Who am I? Who am I? Rattlesnake Envenomations and more. CAPA 2015 Annual Conference. Travis Martois PA-C CAPA Conference 10/11/2015

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1 Rattlesnake Envenomations and more Travis Martois PA-C CAPA Conference 10/11/2015 Who am I? 1990 finished an EMT program and started working on an ambulance in the 911 system Finished the Paramedic program at Mt SAC and began working at Springs Ambulance in Palm Springs and surrounding desert communities Completed the Physician Assistant program at Western University of Health Science. Worked in a family practice office for 1 ½ years Started working in various Emergency Departments in the Inland Empire 2011 Started LLUMC ED as the first PA ever in the ED on Team Venom 2012 Started in Barstow Community ED Who am I? 1

2 Introduction Time is Tissue Crucial to recognize and start tx asap Prevent Life Threatening Complications Dynamic Subspecialty Course will cover from time zero, to follow up care one month later 6 Southern California Natives Southern Pacific Red Diamond Western Diamondback Mojave Green Southwestern Speckled Sidewinder Southern Pacific Rattlesnake 2

3 Southern Pacific Rattlesnake Southern Pacific Rattlesnake Southern Pacific Found throughout Southern CA Nocturnal Venom tissue toxic Coagulopathies Neurological symptoms Young born August to October 3

4 AKA Mojave Green Mojave Rattlesnake Mojave Green Mojave Green 4

5 Mojave Green Diamonds fade to black on tail Mainly found in high desert Venom- neurotoxic with very little local effects Hypotension Red Diamond Rattlesnake Red Diamond 5

6 Red Diamond Rattlesnake Red in color, rings around tail black and white Found in San Bernardino, Morongo Valley Riverside, San Diego and Baja Venom- Local effects and coagulopathies Young are born July-September Western Diamondback Rattlesnake Western Diamondback 6

7 Western Diamondback Diamonds outlined in black and white, rings on tail Open desert areas, Riverside, Indio, Southwestern Edge of SB county Venom- Local injury and coagulopathies Live bearing snake Sidewinder Rattlesnake Sidewinder 7

8 Sidewinder Sidewinder Smallest rattlesnake Horns over its eyes, no diamonds Slithers sideways Desert regions Venom- mild symptoms only Southwestern Speckled 8

9 Southwestern Speckled Southwestern Speckled Speckled Rattlesnake No distinct diamonds Desert side of San Gabriel, San Bernardino, San Jacinto Mtns. Also Hemet, Perris, and Temecula Venom- Local injury, coagulapathies, and some neuro sx 9

10 Rattlesnakes are pit vipers San Bernardino and Riverside counties are the epicenter of bite activity in Southern California though LA County gets its fair amount Identification is not crucial Facts: Background Rattlesnakes may be identified by the rattle at the tip of the tail Fangs are located in the anterior of the mouth Rattlesnakes most common pit viper Pathophysiology Venom is composed of digestive enzymes Spreading factors result in local and systemic injury Pit vipers have large venom glands Dry bites can occur 10

11 Pathophysiology The real danger of snake bites is due to a combination of factors: Toxicity of venom Quantity available Rate of dry bites Size of the fangs Aggressiveness of the snake Likelihood of encounters man vs. snake Bite Factors 1 or 2 puncture sites Drag or puncture Local pain, redness, swelling Bleeding, blister, bullae Metallic taste Envenomations have progressive pain, swelling, redness, blistering, and bruising Absorption occurs quickly and produces toxic effects within minutes Nitty Gritty The Bite 10 % Dry Bites Irreversible Process Venom digests tissue and makes vessels leaky Antivenin stops the process Time is Tissue 11

12 Bite cont In the US mortality is rare, most long term morbidity is due to tissue destruction Breakdown of tissue leads to: Volume depletion Hypotension Shock Death Symptoms Local Injury Local Injury is the most common 12

13 Local Injury Day 1 Local Injury Day 2 Local Injury Day 6 13

14 Local Injury Day 9 Local Injury Day 12 Local Injury 4 weeks later 14

15 Systemic Neurological Systemic Neurological After Antivenin Systemic Metallic Taste Paresthesia Fasiculations ALOC Hypotension Coagulation 15

16 First Aid What not to do Cut the bite site Suck the bite site Apply a tourniquet Pack in Ice Catch the Snake Chug a Beer Cutting and Tourniquets Cutting Damages neurovascular structures Increase infection Risk Does Not Remove the Venom Tourniquets contain venom in one area In pit vipers local symptoms can cause the most morbidity Tourniquets Bottom Line Do not apply a band If already in place, leave until antivenin available Loosen if arterial compromise Check frequently during transport 16

