Adam Algren, MD Medical Toxicology Fellow Georgia Poison Center Clinical Instructor

Adam Algren, MDAdam Algren, MDMedical Toxicology FellowMedical Toxicology Fellow

Georgia Poison CenterGeorgia Poison CenterClinical InstructorClinical Instructor

Emory University Dept. of Emergency MedicineEmory University Dept. of Emergency Medicine

Snakes, Spiders, and Creatures from the Sea

ObjectivesObjectives

Review clinical manifestations of North Review clinical manifestations of North American snake envenomationsAmerican snake envenomations

Review presentation and management of Review presentation and management of black widow and brown recluse spider black widow and brown recluse spider bitesbites

Discuss the indications for the use of Discuss the indications for the use of antivenoms: CroFab and Lactrodectusantivenoms: CroFab and Lactrodectus

Discuss common marine envenomationsDiscuss common marine envenomations

Snake EnvenomationsSnake Envenomations

CrotalidsCrotalids Pit VipersPit Vipers Found in every state except Alaska, Hawaii, Found in every state except Alaska, Hawaii,

MaineMaine 6000-8000 bites/yearly6000-8000 bites/yearly 5-10 deaths/yearly 5-10 deaths/yearly

ElapidsElapids Coral SnakeCoral Snake 69 Bites reported in 200069 Bites reported in 2000

64% Florida64% Florida

NEJM 2002;347:350

CrotalidsCrotalids

CrotalidsCrotalids

CrotalidsCrotalids CrotalusCrotalus

C. adamanteusC. adamanteus Eastern Diamondback Eastern Diamondback rattlesnakerattlesnake

C. atroxC. atrox Western Diamondback rattlesnakeWestern Diamondback rattlesnake C. horridus horridusC. horridus horridus Timber rattlesnakeTimber rattlesnake C. horridus atricaudatusC. horridus atricaudatus Canebrake rattlesnakeCanebrake rattlesnake C. scutulatusC. scutulatus Mojave rattlesnakeMojave rattlesnake C. viridis viridisC. viridis viridis Prairie rattlesnakePrairie rattlesnake C. cerastesC. cerastes Sidewinder rattlesnakeSidewinder rattlesnake

SistrurusSistrurus S. milariusS. milarius Pigmy rattlesnakePigmy rattlesnake S. catenatus spp.S. catenatus spp. Massasauga rattlesnakeMassasauga rattlesnake

AgkistrodonAgkistrodon A. contortixA. contortix CopperheadsCopperheads A. piscivorusA. piscivorus CottonmouthsCottonmouths

Eastern Diamondback RattlesnakeEastern Diamondback RattlesnakeCrotalus adamanteusCrotalus adamanteus

CrotalidsCrotalids

Majority of victims are maleMajority of victims are male Majority of bites occur May-OctoberMajority of bites occur May-October >50% victims of provoked bites are >50% victims of provoked bites are

intoxicatedintoxicated ¾ bites occur to upper extremities¾ bites occur to upper extremities 0-75% of snake’s venom is discharged0-75% of snake’s venom is discharged

Venom replenished within 1 monthVenom replenished within 1 month 5-20% of bites are “dry bites”5-20% of bites are “dry bites”

CrotalidsCrotalids VenomVenom

Components Components MetalloproteinasesMetalloproteinases CollagenasesCollagenases HyaluronidasesHyaluronidases ProteasesProteases

Composition/Composition/potency variespotency varies

SnakeSnake SpeciesSpecies AgeAge SeasonSeason

NEJM 2002;347:351

Western Diamondback rattlesnakeWestern Diamondback rattlesnakeCrotalus atroxCrotalus atrox

Crotalid EnvenomationsCrotalid Envenomations PathophysiologyPathophysiology

Local EffectsLocal Effects Most commonMost common Metalloproteinases and other components damage Metalloproteinases and other components damage

vascular endothelium and basement membranesvascular endothelium and basement membranes Edema, ecchymosis, blisteringEdema, ecchymosis, blistering

Systemic EffectsSystemic Effects CoagulopathyCoagulopathy HypotensionHypotension

Crotalid EnvenomationsCrotalid Envenomations

Pre-hospital ManagementPre-hospital Management Avoid exertionAvoid exertion Immobilize the extremity at or below level of Immobilize the extremity at or below level of

heartheart Rapid transport to nearest emergency dept.Rapid transport to nearest emergency dept. Consider constriction band if there is going to Consider constriction band if there is going to

be a prolonged transport timebe a prolonged transport time Extractor devices probably not helpfulExtractor devices probably not helpful Avoid tourniquet, cryotherapy, electric shock, Avoid tourniquet, cryotherapy, electric shock,

excision, and incisionexcision, and incision McKinney. Ann Emerg Med. 2001;37:168-74.McKinney. Ann Emerg Med. 2001;37:168-74. Alberts. Ann Emerg Med. 2004;43:181-6.Alberts. Ann Emerg Med. 2004;43:181-6.

