SEPTEMBER 2021 | VOLUME 18 | ISSUE 9

PEDIATRIC

Emergency Medicine Practice Evidence-Based Education • Practical Application

CLINICAL CHALLENGES
• What are the typical presentations of
common pediatric envenomations?

• For which types of envenomations is

antivenom available, and what are the
indications for its use?

• Which patients need observation,

and how long should the observation
period be?

Authors
Michael Levine, MD, FACEP, FACMT
Associate Professor of Emergency Medicine,
University of California, Los Angeles, Los Angeles, CA

Nathan Friedman, MD
Department of Emergency Medicine, University of
California, Los Angeles, Los Angeles, CA
Peer Reviewers
Sing-Yi Feng, MD
Associate Professor, Division of Emergency
Medicine, Department of Pediatrics, Medical
Toxicologist, North Texas Poison Center, University
of Texas Southwestern Medical Center, Dallas, TX
Nicole Gerber, MD
Assistant Professor of Clinical Emergency Medicine
and Clinical Pediatrics, Department of Emergency
Medicine, Division of Pediatric Emergency
Medicine, New York-Presbyterian/Weill Cornell
Medical Center, New York, NY
Prior to beginning this activity, see the
“CME Information” on page 21.
Terrestrial Envenomations
in Pediatric Patients:
Identification and
Management in the
Emergency Department
n Abstract
The majority of bites and stings from terrestrial animals are not
dangerous. However, due to their smaller size, children may be
more susceptible to the effects of venom, and they may experi-
ence more-severe envenomation effects than adults. This issue
reviews the basic epidemiology and underlying pathophysiol-
ogy of the bites and stings of spiders, bees and wasps, fire
ants, scorpions, snakes, and lizards. Clinical presentations are
reviewed, and evidence-based recommendations are provided
for management of the envenomated patient. While the patho-
physiology and much of the presentation and treatment are
similar for both children and adults, there can be subtle differ-
ences, which will be highlighted in this review.

For online access, scan with your

smartphone camera or QR code reader app:

This issue is eligible for 4 CME credits. See page 21. EBMEDICINE.NET
 Case Presentations
An 8-year-old boy presents after a rattlesnake bite on his right ankle...
• The boy was hiking with his parents when he was bitten by a rattlesnake. He says the pain began almost
CASE 1

instantly.
• On examination in the ED, he has edema extending from the mid-foot to proximal to the knee. The calf
compartments are soft. Ecchymosis is noted as well as oozing from the 2 puncture wounds.
• You order laboratory studies and wonder if antivenom administration is warranted.

A 9-year-old girl presents after she felt a “pinch” on her arm while raking leaves...
• While en route to the hospital, the girl developed worsening pain at the site and localized sweating
over the affected extremity.
CASE 2

• In the examination room, the girl is crying, appears to be in great discomfort, and has abdominal
cramping. Your examination is notable for a tiny puncture mark surrounded by 2 to 3 cm of erythema
over the right arm but minimal edema.
• Based on these findings, you are concerned that this is a black widow bite. You recall that there is an
antivenom, but you are not sure whether it would be the best choice for this patient.

A 17-month-old boy presents after awakening crying in his crib shortly after midnight...
• The boy resides in Arizona and was in his usual state of health when he went to sleep. The parents note
CASE 3

that the boy is drooling, flailing all of his extremities, and has “funny” eye movements.
• On examination, no bite or sting marks are appreciated.
• Based on the findings and the geographical location, you are concerned for scorpion envenomation
and wonder how to confirm the diagnosis.

n Introduction stopping progression of swelling and reversing system-

In 2018, the American Association of Poison Control
Centers received more than 13,000 calls for bites and
stings involving patients aged <20 years.1 Due to un-
derreporting, it is widely believed that these numbers
significantly underestimate the true prevalence. Ad-
ditionally, because of the relative rarity of these events
and the potential for misidentification of the animal,
the exact prevalence is not known. While many of these
incidents involve relatively minor symptoms, severe tox-
icity and hospitalization are not uncommon, and, rarely,
some envenomations can be fatal.
Neither the underlying mechanisms of action of
the toxin nor the treatment recommendations differ
substantially between pediatric and adult patients.
However, due to their smaller size, children may be
more susceptible to the effects of the venom, and
they may experience more-severe envenomations
than adults, especially in the case of scorpion or hon-
eybee envenomation.
In an effort to minimize severe effects, antivenom
is often used after envenomation. In the United States,
antivenom is available for black widow spiders, bark
scorpions, pit vipers (copperheads, cottonmouths, rat-
tlesnakes), and coral snakes. Historically, most antive-
noms were made from whole immunoglobulin. Wyeth
North American coral snake antivenom was effective at
ic and other hematologic effects of the venom, but was
associated with significant hypersensitivity reactions,
some of which were immediate (eg, anaphylactoid
reactions) and some of which were delayed (eg, serum
sickness).2 Consequently, a safer option was sought,
which led to production of antivenom that contains
Fab or F(ab’)2 fragments. Immunoglobulin G (IgG) is
a large protein that is divided into an Fc (fragment,
crystallizable) portion and a Fab (fragment, antigen
binding) portion.2 Enzymatic cleavage of IgG with pa-
pain can generate 2 Fab fragments, whereas cleavage
with pepsin yields a V-shaped F(ab’)2 fragment.3 Such
enzymatic cleavage allows isolation of the Fab portion,
which retains the antigen-specific binding component,
while eliminating the most immunogenic parts of the
immunoglobulin. Because Fab and F(ab’)2 are small
molecules, they have a distribution that mirrors the ex-
tracellular fluid and have a relatively rapid elimination.
Most antivenoms in the United States today are either
Fab or F(ab’)2.
This issue of Pediatric Emergency Medicine
Practice focuses on the mechanism of action of the
various toxins of common envenomating terrestrial
creatures and provides recommendations for the clini-
cal evaluation and management of pediatric patients
who have been envenomated by spiders, various

