and resins
- Castor bean – one seed is toxic
- Causes multi-organ dysfunction – use aggressive decontamination
- Proteins, peptides and lectins
- Ackee (official fruit of Jamaica) is toxic when not ripe, causes “Jamaican Vomiting Sickness” manifesting with severe hypoglycemia, vomiting, and seizures.
- Phenols and phenylpropanoids
- Capsaicin = pepper spray
- Alkaloids
- Water Hemlock = most common cause of plant-related (ingestion) fatalities in the US
- Cicutoxin, found in all parts of the plant
- Cholinergic manifestations = vomiting, flushing, salivation, bradycardia, hypotension, seizures, and rhabdomyolysis
Heat Stroke
- Definition = core temperature > 106° F with neurological dysfucntion
- Exertional heat stroke – can be rapid, caused by sports/ athletics in the heat. You may see sweating!
- Nonexertional heat stroke – most common in infants or children left in hot cars and elderly
- Treatment
- Cooling! Use evaporative cooling as cold water immersion can cause vasoconstriction making cooling more difficult.
- Treat shivering with benzodiazapines +/- paralytics
- Antipyretics (acetaminophen) not helpful
- Mortality from electrolyte imbalance, cardiac arrhythmias, and multi-organ dysfunction
- In pediatrics, must consider child abuse!
Kylie Birnbaum
Latest posts by Kylie Birnbaum (see all)
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- Venomous Land and Marine Animals, Poisonous Plants and Heat Stroke - April 20, 2017
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