Venom/Burns

Don't let it bite Ya!

100

True or False? Of all snake- bites, 97% occur on the extremities, with two thirds on the upper extremities and one third on the lower extremities.

True. This reversal of historical distribution may reflect bites being provoked rather than accidental

200

In the U.S. only, a deadly coral snake can be differentiated from a king snake by remembering this easy rhyme

Red on yellow, kill a fellow. Red on black, venom lack

300

True or False. An intravenous bite from any venomous snake is likely to be fatal

True. Petechiae, ecchymosis, and serous or hemorrhagic bullae are other local signs. Necrosis of skin and subcutaneous tissue is noted later and may result from inadequate doses of antivenin. Many systemic symptoms, such as weakness, nausea, fever, vomiting, sweating, numbness and tingling around the mouth, metallic taste in the mouth, muscle fasciculations, and hypotension, often occur after pit viper envenomation. Compartment syndrome can occur as edema spreads proximally involving an extremity

400

Identify 3 characteristics that can help you identify a venomous snake

Triangle-shaped head, elliptical pupil, pits, fangs, single row of subcaudal plates on the tail

500

A patient was bit by a venomous snake shows up to your ER. He's hypotensive and nauseous. What do you do?

Calm patient, cardiac monitor, ivf, ekg, labs, type and crossmatch for 4 units of packed red blood cells, monitor for coagulopathy, analgesia, demarcate area, antivenin, supportive care, irrigate area and clean, remove fangs if any, immobilize bitten area w/sling or splint and can wrap in elastic bandage, tetanus shot, NPO, compartment checks, consider abx to cover gram neg's. The use of ice is not helpful in slowing the spread of venom, but an ice bag wrapped in a towel and applied to the bite area helps relieve pain. Ice water immersion and packing of the extremity in ice are dangerous and only contribute to tissue destruction. The use of suction devices has not been shown to be beneficial. The more distal the bite on the extremity, the less toxicity associated with the bite.

Snakes on a plane

100

True or False. The smaller the body of the patient, the lower the relative initial dose that may be required.

False. A bitten child usually receives more venom in proportion to body weight and thus requires more antivenin to neutralize it. Of note, pregnancy is not a contraindication to antivenin therapy.

200

Nurse asks you if she should give the antivenin around the site of the bite, what do you say

Say nay! And even with a history or signs of allergic reaction to antivenin, patients with severe envenomation are treated with a dilute form of antivenin and epinephrine to maximize antivenin administration but minimize allergic symptoms.

300

What is serum sickness and when can it occur? What type of hypersensitivity is that? How do you treat it?

basically an allergic reaction. In most patients who receive more than 10 vials of horse serum–derived antivenin and in approximately 15% of those who receive FabAV, serum sickness develops up to a week later. Type III- immune complex mediated. Tx: Benadryl. if severe: steroids

400

When do you start antivenin for victims of bites by the eastern coral snake or any exotic snake?

before symptoms develop! The toxicity of this venom has a rapid onset, and once [neuro] symptoms develop, it may be too late to reverse the effects with antivenin. The recommended dose is three to five vials in 300 to 500 mL of normal saline. Antivenin is given based on the clinical response. If no antivenin is available, management is based on meticulous supportive care emphasizing the respira- tory and neurologic status.

500

Envenomation by the yellow-bellied sea snake causes severe muscle necrosis with the release of large amounts of myoglobin and also causes neurologic symptoms. What is the best way to manage this?

Although a polyvalent antivenin is available from Australia, maintenance of adequate urine output, alkalinization of urine, and general supportive care are usually sufficient.

Crawlers & Swimmers!

100

Fish puncture wound. what do you do?

remove the spine or sting if possible. xray because many spines and sheaths are radiopaque; sea urchin spines usually break off in the wound; they are so fragile that removing them is difficult without the proper instruments. Use forceps, may need surgery to remove embedded stingers. prophylactic abx. Irrigate wound. HOT WATER IMMERSION!

200

True or False? Nematocyst (jellyfish) stings should be immediately neutralized with vinegar or hot water, and fish stings with hot water

True. Fresh water is not used, because it may stimulate continued nematocyst discharge. Other methods include scraping off residual material with the use of a shaving cream or baking soda slurry. The affected area is then débrided and cleansed.

300

Treatment of black widow spider bite involves.... ?

Control muscle cramps with benzos. One study supports benefit of dantrolene both PO and IV. analgesia. In general, pediatric patients, pregnant women, and the elderly may need to be given Latrodectus anti-venin (Lyovac), which is derived from horse serum; Candidates for antivenin include patients with severe envenomation manifesting as seizures, respiratory failure, or uncontrolled hypertension; pregnant women; and patients not responding to other therapy. dose of the antivenin is one vial diluted in 50 mL of normal saline and administered IV over a period of 15 minutes.

400

Name symptoms of black widow spider bite

Associated symptoms include dizziness, restlessness, ptosis, nausea, vomiting, headache, pruritus, dyspnea, conjunctivitis, facial swelling, sweating, weakness, difficulty speaking, anxiety, and cramping pain in all muscle groups. The patient is usually hypertensive, and cerebrospinal fluid pressure is sometimes elevated. There may be EKG changes similar to those produced by digitalis (downsloping st depression, twav changes, svt, afib, pvc's, heart blocks). dull crampy pain develops in the area of the bite and gradually spreads to include the entire body. Usually, the pain is concentrated in the chest after upper extremity bites or in the abdomen after lower extremity bites. The abdomen may become boardlike, and the patient may complain of severe crampy pain. The abdominal manifestation may mimic pancreatitis, a peptic ulcer, or acute appendicitis, except that abdominal tenderness is usually minimal. Pregnant women may go into premature labor and precipitous delivery. In one case, patient became spiderman

500

This drug has been shown to be helpful in preventing local effects of the venom of a brown recluse.

