Identification and Management of animal bites and stings in emergency department

1. BITES ANDSTINGS
LIJO JOY
JUBILEE MISSION MEDICAL COLLEGE,TCR
09/06/14

2. SNAKE BITE

3. DISCUSSION TOPICS
 INTRODUCTION
 EPIDEMIOLOGY
 CAUSE
 PATHOPHYSIOLOGY + SIGNS & SYMPTOMS
 MANAGEMENT
 PREVENTION
 MYTHS IN KERALA
PRE HOSPITAL MANAGEMENT (FIRST AID)
HOSPITAL MANAGEMENT

4. INTRODUCTION
 A snakebite is an injury caused by a bite from a
snake, often resulting in puncture wounds inflicted
by the animal's fangs and sometimes resulting in
envenomation/ophitoxaemia.
 On the Indian subcontinent, almost all snakebite
deaths have traditionally been attributed to the Big
Four, consisting of the
• Russell's viper
• Indian cobra
• saw-scaled viper
• common krait.

5. Saw Scaled Viper
Common Krait
Spectacled Cobra
Russell’s Viper

6. EPIDEMIOLOGY
 Estimate vary from 1.2 to 5.5 million snakebites,
421,000 to 2.5 million envenomings, and 20,000 to
125,000 deaths globally.
 Since reporting is not mandatory in much of the
world, the data on the frequency of snakebites is
not precise.
 South Asia is by far the most affected region.
 India has the highest number of deaths due to
snake bites in the world with 35,000–50,000 people
dying per year according to World Health
Organization (WHO) direst estimates.

7.  In Kerala, India, only 219 out of 635 patients (34%)
with proven snake bite developed signs of systemic
envenoming.

8. CAUSES
 Snake bite is an important occupational injury
affecting farmers, plantation workers, herders, and
fishermen. They often happen when a person steps
on the snake or approaches it too closely.
 Open-style habitation and the practice of sleeping
on the floor also expose people to bites from
nocturnal snakes.
 The incidence of snake bites is higher during the
rainy season and during periods of intense
agricultural activity . Snake bite incidence and
mortality also increase sharply during extreme
weather events such as floods.

9. PATHOPHYSIOLOGY
 A widespread belief is that snake bites inevitably
result in envenoming. However, bites by
nonvenomous snakes are common and bites by
venomous species are not always accompanied by
the injection of venom (dry bites).
 Since envenomation is completely voluntary, all
venomous snakes are capable of biting without
injecting venom into a person. Snakes may deliver
such a "dry bite" rather than waste their venom on a
creature too large for them to eat, a behaviour
called venom metering.

10.  Some dry bites may also be the result of imprecise
timing on the snake's part, as venom may be
prematurely released before the fangs have
penetrated the person.
 Even without venom, some snakes, particularly
large constrictors can deliver damaging bites; large
specimens often cause severe lacerations, or the
snake itself pulls away, causing the flesh to be torn
by the needle-sharp recurved teeth embedded in
the person.
 While not as life-threatening as a bite from a
venomous species, the bite can be at least
temporarily debilitating and could lead to dangerous
infections if improperly dealt with.

11.  When envenoming does occur, it can be rapidly life-
threatening. Snake venom is a complex mixture of
toxins and enzymes, each of which may be
responsible for one or more distinct toxic actions.
 Classification of venemous snakes can be done on
the basis of constituent of venom & assosiated
clinical signs:
NEUROTOXIC
HAEMOTOXIC
MYOTOXIC
CARDIOTOXIC etc…………..

12. SNAKE VENOMS
 Venom is the toxic saliva that is produced by the
PAROTID GLAND of the poisonous snakes.
 POISON GLANDS – are salivary glands of the
snake and are situated behind the eyes, one on
each side of head above the upper jaw.

13.  Quantity of venom injected at a bite
This is very variable, depending on the species and
size of the snake, the mechanical efficiency of the
bite, whether one or two fangs penetrated the skin
and whether there were repeated strikes.
Although large snakes tend to inject more venom
than smaller specimens of thesame species, the
venom of smaller, younger vipers may be richer in
some dangerous components, such as those
affecting haemostasis.