Crotalid EnvenomationsCrotalid Envenomations HistoryHistory

Circumstance of biteCircumstance of bite Type of snakeType of snake Number of bitesNumber of bites Time since envenomationTime since envenomation First aid providedFirst aid provided Previous history of snake Previous history of snake

envenomation/antivenom treatmentenvenomation/antivenom treatment Sensitivity to horse/sheep seraSensitivity to horse/sheep sera Be cautious with any snakes brought to the EDBe cautious with any snakes brought to the ED

CopperheadCopperheadAkistrodon contortixAkistrodon contortix


Clinical ManifestationsClinical Manifestations LocalLocal

Fang marksFang marks Number of fang Number of fang

marks helpful, but not marks helpful, but not definitivedefinitive

EdemaEdema EcchymosisEcchymosis BullaeBullae



Crotalid EnvenomationsCrotalid Envenomations Clinical ManifestationsClinical Manifestations

SystemicSystemic AnaphylaxisAnaphylaxis Nausea, vomiting, diaphoresis, metallic tasteNausea, vomiting, diaphoresis, metallic taste HypotensionHypotension CoagulopathyCoagulopathy ThrombocytopeniaThrombocytopenia RhabdomyolysisRhabdomyolysis Neurologic EffectsNeurologic Effects

Mojave rattlesnakeMojave rattlesnake

NEJM 2002;347:351

Timber rattlesnakeTimber rattlesnakeCrotalus horridus horridusCrotalus horridus horridus

Canebrake rattlesnakeCanebrake rattlesnake Crotalus horridus atricaudatusCrotalus horridus atricaudatus

Mojave rattlesnakeMojave rattlesnakeCrotalus scutulatusCrotalus scutulatus

Crotalid EnvenomationsCrotalid Envenomations TreatmentTreatment

Remove any constriction band slowlyRemove any constriction band slowly TetanusTetanus Prophylactic antibiotics unnecessary Prophylactic antibiotics unnecessary Consult poison centerConsult poison center Determine antivenom supplies Determine antivenom supplies Document neurovascular exam for extremity Document neurovascular exam for extremity

bitesbites Measure limb circumference every 15 minutesMeasure limb circumference every 15 minutes Labs- CBC, chemistries, PT, PTT, Fibrinogen, CK Labs- CBC, chemistries, PT, PTT, Fibrinogen, CK

CottonmouthsCottonmouths Agkistrodon piscivorusAgkistrodon piscivorus


TreatmentTreatment Surgical treatmentSurgical treatment

Routine surgical treatment not recommendedRoutine surgical treatment not recommended Measure compartment pressures if there is concernMeasure compartment pressures if there is concern Digit dermotomyDigit dermotomy

Hall E. Ann Emerg Med. 2001;37:175-180.Hall E. Ann Emerg Med. 2001;37:175-180.

Crotalid EnvenomationsCrotalid Envenomations AntivenomAntivenom

Wyeth polyvalent antivenomWyeth polyvalent antivenom CroFabCroFab Indications:Indications:

Rapid progression of local effectsRapid progression of local effects Compartment syndromeCompartment syndrome Coagulopathy, ThrombocytopeniaCoagulopathy, Thrombocytopenia Neurologic SymptomsNeurologic Symptoms ShockShock


CroFabCroFab FDA approved in 2000FDA approved in 2000 Sheep derived FabSheep derived Fab IgGIgG Less immunogenicLess immunogenic Eastern/Western Diamondback rattlesnake, Eastern/Western Diamondback rattlesnake,

Mojave rattlesnake, Cottonmouth Mojave rattlesnake, Cottonmouth Skin testing not requiredSkin testing not required 0-14% incidence of immediate hypersensitivity0-14% incidence of immediate hypersensitivity <5% incidence of serum sickness<5% incidence of serum sickness