SEPTEMBER 2021 • www.ebmedicine.net 2 ©2021 EB MEDICINE

stinging insects, scorpions, snakes, and lizards. Indica-
tions for antivenom use and dosing recommendations
are provided.
For a detailed review of marine toxins, see the
April 2020 issue of Pediatric Emergency Medicine
Practice titled “Identification and Management of Ma-
rine Envenomations in Pediatric Patients,” available
at: www.ebmedicine.net/marine-envenomations.4
n Critical Appraisal of the Literature
The literature search was comprised primarily of a
PubMed search. Specific search terms used were
envenomation, spider, Hymenoptera, bee, wasp,
vespid, scorpion, rattlesnake, snake, and Heloderma.
Abstracts from several national toxicology meetings,
including the Scientific Meetings of the American Col-
lege of Medical Toxicology and the annual meeting of
the North American Congress of Clinical Toxicology,
were reviewed for the most current literature. Most
of the literature focused on retrospective reviews and
consensus guidelines. A few randomized clinical trials
were identified, which primarily focused on antive-
noms. Many of the randomized trials are evidence-
based, but many of the clinical practice recommenda-
tions are based on consensus.
n Differential Diagnosis
The differential diagnosis of envenomations can be
quite broad, as patients often do not know what type of
creature bit or stung them. Furthermore, differentiating
venomous bites and stings from nonvenomous bites
and stings can be difficult. The geographic location
where the envenomation occurred may offer some clues
as to what the envenomating creature was. Table 1 pro-
Table 1. Components of the History in the
Assessment of Terrestrial Bites and Stings
• Species of biting or stinging creature (eg, bee, wasp, hornet, ant,
scorpion, snake) or description of creature, if species unknown
• Location where bite or sting occurred, or activity being undertaken at
the time of the bite or sting
• Time elapsed since bite or sting or onset of symptoms
• Progression of symptoms since bite or sting occurred
• Site of bite or sting on the body
• Usual appearance of the affected area
• First aid measures already taken or treatments received
• History of previous bites or stings (how many, location, etc), reaction
to those stings (symptoms, length of reaction, treatment), and any
additional symptoms
• Allergy history including any medications used and any history of
serious allergy, such as anaphylaxis, Stevens-Johnson syndrome,
serum sickness
• Medication history (particularly corticosteroids, other immune-
suppressing drugs, anticoagulants)
• Other medical conditions, or chronic or recent/acute episodes of
illness
• Recent surgical procedures or indwelling devices around area of the
bite or sting
www.ebmedicine.net
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vides questions to ask while taking the history.
In the absence of a clear history of a spider
bite, alternative etiologies should be considered, as
numerous medical conditions can be misdiagnosed
as spider bites. Most commonly, abscesses (particu-
larly those from methicillin-resistant Staphylococcus
aureus) are thought to be spider bites by patients.
Conditions that can be misdiagnosed as loxoscelism
(systemic symptoms from envenomation by a Loxos-
celes reclusa [brown recluse] spider) include infec-
tions (bacterial, fungal, parasitic, and viral), necrotiz-
ing vasculitis, lymphomatoid papulosis, pyoderma
gangrenosum, and pemphigus.5 Black widow bites on
the abdomen have been misdiagnosed as an ab-
dominal pathology, such as appendicitis, because of
the intense pain surrounding the bite. Scorpion stings
might be perceived as an intoxication rather than an
envenomation, due to the symptoms of altered men-
tal status and roving eye movements. Determining
anaphylactic reactions versus direct venom reaction
from massive envenomation (anaphylactoid reactions)
can be a challenge in patients who have been stung
by hymenoptera (bees, wasps, ants, etc). While ana-
phylactic reactions are IgE-mediated, anaphylactoid
reactions are not. Fortunately, treatment for both are
similar, and determination of the specific etiology can
be delayed until the patient is stabilized.
n Prehospital Care
Prehospital care should focus on ensuring adequate
airway, breathing, and circulation. Analgesics can
be administered for pain; fentanyl is preferred, due
to minimal histaminergic effects.6 The immediate
management of patients with massive Hymenoptera
envenomation is to remove the individual from the
swarm. For non-snake envenomations, the extremity
should be placed in a position of comfort. Pressure
immobilization and tourniquets are contraindicated
for North American snake bites.7 For pit viper en-
venomation, the extremity should be splinted and
elevated; the splint should be applied loosely and
posteriorly, to maintain the extremity in full exten-
sion. Patients should be transported in a position of
comfort, ideally to an emergency department (ED)
with capabilities to care for the patient. For snake
bites specifically, this should be to a facility that car-
ries adequate doses of the recommended antivenom.
In cases of a foreign body, there is no urgent need
for removal, and removal should not delay care or
transportation to an ED.
n Spiders
Despite spider bites being relatively common, hu-
man toxicity is rare. Many spiders are too small to
be able to inject venom through human skin. Addi-
tionally, most spiders produce only a small amount
3 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
of venom at a time, and the venom may not result
in significant physiologic activity in humans. There-
fore, although many spiders are venomous, most
are not a threat to humans.8
Laboratory studies are typically not indicated for
routine management of spider envenomations. There
are, however, a few exceptions. In cases of increased
neuromuscular activity due to Latrodectus mactans
(black widow spider) envenomation, creatine kinase
levels and renal function should be monitored. In
cases of L reclusa envenomation, if there is concern
for hemolysis, laboratory studies including bilirubin,
complete blood cell count (CBC), lactate dehydroge-
nase, haptoglobin, creatinine, and free hemoglobin
studies are recommended.
Latrodectus: Widow Spiders
Epidemiology
Spiders belonging to the genus Latrodectus, com-
monly known as the widow spiders, are common
worldwide and can be found in Japan, New Zealand,
Australia, South America, and North America, as
well as southern Europe/western Asia.9 In the United
States, black widow spiders are indigenous to all
of the 48 contiguous states. There are >30 differ-
ent known species of Latrodectus. The female black
widow spider is black, with a 12- to 16-mm thorax
and a shiny red hourglass shape on the ventral side.
(See Figure 1.) The male black widow is smaller and
is not capable of causing human envenomations.
Pathophysiology
The primary toxin produced by the Latrodectus spe-
cies is alpha-latrotoxin, a neurotoxin that binds the
presynaptic neuron, resulting in depolarization of the
neuromuscular junction. In addition, the toxin prevents
Figure 1. Female Black Widow Spider
(Latrodectus mactans)
Republished with permission of McGraw Hill LLC, from Strange and
Schafermeyer's Pediatric Emergency Medicine, 5th edition, Milton
Tenenbein, Charles G. Macias, Ghazala Q. Sharieff, et al, Copyright
2019; permission conveyed through Copyright Clearance Center, Inc.
SEPTEMBER 2021 • www.ebmedicine.net 4
neurotransmitter reuptake in the synapse, with effects
on the sympathetic and parasympathetic nervous
systems.9,10 The toxin results in exocytosis of neu-
rotransmitters involved in both calcium-mediated and
non–calcium-mediated pore formation.
Clinical Presentation
The initial Latrodectus bite is often painful, and a
“target” lesion (which consists of an area of central
pallor surrounded by erythematous rings) may be
present. (See Figure 2.) The pain of the bite itself
may be localized to the site of the bite, but en-
venomation often causes severe muscle pain and
spasms of the back, abdomen, and chest muscles.
Among patients with these lesions, approximately
25% develop latrodectism,6 a syndrome character-
ized by pain, sympathomimetic effects, diaphore-
sis, fasciculations, and back and/or limb pain. The
diaphoresis and muscle spasms can be diffuse or can
be confined to the region of the envenomation.10-12
Atypical manifestations include priapism, fever, car-
diomyopathy, and paresthesias.6,10,12,13 Pain and lo-
cal paresthesias generally develop rapidly, whereas
systemic manifestations may be delayed for several
hours. Symptoms generally peak during the first 48
hours and decline within 2 to 3 days but can persist
for up to a week or longer.
Figure 2. Black Widow Spider Bite
Appearance
Christos Gogos, Vasileios Sachpekidis, Acute myocardial injury caused
by black widow spider (Latrodectus) bite, European Heart Journal -
Case Reports, 2020, volume 4, issue 3, pages 1-2, by permission of
Oxford University Press.
©2021 EB MEDICINE
Treatment
Treatment for Latrodectus envenomation is primar-
ily supportive, consisting of benzodiazepines and
opioids. In cases of severe toxicity, administration of
whole equine-based IgG antivenom can be consid-
ered. This antivenom, which is no longer produced,
can be obtained from the manufacturer on a case-by-
case basis for refractory cases. Its use remains quite
controversial in the toxicology community, however,
due to a small number of fatal cases of anaphylaxis
following its administration.14 Use of this antivenom is
generally not considered first-line therapy because of
the relatively high rate of immediate (anaphylactoid)
or delayed (serum sickness) allergic reactions. In a
recent review of Latrodectus envenomations in the
United States, no deaths were ascribed to the enven-
omation itself, although deaths have occurred due to
administration of the antivenom.11 Of note, F(ab’)2
antibody-based antivenom is currently being devel-
oped, with preliminary data that suggest efficacy in
reducing pain and spasms from envenomation, al-
though the antivenom has not yet obtained approval
from the United States Food and Drug Administration
(FDA).15 Discussion with a medical toxicologist either
on staff or at a Poison Control Center (United States
National Poison Center telephone number: 1-800-
222-1222) is recommended prior to administering
Latrodectus antivenom.
In the past, it was thought that intravenous (IV)
calcium gluconate should be administered. However,
due to a lack of data demonstrating its efficacy, this
treatment is no longer recommended.16
Disposition
Patients bitten by Latrodectus spiders may need to be
admitted if pain control is not achieved with oral medi-
cations. Additionally, if symptoms persist, admission
may be indicated for titration of parenteral benzodi-
azepines and opioids. Otherwise, it is reasonable to
discharge the patient after an observation period of
several hours to ensure that there is no progression of
symptoms.
Loxosceles: Recluse Spiders
Epidemiology
L reclusa is commonly referred to as the brown
recluse or fiddleback spider because of the unique
shape of a violin on its cephalothorax. (See Figure
3.) These spiders are light or dark brown, with an
8- to 15-mm thorax. They live primarily in small,
irregular webs and are frequently found in boxes,
furniture, and basements, or under rocks or wood.
There are approximately 140 species of Loxosceles,
found worldwide.17 In the United States, they are
found primarily in the south and southeast, from
Texas to Georgia and the Gulf of Mexico to Missouri
and southern Illinois. They are most active at night
and generally bite when threatened.17 Envenomation
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from the brown recluse has been “diagnosed” in
virtually every state in the United States, including
many states in which the spider does not reside.8,17,18
Because toxicity from these bites primarily manifests
as necrotic dermal lesions, various soft-tissue infec-
tions can be misdiagnosed as envenomation from this
spider.5 The bites most commonly occur on the trunk,
thigh, or upper arm;12 bites on the hands, feet, neck,
or face are rare.
Fatalities from L laeta (Chilean recluse), found
primarily in South America, are well described. In the
United States, fatal cases have been reported from
envenomation by L reclusa, although the exact preva-
lence has been debated and appears to be much less
common than its South American counterpart.12,17,19
Pathophysiology
There are several different components to Loxosceles
venom. The primary component, sphingomyelinase,
is responsible for the dermonecrotic lesions.6,17 In
addition, the effect of sphingomyelinase D on the
red blood cell membrane activates metalloproteases,
ultimately leading to hemolysis.17
Clinical Presentation
After a bite from a Loxosceles spider, 1 of 4 events
can occur: (1) no effects are seen; (2) pain and ery-
thema are present without systemic manifestations
or sequelae; (3) dermonecrotic injury occurs with
eschar formation; or (4) systemic manifestations oc-
cur.8,17 The initial bite is often painless, and patients
may not immediately be aware of the bite.17 Over
the next several hours, erythema, pruritus, and a
burning pain may develop. The bite area itself can
become pale in appearance, and the surrounding
tissues may become erythematous and edematous.
More-severe envenomations can develop a central
blue-gray wound accompanied by a bull’s eye lesion
Figure 3. Brown Recluse Spider
(Loxosceles reclusa)
Content provider: CDC/ Margaret Parsons. Available at: https://phil.cdc.
gov/Details.aspx?pid=1125
5 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
with an erythematous center, a white ring of indura-
tion, and an outer cyanotic ring,8,12,17 sometimes
referred to as a red, white, and blue appearance.
(See Figure 4.) Hemorrhagic vesicles can form over
the next several days following the bite and prog-
ress to a central area of necrosis and ulceration.
An eschar may form and ultimately dehisce over
several weeks.8,9,12,17
Rarely, systemic manifestations (known as sys-
temic loxoscelism or cutaneous-hemolytic loxosce-
lism) may occur. Systemic manifestations of Loxos-
celes envenomation are more common in pediatric
patients than adults.20 Early manifestations include
low-grade fever and arthralgia,20 followed by gastro-
intestinal complaints, disseminated intravascular co-
agulation, and hemolysis. Rhabdomyolysis and renal
failure typically develop 48 to 72 hours after the en-
venomation, although earlier cases have been docu-
mented.20 If systemic involvement is suspected, serial
hemoglobin levels and plasma free haptoglobin
levels should be obtained. Other laboratory markers
of hemolysis (including lactate dehydrogenase and
indirect bilirubin levels) as well as serial creatinine
and creatine kinase levels should be obtained. The
presence of hemoglobinuria should raise concern for
systemic manifestations.20
Laboratory studies are not routinely indicated
for all Loxosceles envenomations, however, and
should be reserved for individuals with systemic
complaints, such as weakness, fatigue, and pallor.
The diagnosis of cutaneous loxoscelism is clinical. It
is imperative that the patient is located in the cor-
rect geographic distribution of the spider and that
other etiologies, such as infectious etiologies, have
been excluded prior to making the diagnosis of L
reclusa envenomation.
Figure 4. Brown Recluse Spider Bite
Appearance
Reproduced from BMJ Case Reports, Rare case of dermonecrosis
caused by a recluse spider bite in Europe, Monique Cachia, Liam
Mercieca, Charles Mallia, et al, volume 2016, copyright 2016, with
permission from BMJ Publishing Group Ltd.
SEPTEMBER 2021 • www.ebmedicine.net 6
Treatment
Most lesions from recluse spiders require no specific
intervention. In cases of wounds with large cutaneous
lesions, local wound care should be provided, and the
patient’s tetanus vaccination status should be updated,
as indicated. Urgent excision of the wound is not
recommended, as it may result in prolonged recovery
times and possibly worsened cosmetic outcomes. If an
eschar does develop, no surgical intervention should
be performed until after the lesion has become well
demarcated. In such cases, delayed surgical interven-
tion (including skin grafting) may be needed, but this
typically should not be performed for several weeks to
months after the initial envenomation.
There are also inadequate data to recommend
routine prophylactic antibiotics, vasodilators, anti-
histamines, corticosteroids, hyperbaric oxygen, or
polymorphonuclear cell inhibitors (eg, dapsone or
colchicine).6,12 While dapsone was once used, it is no
longer recommended due to low-quality evidence of
its effectiveness in this setting. The use of systemic cor-
ticosteroids should be considered in cases of systemic
loxoscelism, although data are somewhat conflicting.
Disposition
Patients with suspected cutaneous loxoscelism can be
treated in the outpatient setting. If a patient has any
systemic symptoms, however, observation in a moni-
tored setting for at least 24 hours is recommended.
Patients who lack systemic manifestations in the ED
following the initial bite can be discharged home with
strict return precautions, including returning immedi-
ately should any systemic manifestations occur.
n Hymenoptera
The order Hymenoptera contains 3 medically impor-
tant families: Apidae (honeybees and bumblebees),
Vespidae (yellow jackets, wasps, and hornets), and
Formicidae (fire ants). (See Figure 5, page 7.)
Bees and Wasps
Epidemiology
Hymenoptera envenomations are some of the most
common in the United States. Hymenoptera are
fairly passive animals, and they avoid humans unless
disturbed. Paper wasps and bumble bees live in hives
containing 100 to 200 insects, and they are not often
involved in mass envenomations. Social wasps (which
include hornets and yellow jackets) and honeybees
can be involved in massive envenomations, especially
if their colonies are threatened.
Yellow jackets are 10 to 15 mm in length, whereas
hornets are 15 to 40 mm in length. These insects re-
side in colonies of several hundred to a few thousand
insects. The stingers of vespids (eg, yellow jackets,
wasps, and hornets) and bumblebees are not barbed,
and the insect can pull its stinger out of flesh after
©2021 EB MEDICINE
stinging without killing itself, allowing bumblebees
and vespids to sting multiple times.
Honeybees (Apis mellifera) generally reside in
colonies consisting of approximately 40,000 worker
bees and 1 queen bee. The stinger of a honeybee
is barbed, causing it to remain in mammalian flesh.
Because the stinger of the honeybee is attached to its
abdomen, any attempt at removing the stinger results
in disarticulation of that portion of the abdomen and
death of the honeybee.
The Africanized honeybee (Apis mellifera scutel-
lata) was originally introduced in Brazil in an effort to
make honey manufacturing more effective. In 1957,
the bees from 26 hives escaped and have gradu-
ally migrated north.21 Africanized insects are slightly
smaller, but, unlike their non-Africanized counterpart,
they frequently swarm in large groups. In addition,
these bees are capable of long flights without stop-
ping and will often attack following minimal provoca-
tion. While the venom components are not signifi-
cantly different from their European counterparts, the
large number of stings associated with the Africanized
honeybees’ swarming makes them potentially fatal, as
the cumulative venom dose is much greater.21 African-
ized honeybees are attracted to carbon dioxide and
selectively target the head and neck region.
Most cases of human toxicity from bee stings
occur as a result of an IgE-mediated anaphylactic
reaction, presenting with classic diffuse urticarial
hives, bronchoconstriction, and hypotension. Deaths
due to anaphylaxis are more common than anaphy-
lactoid reactions. Because massive envenomations
result in anaphylactoid reactions, pediatric patients
are somewhat more predisposed to life-threatening
envenomations, as there is a relatively greater
amount of venom in each sting on a per-kilogram
body-weight basis.
Pathophysiology
The venom of virtually all Apis species (eg, honeybee
and bumblebee) is similar, with small variations in
composition. The primary component of honeybee
venom is melittin, which causes toxicity by inserting
itself into the phospholipid bilayer of the cell mem-
brane, resulting in the destruction of red blood cells,
platelets, and the vascular endothelium. In addition
to melittin, the phospholipase A2 enzyme is another
prominent component of honeybee venom and is
considered the primary allergen.13,21,22 Hyaluronidase,
another component, can increase tissue permeabil-
ity.13,21 Other components cause histamine release
and inflammatory reactions.
Other than anaphylactic reactions in patients with
a prior immune reaction and allergy to honeybees,