14.  ThereforeBites by small snakes should not be
ignored or dismissed. They should be taken just as
seriously as bites by large snakes of the same
species
 Composition of venom
Snake venoms contain more than 20
different constituents, mainly proteins, including
enzymes and polypeptide toxins.

15. COMPOSITION OF SNAKE VENOM

16. SIGNS AND SYMPTOMS
 The most common symptoms of all snakebites are
overwhelming fear, which may cause symptoms
such as nausea and vomiting, diarrhea, vertigo,
fainting, tachycardia, and cold, clammy skin.
 Dry snakebites, and those inflicted by a non-
venomous species, can still cause severe injury.
There are several reasons for this: a snakebite may
become infected with the snake's saliva and fangs
sometimes harboring pathogenic microbial
organisms, including Clostridium tetani. Infection is
often reported with viper bites whose fangs are
capable of deep puncture wounds. Bites may cause
anaphylaxis in certain people.

17.  Local symptoms and signs in the bitten part
 fang marks
 local pain
 local bleeding
 bruising
 lymphangitis
 lymph node enlargement
 Inflammation (swelling, redness, heat)
 blistering
 local infection, abscess formation
 necrosis

18. Local bleeding from fang marks
Local swelling and bruising
along with blistering
Tissue necrosis

20. MANAGEMENT
 First aid treatment
 Transport to hospital
 Rapid clinical assessment and resuscitation
 Detailed clinical assessment and species diagnosis
 Investigations/laboratory tests
 Antivenom treatment
 Observation of the response to antivenom: decision
about the need for further dose(s) of antivenom
 Supportive/ancillary treatment

21.  Treatment of the bitten part
 Rehabilitation
 Treatment of chronic complications

22. FIRST AID TREATMENT
 Protect the person and others from further bites.
While identifying the species is desirable in certain
regions, risking further bites or delaying proper
medical treatment by attempting to capture or kill
the snake is not recommended.
 Keep the person calm. Acute stress reaction
increases blood flow and endangers the person.
 Call for help to arrange for transport to the nearest
hospital emergency room, where antivenom for
snakes common to the area will often be available.

23.  Make sure to keep the bitten limb in a functional
position and below the person's heart level so as to
minimize blood returning to the heart and other
organs of the body.
 Do not give the person anything to eat or drink. This
is especially important with consumable alcohol, a
known vasodilator which will speed up the
absorption of venom. Do not administer stimulants
or pain medications, unless specifically directed to
do so by a physician.

24.  Remove any items or clothing which may constrict
the bitten limb if it swells (rings, bracelets, watches,
footwear, etc.)
 The bitten limb should be immobilized with a
makeshift splint or sling, and kept below the level
of heart.
 Keep the person as still as possible. Walking is
contraindicated, because muscular contractions
promote venom absorption.

25.  Tight (arterial) tourniquets are not
recommended!
Traditional tight (arterial) tourniquets. To be
effective, these had to be applied around the upper
part of the limb, so tightly that the peripheral pulse
was occluded. This method was extremely painful
and very dangerous if the tourniquet was left on for
too long (more than about 40 minutes), as the limb
might be damaged by ischaemia.

26.  Constriction bands can be applied if there is no
nearby medical facility. Constriction bands can be
used but loose enough that a finger can slide
beneath.
 Ideally, compression bandages should not be
released until the patient is under medical care in
hospital, resuscitation facilities are available and
antivenom treatment has been started.
 Suction and incision are dangerous and should not
be done.

27. RAPID CLINICAL ASSESMENT
 Check for
- Airway
- Breathing
- Circulation
- Disability
 Cardiopulmonary resuscitation may be needed,
including administration of oxygen and
establishment of intravenous access.