Crotalid EnvenomationsCrotalid Envenomations Dart et al. Arch Intern Med. 2001;161:2030-Dart et al. Arch Intern Med. 2001;161:2030-

6.6. 31 patients31 patients 6 or 12 vials CroFab initially6 or 12 vials CroFab initially 16 patients PRN, 15 scheduled16 patients PRN, 15 scheduled

8 patients in PRN group required additional CroFab8 patients in PRN group required additional CroFab 0 patients in scheduled group0 patients in scheduled group

All patients had significant improvement in All patients had significant improvement in snakebite severity scoressnakebite severity scores

6 allergic reactions6 allergic reactions 4 urticaria, 1 urticaria/cough, 1 4 urticaria, 1 urticaria/cough, 1

urticaria/dyspnea/wheezingurticaria/dyspnea/wheezing

In fuse Additional 2 Via ls Dosesat 6, 12, and 18 hours After In itia l Control

Yes

In itia l Contro l Achieved?

NoAdm inister Additional 4 - 6 Via ls o f CroFab(TM)

In itia l Contro l Achieved?

Establish Initial Control o f Envenom ationBy Adm inistering 4 - 6 V ials of CroFab(TM)

Patient with Ind ication forCroFab(TM ) Adm inistration


CroFab for Copperhead envenomationsCroFab for Copperhead envenomations 32 cases 32 cases 25 (78%) were moderate severity25 (78%) were moderate severity 7 had mild laboratory abnormalities7 had mild laboratory abnormalities 23 (72%) achieved control with 4 vials23 (72%) achieved control with 4 vials 4 cases progressed following CroFab4 cases progressed following CroFab No allergic reactionsNo allergic reactions 1 mild case serum sickness1 mild case serum sickness

Lavonas et al. Ann Emerg Med. 2004;43:200-6.Lavonas et al. Ann Emerg Med. 2004;43:200-6.

Crotalid EnvenomationsCrotalid Envenomations Safety and Efficacy of CroFab for Pediatric Safety and Efficacy of CroFab for Pediatric

EnvenomationsEnvenomations 24 patients24 patients Mean age 7.3 (range 1.9-13)Mean age 7.3 (range 1.9-13) All had local swellingAll had local swelling 14 (58%) PT >13sec14 (58%) PT >13sec 3 (12.5%) platelets <150,0003 (12.5%) platelets <150,000 2 (8.3%) fibrinogen <150 mg/dl2 (8.3%) fibrinogen <150 mg/dl Mean number of CroFab vials used 12.3 (4-24)Mean number of CroFab vials used 12.3 (4-24) 5 patients progressive thrombocytopenia5 patients progressive thrombocytopenia ? 1 allergic reaction? 1 allergic reaction

Pizon et al. Acad. Emerg Med. 2007;14:373-6.Pizon et al. Acad. Emerg Med. 2007;14:373-6.

Crotalid EnvenomationsCrotalid Envenomations Recurrence- Local or systemicRecurrence- Local or systemic

Possible explanationsPossible explanations Pharmacokinetic/pharmacodynamic mismatch of Pharmacokinetic/pharmacodynamic mismatch of

venom/antivenomvenom/antivenom CroFab elimination ½ life 15-20 hoursCroFab elimination ½ life 15-20 hours

Late onset of venom effectsLate onset of venom effects Prolonged absorption of venom from woundProlonged absorption of venom from wound

Dissociation of venom/antivenom complexDissociation of venom/antivenom complex Development of host anti-antivenom responseDevelopment of host anti-antivenom response


Post-marketing study of CroFab for Post-marketing study of CroFab for rattlesnakesrattlesnakes 28 patients (3 children)28 patients (3 children) 16/28 achieved local control with 4-6 vials16/28 achieved local control with 4-6 vials 20/28 elevated PT, 6/28 thrombocytopenia, 20/28 elevated PT, 6/28 thrombocytopenia,

12/28 hypofibrinogenemia12/28 hypofibrinogenemia Control achieved in all, 67-80% required >10 vialsControl achieved in all, 67-80% required >10 vials

6/21 had systemic recurrence6/21 had systemic recurrence No significant bleedingNo significant bleeding

No anaphylactic reactionsNo anaphylactic reactions Ruha et al. Ann Emerg Med. 2002;39:609-615 Ruha et al. Ann Emerg Med. 2002;39:609-615

