OTHER SYNDROMES: HYMENOPTERA BITES

OTHER SYNDROMES: HYMENOPTERA BITES …

1. INTRODUCTION

• Bites and envenomation can be very serious and pose resuscitation problems.
•  In Algeria, scorpion venom remains a major concern. 
• Other types of animals can be responsible for fatal accidents:  

                      – snakes

                      – Hymenoptera

                      – spiders

• There may also be bites that are suspected of being rabid. 

2. PHYSIOPATHOLOGICAL MECHANISMS

     2 types of injuries can result from contact with a venomous animal:

            – direct effects of the poison

            – indirect effects through hypersensitivity

3. SCORPIONIC ENVENOMATION
4. EPIDEMIOLOGY 

• The incidence of scorpion stings is high in some regions of Iran, Mexico, and Tunisia. 
• Public health problem in certain Wilayas of our country.
• 50,000 bites/year and no less than 100 deaths
• Creation of a National Committee to Combat Scorpion Poisoning.

2. EVALUATION ELEMENTS  

The species: 

                                    – the black scorpion:

• the most dangerous 
• large species, reaching up to 10 cm 
• brown tint with often black body parts (back, claws) 
• thick tail up to the 4th ring 
• has 6 formidable toxins

                                  – the yellow scorpion: 

• can be dangerous 
• average size 4 to 7 cm 
• light, uniform yellow tint from head to tail 
• the tail is slender 
• has 13 toxins identified to date

3. PHYSIOPATHOLOGY

OTHER SYNDROMES: HYMENOPTERA BITES …

4. CLINICAL PICTURE 

Grade 1:  

                   Isolated local signs  : (one or more)

        – Pain: of varying intensity at the point of injection. 

        – Tingling, redness, swelling. 

         – Paresthesia or burning that may be accompanied by numbness that can be triggered by percussion or touch.

       -Without any general signs. The pain is localized, very violent and can last 24 hours.

Grade 2:  

                    Local signs (more or less marked) and general signs (systematic signs of envenomation); HBP, fever, sweating, chills, digestive disorders, neuromuscular manifestations, etc. 

Grade 3  : Existence of vital failure (3%)

• Respiratory disorders  : acute respiratory failure, polypnea, cyanosis, and in the extreme, cardiogenic or lesional acute pulmonary edema (APO).
• Cardiovascular disorders  : is frequently the cause of death (cardiovascular collapse), all rhythm disorders can be found: tachycardia, bradycardia, atrial fibrillation or VF, AVB, etc. 
•   Central neurological disorders  : this is cerebral suffering secondary to hypoxia: myoclonus, agitation, fasciculations, muscle cramps, thermal dysregulation, disorders of consciousness, convulsions (child), coma.
• Aggravating factors:  

– severe neurological signs

– species and size of scorpions  

– age

– anatomical seat of inoculation

– support time

– associated defects

5. ACTION TO BE TAKEN

• Principles:  

 – take into account the geographical region concerned: classification of areas according to the lethality rate

 Scarification, suction, application of plants and various substances: NO

Tourniquet application: NO

Detersion – disinfection – tetanus vaccination: YES mandatory                       

• In practice: 

Grade 1:   

– Observation for 4 to 6 hours then discharge if no worrying signs occur

– Serotherapy: anti-scorpion serum (SAS): 1 amp IM or IV depending on the form

serum available (not after 6 hours without clinical signs)

-Adjuvant therapy: Pain is an almost constant sign. 

• PARACETAMOL as an analgesic (1 g every 8 to 6 hours).
•  Local application of an anesthetic cream (type Emla® 5%) or ice pack
• OR ASPEGIC: as an analgesic, anti-inflammatory and antipyretic (0.5 to 1g, every 4 to 6 hours);

Grade 2:   

-Hospitalization of at least 24 hours recommended.

-Resuscitation depending on the symptoms observed.

-Serotherapy, SAS: 1 deep IM or IV amp to be repeated every 3 hours if necessary. Beyond 12 hours, SAS is no longer justified.

Grade 3:   

– serotherapy: used because of re-release of toxins, SAS: 1 amp IM or IV every 3 hours if no favorable clinical development.

– Resuscitation in a specialized department with artificial ventilation facilities: tracheal intubation and mechanical ventilation.

 – TRT of cardiogenic OAP and shock: dobutamine with careful vascular filling.  

 – Other symptomatic therapies: – anti-emetics such as Primpéran  

 – antipyretic type Paracetamol – antispasmodics and antihistamines 

 – neuroleptic type Largactil in case of agitation 

 – anticonvulsants such as Valium or Fenugreek  

 – corticosteroids such as hydrocortisone hemisuccinate  

4. SNAKE BITES 
5. EPIDEMIOLOGY     

• Morbidity and mortality from snake envenomation are less well known in our country
• Children, pregnant women and patients with visceral defects are at risk.
• Intravascular bites, or bites located in the mucous membranes and the cephalic region, are typically more serious.
• 10% of bites are followed by envenomation
• 10% of poisonings are serious 

2. PHYSIOPATHOLOGY

• The absence of edema 2 hours after the bite generally rules out envenomation.
• Venom generally combines several actions: 

    – vascular permeability disorders

 – paralysis due to damage to the neuromuscular junction

 – hemolysis

 – coagulation disorders

 – rhythm disorders, low blood pressure

3.    CLINICAL PICTURE 

• Grade 1: Local signs: 

       -The trace of the hooks is clearly visible at the beginning: 2 punctiform skin breaks spaced 5 to 10 mm apart

       – Edema appears quickly, is maximum in 3 to 6 hours, can be very extensive. It is the edema that indicates envenomation.