Figure 5. Hymenoptera: Bees, Wasps, Hornets, and Fire Ants

A B C

D E F
A. Honeybee (Apis mellifera carnica). Source: https://commons.wikimedia.org/wiki/File:Apis_mellifera_carnica_worker_hive_entrance_2.jpg Author:
Makro Freak, Richard Bartz, Munich Makro Freak & Beemaster Hubert Seibring. Used under the Creative Commons Attribution-Share Alike 2.5
Generic license. https://creativecommons.org/licenses/by-sa/2.5/deed.en
B. Bumble bee. Source: https://commons.wikimedia.org/wiki/File:The_flight_of_the_bumble_bee_(8692773501).jpg Author: marsupium photography.
Used under the Creative Commons Attribution-Share Alike 2.0 Germany license. https://creativecommons.org/licenses/by-sa/2.0/deed.en
C. Wasp (Vespula vulgaris). Source: https://commons.wikimedia.org/wiki/File:Vespula_vulgaris5.jpg Author: Holger Gröschl. Used under the Creative
Commons Attribution-Share Alike 2.0 Generic license. https://creativecommons.org/licenses/by-sa/2.0/de/deed.en
D. Hornet (Vespa crabro). Source: https://commons.wikimedia.org/wiki/File:Vespa_crabro-lateral.jpeg Author: Niek Williems. Used under the Creative
Commons Attribution-Share Alike 2.5 Generic license. https://creativecommons.org/licenses/by-sa/2.5/deed.en
E. Paper Wasp (Polistes dominulus). Source: https://commons.wikimedia.org/wiki/File:Polistes_dominulus_fg01.JPG Author: Fritz Geller-Grimm. Used
under the Creative Commons Attribution-Share Alike 2.5 Generic license. https://creativecommons.org/licenses/by-sa/2.5/deed.en
F. Red Fire Ant (Solenopsis invicta). Adobe Stock Photo: 305823900.