Ann Emerg Med 2001;37:2

Ann Emerg Med 2001;37:2

Crotalid EnvenomationCrotalid Envenomation DispositionDisposition

Observe for 6-8 hours if asymptomaticObserve for 6-8 hours if asymptomatic May discharge if asymptomatic with normal May discharge if asymptomatic with normal

labslabs Admit all suspected Mojave rattlesnake Admit all suspected Mojave rattlesnake

envenomations for 24 hoursenvenomations for 24 hours Admit for significant local effects or if labs Admit for significant local effects or if labs

abnormalabnormal

Which snake is poisonous?Which snake is poisonous? King snake

Lampropeltis getulus

Coral Snake

Micrurus fulvius

“Red on yellow, kill a fellow”

“Red on black, venom lack”

Coral Snake EnvenomationsCoral Snake Envenomations

UncommonUncommon Florida, GeorgiaFlorida, Georgia Eastern, Texas, SonoranEastern, Texas, Sonoran Small, ~40 inches full grown, small teethSmall, ~40 inches full grown, small teeth 25% of bites are “dry bites”25% of bites are “dry bites” VenomVenom

Components not well understoodComponents not well understood Zinc dependent acetylcholinesteraseZinc dependent acetylcholinesterase

Coral Snake EnvenomationsCoral Snake Envenomations

Clinical PresentationClinical Presentation 1/3 have mild local swelling1/3 have mild local swelling Mild systemic symptomsMild systemic symptoms May develop localized pain or fasciculationsMay develop localized pain or fasciculations Neurologic symptomsNeurologic symptoms

Normal mental statusNormal mental status CN palsies, weakness/paralysis, respiratory failureCN palsies, weakness/paralysis, respiratory failure

Avg. delay to symptom onset is ~ 2 hoursAvg. delay to symptom onset is ~ 2 hours May be delayed up to 13 hoursMay be delayed up to 13 hours

Kitchens et al. JAMA. 1987;258:1615-8. Kitchens et al. JAMA. 1987;258:1615-8.

Coral Snake EnvenomationsCoral Snake Envenomations TreatmentTreatment

Supportive CareSupportive Care Aggressive airway management, monitor NIFAggressive airway management, monitor NIF Consult poison center, determine antivenom suppliesConsult poison center, determine antivenom supplies Consider NeostigmineConsider Neostigmine Early antivenom administration even if asymptomaticEarly antivenom administration even if asymptomatic

Equine derivedEquine derived 3-5 vials initially, redose additional 5 vials in symptomatic pts3-5 vials initially, redose additional 5 vials in symptomatic pts Reconstitution 15-30 minutesReconstitution 15-30 minutes Immediate hypersenitivity- 6/17 urticaria, 1/39 anaphylaxis Immediate hypersenitivity- 6/17 urticaria, 1/39 anaphylaxis Serum sickness- 4/39 patientsSerum sickness- 4/39 patients

Coral Snake EnvenomationsCoral Snake Envenomations DispositionDisposition

Admit all suspected Coral snake bites for at Admit all suspected Coral snake bites for at least 24 hoursleast 24 hours

Black Widow EnvenomationsBlack Widow Envenomations

Black Widow EnvenomationsBlack Widow Envenomations Latrodectus mactansLatrodectus mactans ~2500 bites/year~2500 bites/year

300-400 severe300-400 severe Prefer dry, dark environmentsPrefer dry, dark environments Only females envenomateOnly females envenomate No deaths in US in past 20 yearsNo deaths in US in past 20 years αα-lactrotoxin-lactrotoxin

Stimulates release of acetylcholine and Stimulates release of acetylcholine and catecholaminescatecholamines

Black Widow EnvenomationsBlack Widow Envenomations Non-specific symptoms can make diagnosis difficultNon-specific symptoms can make diagnosis difficult Bite is not always feltBite is not always felt Pain within 10-60 min, but may be delayedPain within 10-60 min, but may be delayed 75% will only have local symptoms75% will only have local symptoms

Pain, diaphoresis, piloerectionPain, diaphoresis, piloerection Systemic symptoms may develop over several Systemic symptoms may develop over several

hourshours Generalized pain, abdominal pain, priapism, Generalized pain, abdominal pain, priapism,

diaphoresis, tachycardia, hypertension, headache, diaphoresis, tachycardia, hypertension, headache, vomiting, tremorvomiting, tremor

