CRITTERS IN THE WORKPLACE

Recognition & ManagementJohn W Cromer, Jr MD, MS, MSPH

Occ Med Consulting

Case History

41 y/o male maintenance worker at a chemical plant. At end of workshift, he was replacing a pump outdoors. Some spider webs were near pump, which he wiped away while working on pump. On his 45’ drive home, he began feeling a stinging pain on inner thigh. Arriving at home, he felt severe pain in his leg. His wife called EMS, and at the hospital his status was:

General: severe leg pain, diffuse abdominal painT 100 P 120 RR 40 BP 150/90Extremities: sweating, red inner thigh with swelling and blanched

central spotNeuro: normal except abdominal spasms and leg twitchingLab: Electrolytes WNL Urine WNL Glucose & WBCExam of clothing: crushed dark spider, unrecognizable

BITES & STINGS – Arthropod

Initial bite: pin prick sensation or unnoticed

First 2 hours: site becomes red/ purplish, swells and may have halo- shaped lesion

Later symptoms: lymph node pain, chest/ abdominal pain, lower back pain, abdominal rigidity, nausea and vomiting, muscle tremors and

spasms, increased BP, elevated temperature and pulse, confusion, convulsions.

Mortality: < 5%

Clinical Presentation

Ice to wound/bite area

Oral or parenteral pain medications

Muscle relaxants for severe spasms

No added benefit from calcium gluconate

Lactrodoctus-specific Antivenom for severe cases (1st do skin test)

Tetanus prophylaxis

Management and Care

Brown Recluse Spider

Light brown body, ½ - 2 “ long, violin or fiddle markings

Venom very potent, causing tissue injury and destruction

Painless bite

Reaction ranges from mild irritation to life-threatening systemic reaction

90% are small local reactions with effect at local site of bite

Wound forms with central necrosis over 3-4 days, worsens over period of 2 weeks

Mortality is rare

Supportive treatment only

Question: How many eyes does the Brown Recluse Spider have? 2 4 6 8

Characteristics

What Am I ?

1. Tarantula minora

2. Hogna Wolf Spider

3. Hobo Spider

4. Southern House Spider (Kukulcania)

My Name Is:

Fire Ants

Question: From what continent did fire ants first come to the US?

Africa Central America South America Europe Asia

Fact: Fire ant mounds are interconnected by underground tunnels up to 100’ long

Fact: Treatment is supportive only, with topical creams, cool packs, cleansing

Fact: Stings are immunogenic, resulting in sensitization of the victim in many cases

Question: What percent of people stung develop anaphylactic reactions?

1% 10% 30% 50%

Questions and Facts about Fire Ants

Case History

25 y/o female was on walking trail at company site, stepped over log, and was bitten on her ankle by a snake. Snake moved away quickly and could not be identified. She felt immediate pain with swelling in ankle, some shortness of breath, and rapid HR. Was taken by EMS to a nearby ER.

General: sweating, rapid RR, dizzy, nausea, weakBP 90/50 HR 120 irreg RR 26 Temp 99Face: muscle twitching around eyesChest/ heart: OK except for rapid RR / HR with palpitationsAnkle: swelling, ecchymosis and skin hemorrhagesLab: Clotting abn; normal chemistry; WBC

Snake Bites

Broad-banded Copperhead

Initial bite: immediately painful; 1-2 puncture marks

First 1 – 4 hours:

If bite severe with considerable toxin - then local swelling, edema; Hemorrhage at site of bite;Tingling in scalp, muscle twitching, heart

irregularity;Dizziness, nausea, weakness, low BP, rapid pulse;Pulmonary edema, later renal impairment

QUESTION: What percent of viper bites are “dry bites?”10% 25% 50% 75%

Clinical Presentation

MILDLocal cutaneous swelling with tenderness at bite

site

MODERATESignificant extremity swelling with evidence of

systemic toxicity

SEVEREObvious systemic findings, unstable vital signs

and lab evidence of coagulopathy

Pit Viper Wound Grading System

1. How many identified snake bites occur in the USA annually?

a. 1000 – 3000 b. 6000 – 8000

c. 12000 – 14000 minimum

2. How many snake bite-related deaths occur in the USA annually?

a. < 10 b. 75 – 100 c. 300 - 350

Questions?

Healthy 28 y/o female who works on landscape crew for a large company. While driving a riding mower, she encounters a ground hive of yellow jackets. They swarm her and sting her multiple times. She tells coworker that she is allergic to bees, but doesn’t have her EpiPen with her. She is quickly put into coworker’s nearby car and taken to ER 10’ away.

Exam: General – alert but severe resp distress; multiple stings noted

Vitals – P 130 RR 40 T 100 BP 90/50Chest – wheezing in both lungs; HR rapid but regularAbdomen – normal except for hivesExtremities – thready pulseSkin – diffuse hives over arms, chest, back, face

Case History

Yellow Jacket

Honey Bees at Work

Includes bees, hornets (yellow jackets), wasps, and fire ants

Covers 1/3 of all envenomations in U.S.Estimated 50-150 deaths annually – nearly all from

anaphylaxisFour possible reactions to stings:

1 – Local Reaction2 – Toxic Reaction3 – Anaphylaxis4 – Delayed type Hypersensitivity

Hymenoptera

How many stings would typically be a lethal dose in a 170-pound person?

Answer:

a) 30b) 100c) 500d) 1500

Question

If Localized Reaction:

1 – Remove any embedded stingers

2 – Apply cold compresses to sting sites

3 – Administer oral antihistamine [e.g., Benadryl]

4 – Administer oral steroid x 5 days if reaction marked

Management of Hymenoptera Stings

If Systemic/Anaphylactic Reaction:

1 – Give Epinephrine 0.3 ml (1:1000 soln) IM or IV (adult dose) repeating at 15-min intervals, if needed

2 – Perform early intubation if indicated3 – Give H2 blocker medication

[cimetadine/ranitidine]4 – Give inhaled albuterol for bronchospasm5 – Administer IV fluids for hypotension6 – Follow up with immunotherapy desensitization

7 – Wear Medical Alert tag

Management of Hymenoptera Stings

Marine Envenomations

Marine Envenomations

Marine Envenomations

Avoid these Critters:

Coelenterates: Jelly fish, Sea anemones, Corals

Venomous fish: Stingrays, Scorpionfish, Stonefish, Zebrafish, Lionfish, Catfish

Echinoderms: Sea urchins, Starfish, Sea cucumbers, Sand dollars

Marine Envenomations

Coelenterates[Jelly fish, Sea anemones, Corals]

1 - Rinse with sea water (not fresh water)

2 - Soak with weak acid (e.g., vinegar, ammonia, meat

tenderizer)

3 - Ice application for swelling

4 - Treat anaphylaxis, if it occurs

Management of Envenomations

1. True/False: There are 50,000 fatal snake bites annually worldwide.

2. True/False: There are less than 1000 Pit Viper bites annually in the U.S.

3. True/False: Most venomous snakes in the U.S. leave 1or 2 puncture marks, whereas non-venomous snakes typically leave a horseshoe-shaped imprint.

4. True/False: The venom of the brown recluse spider is more potent than that of the rattlesnake.

Final Exam

5. True/False: The idea for the 1950’s movie, Tarantula, starring Leo J. Carroll, was made because he had actually captured a 15-foot wide tarantula on a trek he took in 1949 in a remote area of northern New Guinea.