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<< Bites and Stings – Snakes, Spiders, and Scorpions in the United States

Case Presentation

A 10-year-old boy is brought into an emergency department in San Diego, California after being bitten on the right hand by a rattlesnake. Although the envenomation occurred just one hour ago, there is swelling proceeding up the forearm. The patient is agitated and vomiting, and fine fasciculations of the face and upper extremities are present. The platelet count is 60,000/mm3, the fibrinogen is 90 mg/dL and the PT/PTT are elevated. The parents are frightened and want to know what you are going to do for their son.

A five-year-old girl in Jacksonville, Florida was bitten on the right ankle by a small snake that was red, yellow, and black in color. Her parents initially did not seek medical attention since she had no symptoms and seemed fine. Several hours later, she is brought by ambulance to your emergency department due to difficulty swallowing, ptosis, generalized weakness, and shallow respirations. What snake is responsible for this patient's symptoms and what are your priorities of treatment for this life-threatening envenomation?

A 13-year-old girl in Dallas, Texas was bitten on the left thigh by a black widow spider when she was looking for an old toy in the garage. On presentation to your emergency department, she is grimacing, restless, diaphoretic, and tachycardic, with severe pain and cramping of her left thigh and abdominal muscles. What is causing these impressive symptoms and what therapeutic measures should be implemented to treat this envenomation?

A two–year-old boy was stung on the left foot by a scorpion while he and his family were visiting Tucson, Arizona. He is brought to a local emergency department where he is noted to be agitated and drooling excessively with wandering eye movements. He has fine fasciculations of his tongue and intermittent shaking of his extremities. He is tachycardic with a heart rate of 190 beats per minute. His parents are very nervous and ask you if he is going to be okay.

Case Conclusions

The snake responsible for this envenomation was a
Southern Pacific Rattlesnake (Crotalus viridis helleri). You controled the patient's pain with opioids and began treatment with CroFab®. After the initial dose of antivenom, the child's thrombocytopenia improved and the swelling stopped progressing. He was admitted to the hospital for further observation and continuing antivenom therapy. The fasciculations gradually resolved and the child was kept comfortable with opioids and benzodiazepines. The next day, after finishing the antivenom protocol, the patient's pain was well controlled with opioids and the swelling improved. There were no further changes on his morning laboratory values . The patient was discharged home on oral pain medications, with a warning that the swelling may take several weeks to completely resolve. You told his parents to follow-up with his pediatrician for reexamination and recheck of his blood counts and coagulation studies.

The implicated snake in this vignette is the coral snake, an elapid. The venom in coral snakes is a neurotoxin causing respiratory failure. In this case, the child was immediately intubated, placed on ventilatory support, and transferred to the intensive care unit. Attempts were made by the physicians to locate Antivenin (Micrurus fulvius) without success and the decision was made to manage the child with supportive care and antivenom therapy was not pursued further. After two days, the effects of the neurotoxic venom began to wear off and the patient started to have spontaneous respirations. By day four, the patient was extubated and maintained her own respirations, though she had some residual generalized weakness. She was discharged home by day five of hospitalization with instructions to her parents to follow-up with her general physician.

The patient's symptoms are caused by α-latrotoxin, a potent neurotoxin. You immediately began treating this patient with opioids and benzodiazepines in order to control her pain and anxiety. Your hospital pharmacy had latrodectus antivenom available. However, after discussing the risks and benefits of the treatment options, the family declined antivenom therapy. You admitted the child to the observation unit on opioids and benzodiazepines. In the morning, her pain was much improved and she was discharged home on oral pain medications.

Based on the patient's presentation, he was likely
stung by Centruroides exilicauda, the bark scorpion. As you were speaking with the family, your staff members called the Arizona State University to inquire if there were any units of the scorpion antivenom still available. They were told that the antivenom stores are now expired and can not be used. You started the patients on opioids and benzodiazepines in order to control his pain and anxiety as well as other supportive measures, such as intravenous fluids. He responded to the treatment by becoming less anxious and less tachycardic. You admitted him to the pediatric ward where, over the next two days, he continued to require opioids and benzodiazepines. His fasciculations and drooling gradually improved. On day three, the patient's pain had greatly diminished and he was discharged home on oral pain medications with instructions to the parents to follow up with his pediatrician.

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Last Modified: 08/17/2017
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