28. DETAILED CLINICAL ASSESSMENT &
SPECIES DIAGNOSIS
 History
- In what part of your body have you been
bitten?
Evidence of snake bite, Assess nature & extent of local signs
-When were you bitten?
Assess the severity
-Where is the snake that bit you?
Identification of snake

29. •Non Poisonous Snakes
Head - Rounded
Fangs - Not present
Pupils - Rounded
Anal Plate - Double row of plates
Bite Mark - Row of small teeth.
•Poisonous Snakes
Head - Triangle - except Cobra
Fangs - Present
Pupils - Elliptical pupil
Anal Plate - Single row of plates
Bite Mark - Fang Mark
Identification of snake

30.  Physical examination
1.Examination of the bitten part
- Extent of swelling, extent of tenderness to
palpation noted, Lymph nodes draining the limb
should be palpated.If possible, intracompartmental
pressure should be measured and the blood flow
and patency of arteries and veins assessed.
- Early signs of necrosis may include blistering,
demarcated darkening or paleness of the skin, loss
of sensation and a smell of putrefaction (rotting
flesh).

31. 2.General examination
- Measure the blood pressure and heart rate.
- Examine the skin and mucous membranes for
evidence of petechiae, purpura, ecchymoses and,
in the conjunctivae, chemosis.
- Examine the gingival sulci -may show the earliest
evidence of spontaneous systemic bleeding.
- Examine the nose for epistaxis.
- Abdominal tenderness may suggest
gastrointestinal or retroperitoneal bleeding.

32. - Loin (low back) pain and tenderness suggests
acute renal ischaemia (Russell’sviper bites).
- Intracranial haemorrhage is suggested by
lateralising neurological signs,asymmetrical pupils,
convulsions or impaired consciousness (in the
absence ofrespiratory or circulatory failure).
- To exclude early neurotoxic envenoming, ask the
patient to look up and observe whether the upper
lids retract fully.
- Test eye movements for evidence of early external
ophthalmoplegia. Check the size and reaction of
the pupils.

33.  Check the muscles innervated by the cranial
nerves(facial muscles, tongue, gag reflex etc). The
muscles flexing the neck may be paralysed,giving
the “broken neck sign”.
Broken Neck Sign in Russel”s Viper Bite

34. INVESTIGATIONS/ LABORATORY DIAGNOSIS
 20 minute whole blood clotting test (20WBCT)
-Very useful and informative bedside test requires
very little skill and only one piece of apparatus - a
new, clean, dry, glass vessel (tube or bottle).
-Place a few mls of freshly sampled venous blood in
a small glass vessel & Leave undisturbed for 20
minutes at ambient temperature
-Tip the vessel once.If the blood is still liquid
(unclotted) and runs out, the patient has
hypofibrinogenaemia(“incoagulable blood”) as a
result of venom-induced consumption
coagulopathy.

35.  Haemoglobin concentration/haematocrit:
a transient increase indicates haemoconcentration
resulting from a generalised increase in capillary
permeability(eg in Russell’s viper bite). More often,
there is a decrease reflecting blood loss or, in the
case of Russell’s viper bite, intravascular
haemolysis.
 Platelet count: this may be decreased in victims of
viper bites.
 White blood cell count: an early neutrophil
leucocytosis is evidence of systemic envenoming
from any species.
 Bleeding Time should be done to rule out any
bleeding abnormalities.

36.  Plasma/serum may be pinkish or brownish if there
is gross haemoglobinaemia or myoglobinaemia.
 Arterial blood gases and pH may show evidence of
respiratory failure (neurotoxic envenoming) and
acidaemia (respiratory or metabolic acidosis).
 Desaturation: arterial oxygen desaturation can be
assessed non-invasively in patients with respiratory
failure or shock using a finger oximeter.
 Urine examination: the urine should be tested by
dipsticks for blood/haemoglobin/myoglobin.
Massive proteinuria is an early sign of the
generalised increase in capillary permeability in
Russell’s viper envenoming.

37. ANTIVENOM TREATMENT
 The first antivenom was developed in 1895 by
French physician Albert Calmette for the treatment
of Indian cobra bites.
 Antivenom is immunoglobulin (usually the enzyme
refined F(ab)2 fragment of IgG)purified from the
serum or plasma of a horse or sheep that has been
immunised with the venoms of one or more species
of snake.
 Antivenom is injected into the person intravenously,
and works by binding to and neutralizing venom
enzymes. It cannot undo damage already caused
by venom, so antivenom treatment should be
sought as soon as possible.

