Wednesday Wrap Up – 4/19/2017

Wrap up of our conference day focused on pediatrics and environmental emergencies.


Dr. Subramaniam on Venomous Land Animals


  • 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)
  • Call the Poison center and your local zoo or snake center (in NYC this is Jacobi Hospital)


  • 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
  • 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
  • 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!




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Kylie Birnbaum

Emergency Medicine Resident at Kings County Hospital / SUNY Downstate @KBirnbaumMD

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