Dapsone, 50-200 mg/day. If used within 48 hours, it may limit the size of the lesion that develops. However, dapsone may cause methemoglobinemia and hemolysis in patients with glucose-6-phosphate dehydrogenase deficiency. Analgesics and antibiotics should be used as indicated during the course of the disease, although infection is not common. Dialysis may be necessary if acute renal failure develops, and surgical consultation should be obtained for evaluation of the wound.

Burn baby burn

100

This is a burn that's limited to the epidermis and characterized by erythema and pain

First degree burn. They generally heal within several days to a week.

200

the degree of burns that extend through the epidermis and into the dermis.

Second degree, or partial thickness. They may be divided into superficial and deep partial-thickness injuries. Superficial second-degree burns are limited to the superficial (papillary) dermis. The skin is erythematous and forms pink/clear blisters, and the surface can be moist. The wound blanches on pressure and is painful. These take 2-3 weeks to heal. Deep second-degree burns extend through the epidermis into the deep (reticular) dermis. They appear white with some erythematous areas with less blanching and moisture than the superficial second-degree burns . Often form pink/hemorrhagic blisters and take weeks-months to heal or may progress to third-degree burn and require graft.

300

What is the TBSA burn percentage of a burn involving a palm and some fingers?

1-1.5%

400

For larger burns, the “rule of nines” is useful. This rule states that the allocation of percentage of TBSA in an adult patient can be estimated as follows:

18% for the front and 18% for the back of the trunk, 18% for each lower extremity, 9% for the head and 9% for each upper extremity, and 1% for the perineal area.

500

How do you manage a burn? What is the preferred IV Fluid of choice?

ABC's! If the patient has a compromised airway, orotracheal intubation should be performed. If there is a suspected inhalation injury or CO or cyanide intoxication, the patient should be placed on 100% oxygen delivered by a non-rebreather mask. Analgesia. Tetanus shot. If the patient is alert and oriented and the areas of unburned skin are warm and dry, the patient is adequately perfusing his or her vital organs. Lactated Ringer’s (LR) solution is the preferred fluid because it may reduce the risk of hyperchloremic acidosis associated with use of normal saline. Cover burns with clean dressing. Cooling with tap water or a commercially available cooling blanket helps reduce pain. Care should be taken to minimize hypothermia, especially when ambient temperature is low.

Feeling hot hot hot

100

Patient presents with difficulty breathing after exposure to superheated steam and toxic fumes. First step....? and why?

Since rapid and progressive upper airway edema may develop within minutes, if there is doubt regarding upper airway compromise, fiberoptic laryngoscopy should be performed. Endotracheal intubation guided by fiberoptic laryngoscopy may be more useful. All patients with moderate to severe burns and those with suspected inhalation injury should receive supplemental humidified oxygen to maintain an oxygen saturation greater than 92%. Traditionally, inhalation injury was diagnosed based on clinical findings such as facial burns, singed nasal hairs, carbonaceous sputum, and a history of injury within a closed space. However, these findings are neither highly sensitive nor highly specific. Similarly, wheezing, crepitations, hypoxemia, and abnormalities on the initial chest radiograph may or may not be present in the ED, except in the most severely injured. BEST WAY IS DIRECT VISUALIZATION OF AIRWAY: Findings of inhalation injury include the presence of soot, charring, and mucosal inflammation, edema, or necrosis.

200

Initial Vent settings in a burn patient should be: .....

TV 6-8 ml/kg predicted body weight, RR 8-12 adults, plateau pressures <35, peep 5-8. goal is to keep O2 > 92%. Larger tidal volumes may be required if oxygenation is not adequate. For hyperoxic lung injury to be minimized, oxygen concentrations should be titrated to the lowest concentrations that maintain adequate oxygenation.

300

Name some indications for Endotracheal intubations & Mechanical ventilation in Burn patients

Upper airway obstruction, inability to handle secretions, hypoxemia despite 100% O2, patient obtundation, muscle fatigue suggested by a high or low respiratory rate, Hypoventilation (Pco2 > 50 mm Hg and a pH < 7.2), patient too talkative

400

Discuss treatment options for wheezing burn patients

Bronchodilators help the wheezing and may also improve mucociliary function. Frequent airway suctioning and chest physiotherapy are also helpful at removing secretions. Aerosolized N-acetylcysteine with or without aerosolized heparin also helps break down thick mucous secretions. An example of a treatment protocol for patients with inhalation injury may include 5000 to 10,000 units of heparin and 3 mL of normal saline nebulized every 4 hours, alternating with 3 to 5 mL of aerosolized 20% N-acetylcysteine.

500

Parkland formula, go!

volume of 4 mL/kg/%TBSA of LR to be given over the first 24 hours, with half of the volume given over the first 8 hours. Burn patients should be resuscitated with only as much fluid as is necessary to maintain organ perfusion. Organ perfusion can be estimated by heart rate, blood pressure, level of consciousness, capillary refill, and a urine output of 0.5 to 1.0 mL/kg/hr in adults or 1.0 to 1.5 mL/kg/hr in children. Certain patient groups may require additional fluid, including patients with inhalation injury, those with electrical burns, and those in whom resuscitation is delayed. careful monitoring of the volume of urine output and clinical signs of tissue turgor and adequate resuscitation are key to avoid under or over-resuscitation.