Symptoms peak within 12-24 hoursSymptoms peak within 12-24 hours Typically resolves over 24-72 hoursTypically resolves over 24-72 hours

Black Widow EnvenomationsBlack Widow Envenomations TreatmentTreatment

Opiates, benzodiazepinesOpiates, benzodiazepines 115/163 patients had resolution of pain115/163 patients had resolution of pain

No evidence to support calciumNo evidence to support calcium 23/24 no improvement23/24 no improvement

AntivenomAntivenom Severe/refractory pain, severe hypertension, Severe/refractory pain, severe hypertension,

threatened abortionthreatened abortion Equine IgGEquine IgG 58 patients received 1 vial; all had pain resolution <2 58 patients received 1 vial; all had pain resolution <2

hrshrs 4 urticaria, 1 analphylaxis death4 urticaria, 1 analphylaxis death

Clark et al. Ann Emerg Med. 1992;21:782-7.Clark et al. Ann Emerg Med. 1992;21:782-7.

Black Widow EnvenomationsBlack Widow Envenomations DispositionDisposition

Discharge if symptoms improveDischarge if symptoms improve May discharge if antivenom givenMay discharge if antivenom given

Observe for 2 hours after completion of infusionObserve for 2 hours after completion of infusion

Brown Recluse EnvenomationsBrown Recluse Envenomations

Loxosceles reclusaLoxosceles reclusa April-October ? more bites at night Prefers warm, dry environment Venom

Sphingomyelinase D, Sphingomyelinase D,

hyaluronidase, phosphohydrolaseshyaluronidase, phosphohydrolases


Most bites have a benign courseMost bites have a benign course May progress over several hoursMay progress over several hours Pain, induration, ecchymosisPain, induration, ecchymosis May develop serous/bloody blistersMay develop serous/bloody blisters GravitationalGravitational Necrosis at 2-4 days, heals over 6-8 Necrosis at 2-4 days, heals over 6-8

weeksweeks



Brown Recluse EnvenomationsBrown Recluse Envenomations Bacterial InfectionsBacterial Infections

Orf, Anthrax, Orf, Anthrax, LeishmaniosisLeishmaniosis

Bee StingBee Sting Skin cancerSkin cancer Drug reactionsDrug reactions

Coumadin, TEN, SJSCoumadin, TEN, SJS Ecthyma gangrenosumEcthyma gangrenosum Erythema migransErythema migrans Erythema nodosumErythema nodosum Erythema multiformeErythema multiforme Emboli, septicEmboli, septic Fire antsFire ants FrostbiteFrostbite MitesMites

Necrotizing fascitisNecrotizing fascitis Polyarteritis nodosaPolyarteritis nodosa Purpura fulminansPurpura fulminans Pyoderma Pyoderma

gangrenosumgangrenosum ScrofulaScrofula SporotrichosisSporotrichosis Systemic gonorrheaSystemic gonorrhea SclerodermaScleroderma Tick bitesTick bites UlcersUlcers Viral infectionsViral infections VasculitisVasculitis


Systemic loxoscelismSystemic loxoscelism Not proportional to dermal findingsNot proportional to dermal findings

4/111 patients4/111 patients 6/546 pediatric series6/546 pediatric series

? More common in children? More common in children Develops within 72-96 hoursDevelops within 72-96 hours Fever, nausea, myalgias, arthralgias, headacheFever, nausea, myalgias, arthralgias, headache Jaundice, coagulopathy, hemolysis, renal Jaundice, coagulopathy, hemolysis, renal

failurefailure Mortality from hemolysis, DICMortality from hemolysis, DIC

Wright et al. Ann Emerg Med. 1997;30:28-32.Wright et al. Ann Emerg Med. 1997;30:28-32. Elbahlwan et al. Pediatr Emerg Care. 2005;21:177-Elbahlwan et al. Pediatr Emerg Care. 2005;21:177-

180.180.

