Wednesday Wrap-Up: Things That Sting You and BRASH Syndrome

Here are some highlights from our weekly education conference from May 1, 2019.

Dr. Andy Wong gave his senior lecture on “Things That Sting You”:

Fire Ants sting you

• They are found in the Southeast US
• Local care for stings is all that’s needed – use ice for pain and hydrocortisone cream for itching
• Bites are sterile, so no need for antibiotics
• Bites will heal over 2 weeks
• The most dangerous thing about a fire ant sting is anaphylaxis from hypersensitivity to the venom

Bees and Wasps sting you

• Like fire ants, bee venom can cause anaphylactic reactions; 3% of stings lead to anaphylaxis
• Scrape the bee stinger out with a credit card
• Again use local wound care – ice and hydrocortisone cream
• Topical toothpaste on the sting can help with pain
• If being attacked by bees – DON’T swat at them, DO run away, DON’T jump in water – they’ll just wait for you at the top and bite your face when you come up to breathe

Ticks kind of sting you

• Ticks have to be attached for over 36 hours to transmit Lyme Disease – if you remove a tick and it’s flat – i.e. not engorged with blood – it probably hasn’t been on that long so no need for prophylactic antibiotics
• Grab the tick by the head with tweezers to remove it – DON’T use fire or Vaseline or other weird home remedies for removal

Scorpions sting you

• They are found in the Southwest US
• Scorpion venom opens sodium channels which can lead to nerve dysfunction and muscle spasms
• Use anti-venom if patients are having neurological symptoms
• Remember the scorpion stings can cause pancreatitis (board review questions)

Spiders bite you

• Brown Recluse:
  • They like to hide inside in dark areas so check your shoes; they won’t be found outdoors
  • They cause necrotic local wounds
  • Local wound care is all that’s needed – elevate the limb, apply ice; no other treatments have been shown to work
• Black Widow:
  • Typically found outdoors
  • Can cause severe muscle rigidity and abdominal pain
  • Treat symptomatically with benzodiazepines and call Poison Control to see if you should use anti-venom

Snakes bite you

• Pit vipers – rattlesnakes, copperheads, cottonmouths
  • Responsible for 90% of snake bites in the US
  • Cause severe local wounds that can lead to compartment syndrome
  • DON’T suck out the venom – you’ll just infect the wound with your gross mouth
  • DON’T place a tourniquet or compression wrap – especially for pit vipers cause that just keeps the venom local to cause more damage
• Coral snakes
  • “Red touch yellow, kill a fellow”
  • Coral snakes are shy and don’t like to bite, so leave them alone
  • Found mostly in the Southeast US
  • Cause neurological dysfunction that can be so severe it leads to respiratory failure
  • DON’T suck out the venom – you’ll just infect the wound with your gross mouth
  • DO apply a compressive limb wrap if it’s a neurotoxin snake i.e. Coral Snake
• In the ED – evaluate for anaphylaxis, call Poison Control, maybe give anti-venom (only available for pit vipers, not coral snakes)

Sea Urchins stick you with spiny things

• They inject a dye from their stingers, so it’s hard to tell if there is still a stinger in there; use X-ray or ultrasound to evaluate for retained stingers, because retained stingers cause long term pain
• For all fish/aquatic envenomations: DO hot water immersion for pain for 30 minutes minimum (denatures venom proteins) and give prophylactic antibiotics to cover for vibrio if the wound is deep or dirty

Jellyfish sting you

• The most venomous jellyfish are in Australia and can kill you by causing potassium leak in cells leading to hyperkalemia and dysrhythmia f
• DON’T pee on it
• DON’T use freshwater to rinse the sting, this will activate the stingers
• DO scrape the stingers off with a card
• DO use vinegar on the stings to neutralize the stinging cells
• DO use hot water immersion and topical steroids

Dr. Eric Roseman gave our EM-Critical Care Medicine lecture on “BRASH Syndrome”:

• The differential diagnosis for bradycardia is huge: MI, AV block, myocarditis, lupus, electrolyte imbalance, thyroid disorder, adrenal disorder, hypothermia, spinal shock, overdose (BB or CCB) – to name just a few
• Dr. Roseman argues that we should keep the ACLS algorithm in mind, but we are resuscitationists and we should be better than this algorithm
• Instead of using “symptomatic vs asymptomatic” a better way to separate out bradycardia is “stable vs unstable/peri-arrest”
  • Stable, symptomatic patients are compensating; you have some time to think about a differential and your treatment options
  • Unstable patients may be peri-arrest – you should be treating immediately and broadly
• So what is the broad immediate treatment for peri-arrest bradycardia? Is giving atropine really the best first step?
  • Atropine is an anticholinergic that acts on the SA and AV node, inhibiting parasympathetic tone; therefore, it should only really work in cholinergic toxidrome or a hyper-vagal state.
  • Studies have shown atropine is actually not very helpful in bradycardia, working 30 to 60% of the time
  • Epinephrine, on the other hand, works in several ways to combat bradycardia and instability – it increases inotropy and chronotropy and causes vasoconstriction
  • The PALS algorithm says use epinephrine first – maybe we should reach for epinephrine first for adults
• Which bradycardic patients actually benefit from a transvenous pacemaker?
  • Patients with complete heart block who will need a permanent pacemaker.
  • Dr. Roseman argues that for the ED, it should be the last effort in a patient where meds have not worked – you should first be looking for the underlying cause of the bradycardia and trying to treat this medically
  • If the patient is hyperkalemic, there may not be ventricular capture
• Why isn’t calcium one of the first medications recommended in the ACLS bradycardia pathway?
  • Maybe because of digoxin and fear for “stone heart”? But we now know this isn’t a real entity
  • You should probably give calcium off the bat with your epinephrine
• Our case turned out to be BRASH syndrome (Bradycardia, Renal Failure, AV blocker, Shock, Hyperkalemia)
• It is a proposed syndrome that has not been proven and is based on case reports
• It is thought to be due to a synergistic effect of calcium channel blockers or beta-blockers AND AKI with resulting hyperkalemia all leading to a bradycardia that is more severe than what would be expected from the sum of its individual causes
• How do you treat BRASH Syndrome? Treat the hyperkalemia with calcium, albuterol, insulin, furosemide, etc; treat the AKI with IV fluids; treat the bradycardia and hypotension with epinephrine, dopamine, or isoproterenol

Here is a link to more information on BRASH Syndrome from the person who created the acronym.

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Charles Murchison

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