38.  They can be either monovalent or polyvalent,
depending on the number of species (single or
multiple, respectively) whose venoms are used for
immunization. Although monovalent antivenom has
often been considered more efficacious, the
production of polyvalent antivenom is preferred in
many countries as snake species identification is
generally not possible for the attending physician.
 Local administration & Intramuscular Injection of
antivenom is not recommended!
 Snakes inject the same dose of venom into children
and adults. Children must therefore be given
exactly the same dose of antivenom as adults.

39.  Epinephrine (adrenaline) should always be drawn
up in readiness before antivenom is administered to
counter the reactions such as:
-Early anaphylactic reactions: usually within 10-
180 minutes of starting antivenom , the patient
begins to itch (often over the scalp) and develops
urticaria, dry cough , fever, nausea, vomiting,
abdominal colic, diarrhea and tachycardia.
-Pyrogenic (endotoxin) reactions usually develop
1-2 hours after treatment .Symptoms include
shaking chills (rigors), fever, vasodilatation and a
fall in blood pressure. Febrile convulsions may be
precipitated in children.

40.  Late (serum sickness type) reactions develop 1-12
(mean 7) days after treatment . Clinical features
include fever, nausea, vomiting, diarrhea, itching,
recurrent urticaria , arthralgia, myalgia,
lymphadenopathy, periarticular swellings,
mononeuritis multiplex,proteinuria with immune
complex nephritis and rarely encephalopathy.
 Criteria for repeating the initial dose of antivenom:
-Persistence or recurrence of blood incoagulability
after 6 hr of bleeding after1-2 hr.
-Deteriorating neurotoxic or cardiovascular signs
after 1-2 hr.

41. SUPPORTIVE/ANCILLARY TREATMENT
 The management of envenomed snake bites is not
limited to the administration of antivenoms.
 In the case of neurotoxic envenoming, artificial
ventilation and careful airway management are
crucial to avoid asphyxiation in patients with
respiratory paralysis.
 Anticholinesterase drugs such as edrophonium can
partly overcome blockade by postsynaptic
neurotoxins and have shown good efficacy in cobra
bite envenoming.
 A booster dose of tetanus toxoid should be
administered but only in the absence of
coagulopathy.

42.  Bacterial infections can develop at the bite site,
especially if the wound has been incised or
tampered with nonsterile instruments, and may
require antibiotic treatment.
 Necrosis on the bitten limb may require surgery and
skin grafts, particularly in the case of cobra bites.
 Tensed swelling, pale and cold skin with severe
pain may suggest increased intracompartmental
pressure in the affected limb. A clear proof of
significant compartment syndrome by measurement
of substantially elevated intracompartmental
pressures is a prerequisite. However, fasciotomy is
rarely justified. In particular, it can be disastrous
when performed before coagulation has been
restored.

43. PREVENTION
 Many bites could be avoided by educating the
population at risk. Sleeping on a cot (rather than on
the floor) and under bed nets decreases the risk of
nocturnal bites.
 Rubbish, termite mounds, and firewood, which
attract snakes, can be removed from the vicinity of
human dwellings.
 Attempts can be made to prevent the proliferation
of rodents in the domestic and peridomestic area.
 Thatched roofs, and mud and straw walls are
favoured hiding places for snakes and should be
checked frequently.

44.  Using a torch/flashlight while walking on footpaths
at night, and wearing boots and long trousers
during agricultural activities, could significantly
reduce the incidence of bites.
 Snakes are most likely to bite when they feel
threatened, are startled, are provoked, or have no
means of escape when cornered. Leave the area of
a snake is recommended.
 When dealing with direct encounters it is best to
remain silent and motionless. If the snake has not
yet fled it is important to step away slowly and
cautiously.

45.  It is also important to avoid snakes that appear to
be dead, as some species will actually roll over on
their backs and stick out their tongue to fool
potential threats. A snake's detached head can
immediately act by reflex and potentially bite. The
induced bite can be just as severe as that of a live
snake. Dead snakes are incapable of regulating the
venom they inject, so a bite from a dead snake can
often contain large amounts of venom.

46. MYTHS IN SNAKE BITE TREATMENT IN
KERALA
 Visha Vaidya
-one branch of traditional healing, popular in Kerala,
mostly in Palakad and Trichur.
-deals with management of poisonous bites,
poisonous substances and their action, Antidotes
and Understanding of poisonous creatures.
-Treatment include herbals, administered as nasal
drops, eye drops and oral medicine, strict food
regulations, Abstaining from alcohol and non
vegetarian foods , rituals and offerings to God.

