Pediatric Terrestrial Envenomations: Identification and Management in the ED -
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Terrestrial Envenomations in Pediatric Patients: Identification and Management in the Emergency Department (Trauma CME and Pharmacology CME)

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About This Issue

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 experience more-severe envenomation effects than adults. This issue reviews the basic epidemiology and underlying pathophysiology of bites and stings from common envenomating terrestrial creatures and provides recommendations for the clinical evaluation and management of pediatric patients who have been envenomated. You will learn:

The mechanism of action of the venom from North American spiders, bees and wasps, fire ants, scorpions, snakes, and lizards

Key components to address when taking the history

The common presentations for various envenomations

When diagnostic studies are indicated and which may be the highest-yield

Recommendations for management of envenomation by each of the terrestrial creatures

Indications for antivenom use and dosing recommendations

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Differential Diagnosis
  7. Prehospital Care
  8. Spiders
    1. Latrodectus: Widow Spiders
      1. Epidemiology
      2. Pathophysiology
      3. Clinical Presentation
      4. Treatment
      5. Disposition
    2. Loxosceles: Recluse Spiders
      1. Epidemiology
      2. Pathophysiology
      3. Clinical Presentation
      4. Treatment
      5. Disposition
  9. Hymenoptera
    1. Bees and Wasps
      1. Epidemiology
      2. Pathophysiology
      3. Treatment
      4. Disposition
    2. Fire Ants
      1. Epidemiology
      2. Pathophysiology
      3. Clinical Presentation
      4. Treatment
      5. Disposition
  10. Scorpions
    1. Epidemiology
    2. Pathophysiology
    3. Clinical Presentation
    4. Treatment
    5. Disposition
  11. Snakes
    1. Epidemiology
    2. Crotalinae
      1. Pathophysiology
      2. Clinical Presentation
      3. Treatment
      4. Disposition
    3. Elapidae
      1. Pathophysiology
      2. Treatment
      3. Disposition
  12. Venomous Lizards
    1. Epidemiology
    2. Pathophysiology
    3. Clinical Presentation
    4. Treatment
    5. Disposition
  13. Special Populations
  14. Controversies and Cutting Edge
    1. Anascorp® Dosing
    2. Snake Bite Antivenom Dosing
      1. CroFab® Maintenance Dosing
      2. Ideal Antivenom Dosing for Patients With Copperhead or Cottonmouth Envenomation
      3. Anavip® Antivenom
  15. Time- and Cost-Effective Strategies
  16. Summary
  17. Risk Management Pitfalls for Terrestrial Envenomations in Pediatric Patients
  18. Case Conclusions
  19. Clinical Pathway for Management of Rattlesnake Envenomation
  20. Tables and Figures
    1. Table 1. Components of the History in the Assessment of Terrestrial Bites and Stings
    2. Table 2. Scorpion Envenomation Grading
    3. Table 3. Obtaining the History of Snake Bites
    4. Figure 1. Female Black Widow Spider (Latrodectus mactans)
    5. Figure 2. Black Widow Spider Bite Appearance
    6. Figure 3. Brown Recluse Spider (Loxosceles reclusa)
    7. Figure 4. Brown Recluse Spider Bite Appearance
    8. Figure 5. Hymenoptera: Bees, Wasps, Hornets, and Fire Ants
    9. Figure 6. Bark Scorpion (Centruroides sculpturatus)
    10. Figure 7. Coral Snake (Micrurus fulvius)
    11. Figure 8. Scarlet King Snake (Lampropeltis elapsoides)
  21. References

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 experience more-severe envenomation effects than adults. This issue reviews the basic epidemiology and underlying pathophysiology 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 pathophysiology and much of the presentation and treatment are similar for both children and adults, there can be subtle differences, which will be highlighted in this review.

Case Presentations

CASE 1
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 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.
CASE 2
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.
  • 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.
CASE 3
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 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.

Clinical Pathway for Management of Rattlesnake Envenomation

Clinical Pathway for Management of Rattlesnake Envenomation

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Tables and Figures

Table 1. Components of the History in the Assessment of Terrestrial Bites and Stings

Table 2. Scorpion Envenomation Grading
Table 3. Obtaining the History of Snake Bites
Figure 1. Female Black Widow Spider (Latrodectus mactans)
Figure 2. Black Widow Spider Bite Appearance

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

3. * Bush SP, Ruha AM, Seifert SA, et al. Comparison of F(ab’)2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial. Clin Toxicol (Phila). 2015;53(1):37-45. (Randomized controlled trial; 121 patients) DOI: 10.3109/15563650.2014.974263

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

9. * Vetter RS. Clinical consequences of toxic envenomation by spiders. Toxicon. 2018;152:65-70. (Review) DOI: 10.1016/j.toxicon.2018.07.021

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

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

31. * Skolnik AB, Ewald MB. Pediatric scorpion envenomation in the United States: morbidity, mortality, and therapeutic innovations. Pediatr Emerg Care. 2013;29(1):98-103. (Review) DOI: 10.1097/PEC.0b013e31827b5733

38. World Health Organization. Venomous snakes distribution and species risk categories. Accessed August 15, 2021. (Government report)

39. National Institute for Occupational Safety and Health. Venomous snakes. Accessed August 15, 2021. (Government report)

44. * Ruha AM, Curry SC, Albrecht C, et al. Late hematologic toxicity following treatment of rattlesnake envenomation with crotalidae polyvalent immune Fab antivenom. Toxicon. 2011;57(1):53-59. (Retrospective chart review; 66 patients) DOI: 10.1016/j.toxicon.2010.09.014

48. Anavip® Crotalidae immune F(ab')2 (equine). Accessed August 15, 2021. (Package insert)

Subscribe to get the full list of 51 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: envenomation, pediatric envenomation, terrestrial envenomation, venom, antivenom, immunoglobulin G, IgG, Fc, Fab, F(ab’)2, anaphylactoid reaction, anaphylactic reaction, allergic reaction, sting, bite, spider, Latrodectus mactans, black widow, Loxosceles reclusa, brown recluse, Hymenoptera, Apidae, bee, honeybee, Africanized honeybee, bumblebee, Vespidae, vespid, yellow jacket, wasp, hornet, Formicidae, Solenopsis invicta, fire ant, scorpion, Centruroides sculpturatus, bark scorpion, Anascorp, snake, Crotalinae, pit viper, copperhead, cottonmouth, rattlesnake, CroFab, Anavip, Elapidae, coral snake, dry bite, lizars, Heloderma, Gila monster, beaded lizard

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Publication Information
Authors

Michael Levine, MD, FACEP, FACMT; Nathan Friedman, MD

Peer Reviewed By

Sing-Yi Feng, MD; Nicole Gerber, MD

Publication Date

September 2, 2021

CME Expiration Date

September 2, 2024

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 0.5 Trauma CME and 1 Pharmacology CME credits.

Pub Med ID: 34403224

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CME Information

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