       -The skin is cold, ecchymotic, purpuric, blisters are observed

       -The pain is constant but of variable intensity  

       – local complications (necrosis) are rare

• Grade 2: Regional signs  : correspond to the extension of the edema
• Grade 3: General signs:  

– Digestive disorders  : nausea, vomiting, more rarely abdominal pain and diarrhea.  

 – Neurological disorders  : anxiety, agitation, sometimes drowsiness or convulsive crises and coma.  

 – Hyperthermia at 38.5°C outside of any infectious complication.  

 – Hypotension is generally moderate. However, significant circulatory insufficiency may be observed in the event of envenomation treated late. 

– Cardiovascular disorders  : repolarization disorders 

 – Hemolysis and DIC in severe forms.

OTHER SYNDROMES: HYMENOPTERA BITES …

4. ACTION TO BE TAKEN

Grade 1  :       

                  First Aid TRT:  

• Calm and lay the patient down  
• Disinfection of the wound with an antiseptic (Dakin*, Betadine*)  
• Moderately compressive dressing  
• Immobilization of the affected limb  
• No tourniquet as it aggravates local injuries 
• Local refrigeration   

                       Medical TRT: 

• Benzodiazepine anxiolysis  
• Painkillers: paracetamol.
• Anti-anaerobic ATB: penicillin G (3 to 6 M Units) 
• Anti-tetanus gamma globulins  
• TRT of anaphylactic shock with adrenaline and filling

Grade 2  :       

• First aid TRT: same as grade 1  
• Medical TRT: same as grade 1 plus corticosteroids such as solumedrol* (although efficacy not proven) 
• Specific TRT: immunotherapy against viper venom

Grade 3:        

• First aid TRT: same as grade 1  
• Medical TRT: same as grade 2 
• Specific TRT: immunotherapy  
• TRT of hemodynamic disorders

5. HYMENOPTERA STINGS      

Wasps, bees, ants

• Bee or wasp venom is hemolytic, neurotoxic and has a histamine action.
• The bee has a barbed stinger that remains fixed in the dermis after the sting, causing the death of the animal; the wasp, on the contrary, has a slightly barbed stinger and can therefore sting several times.
• Reaction to a sting: 

          – acute pain

          – erythema

          – local swelling 

          – intense itching 

• In soft tissues, the edema can be very intense (eyelids); in case of inhalation, there is exposure to pharyngolaryngeal edema.
• In sensitized individuals, a single sting can cause anaphylactic shock.
• Look for the stinger and remove it, taking care not to press the gland so as not to spread more venom.
• Cool anti-itch lotions, local antihistamines, ice.
• IV corticosteroids: solumedrol* 1 mg/kg, effectiveness is not immediate.
• Adrenaline: amp to 1 mg, reduced to 10 ml, inject cc/cc in case of shock.
• In case of respiratory distress: tracheal intubation, tracheotomy to maintain freedom of the airways.

6. SPIDERS

• The bite of many spiders is locally irritating and several species can cause serious or even fatal poisoning.
• The venom causes hyperalgic lumbar, abdominal or facial muscle contractions, erythematous rash, neurovegetative disorders (variation in temperature and blood pressure).
• In our region, spider bites are not very dangerous.
• CAT: Analgesics including opiates in exotic spider bites.

7. TICKS

• They attach themselves by their rostrum.
• Ether will make them let go.
• Exceptional transmission of ascending paralysis and polyradiculoneuritis.

8. JELLYFISH

• They are urticarial with sometimes general malaise, cramps.
• Removal of filaments adhering to the skin by rubbing with dry sand, ointment, analgesics, antihistamines.

9. SUSPECTED RABIES BITES   

• Rabies can be transmitted to humans by dogs, cats, cattle, and foxes.
• As soon as the diagnosis of rabies can be made, general TRT should be applied to the victim in a rabies center.
• If the animal could not be captured and if the risk of contamination is probable, vaccination is necessary: ​​14 SC injections at a rate of one per day carried out in a specialized center.
• Anaphylactic shock is treated with adrenaline and corticosteroids (Quincke’s edema).

OTHER SYNDROMES: HYMENOPTERA BITES …

  Untreated cavities can reach the nerve of the tooth.
Porcelain veneers restore a bright smile.
Misaligned teeth can cause headaches.
Preventative dental care avoids costly treatments.
Baby teeth serve as a guide for permanent teeth.
Fluoride mouthwash strengthens tooth enamel.
An annual checkup helps monitor oral health.
 

OTHER SYNDROMES: HYMENOPTERA BITES