47.  Kani tribe of the Western Ghats of Kerala apply
‘Vishakallu’, a medicated stone with anti - poisoning
properties to the affected area (snake bite) which is
administered only by experienced tribal healers.
 It is directly applied to the bitten part. It sticks there
and absorbs the venom from the wound. During this
operation, Lord Siva is propitiated by chanting
mantras.
 When all the venom is absorbed the stone falls
away automatically. The stone is immersed in cow’s
milk for detoxification for 2 hours.It is again dried
and stored in cow dung ash. It is believed from
experience that it can be used 20 times.

48. DOG BITE

49.  In 2010, an estimated 26,000 people died from
rabies, down from 54,000 in 1990.The majority of
the deaths occurred in Asia and Africa.
 India has the highest rate of human rabies in the
world, primarily
-because of stray dogs,whose number has greatly
increased since a 2001 law forbade the killing of
dogs.
-a form of mass hysteria or group delusion known
as puppy pregnancy syndrome (PPS). Dog bite
victims with PPS (both male and female) become
convinced that puppies are growing inside them,
and often seek help from faith healers rather than
from conventional medical services. In cases where
the bite was from a rabid dog, this decision can
prove fatal.

50.  Dog bites account for more than 90% of all animal
bites.
 Infections, including tetanus and rabies, need to be
considered.
 Wound cleaning decreases the risk of infection.
 Skin repair increases the risk of infection, and the
decision to suture the skin balances the risk of
infection versus the benefit of a better appearing
scar.

51.  The risk of being bitten by a dog increases if there
is a dog in the home; the more dogs there are, the
greater the risk. Men are more frequent victims than
women.
 Dogs have rounded teeth, and it is the pressure
exerted by their jaws that can cause significant
damage to the tissues under the skin, including
bones, muscles, tendons, blood vessels, and
nerves.

52.  The dog bite victim needs to be taken to a safe
place away from the assailant dog to prevent
further attack and injury. Since dog bites can cause
significant damage beneath the skin, a type of
injury that cannot always easily be appreciated,
medical care should be accessed by a health care
practitioner.
 Wounds should be kept elevated and, if possible,
washing the wound with tap water may be
attempted.
 Information should be obtained from the dog's
owner about the dog's rabies immunization status,
but if this is not possible, hospital, animal control
centers, or law enforcement personnel will help
gather any required information.

53.  Medical care should be accessed if the dog bite
disrupts the skin causing a puncture, laceration, or
tear. As well, if there is pain at or near the injury
site, underlying structures may have been damaged
and medical care may be needed.
 If the skin is not disturbed, or if there is a minimal
abrasion present, it may be reasonable to watch for
signs of infection (pain, redness, warmth, swelling,
and drainage of pus or fluid) before seeking
medical care.

54. RABIES
 Rabies ( from Latin: rabies, "madness") is a viral
disease that causes acute inflammation of the brain
in humans and other warm-blooded animals.
 Exposure to a rabid animal does not always result
in rabies. If treatment is initiated promptly following
a rabies exposure, rabies can be prevented. If a
rabies exposure is not treated and a person
develops clinical signs of rabies, the diseased
almost always results in death.

55.  Early symptoms may include fever and tingling at
the site of exposure. This is then followed by either
violent movements, uncontrolled excitement, and
fear of water or an inability to move parts of the
body and confusion followed by loss of
consciousness.
 In both cases once symptoms appear it nearly
always results in death.
 The period between infection and the first flu-like
symptoms is typically 2 to 12 weeks. Incubation
periods as short as four days and longer than six
years have been documented, depending on the
location and severity of the inoculating wound and
the amount of virus introduced . The time is
dependent on the distance the virus must travel to
reach the central nervous system.

56.  The disease is spread to humans from another
animal, commonly by a bite or scratch. Infected
saliva that comes into contact with any mucous
membrane is also a risk.
 Globally most cases are a result of dog bite.

