OHSU

Bites and Stings

Jenna M. Wiley, MD
Wilderness Medicine Fellow
Oregon Health & Science University
Sept 18, 2020
Question

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• What animal causes the most deaths in the U.S.?
Objectives

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• Prevention, Identification, Treatment
• Bee stings
• Scorpion stings
• Mammal bites
• Snake bites
• Spider bites
• Tick bites
Arthropod Bites in U.S.

OHSU
Vaughn MG, Holzer KJ, Carbone JT, Salas-Wright CP. Arthropod Bites and Stings Treated in Emergency Departments: Recent
Trends and Correlates. Wild & Env Med; 2019: 30(4): 394-400
Hymenoptera

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• Three families
• Hornets, wasps, yellow jackets
• Bees
• Ants and fire ants

Source: Wikimedia commons

Hymenoptera

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• Allergic reactions leading to
anaphylaxis are the most
common reason for deaths

Source: Wikimedia commons

Hymenoptera Treatment

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• Remove stinger
• Wash with soap and water
• Ice
• Treat anaphylaxis
• epinephrine
• diphenhydramine (Benadryl)

Source: Wikimedia commons

OHSU
Scorpions

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• Most stings cause local
symptoms
• Deaths rare, usually
multiple stings
• Elderly
• Children Source: NPS.gov

• Severe symptoms usually

from Centruroides species
• “bark” scorpion
• Southwest U.S.
Bear Attacks

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Source: nps.gov

Source: Wikimedia commons Source: Wikimedia commons

Cougar attacks

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• Becoming more common
• Stalk, pounce and break
the cervical spine
• May be scared off by
aggressive behavior
• Fight back with any object
available
• Do NOT run away
Cougar attacks

OHSU
• Becoming more common
• Stalk, pounce and break
the cervical spine
• May be scared off by
aggressive behavior
• Fight back with any object
available
• Do NOT run away
 Animal bites

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• Initial Treatment
• Examine for blunt
trauma/crushing
injury/bleeding
• Examine penetrating trauma
for deep neurovascular and
tissue damage
• Irrigate and debride wound
• Antibiotics
 Animal bites

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• Rabies
• Bats
• Racoons
• Skunks
• Foxes
• Coyotes

Source: https://www.cdc.gov/rabies/location/usa/surveillance/wild_animals.html

• Irrigate and debride, can

use viricidal agent like
povidone iodine
OHSU
 Northern Pacific Rattlesnake

Venomous Snakes

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• 9,000 ED visits annually in
U.S.3
• Venomous species account
for approx 1/3 of these
visits3 Source: californiaherps.com

• Native to the U.S.

California Mountain King Snake Coral Snake

• Pit vipers
• (subfamily Crotalinae)
• Coral snakes
• (family Elapidae)

Source: OR Dept Fish & Wildlife

Source: nps.gov
 US Pit Vipers

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• Anatomy
• Triangular heads
• Elliptical pupils
• Heat sensitive pits
between their eyes and
nose
• Hinged teeth that swing
to 90º
Pit Viper Envenomation

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• Amount of venom varies
among species
• Hemotoxic vs Neurotoxic
• Seriousness depends on:
• Duration of fang contact
• How deep fangs pierce
• Health of patient
• Allergy to venom
• How agitated snake was
• Age of the snake
Source: Encyclopedia Britannica • Intravenous injection
Pit Viper Envenomation

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• Venom causes local tissue
necrosis and systemic
symptoms
• Cannot determine severity
of envenomation by initial
symptoms
• 1 bite in 4 carries no
venom (“dry bite”)

Source: www.nydailynews.com
Snake bite field Treatment

OHSU
Oral suction Electrotherapy
How should you treat a
snake bite in the field when Mechanical suction Tourniquet
you suspect envenomation?
Wound care Incision & Bleeding

Sling Pressure wrap

Evacuate Ice packs

Snake bite field Treatment

OHSU
How should you treat a
Oral suction Electrotherapy

snake bite in the field when

you suspect envenomation? Mechanical suction Tourniquet

Wound care Incision & Bleeding

Sling Pressure wrap

Evacuate Ice packs

Spider bites

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• At least 60 types of spiders Source: Wikimedia Commons Source: nps.gov
are known to bite humans
• All spiders are venomous
• Just 3 spiders in N. America
are venomous
• Black widow
• Brown recluse
• Hobo

Source: Wikimedia Commons

Black Widow

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• Red hourglass
• Venom is potent neurotoxin
• Rarely fatal Source: Wikimedia Commons