17 Suction Devices They don t remove the venom they just suck Bush, Sean P. Snakebite Suction Devices Don t Remove Venom: They Just Suck Annals of Emergency Medicine. February (2) Treatment - Prehospital Do nothing to injure or impede travel to ED Limb at neutral position Oxygen Cardiac Monitor Treatment- Prehospital 2 large bore IVs ACLS Protocols Treat Hypotension as per protocols Minimize activity Remove tight fitting clothing and jewelry 17

18 Treatment Prehospital Mark edema every 5 minutes If tourniquet in place do not remove Transport to a Tertiary Care Center whenever possible Treatment ED Time is Tissue Treat as Emergent Remove Tight fitting clothing and jewelry Oxygen Cardiac Monitor Pulse OX 2 IV Lines Treatment -ED Measure from most distal fang mark to leading edge of advancing edema Repeat as necessary to gauge progression q 5-15 minutes After initial control q 1-2 hours Severe pain can be sign of progression 18

19 Treatment ED Maintain extremity in neutral position NPO Urine output IV fluid bolus and maintence fluids High Risk Patient Pregnancy Children dosing is the same May have to adjust fluid volume in small children and infants Co-morbidities- HTN, Diabetes, elderly, previous MI Stress to a fragile system Treatment Determine need for antivenin- Dry bite vs. Envenomation Allergic to Sheep serum, papaya, latex or Horse Serum DOSING IS NOT WEIGHT BASED 19

20 CROFAB Determine the need for antivenin Be sure to ask if allergic to : Sheep, Sheep serum, Papaya, or Latex DOSAGE IS NOT WEIGHT BASED Crofab- Initial Dose 4-6 vials Each vial reconstituted with 10 cc of STERILE WATER And gently swirled is very fragile should not be shaken Initial Dose - Crofab Crofab Once dissolved all vials are added to 250cc normal saline Firstremove 40-60cc of saline from bag and then inject each vial into bag gently Then rotate bag gently to mix with saline 20

21 First Initial Dose Infuse initial dose slowly Over the first 20 minutes cc/hours Initial Dose Ifno reaction Increase to 250cc/hr Repeat dose prn until initial control is achieved Initial Control Initial Control : Progression of swelling is stopped Pain is controlled Coagulation parameters are trending towards normal 21

22 maintenance dosing 2vials every six hours forup to 18 hours Then2 vials prn reoccurrence or coagulopathy Next dose in 6 hours Then the next doseis 18hours after initial Then the next dose 12 hours after initial Infusing Crofab Prepare to manage adverse reactions First 10 minutes MD at bedside No skin test required Must be used within 4 hours of reconstitution Treatment If at any time the patient shows signs of reaction stop infusion and treat accordingly Patient stable can go to med/surg unit or ED observation unit If unstable ICU 22

23 Other considerations Dry bites observed for at least 8 hours All bites require antivenin hours Pain relief with narcotics only No NSAIDS, ASPIRIN TORADOL, LOVENOX OR HEPARIN Other factors Update tetanus Most bites do not require tetanus Initial labs CBC, PT, PTT, Fibrinogen Assay, Type and Screen Recheck labs the same initial plus Lytes, BUN, creatinine and CK ALL PATIENTS NEED FLUID BOLUS AND MAINTENCE FLUIDS Resources Transfer to Tertiary Care Center Do not hold antivenin prior to transfer. 23

24 Discharge Labs checked every 3 days ( must be done STAT) Watch for any signs of bleeding No contact sports, surgery or dental work for two weeks Discharge Signs of infection Serum sickness, fever, joint pain, rash for up to 3 weeks after antivenin Pain control Tylenol and narcotics Plenty of liquids and look for coca-cola urine Treat coagulopathies with antivenin Summary Antivenin as soon as possible No cutting, sucking or tourniquets IV Fluids and Pain Meds Transfer to Tertiary Care Center ER when possible 24

25 Gila Monster Gila Monster Gila Monster Range 25

26 Gila Monster These large reptiles have a reputation for clamping down on a victim with their teeth and not letting go. Most serious bites occur when the Gila monster's lower jaws secure a firm hold on the victim that lasts for several minutes Gila Monster Bites They clamp down and hold on If possible submerge lizard underwater to get it to release Can use a large stick to pry open jaw Put a flame under the jaw Gila Monster Extremely Painful Localized swelling Nausea Vomiting High blood pressure Weakness Faintness Excessive perspiration Chills Fever 26