Brown Recluse EnvenomationsBrown Recluse Envenomations TreatmentTreatment

Wound careWound care Prophylactic antibiotics unnecessaryProphylactic antibiotics unnecessary LabsLabs

CBC, chemistries, LDH, retic count, PT, PTT, CBC, chemistries, LDH, retic count, PT, PTT, fibrinogen, UA, plasma free hemoglobin, type & fibrinogen, UA, plasma free hemoglobin, type & screenscreen

Avoid dapsone/early surgical treatmentAvoid dapsone/early surgical treatment ? Early HBO? Early HBO Steroids for hemolysisSteroids for hemolysis


DispositionDisposition Admit for systemic complicationsAdmit for systemic complications ChildrenChildren

Consider daily out-patient labs for 96 hours Consider daily out-patient labs for 96 hours

Marine EnvenomationsMarine Envenomations

JellyfishJellyfish Box JellyfishBox Jellyfish Portuguese man-of-warPortuguese man-of-war

StingraysStingrays ScorpaenidaeScorpaenidae

LionfishLionfish

Box JellyfishBox Jellyfish Chironex fleckeriChironex fleckeri

15 tentacles up to 7 meters in length Found along northern coast of Australia Responsible for >60 deaths in past

century

Box JellyfishBox Jellyfish Millions of nematocysts/jellyfish tentacleMillions of nematocysts/jellyfish tentacle VenomVenom

Cardiotoxic/myotoxicCardiotoxic/myotoxic Increases intracellular Na/CaIncreases intracellular Na/Ca

Most stings are minorMost stings are minor Death possible within minutesDeath possible within minutes

with severe envenomationswith severe envenomations

Box jellyfishBox jellyfish Clinical ManifestationsClinical Manifestations

Immediate painImmediate pain Skin wheals/vesiclesSkin wheals/vesicles Delayed hypersensitivity reaction commonDelayed hypersensitivity reaction common Hypotension/cardiac arrestHypotension/cardiac arrest

O’Reilly. Med J Aust. 2001;175:652-5.O’Reilly. Med J Aust. 2001;175:652-5.

Box jellyfishBox jellyfish

Portuguese man-of-warPortuguese man-of-war

Portuguese man-of-warPortuguese man-of-war

Physalia sp.Physalia sp. Responsible for thousands of stings in USResponsible for thousands of stings in US Found along Atlantic/Gulf coastsFound along Atlantic/Gulf coasts Tentacles may be up to 30 metersTentacles may be up to 30 meters Most envenomations minor, deaths rareMost envenomations minor, deaths rare Immediate pain/skin reactionImmediate pain/skin reaction

Jellyfish TreatmentJellyfish Treatment Supportive careSupportive care Irrigate with 5% acetic acidIrrigate with 5% acetic acid Remove tentaclesRemove tentacles Wound careWound care Pain medsPain meds Consider prophylactic antibioticsConsider prophylactic antibiotics Monitor for delayed reactionsMonitor for delayed reactions

StingraysStingrays

StingraysStingrays Tropical/temperate environmentsTropical/temperate environments Shallow watersShallow waters Non-aggressiveNon-aggressive 1-4 spines1-4 spines 17 deaths reported worldwide17 deaths reported worldwide VenomVenom

Phosphodiesterases, serotonin,Phosphodiesterases, serotonin,

5’-nucleotidase5’-nucleotidase Immediate pain lasting 6-48 hrImmediate pain lasting 6-48 hr Vomiting, dizziness, weakness,Vomiting, dizziness, weakness,

syncope, cramps, arrhythmias, hypotensionsyncope, cramps, arrhythmias, hypotension

StingraysStingrays

Immediate cold water irrigationImmediate cold water irrigation Then warm water (40-42Then warm water (40-42°) immersion°) immersion

Pain medsPain meds Wound managementWound management Consider prophylactic antibioticsConsider prophylactic antibiotics

Cook et al. J Emerg Med. 2006;30:345-7.Cook et al. J Emerg Med. 2006;30:345-7.

LionfishLionfish

LionfishLionfish Pterois sp.Pterois sp. Atlantic, Pacific, CaribbeanAtlantic, Pacific, Caribbean Popular aquarium fishPopular aquarium fish 12 or 13 dorsal spines with 12 or 13 dorsal spines with

venom glandsvenom glands Venom poorly characterizedVenom poorly characterized Severe pain lasting 6-12 hoursSevere pain lasting 6-12 hours Systemic effects rare Systemic effects rare

LionfishLionfish

Warm water (45Warm water (45°) immersion for 30-90 °) immersion for 30-90 minmin

Pain medsPain meds Wound careWound care Consider prophylactic antibioticsConsider prophylactic antibiotics

Vetrano et al. J Emerg Med. 2002;23:379-382.Vetrano et al. J Emerg Med. 2002;23:379-382.

Questions?Questions?

Documents

Adam Algren, MD Medical Toxicology Fellow Georgia Poison Center Clinical Instructor