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most envenomations result in local pain, erythema,
and edema. Massive envenomations, however, can
result in significant systemic manifestations regard-
less of prior immune reaction or exposure. Based on
animal models, it has been estimated that the median
lethal number of stings is 18 stings per kilogram body
weight.23 However, deaths have been reported with
as few as 125 stings.24 Severe systemic toxicity can
occur with far fewer stings.24 Systemic manifestation
after massive envenomations can include gastrointes-
tinal complaints (eg, vomiting and diarrhea). Third-
spacing of fluids and edema can occur, with resultant
hypotension and shock. Hemolysis, rhabdomyolysis,
hepatic injury, renal failure, cardiac toxicity, and
multisystem organ failure can ensue.21,24 Importantly,
many of these manifestations may not be apparent
immediately, and may develop within 8 to 12 hours.
Treatment
Research has demonstrated that nearly all of a bee’s
venom is injected within 30 seconds of the sting.25
Therefore, the initial management of victims of bee
envenomations should not focus on removal of the
stingers. In the past, it was suggested that a credit
card or other object should be used to scrape out
the stinger (rather than pulling it out with tweezers
or forceps) to avoid further release of venom. How-
ever, because it is now recognized that the stinger is
essentially deplete of venom by the time the patient
reaches the hospital, the method of removing the
stinger is inconsequential.25 Although removal need
not be a priority step in management, stingers are a
foreign body and potential irritant, and they should
be removed when the patient is stabilized. lethal due to either anaphylaxis or massive envenom-
The first step in management of Hymenoptera
envenomation is to ensure that the patient has a pat-
ent airway. Facial edema may develop and, if there is
concern for airway compromise, endotracheal intuba-
tion may be required. Aggressive resuscitation should
be provided with IV crystalloid fluids at a starting dose
of 20 to 40 mL/kg, up to a maximum of 2 L. Additional
fluid therapy should be guided by clinical response.
Systemic corticosteroids (eg, 1-2 mg/kg of IV
methylprednisolone) should be administered as soon
as possible. Patients with hypotension or evidence
of shock should receive epinephrine, which can be
administered either as an intramuscular (IM) injection
(0.15 mg for patients weighing 15-30 kg; 0.3 mg for
patients weighing ≥30 kg) or as a continuous IV infu-
sion (starting dose 0.1 mcg/kg, titrating up). Typically,
2 IM doses are attempted before IV epinephrine is
initiated. Antihistamines and analgesics should be
administered based on the patient’s symptoms. It is
important to recognize that, regardless of whether a
patient is experiencing an anaphylactic reaction or an
anaphylactoid reaction, the immediate treatment is
essentially the same. Hymenoptera envenomations are
best treated with a combination of antihistamines (H1
SEPTEMBER 2021 • www.ebmedicine.net 8
antagonists [1 mg/kg IV or oral diphenhydramine] and
H2 antagonists [0.5 mg/kg/dose famotidine every 12
hours, max 40 mg]), corticosteroids, and epinephrine.
For pediatric patients who have between 2 and
50 stings (or <2 stings/kg), laboratory parameters
should be obtained at presentation and at 6 hours af-
ter presentation. These laboratory tests should assess
for renal injury, hepatic injury, cardiac injury, rhabdo-
myolysis, hemolysis, and coagulopathy.
Disposition
Patients with systemic manifestations should be admitted
to an intensive care unit (ICU). Because of the potential
for delayed onset of many symptoms, a child who has
≥50 honeybee stings (or ≥2 stings/kg for children weigh-
ing <25 kg) should be admitted to a monitored setting
for 24 hours.6 If renal injury, hepatic injury, cardiac injury,
rhabdomyolysis, hemolysis, or coagulopathy are pres-
ent, the patient should be admitted to an ICU, regardless
of the number of stings. Patients who suffer systemic
manifestations as a result of an anaphylactic reaction (but
not necessarily from a massive envenomation) should be
given a prescription for an epinephrine autoinjector and a
referral to an allergist upon discharge.
Fire Ants
Epidemiology
The majority of fire ants that envenomate humans and
affect crops are red fire ants (Solenopsis invicta), which
were accidentally introduced to Alabama from Brazil in
the 1940s. These ants migrated out of Alabama, and
are now found throughout the southern United States,
from Virginia to California.26 Fire ant stings may be
ation. As with other Hymenoptera, fatalities due to
anaphylaxis often occur shortly after the envenom-
ation, whereas death from massive envenomation may
occur more than 24 hours after the event.27
Fire ants are typically 3 to 4 mm in length,
although the queen fire ant can be up to 1 cm in
length. Mounds with multiple queens can contain
up to 500,000 worker fire ants. Unlike other Hyme-
noptera that primarily attack when threatened, fire
ants are aggressive without provocation. Attacks on
livestock and wildlife are common, and indoor attacks
on debilitated humans (eg, nursing home patients)
are increasingly being reported.28,29 Prior to stinging,
the fire ant bites its prey, locking its mandibles into
the soft tissue of the prey. The fire ant then stings the
victim and withdraws the stinger (the stinger is not
barbed). While remaining attached to the victim with
the strong mandible, the fire ant will rotate its body
and sting again multiple times.27
Pathophysiology
The venom of fire ants is a water-insoluble alkaloid.26
The primary components of the venom include a
hyaluronidase, a phospholipase, and the enzyme
©2021 EB MEDICINE
N-acetyl-beta-glucosaminidase. The venom has
hemolytic, cytotoxic, and neurotoxic components that
inhibit sodium-potassium adenosine triphosphatase,
reduce cellular respiration, and uncouple oxidative
phosphorylation. In addition, the venom can result
in impaired neutrophil and platelet function, which
activates the coagulation system and results in a
hypercoagulable state.29
Clinical Presentation
Following envenomation, a characteristic pattern of
toxicity can be observed. A local wheal and flair char-
acterized by a central edematous papule surrounded
by a pink-colored halo can occur within 20 minutes of
the exposure.28,30 This lesion is typically 25 to 50 mm
in diameter. Approximately 2 hours after the appear-
ance of the wheal, vesicles or pustules can develop.
The fluid inside the vesicles is initially clear, but
becomes cloudy within 8 hours; although cloudy, the
contents of the pustule are typically sterile.26 Necrosis
can develop within 24 hours. Some patients can de-
velop large local reactions that are IgE-mediated and
mast cell-dependent. Occasionally, these lesions are
large enough to cause vascular compromise.30 Histo-
logically, a classic triad can be observed, consisting of
a subepidermal pustule, dermal neutrophilic infiltrate,
and basophilic collagen degeneration.26
While anaphylactic reactions can occur in pre-
disposed individuals who are stung a single time,
systemic manifestations of massive fire ant envenom-
ation typically require a minimum of 50 to 100 stings.
These manifestations are a direct response to the
venom, and include rhabdomyolysis, disseminated in-
travascular coagulation, and seizures. Diffuse urticarial
rash, bronchoconstriction, and cardiovascular collapse
can also occur.27
Following envenomation by multiple fire ants,
serum laboratory tests such as creatine kinase and a dis-
seminated intravascular coagulation profile (prothrom-
bin time, platelets, fibrinogen, D-dimer, and/or fibrin
split products) may be indicated to assess for rhabdo-
myolysis or disseminated intravascular coagulation.
While exact recommendations are lacking, it is prudent
to check laboratory studies on patients with multiple
bites, especially pediatric patients, elderly patients,
and any patient with systemic involvement.
Treatment
Treatment for cutaneous symptoms is largely support-
ive. Antihistamines, topical corticosteroids, and cool
compresses are often used. Topical or subcutaneous
lidocaine may be used for patients with severe pain.
Patients with systemic toxicity should receive aggressive
supportive care in an ICU. Hypotension should be treat-
ed with IV fluid resuscitation (eg, 20 mL/kg crystalloid
fluids for pediatric patients), as well as with epinephrine
as either an IM injection or as a continuous IV infusion.
Systemic corticosteroids and antihistamines should be
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administered as well. See the “Treatment” section for
Bees and Wasps on page 8 for dosing information.
Disposition
Patients with ongoing pain should be observed for
6 hours to ensure that systemic symptoms do not
develop. Patients with severe pain or systemic mani-
festations should be observed for 12 to 24 hours.
If no further symptoms develop, the patient can be
discharged home.
n Scorpions
Epidemiology
While there are >1400 species of scorpions worldwide,
only 30 are capable of producing clinically relevant
envenomation. The only scorpion in the United States
that is potentially lethal is the bark scorpion (Centru-
roides sculpturatus). (See Figure 6.) This scorpion,
which resides primarily in Arizona, is a tan-brown color
and ranges from 1.3 to 7.6 cm in length.31 It is the only
North American scorpion capable of walking up a ver-
tical wall. The scorpion body consists of 4 pairs of legs,
a pair of grasping claws, mouthparts, a thorax, and a
tail. The tail is a 6-segmented structure extending from
the abdomen and terminating in a pointed telson that
contains paired venom glands and the stinger.
While scorpion stings are quite common in the
southwestern United States, most cases result in only
minor toxicity. Despite stings to adults being more
common, children are disproportionately severely en-
venomated and are more likely than adults to require
intensive supportive care.32 In the 1930s, there were
40 deaths reported due to scorpion envenomations,
with most of these cases occurring in infants and
children.33 Due to improvements in access to care as
Figure 6. Bark Scorpion (Centruroides
sculpturatus)
Source: https://commons.wikimedia.org/wiki/File:Bbasgen-scorpion-front.
jpg. Author: Musides. Used under the Attribution-ShareAlike 3.0 Unported
license. https://creativecommons.org/licenses/by-sa/3.0/deed.en
9 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
well as the medical care itself, deaths due to scorpion
envenomations are currently extremely rare.1
Pathophysiology
The venom of the bark scorpion is a complex mixture
of various proteins, including neurotoxins that act on
the sodium channels during their depolarized state,
resulting in inactivation of the channel. The end result
is a prolonged action potential and increased and
repetitive axonal firing that causes increased release
of acetylcholine and catecholamine.31
Clinical Presentation
Following a scorpion sting, most patients exhibit
relatively minor symptoms, primarily local pain that
typically presents immediately (if present), and the
symptoms progress over the next hour. Because the
venom lacks dermonecrotic components, the sting
site is often not visible. In cases of diagnostic uncer-
tainty, a tap test (in which tapping the envenomated
area elicits a painful reaction) can assist in establishing
the diagnosis.
A grading system has been developed to classify
scorpion envenomations and aid in the determination of
which patients should receive antivenom. (See Table 2.)
A grade I envenomation results in pain and/or pares-
thesias confined to the envenomation site. A grade II
envenomation has pain and/or paresthesias both at
the sting site as well as in surrounding tissues. Grades
III and IV envenomations are characterized by the pres-
ence of either cranial nerve or skeletal muscle dysfunc-
tion (grade III), or both cranial nerve dysfunction and
skeletal muscle dysfunction (grade IV).32,34
Most patients with high-grade envenomations
have tachycardia, hypertension, and diaphoresis. Vom-
iting occurs in approximately one-third of patients with
severe toxicity, and it typically occurs relatively early in
the clinical course and resolves spontaneously.33 Cra-
nial nerve abnormalities include tongue fasciculations,
opsoclonus-like roving eye movements, and bulbar
muscle dysfunction resulting in impaired swallowing.
Drooling is common, and aspiration is possible.6,34,35
Commonly encountered neuromuscular abnormalities
include fasciculations, opisthotonos, ataxia, and flailing
of the extremities.6,31,35
Table 2. Scorpion Envenomation
Grading32 symptoms or those with severe symptoms who do not
Grade Signs/Symptoms
I Pain and/or paresthesias confined to the envenomation site
II Pain and/or paresthesias both at the sting site as well as in
surrounding tissues
III Either cranial nerve dysfunction or skeletal muscle
dysfunction
IV Both cranial nerve dysfunction and skeletal muscle
dysfunction
SEPTEMBER 2021 • www.ebmedicine.net 10
Treatment
Historically, antivenom therapy consisted of whole
IgG derived from goat serum. However, its antibody
structure caused high immunogenicity with both im-
mediate (anaphylactoid) and delayed (serum sickness)
hypersensitivity reactions.36 Manufacturing of this
antivenom was discontinued in 2001. After remaining
supplies of the antivenom were exhausted, support-
ive care was the only option available to patients
outside of clinical trials. During the time when anti-
venom was not available, 20% of pediatric patients
presenting with high-grade scorpion envenomations
in Arizona required endotracheal intubation for re-
spiratory failure.36 In August 2011, an equine-based
Centruroides (scorpion) immune F(ab’)2 antivenom
(Anascorp®) was approved by the FDA for the treat-
ment of severe scorpion envenomations. The recom-
mended initial starting dose of Anascorp® is 3 vials,
with additional vials given as needed. The number of
vials is independent of the patient’s weight; thus, the
starting dose is the same for both children and adults.
However, a retrospective study found that 1-vial serial
dosing was as effective as 3-vial full dosing, with chil-
dren in both groups having resolution of symptoms
within 4 hours of therapy initiation. No additional
complications or adverse clinical outcomes were ob-
served in the 1-vial serial dosing group.37
Because of the high cost of Anascorp®, some cli-
nicians may prefer aggressive supportive care rather
than antivenom administration.36 Supportive care
includes parenteral opioid analgesics for pain (eg,
fentanyl 1-2 mcg/kg IV) in conjunction with benzodi-
azepines for neuromuscular hyperactivity (eg, mid-
azolam 0.01-0.05 mg/kg IV). While most patients who
are envenomated develop minimal—if any—symp-
toms, the clinician treating patients with high-grade
envenomations must be prepared to provide aggres-
sive supportive care that may include endotracheal
intubation with mechanical ventilation.
Disposition
Patients with North American scorpion stings can
be discharged if all of the following criteria are met:
(1) symptoms are controlled with oral medication or
symptoms resolve after antivenom administration,
(2) vital signs have normalized, and (3) there are no
clinical findings of aspiration following an observation
period of several hours. Patients who have persistent
receive antivenom should be admitted to the hospital
for further treatment and observation.
n Snakes
Epidemiology
Worldwide, venomous snakes account for more cases
of severe morbidity and mortality than any other
animal. It is estimated that nearly 2.5 million individu-
©2021 EB MEDICINE
als are bitten by venomous snakes annually, with
125,000 individuals dying as a result of these enven-
omations.38 There are approximately 3000 unique
species of snakes, of which 600 are venomous and
200 are medically important.38 Venomous snakes that
are indigenous to the United States include Crotali-
nae (pit vipers) and Elapidae (coral snakes). The North
American pit vipers (named for the heat-sensing
pit on the head of the snake) include copperheads,
rattlesnakes, and cottonmouths. In the United States,
it is estimated that 9000 individuals will be bitten by
venomous snakes annually, resulting in 5 deaths.39
The North American Snakebite Registry (NASBR), a
national database of prospectively collected data on
snakebites, reported 450 snakebites across 10 states
between 2013 and 2015, almost all of which were pit
viper envenomations.40 Rattlesnakes are responsible
for the majority of the envenomations and for the
greatest amount of morbidity and mortality.
While snake venoms are quite heterogeneous
among different species, they all serve 3 main pur-
poses: (1) acquisition of prey, (2) digestion of prey,
and (3) defense from real or perceived threats. Venom
contains low-molecular-weight proteins and peptides
that are directly toxic to certain cell types and enzymes
that break down specific tissues or cell membranes.
The venom of the North American pit viper is directly
destructive to local tissues, causes increased capillary
permeability, and inhibits platelets and fibrinogen.
Some species contain a neurotoxic component. The
exact venom composition varies among different spe-
cies of snakes and even differs within a given snake
species, depending on the time of year, the age of the
snake, and its geographic location.
Crotalinae
Crotalinae snakes have long, highly mobile, hollow
fangs that permit the snake to strike its prey and quickly
retreat. In approximately 75% of cases, venom is de-
posited in the subcutaneous tissue; the remaining 25%
of bites are “dry bites” in which no venom is injected.
Because venom can be deposited through either fang,
clinically relevant envenomations can occur even if there
is only a single puncture wound. Conversely, because
the snakes also have small teeth, some individuals will
have more than 2 puncture wounds noted.
Despite receiving a disproportionate amount of
venom compared to body weight, pediatric patients
do not present significantly differently from adults,
nor do they experience a difference in treatment
parameters or complications.41
Pathophysiology
The Mojave rattlesnake can contain either of 2 distinct
types of venom: A or B. Snakes that contain venom
A (which contains Mojave toxin) have a curare-like
mechanism of action that can result in a nondepolariz-
ing neuromuscular blockade. Clinically, a descending
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paralysis would be observed. Most Mojave rattle-
snakes contain venom B, and thus lack any significant
neurotoxicity. The Southern Pacific rattlesnake (C
oreganus helleri) can also produce neurologic toxicity,
including ataxia and dysarthria.
Various metalloproteinases are associated with
the hemorrhagic effects in Crotalinae venom. These
metalloproteinases destroy the capillary basement
membrane and capillary endothelial cells, ultimately
resulting in edema and ecchymosis;42 platelets then
occlude damaged capillaries. The venom can also
affect the coagulation cascade, resulting in coagu-
lopathy. Because the venom does not activate factor
XIII, fibrin cross-linking does not occur, and the body’s
endogenous fibrinolytic system degrades the ineffec-
tive clot, resulting in hypofibrinogenemia and fibrino-
lysis.42 Thrombocytopenia can occur relatively early
after envenomation, due to platelet aggregation,
sequestration, and consumption.43
Patients with rattlesnake envenomations can
also develop late hematologic toxicities,44,45 such
as recurrent or delayed-onset thrombocytopenia
and/or coagulopathy. Recurrent hematologic
toxicities are characterized by abnormal hematologic
laboratory findings during the index hospitalization
that improved with antivenom, to again become
abnormal several days later. Late hematologic toxicity
is characterized by the development of new abnormal
hematologic laboratory parameters at least 4 days
after the envenomation.45
Clinical Presentation
Nausea, vomiting, and tachycardia may occur shortly
after a Crotalinae bite. Hypotension may occur and
may be multifactorial in origin (pre-existing dehydra-
tion and third-spacing of fluids from increased capillary
permeability). While rare, hypotension can also occur
in the setting of anaphylactoid reactions, and other
manifestations of anaphylactoid reactions, such as
bronchospasm and urticarial rash, may be present.
Typically, within a few hours of venom deposition,
pain and edema occur. However, the onset of edema
may be delayed or less impressive in children than
in adults, especially in children with lower extrem-
ity envenomations. Following venom deposition,
the venom is absorbed and transported through
the lymphatic system. Individuals will often develop
tenderness over the proximal lymph nodes (eg, the
femoral lymph nodes in lower extremity bites and
the axillary lymph nodes in upper extremity bites).
Patients envenomated by pit vipers often complain
of a metallic taste in their mouth.42 Localized neuro-
muscular effects (eg, fasciculations and myokymia)
may be present, depending on the specific species of
snake. Local oozing is often noted from the puncture
wounds. However, even with associated profoundly
abnormal laboratory values, clinically significant hem-
orrhage is very uncommon.
11 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
 The initial evaluation of a patient with a suspected
pit viper envenomation should focus on a thorough his-
tory and physical examination. Table 3 provides ques-
tions to ask while taking the history. Serial examinations
should be performed every 15 to 30 minutes to assess
for progression of edema.42 Some experts advocate
for marking the leading edge by drawing a line on the
skin and assessing when and where the edema stops.
Because this method is often subjective, others advo-
cate for serial measurements of the circumference of
the mid-foot, mid-calf, and mid-thigh (in lower extrem-
ity bites), or mid-hand, mid-forearm, and mid-upper
arm (in upper extremity bites). When using the latter
method, it is important to mark the area measured, so
serial measurements are taken at the same location.
Laboratory studies (including a CBC, prothrombin
time, and fibrinogen level) should be obtained. The
CBC may reveal thrombocytopenia, but it may also re-
veal elevated hemoglobin due to hemoconcentration.
In the absence of any abnormalities on the initial blood
work or physical examination, these laboratory param-
eters should be repeated in 6 to 8 hours. Patients may
also develop early hematologic toxicities that may be
present on admission or within the first several hours
after envenomation. Such hematologic abnormalities