57. DIAGNOSIS
 Rabies can be difficult to diagnose because, in the
early stages, it is easily confused with other
diseases or aggressiveness.
 The reference method for diagnosing rabies is the
Fluorescent Antibody Test (FAT) which is
recommended by World Health Organization
(WHO).
 The FAT relies on the ability of a detector molecule
(usually fluorescein isothiocyanate) coupled with a
rabies specific antibody forming a conjugate to bind
to and allow the visualization of rabies antigen
using fluorescent microscopy techniques.

58.  The diagnosis can also be made from saliva, urine,
and cerebrospinal fluid samples, but this is not as
sensitive and reliable as brain samples.[
 Cerebral inclusion bodies called Negri bodies are
100% diagnostic for rabies infection but are found
in only about 80% of cases.
 If possible, the animal from which the bite was
received should also be examined for rabies.

59. DIFFERENTIAL DIAGNOSIS
 Encephalitis, in particular infection with viruses
such as herpesviruses, enteroviruses, and
arboviruses( West Nile virus).
 The most important viruses to rule out are herpes
simplex virus type one, varicella zoster virus, and
(less commonly) enteroviruses, including
coxsackieviruses, echoviruses, polioviruses, and
human enteroviruses 68-71.

60. PREVENTION
 Do not approach a stray or unfamiliar dog,
especially if its owner is not present.
 If a confrontation occurs, do not make eye contact
and do not run or scream.
 Do not approach an unfamiliar dog while it is eating,
sleeping, or caring for puppies.
 Do not leave young children or infants
unsupervised with a dog.
 Contacting an animal control officer upon observing
a wild animal or a stray, especially if the animal is
acting strangely

61.  If bitten by an animal, washing the wound with soap
and water for 10 to 15 minutes and contacting a
healthcare provider to determine if post-exposure
prophylaxis is required
 Vaccinating dogs, cats, rabbits, and ferrets against
rabies
 Keeping pets under supervision

62. TREATMENT
 Almost all human cases of rabies were fatal until a
vaccine was developed in 1885 by Louis Pasteur
and Émile Roux. Their original vaccine was
harvested from infected rabbits, from which the
virus in the nerve tissue was weakened by allowing
it to dry for five to 10 days.
 Treatment after exposure can prevent the disease if
administered promptly, generally within 10 days of
infection.

63.  Thoroughly washing the wound as soon as possible
with soap and water for approximately five minutes
is very effective in reducing the number of viral
particles.
 Patients should receive one dose of human rabies
immunoglobulin (HRIG) and four doses of rabies
vaccine over a 14-day period.The immunoglobulin
dose should not exceed 20 units per kilogram body
weight.
 The rabies vaccine is available as:
- Human diploid cell vaccine (HDCV)
- Purified chick embryo cell vaccine (PCECV)
 The first dose may be given at any time.The second
dose should be given seven days later.The third
dose should be given 21 or 28 days after the
first dose.Booster doses of vaccine are
recommended every two years.

64.  Patients who have previously received pre-
exposure vaccination do not receive the
immunoglobulin, only the postexposure
vaccinations on days 0 and 2.
 As much as possible of this dose should be
infiltrated around the bites, with the remainder
being given by deep intramuscular injection at a site
distant from the vaccination site.
 Intramuscular vaccination should be given into the
deltoid, not gluteal area, which has been associated
with vaccination failure due to injection into fat
rather than muscle.In infants, the lateral thigh is
used as for routine childhood vaccinations.

65. BEE & WASP STING

66. WASP BEE

67.  Bee Sting in most of the situations is potentially
serious. The spectrum of bee sting disease ranges
from mild local reaction to death.
 A bee sting is strictly a sting from a bee (honey
bee, bumblebee, sweat bee, etc.). In the vernacular
it can mean a sting of a bee, wasp, hornet, or
yellow jacket.
 Bee stings differ from insect bites, and the venom
or toxin of stinging insects is quite different.
Therefore, the body's reaction to a bee sting may
differ significantly from one species to another.
 In people with insect sting allergy, a bee sting may
trigger a dangerous anaphylactic reaction that is
potentially deadly. Honey bee stings release
pheromones that prompt other nearby bees to
attack.