27 Gila Monster Bites First aid in the field may include Irrigating the wound with plenty of water Immobilize the affected limb at heart level Reassure the patient. Gila Monster Bites Need to explore the wound for broken teeth Can use 1% lidocaine for local pain control Irrigate with copious amounts of saline Update tetanus Treat with Broad-spectrum Antibiotics Frequent wound checks after discharge Gila Monster Bites 27

28 Gila Monster Bites Spider Bites Black Widow Black widow spiders (Latrodectus mactans) may be black or brown with a leg span of approximately one to two inches. Most can be identified by a red hourglass marking on the abdomen. They are located throughout the United States. Their toxin causes nerve cell dysfunction and muscle cell twitching. Only females cause envenomations. 28

29 Male vs. Female Black Widow Males are usually brown Males much smaller Females are black Females kill and eat males after breeding Black Widow Signs and symptoms of a Black Widow Bite: Abdominal Pain/Cramping Generalized Muscle Pain Foot Pain Swollen Eyelids Excessive Sweating (Diaphoresis) Visible Bite Headache Shortness of Breath Chest Tightness Tremors Dizziness/Fainting Clean the area with copious amounts of irrigation. Some bites will require narcotic pain medications and muscle relaxants. Antivenin is used at for severe bites but is rare 29

30 Black Widow Antivenin Many patients will react to the antivenin due to the Horse Serum Most bites will not be treated due to mild symptoms Practitioner must be present during infusion of antivenin Black Widow bites Brown Recluse Spider 30

31 Brown Recluse spider Brown recluse spiders (Loxosceles reclusa) are tan to dark brown with a leg span of approximately 1 inch. Many have a violin-shaped marking on the chest. They are located mainly in the south central United States but recently are found in the southwest and west coast. Brown Recluse Spider Bites Victims may experience these symptoms: Severe pain at bite site after about four hours, severe itching, nausea, vomiting, fever, and myalgias (muscle pain). Brown Recluse spider Severe bites can cause large necrotic lesions or open wounds. Most bites will cause a mild localized reaction. Treatment can include Antihistamines, Narcotic type pain medication as well as possibly antibiotics. Reevaluation of the wound should be done daily for the first 3-4 days and then afterward as needed 31

32 Brown Recluse bites Brown Widow Brown Widow Established in Southern California in early 2000 Unsure where it originates from, either South America or Africa. Has been in South Florida for many years Prefers tropical and subtropical areas 32

33 Brown Widow The coloration of a brown widow consists of a mottling of tan and brown with black accent marking The Brown Widow Spider does have an hourglass but it is typically an orange shade 33

34 Brown Widow The bite of a brown widow spider is minor in comparison to that of a black widow Although one frequently cited study demonstrates that, drop per drop, brown widow spider venom is as toxic as other widow species The weaker effect of brown widow bites on humans is possibly because the brown widow does not have or cannot inject as much venom as its larger relatives Treatment Brown Widow Usually an Antihistamine is all that is needed Severe envenomation mild need Ativan/Valium for muscle spasms Brown Widow 34

35 Wolf Spider Wolf Spider They have eighteyes arranged in three rows. The bottom row consists of four small eyes, the middle row has two very large eyes and the top row has two medium-sized eyes Wolf Spider Wolf spiders will inject venom if continually provoked. Symptoms of their venomous bite include swelling, mild pain and itching Treatment Antihistamine 35

36 Wolf Spider The Carolina wolf spider is the Official State Spider of South Carolina. Designated as such in 2000, South Carolina is the only U.S. state that recognizes a state spider Wolf Spider Wolf Spider caring eggs 36

37 Hobo Spider Hobo Spider The hobo spider does not live in California and has never been documented in the state In North America, this spider lives in the Pacific Northwest from British Columbia east to Montana, Wyoming and Colorado and south through Oregon and northern Utah Scorpion Stings 37

38 Scorpion Stings Most common scorpion in the Inland Empire is the Desert Hairy Scorpion. The Desert Hairy scorpion is only mildly venomous. Treat symptomatically unless the patient develops an allergy. Feels like a bad bee sting Localized erythemia and edema Treat with Antihistamines and H2 blockers Consider steroids and albuterol Ice to area for edema is ok In California most all scorpions stings are treated the same. There are over 80 different species of scorpions in California. Most all cause only a localized reaction 38

39 Arizona Bark Scorpion Arizona Bark Scorpion Most Venomous scorpion in the US Very painful Feels like electric shocks or jolts Can cause partial temporary paralysis and or numbness to area of sting Lasts for hours Antivenin research is ongoing and an Antivenin is available but 99% of patients all will react to the antivenin. Fatalities in the US from Scorpions are very rare and limited to the very young and very old. 39

40 Questions? 40