include either thrombocytopenia and/or coagulopathy,
which can be characterized by a low fibrinogen and or
an elevated prothrombin time.
Treatment
The envenomated limb should be splinted in extension
and elevated at the level of the heart. Pressure immo-
bilization bandages are not recommended for man-
agement of North American Crotalinae snake bites.36
Tourniquets, ice, and suction devices were once con-
sidered desirable field treatments for North American
snake bites, but mounting evidence discourages their
use in the field or in the ED. Analgesics should be
administered liberally, and opioids are preferred. Due
to lack of histamine release, fentanyl (1-2 mcg/kg IV)
is often considered the preferred opioid. Nonsteroidal
anti-inflammatory drugs (NSAIDs) should be avoided
due to their antiplatelet effects.
While extremity edema can be impressive and
may be difficult to distinguish from compartment
syndrome, true compartment syndrome following
North American pit viper bites is very uncommon.
Fasciotomy should not be performed without clearly
Table 3. Obtaining the History of Snake
Bites
• Did you see the snake?
• Did the snake have any distinct markings?
• Did the snake have a rattle?
• What were you doing when you were bitten?
• Have you previously been envenomated by a snake?
• If so, did you receive antivenom?
www.ebmedicine.net
SEPTEMBER 2021 • www.ebmedicine.net 12
documented elevated compartment pressures de-
spite administration of additional antivenom.6,42 Co-
agulopathy should be corrected prior to fasciotomy.
Patients with coagulopathy, thrombocytopenia,
or significant progressive edema should receive
antivenom.6,42 There are now 2 antivenom products
approved for use in the United States: Crotalidae
polyvalent immune Fab (CroFab®), FDA-approved for
use in 2000; and Crotalidae equine immune F(ab’)2
(Anavip®), FDA-approved for use in 2015. Both
antivenoms are approved for the treatment of rattle-
snake, copperhead, and cottonmouth bites.
CroFab® is a lypholized powder that requires slow
reconstitution with gentle stirring to avoid formation
of bubbles and to avoid the breakdown/denaturing of
the protein, which would render it useless. CroFab®
is made from the venom of 4 snake species: Crotalus
atrox (Western diamondback), C adamanteus (Eastern
diamondback), C scutulatus (Mojave rattlesnake), and
Agkistrodon piscivorus (cottonmouth). Four flocks
of sheep are immunized utilizing the venom of the
different snakes. The serum is then obtained, and
the antibodies are separated from the serum. Papain
is used to cleave the antibody to obtain the Fab
fragment. Adult and pediatric patients who present
with hemodynamic instability or other immediate
life-threatening events should receive 8 to 12 vials of
CroFab® antivenom.43 For all other patients with evi-
dence of toxicity, an initial dose of 4 to 6 vials of Cro-
Fab® antivenom should be administered, and repeat
laboratory tests should be obtained 1 hour after the
infusion is complete. If laboratory parameters worsen
or if edema progresses, the initial dose should be
repeated. The current FDA-approved dosing regimen
recommends 2 additional vials of antivenom admin-
istered at 6, 12, and 18 hours after initial control is
achieved. Many toxicologists have moved away from
routine maintenance dosing, and rather employ an
“as needed” approach, in which scheduled mainte-
nance doses are not administered, and additional
antivenom is administered based on progression of
edema or worsening laboratory parameters.46 There is
no dosing adjustment required for pediatric patients.
Anavip® is made from the venom of the snakes
Bothrops asper (fer-de-lance) and C durissus (South
American rattlesnake). Horses are immunized utilizing
the venom, and antibodies are then isolated from the
serum. Pepsin is used to cleave the antibody to obtain
a V-shaped F(ab’)2 fragment. Anavip® reconstitutes
more quickly than CroFab®, has been shown to reduce
late hematologic toxicities, and requires no routine
maintenance dosing compared to CroFab®, although
overall comparative data are quite limited.3,47 The
current FDA-approved regimen for Anavip® dosing is
10 vials administered initially for all patients with toxic-
ity, with monitoring and retesting parameters similar
to CroFab®. Dosing of Anavip® should be repeated
(with 4 vials) as necessary to achieve control of enven-
©2021 EB MEDICINE
omation; once symptoms and laboratory findings
stabilize, no additional dosing is routinely neces-
sary.48 All patients who receive either antivenom
should also receive an IV crystalloid fluid bolus of at
least 20 mL/kg. Patients with copperhead bites often
require only a single dose of 4 vials of CroFab®,42
but patients can be redosed in the rare instance of
recurrent symptoms.
The initial dose of antivenom should be admin-
istered in a minimum volume of 250 mL of normal
saline. The infusion should begin at 25 mL/hr and be
doubled steadily every 5 to 10 minutes, such that the
full infusion should be completed in just over 1 hour.
With each rate increase, evidence of anaphylactoid
reaction should be assessed. If an anaphylactoid
reaction occurs, the infusion should be stopped, and
1 mg/kg of IV diphenhydramine should be adminis-
tered. If continuation of the antivenom is indicated,
the infusion should be restarted at a lower rate, with
concurrent infusion of epinephrine, if required. While
the rates of anaphylactoid reactions are much lower
with CroFab® antivenom than with the previously
used Wyeth antivenom, it is still recommended that
antihistamines, corticosteroids, and epinephrine
should be immediately available when administering
antivenom. Overall, adverse events are similar be-
tween CroFab® and Anavip®.3,47
Unless a patient with a pit viper bite is actively
bleeding or requires an emergent surgical procedure,
platelets should not be transfused, as the toxin will
destroy them as well as the patient’s native platelets.
Early thrombocytopenia should resolve with antive-
nom administration. When antivenom is administered
for swelling, the limb should not be expected to
return to normal size at the time of treatment; the
antivenom should halt progression of swelling only.
In addition to antivenom administration, ad-
equate supportive care should be ensured. Patients
should have local wound care, including debridement
of any hemorrhagic blebs that form. Tetanus vaccina-
tions should be updated, as indicated. Due to the in-
nate antimicrobial properties of venom, prophylactic
antibiotics are not recommended.
Disposition
Patients who have an apparent dry bite (no cutane-
ous signs of edema and normal laboratory studies at
both initial presentation and 6-8 hours later) can be
discharged home. Other patients without any evidence
of toxicity based on examination or laboratory param-
eters should be observed for 8 hours and then con-
sidered for discharge to home. Pediatric patients with
lower extremity bites are at an increased risk for de-
layed edema, so they should be observed for 12 to 24
hours.41,42 Observation for 24 hours should be strongly
considered for pediatric patients with lower extremity
bites due to the difficulty in appreciating subtle early
edema. It should be noted that, because antivenom
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stops the progression of edema but does not reverse
edema, the edema that is present may last up to sev-
eral weeks. Furthermore, upon discharge, if patients
put the extremity in a dependent position, edema
and pain will likely increase. Upon discharge, patients
should be given an adequate amount of analgesics,
but NSAIDs should be avoided. Patients with evidence
of toxicity, based on either the physical examination
or laboratory parameters, should be admitted to a
monitored setting for at least 24 hours. Patients with
moderate and progressive or severe toxicity should
be admitted to an intensive care setting for frequent
laboratory checks and close monitoring.
Because of the risk for late hematologic toxicity,
patients who receive antivenom, or who have mani-
festations of toxicity, should have laboratory param-
eters obtained at 3 to 5 days and at 5 to 7 days after
the last dose of antivenom.6 Retreatment thresholds
are complex, and should be discussed with a medical
toxicologist, especially because patients with late he-
matologic toxicity often respond poorly to additional
antivenom. Patients with manifestation of an enven-
omation should be admitted to the hospital.
Elapidae
Coral snakes are the only venomous elapids that
are indigenous to North America. These snakes
are brightly colored and easily identifiable by their
alternating red, yellow, and black color bands. Coral
snakes are often confused with the nontoxic king
snake. However, several features can be used to
distinguish these snakes. The red band touches the
yellow band in the coral snake, while the red band
touches the black band in the king snake, leading to
the well-known adage, “Red on yellow kills a fellow.
Red on black, venom lack.” (See Figures 7 and 8,
page 14.) Furthermore, coral snakes have a black
snout, while king snakes have a red snout.
Among the coral snakes, the Sonoran coral snake
(Micruroides euryxanthus), found in the Sonoran Des-
ert of Arizona and northern Mexico and in the south-
west corner of New Mexico, is generally not consid-
ered a medically important snake, as no case of severe
toxicity has been described following envenomation
by this snake. In contrast, the Eastern coral snake (M
fulvius) and the Texas coral snake (M tener) are much
more potent.
Pathophysiology
Unlike the fangs of rattlesnakes, coral snakes have
small, fixed, rear teeth, requiring the snake to remain
attached for up to several seconds in order for venom
delivery to occur. Consequently, the snake is unable
to strike rapidly; rather, it must “chew” on the victim
in order to inject venom.
Coral snake bites typically do not result in significant
tissue destruction. However, the neurotoxic effects
that do develop may do so in a delayed fashion.49
13 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
Neurologic effects include ptosis, bulbar muscle
weakness, fasciculations, and, ultimately, respiratory
arrest; the proximate cause of death in most coral
snake envenomations is respiratory arrest. Respiratory
paralysis can be delayed for up to 12 hours.49 Therefore,
all patients bitten by coral snakes, except the Sonoran
coral snake, should be admitted for observation.
Thrombocytopenia or coagulopathy should not be
expected following coral snake envenomation.
Figure 7. Coral Snake (Micrurus fulvius)
Source: https://commons.wikimedia.org/wiki/File:Coral_009.jpg. Author:
Norman.benton. Used under the Creative Commons Attribution-Share
Alike 3.0 Unported license. https://creativecommons.org/licenses/by-
sa/3.0/deed.en
Figure 8. Scarlet King Snake (Lampropeltis
elapsoides)
Source: https://commons.wikimedia.org/wiki/File:Scarlet_King_
Snake_(Lampropeltis_elapsoides)_(32391807822).jpg. Author: Peter
Paplanus. Used under the Creative Commons https://en.wikipedia.
org/wiki/en:Creative_Commons Attribution 2.0 Generic license https://
creativecommons.org/licenses/by/2.0/deed.en.
SEPTEMBER 2021 • www.ebmedicine.net 14
Treatment
There are no data demonstrating benefit from the use
of pressure immobilization bandages in clinical prac-
tice with North American neurotoxic elapid envenom-
ations; however, in unique situations in which there
is a significant delay to medical attention, pressure
immobilization bandages may be considered. Caution
should be used, since systemic absorption may be
increased if the bandage is applied too tightly.
In the past, it was thought that all patients bitten
by a coral snake should be admitted and receive
antivenom. However, Wyeth Pharmaceuticals discon-
tinued production of North American coral snake anti-
venom, and supplies are limited. For the past several
years, the FDA has extended the expiration dates for
the available antivenom due to the limited supplies.
Thus, one approach is to observe all patients with
potential coral snake bites in a monitored setting for
24 hours. Antivenom should be reserved for patients
with neurologic abnormalities. At the first indication
of muscle weakness, 3 to 5 vials of antivenom should
be administered in 250 mL of normal saline (0.9%
sodium chloride). If respiratory insufficiency develops
and no antivenom is available, endotracheal intuba-
tion may be required.
A phase III study (NCT01337245) evaluating a
new antivenom for the treatment of coral snake bites
(an F(ab’)2 fragment; anticipated brand name Cor-
almyn®) has been conducted recently, though the
results have not yet been released.
Disposition
All patients bitten by a coral snake should be admit-
ted to the hospital to monitor for possible develop-
ment of neurologic toxicity.
n Venomous Lizards
Epidemiology
There are 2 venomous North American lizards: the
Gila monster (Heloderma suspectum), found in the
desert in the southwestern United States (eg, Arizona,
New Mexico), and the beaded lizard (H horridum),
primarily found in Mexico. Because these animals are
nocturnal and shy, and primarily bite only when being
handled, human bites from these lizards are relatively
uncommon.
Pathophysiology
The venom contains a mixture of enzymes including
phospholipase A2, hyaluronidase, serotonin, gilatoxin,
and vasoactive peptides. The hyaluronidase likely per-
mits the remainder of the venom to spread throughout
the tissues. The gilatoxin is responsible for inducing
hypotension and increasing bradykinin levels.
©2021 EB MEDICINE
Clinical Presentation
The lizards are known to latch on to their victim and
are often difficult to remove. The patient may com-
plain of severe pain. Hypotension and angioedema
are often encountered. Severe leukocytosis is com-
mon. No specific diagnostic tests are recommended,
but radiographs may be indicated to assess for
retained teeth.
Treatment
Treatment is largely supportive, as there is no an-
tivenom available. Hypotension should be treated
first with an IV crystalloid bolus, and if hypotension
persists, direct-acting vasopressors (eg, epinephrine
or norepinephrine) may be indicated. Corticosteroids
and diphenhydramine may be indicated for treatment
of angioedema. Patients with angioedema should be
intubated if there is concern for airway compromise.
Since these lizards “chew” versus strike, the
wound should be examined for embedded teeth.
Prophylactic antibiotics may be needed.
Disposition
Patients should be observed for 6 hours after the bite.
If there are no signs of toxicity, the patient can be dis-
charged. Angioedema warrants admission to the ICU.
n Special Populations
Pediatric patients, elderly patients, and debilitated
patients may be at higher risk for developing severe
systemic manifestations after a fire ant attack. Pedi-
atric patients are considered more likely to develop
high-grade envenomations following scorpion stings,
likely because they receive a higher amount of venom
on a per-kilogram basis. Patients on anticoagulants or
antiplatelet agents are at greater risk for hemorrhagic
complications following rattlesnake envenomation.50
In addition, pregnant women may be at increased risk
for toxicity after a snake bite.51
n Controversies and Cutting Edge
Anascorp® Dosing
The exact dosing of Anascorp® is controversial. The
FDA-approved dosing is 3 vials for patients with high-
grade envenomations (grade III or IV). However, recent
data indicate that 1 vial may suffice, without additional
complications or adverse clinical outcomes.37
Snake Bite Antivenom Dosing
CroFab® Maintenance Dosing
There is much debate about the need for routine main-
tenance dosing of CroFab®. While some literature has
demonstrated that routine maintenance dosing may
not be needed, others advocate for its routine use. A
study in Phoenix in which rattlesnake-envenomated pa-
tients were treated at the bedside by medical toxicolo-
GROUP SUBSCRIPTIONS: groups@ebmedicine.net
gists (experts at managing snake bite patients) found
shorter lengths of stay and less antivenom used in
the group that was given additional antivenom on an
as-needed basis compared to the group that received
routine maintenance dosing.46 However, the external
validity of that study has been questioned.
Ideal Antivenom Dosing for Patients With
Copperhead or Cottonmouth Envenomation
There is also some question regarding the ideal dosing
of antivenom for patients with copperhead or cotton-
mouth envenomations. Use of the same dosing recom-
mendations as for treatment of rattlesnakes has been
questioned. While hematologic toxicity can occur, it is
typically characterized only by pain and edema.
Anavip® Antivenom
In April 2021, Anavip® was approved for the treat-
ment of all North American pit viper envenomations.
Previously, it had FDA approval only for treatment of
North American rattlesnakes. Now, with the expand-
ed approval, it can be used for treatment of copper-
heads and cottonmouths, in addition to rattlesnakes.
n Time- and Cost-Effective Strategies
• Antivenom should not be administered empiri-
cally for all Crotalinae envenomations. Antivenom
should be administered only when there are
laboratory abnormalities (eg, thrombocytopenia,
coagulopathy, hypofibrinogenemia) or in the set-
ting of progressive swelling.
• Given the limited supply of antivenom, coral
snake antivenom should not be administered
empirically unless there is a manifestation of
neurologic compromise. Once the first sign or
symptom of toxicity develops, antivenom should
be administered.
• Fasciotomy should not be performed for pit viper
bites without clearly documented elevated com-
partment pressures that persist despite elevation
of the extremity and administration of additional
antivenom.
n Summary
While bites and stings from venomous animals are
somewhat rare, it is imperative that emergency clini-
cians correctly diagnose the bite or sting to allow for
proper treatment to be administered. Emergency
clinicians should be able to identify the envenomations
that require antivenom and those that can be treated
with supportive care or other methods. Knowledge
of current information on the treatment of pediatric
envenomations is key to proper care and disposition
of these patients. Patients with black widow spider
bites may present with severe abdominal or back pain,
along with fasciculations and diaphoresis. Treatment
15 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
 Risk Management Pitfalls for Terrestrial
Envenomations in Pediatric Patients
1. “I wanted to make the patient with the black
widow bite feel better without using opioids,
so I gave him Latrodectus antivenom. He had
an anaphylactoid reaction to the antivenom
and felt worse!” Reserve black widow (L mac-
tans) antivenom for individuals with end-organ
dysfunction or for those who have failed conser-
vative management with opioids and benzodi-
azepines. Antivenom should not be a first-line
therapy.
2. “The patient was bitten by a black widow. I
administered calcium, but the symptoms did
not improve.” Calcium is not recommended for
patients with black widow bites, as data have not
demonstrated its efficacy.
3. “This patient who resides in the Northeast
was diagnosed with a brown recluse bite 2
days ago. However, on examination today,
there appears to be significant cellulitis around
the bite.” Be extremely cautious about making
the diagnosis of a brown recluse bite in patients
who live in areas outside the typical geographic
distribution of the brown recluse spider. In such
situations, the lesions are much more likely to be
an abscess than a brown recluse bite. Do not mis-
take a necrotizing soft-tissue infection for a brown
recluse bite.
4. “We removed 200 bee stingers from the child,
but he was still hypotensive.” Do not delay the
initial resuscitation of a patient who presents fol-
lowing a massive Hymenoptera envenomation to
remove the stingers. Research has demonstrated
that 90% of a bee’s venom is injected within the
first 30 seconds after a sting, and virtually 100% is
injected at 1 minute. Therefore, the initial man-
agement of victims of massive Hymenoptera en-
venomations should not focus on stinger removal.
5. “The patient said he was stung by nearly 60
bees, but he looked good after 4 hours. We
assumed he was exaggerating, so we sent him
home. He returned in renal failure 2 days lat-
er.” Because of the potential for delayed onset of
many symptoms, a child who has ≥50 honeybee
stings (or ≥2 stings/kg for children weighing <25
kg) should be admitted to a monitored setting for
24 hours.
SEPTEMBER 2021 • www.ebmedicine.net 16
6. “The patient looked like he had a classic ana-
phylactic reaction, but he had not been stung
before.” Anaphylactic reactions to venom have
preformed antibodies, while massive envenom-
ations can result in anaphylactoid reactions without
any prior exposure. However, the treatment is the
same, and it should focus on ensuring airway pa-
tency and using IM epinephrine, IV fluid boluses,
H1 and H2 antagonists, and corticosteroids.
7. “To reduce absorption of the venom, we
applied a tight tourniquet to the arm of the
rattlesnake bite victim.” Do not apply ice, tour-
niquets, suction devices, or other similar objects
to the skin of a rattlesnake bite, as systemic ab-
sorption may actually be increased. The enveno-
mated limb should be splinted in extension and
elevated.
8. “The patient was bitten by a rattlesnake, but
he had only minor pain, so we gave him ibu-
profen.” Due to their antiplatelet effects, avoid
the use of NSAIDs for the treatment of pain as-
sociated with pit viper envenomation.
9. “My patient who was bitten by a rattlesnake
had impressive swelling and some skin necro-
sis, so we administered prophylactic antibiot-
ics.” Do not administer prophylactic antibiotics
for a Crotalinae envenomation. Antibiotics should
be reserved for patients in whom clinical signs or
symptoms of infection develop.
10. “The patient said the snake that bit him had a
combination of black, red, and yellow bands.
The patient didn’t have any symptoms, so we
assumed it was a king snake.” Do not mistake
a coral snake bite for a king snake bite simply
because of a lack of symptoms during the initial
ED evaluation. If there is concern that a snake
may have been an elapid and the patient was
in an area where neurotoxic coral snakes reside,
prolonged observation may be required to ensure
that delayed neurotoxicity does not develop.
©2021 EB MEDICINE
 Case Conclusions
The 8-year-old boy who presented after a bite by a rattlesnake...
The patient’s laboratory test results were as follows: hemoglobin, 17.5 g/dL; platelets, 52x109/L; prothrombin
time, 58 seconds; and fibrinogen, <5 mg/dL. The patient was administered 6 vials of Crofab® antivenom;
CASE 1