68.  The larger drone bees, the males, do not have
stingers. The female worker bees are the only ones
that can sting, and their stinger is a modified
ovipositor. The queen bee has a smooth stinger
and can, if need be, sting skin-bearing creatures
multiple times, but the queen does not leave the
hive under normal conditions.
 Although it is widely believed that a worker honey
bee can sting only once, this is a partial
misconception: When a honey bee stings a person,
it cannot pull the barbed stinger back out. It leaves
behind not only the stinger, but also part of its
abdomen and digestive tract, plus muscles and
nerves. This massive abdominal rupture kills the
honey bee. Honey bees are the only species of
bees to die after stinging

69.  The sting's injection of apitoxin into the victim is
accompanied by the release of alarm pheromones,
a process which is accelerated if the bee is fatally
injured.
 The main component of bee venom responsible for
pain in vertebrates is the toxin melittin.
 Histamine and other biogenic amines may also
contribute to pain and itching.
 In one of the medical uses of honey bee products,
apitherapy, bee venom has been used to treat
arthritis and other painful conditions.

70. TREATMENT
 If the person does not have severe allergy
symptoms:
1. Remove the Stinger
-Scrape the area with a fingernail or use tweezers
to remove it.
-Don't pinch the stinger -- that can inject more
venom.
2. Control Swelling
-Ice the area.
-If stung on arm or leg, elevate it.
-Remove any tight-fitting jewelry from the area of
the sting. As it swells, rings or bracelets might be
difficult to remove.

71. 3. Treat Symptoms
-For pain, take an over-the-counter painkiller like
acetaminophen or ibuprofen. Do not give aspirin to
anyone under age 18.
-For itchiness, take an antihistamine. You can also
apply a mixture of baking soda and water or
calamine lotion.
4. Follow-Up
-It might take 2-5 days for the area to heal. Keep it
clean to prevent infection.

72.  If the person does have severe allergy symptoms
(anaphylaxis):
1. Seek emergency care
if the person has any of these symptoms or a history of
severe allergic reactions (anaphylaxis), even if there are
no symptoms:
-Difficulty breathing or wheezing
-Tightness in the throat or a feeling that the airways are
closing
-Hoarseness or trouble speaking
-Nausea, abdominal pain, or vomiting
-Fast heartbeat or pulse
-Skin that severely itches, tingles, swells, or turns red
-Anxiety or dizziness
-Loss of consciousness

73. 2. Inject Epinephrine Immediately
-If the person has an anaphylaxis action plan from a
doctor for injecting epinephrine and other emergency
measures, follow it. Otherwise, if the person carries an
epinephrine shot or one is available:
-If the person has a history of anaphylaxis, don't wait for
signs of a severe reaction to inject epinephrine.Inject
epinephrine into outer muscle of the thigh. Avoid
injecting into a vein or buttock muscles.
-Do not inject medicine into hands or feet, which can
cause tissue damage.
-The person may need more than one injection if there's
no improvement after the first. For an adult, inject again
after 10 to 20 minutes. For a child, inject again after 5 to
30 minutes.
-A person should always go to the ER after an
epinephrine injection, even if the symptoms subside.

74. 3. Do CPR if the Person Stops Breathing
-For a child, start CPR for children.
-For an adult, start adult CPR.
4. Follow-Up
-Make sure that someone stays with the person for
24 hours after anaphylaxis in case of another
attack.
-Report the reaction to the person's doctor.
The sting may be painful for a few hours. Swelling
and itching may persist for a week. The area should
not be scratched as it will only increase the itching
and swelling.

75.  If a reaction persists for over a week or covers an
area greater than 7–10 cm (3 or 4 inches), medical
attention should be sought.
 Doctors often recommend a tetanus immunization.
 For about 2 percent of people, a hypersensitivity
can develop after being stung, creating a more
severe reaction when stung again later.
 People known to be highly allergic may carry
around epinephrine in the form of a self-injectable
EpiPen for the treatment of an anaphylactic shock.

76. MANAGEMENT OF ANAPHYLAXIS
 FIRST LINE THERAPY
Airway &oxygenation
Decontamination
Epinephrine
Crystalloids
 SECOND LINE THERAPY
Corticosteroids
Antihistamines