• Signs/Symptoms
• Headache, chills, fever, heavy sweating, dizziness,
nausea and vomiting, and severe abdominal pain
• Occur within 30 to 60 minutes of the bite

• Treatment
• Ice (pain control)
• Antivenin
OHSU
http://watchingtheworldwakeup.blogspot.com/2008/06/black-widows-part-1-chemistry-of-venom.html
 Source: nps.gov

Brown Recluse

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• Violin marking on top of body

• Signs/Symptoms
• Initially painless (may be 2-8 hrs before onset of
symptoms)
• Necrotic lesion

• Treatment
• Clean with soap and water
• Elevate and loosely immobilize the extremity
• Cold compress
• Oral analgesics
• Hospitalize if systemic symptoms
 Source: nps.gov

Brown Recluse

OHSU
• Violin marking on top of body

• Signs/Symptoms
• Painless (may be 2-8 hrs before symptoms)
• Rash that may become necrotic over days to
weeks

• Treatment
• Clean with soap and water
• Elevate and loosely immobilize the extremity
• Cold compress
• Oral analgesics
• Hospitalize if systemic symptoms
 Source: nps.gov

Brown Recluse

OHSU
• Violin marking on top of body

• Signs/Symptoms
• Painless (may be 2-8 hrs before symptoms)
• Rash that may become necrotic over days to
weeks

• Treatment
• Clean with soap and water
• Elevate and loosely immobilize the extremity
• Cold compress
• Oral analgesics
• Hospitalize if systemic symptoms

Source: Pattie et al. Brown Recluse Bite. JET EM. 2019

Hobo Spider

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• 10-15 mm with yellow-green tint
• Builds funnel webs
Source: Wikimedia Commons

• Signs/Symptoms
• Local necrosis usually within 36 hrs

• Treatment
• Supportive
• Clean site with soap and water
• Oral analgesics
OHSU
Source: https://utahpests.usu.edu/uppdl/hobo-spiders
TIcks

OHSU Source: CDC

OHSU
Source: igenex.com
TIcks

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• Prevention • Treatment
• Long-sleeved, loose-fitting clothes • Remove tick as soon as possible
tucked in • Infection less likely if tick
• DEET, permethrin removed in < 24 hrs
• Tick checks • Use tweezers
• Grab tick near skin, pull
back with gentle, steady
pressure
Source: CDC
• Clean bite area
Recall

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• In what type of bite should ice be avoided?
Summary

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• Hymenoptera
• Responsible for many deaths in U.S.
• Treat anaphylaxis

• Scorpions
• Most cause mild-moderate pain
• Bark scorpions responsible for significant
symptoms that require evacuation
Summary

OHSU
• Bites from terrestrial animals
• Wound cleansing
• Evaluate for foreign bodies
• Monitor for signs of infection
• Consider rabies and tetanus risk

• Snakes
• Evacuate unless you know for sure it was a
nonvenomous snake bite
• Local wound care
Summary

OHSU
• Ticks
• Remove with gentle traction
• Monitor for development of systemic
symptoms

• Spiders
• Black widow bites require significant
analgesia
• All others can be monitored as risks are
low
 References

OHSU
1. Center for Disease Control and Prevention: https://www.cdc.gov/rabies/index.html
2. Forrester JA, Weiser TG, Forrester JD. An Update on Fatalities Due to Venomous and Nonvenomous Animals
in the United States (2008–2015). Wild & Environ Med , 2018; 29 (1): 36
3. Kanaan NC, Ray J, Stewart M, Russell K, Fuller M, Bush SP, Caravati EM, Cardwell MD, Norris RL, Weinstein SA.
Wilderness Medical Society Practice Guidelines for the Treatment of Pitviper Envenomations in the United
States and Canada. Wild & Environ Med 2015: 26, 472-87.
4. Patti LA, Landgraf B, Bryczkowski C. Brown Recluse Spider Bite. JET EM. 2019: 4(3)
5. Quinn RH, Wedmore I, Johnson E, Islas A, Anglim A, Zafren K, Bitter C, Mazzorana V. Wilderness Medical
Society Practice Guidelines for Basic Wound Management in the Austere Environment: 2014 Update
6. Vaughn MG, Holzer KJ, Carbone JT, Salas-Wright CP. Arthropod Bites and Stings Treated in Emergency
Departments: Recent Trends and Correlates. Wild & Env Med; 2019: 30(4): 394-400