however, despite the initial loading dose of antivenom, the edema progressed, although there was some
improvement in the laboratory parameters when they were checked again. Because of the worsening edema,
an additional 6 vials of antivenom were administered, and edema progression halted. Subsequent laboratory
values were improved. The patient was admitted overnight for serial examinations, follow-up laboratory tests,
and additional antivenom therapy. After discharge, he was seen twice in follow-up and did not develop any
evidence of recurrent thrombocytopenia or coagulopathy. The patient made a full recovery.

The 9-year-old girl who presented after she complained of a “pinch” on her arm while raking leaves...
The patient’s laboratory findings were unrevealing, except for mild leukocytosis. On examination, you noted
CASE 2

a bull’s eye rash, consistent with a black widow envenomation. The patient's condition improved with ben-
zodiazepines and opioids. You confirmed that the use of antivenom in this patient may be more dangerous
than the actual envenomation, so given the patient's improvements with treatment, you did not administer
the antivenom.

The 17-month-old boy who presented after awakening crying in his crib shortly after midnight...
The patient was noted to be tachycardic and hypertensive. He was agitated, screaming, and appeared to
CASE 3

have noncontrollable movements of his arms and legs. In addition, roving eye movements were noted.
There were no lesions on the skin, but a positive tap test was noted on the foot, confirming your suspicion
of a bark scorpion envenomation. The patient was given 3 vials of scorpion antivenom with resolution of his
symptoms, and was discharged home a few hours after presentation.

should consist of benzodiazepines and opioids, with
antivenom being reserved for those who fail traditional
measures. Brown recluse envenomation may result in
significant local tissue injury, but debridement should
be delayed pending clear delineation of the extent
of necrosis. Corticosteroids can be administered for
systemic loxoscelism. Patients with Hymenoptera
envenomation may present with an anaphylactic reac-
tion if there is prior exposure; massive envenomation
presents similarly and is anaphylactoid owing to the
large amount of melittin injected. Treatment is largely
supportive, but corticosteroids should be administered
for massive envenomations. A bark scorpion sting can
cause significant neurotoxicity, especially in pediatric
patients, and patients with high-grade envenomation
may benefit from antivenom. Patients with snake bites
should be assessed carefully to determine whether
there are signs of toxicity or not (eg, a dry bite) and
administer antivenom appropriately.
n References
Evidence-based medicine requires a critical appraisal
of the literature based upon study methodology and
number of subjects. Not all references are equally
robust. The findings of a large, prospective, random-
ized, and blinded trial should carry more weight than
a case report.
To help the reader judge the strength of each refer-
ence, pertinent information about the study, such as the
type of study and the number of patients in the study is
included in bold type following the references, where
available. The most informative references cited in this
paper, as determined by the authors, are noted by an
asterisk (*) next to the number of the reference.
1. Gummin DD, Mowry JB, Spyker DA, et al. 2018 Annual report
of the American Association of Poison Control Centers’ National
Poison Data System (NPDS): 36th annual report. Clin Toxicol
(Phila). 2019;57(12):1220-1413. (Retrospective database review)
2. Seifert SA, Warrick BJ. Immunotherapy. In: Brent J, Burkhart
K, Dargan P, et al, ed. Critical Care Toxicology: Diagnosis and
Management of the Critically Poisoned Patient. 2nd ed. Cham:
Springer; 1997:2843-2857. (Textbook chapter)
3.* Bush SP, Ruha AM, Seifert SA, et al. Comparison of F(ab’)2
versus Fab antivenom for pit viper envenomation: a prospec-
tive, blinded, multicenter, randomized clinical trial. Clin Toxicol
(Phila). 2015;53(1):37-45. (Randomized controlled trial; 121
patients) DOI: 10.3109/15563650.2014.974263
4. Spyres MB, Lapoint J. Identification and management of marine
envenomations in pediatric patients. Pediatr Emerg Med Pract.
2020;17(4):1-24. (Review)
5. Stoecker WV, Vetter RS, Dyer JA. NOT RECLUSE-a mnemonic
device to avoid false diagnoses of brown recluse spider bites.
JAMA Dermatol. 2017;153(5):377-378. (Review)
6.* Levine M, Ruha AM, Graeme K, et al. Toxicology in the ICU:
part 3: natural toxins. Chest. 2011;140(5):1357-1370. (Review)
DOI: 10.1378/chest.11-0295
7. O’Connor AD, Ruha AM, Levine M. Pressure immobilization
bandages not indicated in the pre-hospital management of
North American snakebites. J Med Toxicol. 2011;7(3):251.

GROUP SUBSCRIPTIONS: groups@ebmedicine.net 17 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.

 Clinical Pathway for Management of Rattlesnake
Envenomation

Patient presents following a

rattlesnake bite

• Obtain vital signs, CBC, PT,

fibrinogen levels
• Splint limb in extension and elevate

Signs of envenomation
(eg, edema, shock, or abnormal
laboratory findings)?

NO YES

• Perform serial examinations over the • Administer:

next 6 hours l
6 vials of CroFab®
• Update tetanus vaccination as OR
needed l
10 vials of Anavip®
• Administer analgesics (eg, 1-2 mcg/kg
fentanyl IV), as needed
• Avoid NSAIDs
• Repeat laboratory tests 1 hr after
completion of antivenom infusion

Did signs/symptoms of envenomation

develop during the 6 hours of
observation? Laboratory findings worsening or edema
progressing?

NO YES
YES NO

Recheck CBC, PT, fibrinogen

• Administer additional antivenom Admit for serial examinations, serial
based on original antivenom given: laboratory studies, and possible
l
6 vials of CroFab® additional antivenom
OR
l
4 vials of Anavip®
• Repeat laboratory tests
Evidence of thrombocytopenia and/or
coagulopathy?

NO YES

Observe in house if lower extremity

bite; otherwise, discharge home with
supportive care and return precautions.

Abbreviations: CBC, complete blood cell count; IV, intravenous; NSAIDs, nonsteroidal anti-inflammatory drugs; PT, prothrombin time.

SEPTEMBER 2021 • www.ebmedicine.net 18 ©2021 EB MEDICINE

 (Position statement)
8. Hauke TJ, Herzig V. Dangerous arachnids-fake news or reality?
Toxicon. 2017;138:173-183. (Review)
9.* Vetter RS. Clinical consequences of toxic envenomation by
spiders. Toxicon. 2018;152:65-70. (Review)
DOI: 10.1016/j.toxicon.2018.07.021
10. Levine M, Canning J, Chase R, et al. Cardiomyopathy following
latrodectus envenomation. West J Emerg Med. 2010;11(5):521-
523. (Case report; 1 patient)
11. Murphy CM, Hong JJ, Beuhler MC. Anaphylaxis with Latro-
dectus antivenin resulting in cardiac arrest. J Med Toxicol.
2011;7(4):317-321. (Review)
12. Isbister GK, Fan HW. Spider bite. Lancet. 2011;378(9808):2039-
2047. (Review)
13. Quan D. North American poisonous bites and stings. Crit Care
Clin. 2012;28(4):633-659. (Review)
14. Offerman SR, Daubert GP, Clark RF. The treatment of black wid-
ow spider envenomation with antivenin Latrodectus mactans: a
case series. Perm J. 2011;15(3):76-81. (Case series; 4 patients)
15.* Dart RC, Bush SP, Heard K, et al. The efficacy of antivenin
Latrodectus (black widow) equine immune F(ab’)(2) versus
placebo in the treatment of latrodectism: a randomized,
double-blind, placebo-controlled, clinical trial. Ann Emerg
Med. 2019;74(3):439-449. (Randomized controlled trial; 60
patients) DOI: 10.1016/j.annemergmed.2019.02.007
16. Clark RF, Wethern-Kestner S, Vance MV, et al. Clinical presen-
tation and treatment of black widow spider envenomation:
a review of 163 cases. Ann Emerg Med. 1992;21(7):782-787.
(Retrospective study; 163 patients)
17. Lopes PH, Squaiella-Baptistão CC, Marques MOT, et al.
Clinical aspects, diagnosis and management of Loxosceles
spider envenomation: literature and case review. Arch Toxicol.
2020;94(5):1461-1477. (Systematic review)
18. Furbee RB, Kao LW, Ibrahim D. Brown recluse spider envenom-
ation. Clin Lab Med. 2006;26(1):211-226. (Review)
19. Rosen JL, Dumitru JK, Langley EW, et al. Emergency depart-
ment death from systemic loxoscelism. Ann Emerg Med.
2012;60(4):439-441. (Case report; 1 patient)
20. Hogan CJ, Barbaro KC, Winkel K. Loxoscelism: old obstacles,
new directions. Ann Emerg Med. 2004;44(6):608-624. (Review)
21. Hughes RL. A fatal case of acute renal failure from evenoming
syndrome after massive bee attack: a case report and literature
review. Am J Forensic Med Pathol. 2019;40(1):52-57. (Case
report and review)
22. Silva GBDJ, Vasconcelos AGJ, Rocha AMT, et al. Acute kidney
injury complicating bee stings - a review. Rev Inst Med Trop Sao
Paulo. 2017;59:e25. (Review)
23.* Lovecchio F, Cannon RD, Algier J, et al. Bee swarmings in
children. Am J Emerg Med. 2007;25(8):931-933. (Prospective
study; 19 patients) DOI: 10.1016/j.ajem.2007.02.006
24. Schmidt JO. Clinical consequences of toxic envenomations by
Hymenoptera. Toxicon. 2018;150:96-104. (Review)
25. Lee JA, Singletary E, Charlton N. Methods of honey bee
stinger removal: a systematic review of the literature. Cureus.
2020;12(5):e8078. (Systematic review)
26. Villada G, Hafeez F, Ollague J, et al. Imported fire ant enven-
omation: a clinicopathologic study of a recognizable form of
arthropod assault reaction. J Cutan Pathol. 2017;44(12):1012-
1017. (Case series; 7 patients)
27. Fitzgerald KT, Flood AA. Hymenoptera stings. Clin Tech Small
Anim Pract. 2006;21(4):194-204. (Review)
28. Goddard J, Jarratt J, de Castro FR. Evolution of the fire ant le-
sion. JAMA. 2000;284(17):2162-2163. (Case report; 1 patient)
29. deShazo RD, Kemp SF, deShazo MD, et al. Fire ant attacks on
patients in nursing homes: an increasing problem. Am J Med.
GROUP SUBSCRIPTIONS: groups@ebmedicine.net
2004;116(12):843-846. (Case reports and review; 6 patients)
30. Kemp SF, deShazo RD, Moffitt JE, et al. Expanding habitat of
the imported fire ant (Solenopsis invicta): a public health con-
cern. J Allergy Clin Immunol. 2000;105(4):683-691. (Review)
31.* Skolnik AB, Ewald MB. Pediatric scorpion envenomation in the
United States: morbidity, mortality, and therapeutic innova-
tions. Pediatr Emerg Care. 2013;29(1):98-103. (Review)
DOI: 10.1097/PEC.0b013e31827b5733
32. Curry SC, Vance MV, Ryan PJ, et al. Envenomation by the
scorpion Centruroides sculpturatus. J Toxicol Clin Toxicol.
1983;21(4-5):417-449. (Review)
33. Stahnke HL. Arizona’s lethal scorpion. Ariz Med. 1972;29(6):490-
493. (Review)
34. Coorg V, Levitan RD, Gerkin RD, et al. Clinical presentation
and outcomes associated with different treatment modali-
ties for pediatric bark scorpion envenomation. J Med Toxicol.
2017;13(1):66-70. (Retrospective study; 156 patients)
35. Patel A, Elston DM. What’s eating you? Bark scorpions (Cen-
truroides exilicauda and Centruroides sculpturatus). Cutis.
2020;105(5):239-240. (Review)
36. O’Connor A, Ruha AM. Clinical course of bark scorpion
envenomation managed without antivenom. J Med Toxicol.
2012;8(3):258-262. (Retrospective chart review; 88 patients)
37. Quan D, LoVecchio F, Bhattarai B, et al. Comparing clinical
outcomes between two scorpion antivenom dosing strategies
in children. Clin Toxicol (Phila). 2019;57(9):760-764. (Retrospec-
tive review; 141 children)
38. World Health Organization. Venomous snakes distribution and
species risk categories. Available at: http://apps.who.int/blood-
products/snakeantivenoms/database. Accessed August 15,
2021. (Government report)
39. National Institute for Occupational Safety and Health. Venom-
ous snakes. Available at: https://www.cdc.gov/niosh/topics/
snakes/default.html#:~:text=It%20has%20been%20estimat-
ed%20that,did%20not%20seek%20medical%20care. Accessed
August 15, 2021. (Government report)
40. Ruha AM, Kleinschmidt KC, Greene S, et al. The epidemiology,
clinical course, and management of snakebites in the North
American Snakebite Registry. J Med Toxicol. 2017;13(4):309-
320. (Review)
41. Levine M, Ruha AM, Wolk B, et al. When it comes to snake-
bites, kids are little adults: a comparison of adults and children
with rattlesnake bites. J Med Toxicol. 2020;16(4):444-451.
(Retrospective chart review; 420 patients)
42. Lavonas EJ, Ruha AM, Banner W, et al. Unified treatment algo-
rithm for the management of crotaline snakebite in the United
States: results of an evidence-informed consensus workshop.
BMC Emerg Med. 2011;11:2. (Database review and consen-
sus statement)
43. Corbett B, Clark RF. North American snake envenomation.
Emerg Med Clin North Am. 2017;35(2):339-354. (Review)
44.* Ruha AM, Curry SC, Albrecht C, et al. Late hematologic toxicity
following treatment of rattlesnake envenomation with crotali-
dae polyvalent immune Fab antivenom. Toxicon. 2011;57(1):53-
59. (Retrospective chart review; 66 patients)
DOI: 10.1016/j.toxicon.2010.09.014
45. Seifert SA, Mascarenas DN, Fullerton L, et al. Unpredicted
late-, new-onset thrombocytopenia and hypofibrinogenemia
in Fab antivenom-treated rattlesnake envenomation. Toxicon.
2020;184:55-56. (Case series; 3 patients)
46. Spyres MB, Skolnik AB, Moore EC, et al. Comparison of antivenom
dosing strategies for rattlesnake envenomation. Crit Care Med.
2018;46(6):e540-e544. (Retrospective study; 310 patients)
47. Mascarenas DN, Fullerton L, Smolinske SC, et al. Comparison
of F(ab’)(2) and Fab antivenoms in rattlesnake envenomation:
first year’s post-marketing experience with F(ab’)(2) in New
19 © 2021 EB MEDICINE. ALL RIGHTS RESERVED.
 Mexico. Toxicon. 2020;186:42-45. (Retrospective chart review;
37 patients)
4. Which of the following statements about the
48. Anavip Crotalidae immune F(ab')2 (equine). Available at:
® initial bite of a brown recluse spider is TRUE?
https://anavip-us.com/pi/. Accessed August 15, 2021. (Pack- a. It is very painful.
age insert) b. Necrosis can present within 6 hours.
49. Kitchens CS, Van Mierop LH. Envenomation by the Eastern c. Prompt administration of antivenom prevents
coral snake (Micrurus fulvius fulvius). A study of 39 victims. necrotic lesions from forming.
JAMA. 1987;258(12):1615-1618. (Retrospective chart review; d. The initial bite may be unnoticed due to a
39 patients)
lack of significant pain at the time of the bite.
50. Levine M, Ruha AM, Padilla-Jones A, et al. Bleeding following
rattlesnake envenomation in patients with preenvenomation use
of antiplatelet or anticoagulant medications. Acad Emerg Med. 5. What is the minimum number of bee stings to
2014;21(3):301-307. (Retrospective chart review; 319 patients) mandate admission?
51. Moore EC, Porter LM, Ruha AM. Rattlesnake venom-induced a. 5
recurrent coagulopathy in first trimester pregnant women - two b. 10
cases. Toxicon. 2019;163:8-11. (Case report and literature c. 25
review)
d. 50

n CME Questions 6. Which of the following can help identify a scor-

Current subscribers receive CME credit pion sting?
absolutely free by completing the follow- a. A large bull’s eye lesion
ing test. Each issue includes 4 AMA PRA b. Lymphatic streaks traveling away from the
Category 1 CreditsTM, 4 ACEP Category I sting site
credits, 4 AAP Prescribed credits, or 4 c. A tap test
AOA Category 2-A or 2-B credits. Online testing is d. Application of tap water
available for current and archived issues. To receive
your free CME credits for this issue, scan the QR 7. Following a scorpion sting, a 3-year-old boy
code below with your smartphone or visit has roving eye movements but no diffuse
www.ebmedicine.net/P0921 motor involvement. Which of the following
grades most accurately describes the grade of
envenomation of this patient?
a. Grade I
b. Grade II
c. Grade III
d. Grade IV

1. Which of the following prehospital therapies 8. The use of antivenom may be considered for
is recommended in the management of North treatment of which type of envenomation?
American pit viper bites? a. Massive honeybee envenomation
a. Application of ice b. Massive fire ant envenomation
b. Use of a commercial suction device c. Gila lizard bite
c. Splint and elevate d. Southern Pacific rattlesnake bite
d. Immersion in cold water
9. For a patient who received antivenom for a
2. Which of the following statements about black rattlesnake bite, which of the following repre-
widow envenomations is TRUE? sents the ideal follow-up strategy after dis-
a. The bite is typically painless. charge from the hospital?
b. Calcium chloride, but not gluconate, should a. Follow up at 1 to 3 days and at 10 days
be administered as soon as possible. b. Follow up at 3 to 5 days and at 5 to 7 days
c. Only the male spider is capable of causing c. Follow up at 2 weeks only
human envenomation. d. No follow-up appointment is required.
d. Pain, diaphoresis, or fasciculations can be
localized or diffuse. 10. Which of the following would be an indica-
tion for antivenom therapy after a coral snake
3. Which of the following is frequently misdiag- envenomation?
nosed as a brown recluse bite? a. Dysphagia
a. Soft-tissue infection b. Thrombocytopenia
b. Stevens-Johnson syndrome c. Hyperfibrinoginemia
c. Gilbert disease d. Hypofibrinoginemia
d. Cushing ulcers

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In Upcoming issues of Pediatric
Emergency Medicine Practice
JUNE 2021 | VOLUME 18 | ISSUE 6
PEDIATRIC
Emergency Medicine Practice
CLINICAL CHALLENGES:
• Which patients are at low risk for
clinically important traumatic brain
injury?
• Which patients need a cranial CT scan
and which can be observed safely in the
ED without imaging?
• What are the risk factors for post–
concussion syndrome?
• What discharge guidance should be
given to patients with concussion?
Authors
Madeline Joseph, MD, FACEP, FAAP
Professor of Emergency Medicine and Pediatrics,
Associate Dean for Inclusion and Equity, Emergency
Medicine Department, University of Florida College
of Medicine-Jacksonville, Jacksonville, FL
Audrey Paul, MD, PhD
Assistant Professor; Pediatric Emergency Medicine;
NYU Long Island School of Medicine, New York, NY
Peer Reviewers
Susan B. Kirelik, MD, FAAP
Pediatric Emergency Physician, Rocky Mountain
Hospital for Children; Medical Director, Rocky
Mountain Pediatric OrthoONE Center for
Concussion, Denver, Colorado
Todd W. Lyons, MD, MPH
Assistant Professor of Pediatrics and Emergency
Medicine, Harvard Medical School, Division of
Emergency Medicine, Boston Children’s Hospital,
Boston, MA
Prior to beginning this activity, see
“CME Information” on page 23.
This issue is eligible for 4 CME credits. See page 23.
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n Abstract
Mild traumatic brain injury (mTBI) and concussion, a subtype of
mTBI, commonly present to the emergency department (ED)
and may present with symptoms identical to those associated
with more severe TBI. The development and use of clinical de-
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CME Information
Date of Original Release: September 1, 2021. Date
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CME Objectives: Upon completion of this activity, you should be
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from various venomous terrestrial animals in North America; (2)
review indications for antivenom therapy to treat envenomations
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The Pediatric Emergency Medicine Practice Editorial Board
EDITORS-IN-CHIEF
Ilene Claudius, MD
Associate Professor; Director, Process &
Quality Improvement Program, Harbor-
UCLA Medical Center, Torrance, CA
Tim Horeczko, MD, MSCR, FACEP,
FAAP
Associate Professor of Clinical Emergency
Medicine, David Geffen School of Medicine,
UCLA; Core Faculty and Senior Physician,
Los Angeles County-Harbor-UCLA Medical
Center, Torrance, CA
EDITORIAL BOARD
Jeffrey R. Avner, MD, FAAP
Chairman, Department of Pediatrics,
Professor of Clinical Pediatrics,
Maimonides Children's Hospital of
Brooklyn, Brooklyn, NY
Steven Bin, MD
Associate Clinical Professor, UCSF School
of Medicine; Medical Director, Pediatric
Emergency Medicine, UCSF Benioff
Children's Hospital, San Francisco, CA
Richard M. Cantor, MD, FAAP,
FACEP
Professor of Emergency Medicine and
Pediatrics; Section Chief, Pediatric
Emergency Medicine; Medical Director,
Upstate Poison Control Center, Golisano
Children's Hospital, Syracuse, NY
Steven Choi, MD, FAAP
Chief Quality Officer and Associate Dean for
Clinical Quality, Yale Medicine/Yale School
of Medicine; Vice President, Chief Quality
Officer, Yale New Haven Health System,
New Haven, CT
Ari Cohen, MD, FAAP
Chief of Pediatric Emergency Medicine,
Massachusetts General Hospital; Instructor
in Pediatrics, Harvard Medical School,
Boston, MA
Jay D. Fisher, MD, FAAP, FACEP
Clinical Professor of Emergency Medicine
and Pediatrics, University of Nevada, Las
Vegas School of Medicine, Las Vegas, NV
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Marianne Gausche-Hill, MD, FACEP,
FAAP, FAEMS
Medical Director, Los Angeles County EMS
Agency; Professor of Clinical Emergency
Medicine and Pediatrics, David Geffen
School of Medicine at UCLA; Clinical
Faculty, Harbor-UCLA Medical Center,
Department of Emergency Medicine, Los
Angeles, CA
Michael J. Gerardi, MD, FAAP,
FACEP, President
Associate Professor of Emergency Medicine,
Icahn School of Medicine at Mount Sinai;
Director, Pediatric Emergency Medicine,
Goryeb Children's Hospital, Morristown
Medical Center, Morristown, NJ
Sandip Godambe, MD, PhD
Chief Quality and Patient Safety Officer,
Professor of Pediatrics, Attending Physician
of Emergency Medicine, Children's Hospital
of The King's Daughters Health System,
Norfolk, VA
Ran D. Goldman, MD
Professor, University of British Columbia,
Pediatric Emergency Physician, BC
Children’s Hospital, Vancouver, BC, Canada
Alson S. Inaba, MD, FAAP
Pediatric Emergency Medicine Specialist,
Kapiolani Medical Center for Women &
Children; Associate Professor of Pediatrics,
University of Hawaii John A. Burns School of
Medicine, Honolulu, HI
Madeline Matar Joseph, MD,
FACEP, FAAP
Professor of Emergency Medicine and
Pediatrics, Associate Dean for Inclusion and
Equity, Emergency Medicine Department,
University of Florida College of Medicine-
Jacksonville, Jacksonville, FL
Anupam Kharbanda, MD, MSc
Chief, Critical Care Services, Children's
Hospital Minnesota, Minneapolis, MN
Tommy Y. Kim, MD
Health Sciences Clinical Professor of
Pediatric Emergency Medicine, University
of California Riverside School of Medicine,
Riverside Community Hospital, Department
of Emergency Medicine, Riverside, CA
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Melissa Langhan, MD, MHS Adam E. Vella, MD, FAAP
Associate Professor of Pediatrics and Associate Professor of Emergency Medicine
Emergency Medicine; Fellowship Director, and Pediatrics, Associate Chief Quality
Director of Education, Pediatric Emergency Officer, New York-Presbyterian/Weill Cornell
Medicine, Yale University School of Medicine, New York, NY
Medicine, New Haven, CT
David M. Walker, MD, FACEP, FAAP
Robert Luten, MD Chief, Pediatric Emergency Medicine,
Professor, Pediatrics and Emergency Department of Pediatrics, Joseph M. Sanzari
Medicine, University of Florida, Children’s Hospital, Hackensack University
Jacksonville, FL Medical Center; Associate Professor of
Pediatrics, Hackensack Meridian School of
Garth Meckler, MD, MSHS Medicine, Hackensak, NJ
Associate Professor of Pediatrics, University
of British Columbia; Division Head, Pediatric Vincent J. Wang, MD, MHA
Emergency Medicine, BC Children's Professor of Pediatrics and Emergency
Hospital, Vancouver, BC, Canada Medicine; Division Chief, Pediatric
Emergency Medicine, UT Southwestern
Joshua Nagler, MD, MHPEd
Medical Center; Director of Emergency
Associate Division Chief and Fellowship
Services, Children's Health, Dallas, TX
Director, Division of Emergency Medicine,
Boston Children's Hospital; Associate INTERNATIONAL EDITOR
Professor of Pediatrics and Emergency
Lara Zibners, MD, FAAP, FACEP,
Medicine, Harvard Medical School,
MMEd
Boston MA
Honorary Consultant, Paediatric Emergency
James Naprawa, MD Medicine, St. Mary's Hospital Imperial
Attending Physician, Emergency College Trust, London, UK; Nonclinical
Department USCF Benioff Children's Instructor of Emergency Medicine, Icahn
Hospital, Oakland, CA School of Medicine at Mount Sinai, New
York, NY
Joshua Rocker, MD
Associate Chief and Medical Director, PHARMACOLOGY EDITOR
Assistant Professor of Pediatrics and
Aimee Mishler, PharmD, BCPS
Emergency Medicine, Cohen Children's
Emergency Medicine Pharmacist, Program
Medical Center of New York, New Hyde
Director – PGY2 Emergency Medicine
Park, NY
Pharmacy Residency, Valleywise Health
Steven Rogers, MD Medical Center, Phoenix, AZ
Associate Professor, University of
Connecticut School of Medicine, Attending
Emergency Medicine Physician, Connecticut
Children's Medical Center, Hartford, CT
Jennifer E. Sanders, MD, FAAP,
FACEP
Assistant Professor, Departments of
Pediatrics, Emergency Medicine, and
Education, Icahn School of Medicine at
Mount Sinai, New York, NY
Christopher Strother, MD
Associate Professor, Emergency Medicine,
Pediatrics, and Medical Education; Director,
Pediatric Emergency Medicine; Director,
Simulation; Icahn School of Medicine at
Mount Sinai, New York, NY
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 Points & Pearls
QUICK READ
SEPTEMBER 2021 | VOLUME 18 | ISSUE 9
Points
• Envenomation by Latrodectus mactans (black
widow spiders) can result in significant pain and
hyperadrenergic symptoms. Treatment should first
be focused on ensuring adequate administration of
opioids and benzodiazepines.
• Use of Latrodectus antivenom is generally not con-
sidered first-line therapy because of the relatively
high rate of immediate (anaphylactoid) or delayed
(serum sickness) allergic reactions.
• Because toxicity from Loxosceles (brown recluse)
bites primarily manifests as necrotic dermal lesions,
various soft-tissue infections are often incorrectly
ascribed to envenomation from this spider.
• Patients envenomated by a Loxosceles spider
should be observed for necrotic lesions and sys-
temic effects. Hemolysis should be treated with
corticosteroids.
• Massive hymenoptera envenomation can result in
multisystem organ involvement. Treatment with
corticosteroids is indicated even though the reac-
tion is not IgE-mediated.
• Because of the potential for delayed onset of many
symptoms, a child who has ≥50 honeybee stings
(or ≥2 stings/kg for children weighing <25 kg)
should be admitted to a monitored setting for 24
hours.10 For pediatric patients who have between 2
and 50 stings (or <2 stings/kg), laboratory param-
eters should be obtained at presentation and at 6
hours after presentation.
• Because bark scorpion venom lacks dermonecrotic
components, the sting site is often not visible. In
cases of diagnostic uncertainty, a tap test (in which
tapping the envenomated area elicits a painful
reaction) can assist in establishing the diagnosis.
• Patients with symptoms other than pain following a
bark scorpion envenomation should be observed.
Those with evidence of neurotoxicity should be
assessed for the need for antivenom. In cases of
high-grade envenomation in which antivenom is not
available, intensive care admission is often required.
• Patients with rattlesnake envenomations should
have the extremity splinted in full extension and
elevated. Ice, tourniquets, and compression ban-
dages are not recommended.
SEPTEMBER 2021 • www.ebmedicine.net 24
Terrestrial Envenomations
in Pediatric Patients:
Identification and Management
in the Emergency Department
Pearls
l Massive Hymenoptera envenomations require
admission and corticosteroid administration, even
if the patient is clinically improved after a short
period of observation.
l For children who have been bitten by a rattle-
snake, edema in the lower extremities may be
delayed and difficult to appreciate. Consequently,
all children with lower extremity bites should be
admitted and observed for 12 to 24 hours.
l During administration of any antivenom (espe-
cially whole IgG molecules), careful monitoring for
anaphylactoid reactions is required.
l Because of the antimicrobial aspects of snake
venom, routine antibiotics are not indicated fol-
lowing envenomation.
• Patients who have a hematologic or cutaneous mani-
festation of toxicity following a rattlesnake bite can
be treated with CroFab® or Anavip®.
• Due to their antiplatelet effects, NSAIDs should be
avoided for the treatment of pain associated with pit
viper envenomation.
• Do not perform a fasciotomy for pit viper bites with-
out clearly documented elevated compartment pres-
sures that persist despite elevation of the extremity
and administration of additional antivenom.
• Given the current shortages, antivenom should be
reserved for patients who have been bitten by a coral
snake who have symptoms, and it should be admin-
istered at the first sign of symptoms, which is often
mild ptosis.
• Gila monster envenomations are uncommon, due
to the shy nature of the animal. However, in cases
of envenomation, the animal often latches onto the
victim vigorously, and it may be difficult to remove.
The victim may develop angioedema.
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