BITES AND STINGS

LIJO JOYJUBILEE MISSION MEDICAL COLLEGE,TCR

09/06/14

SNAKE BITE

DISCUSSION TOPICS INTRODUCTION EPIDEMIOLOGY CAUSE PATHOPHYSIOLOGY + SIGNS & SYMPTOMS MANAGEMENT

PREVENTION MYTHS IN KERALA

PRE HOSPITAL MANAGEMENT (FIRST AID)

HOSPITAL MANAGEMENT

INTRODUCTION A snakebite is an injury caused by a bite from

a snake, often resulting in puncture wounds inflicted by the animal's fangs and sometimes resulting in envenomation/ophitoxaemia.

On the Indian subcontinent, almost all snakebite deaths have traditionally been attributed to the Big Four, consisting of the

• Russell's viper• Indian cobra• saw-scaled viper• common krait.

Saw Scaled Viper

Common Krait

Spectacled Cobra

Russell’s Viper

EPIDEMIOLOGY Estimate vary from 1.2 to 5.5 million

snakebites, 421,000 to 2.5 million envenomings, and 20,000 to 125,000 deaths globally.

Since reporting is not mandatory in much of the world, the data on the frequency of snakebites is not precise.

South Asia is by far the most affected region.

India has the highest number of deaths due to snake bites in the world with 35,000–50,000 people dying per year according to World Health Organization (WHO) direst estimates.

In Kerala, India, only 219 out of 635 patients (34%) with proven snake bite developed signs of systemic envenoming.

CAUSES Snake bite is an important occupational

injury affecting farmers, plantation workers, herders, and fishermen. They often happen when a person steps on the snake or approaches it too closely.

Open-style habitation and the practice of sleeping on the floor also expose people to bites from nocturnal snakes.

The incidence of snake bites is higher during the rainy season and during periods of intense agricultural activity . Snake bite incidence and mortality also increase sharply during extreme weather events such as floods.

PATHOPHYSIOLOGY A widespread belief is that snake bites

inevitably result in envenoming. However, bites by nonvenomous snakes are common and bites by venomous species are not always accompanied by the injection of venom (dry bites).

Since envenomation is completely voluntary, all venomous snakes are capable of biting without injecting venom into a person. Snakes may deliver such a "dry bite" rather than waste their venom on a creature too large for them to eat, a behaviour called venom metering.

Some dry bites may also be the result of imprecise timing on the snake's part, as venom may be prematurely released before the fangs have penetrated the person.

Even without venom, some snakes, particularly large constrictors can deliver damaging bites; large specimens often cause severe lacerations, or the snake itself pulls away, causing the flesh to be torn by the needle-sharp recurved teeth embedded in the person.

While not as life-threatening as a bite from a venomous species, the bite can be at least temporarily debilitating and could lead to dangerous infections if improperly dealt with.

When envenoming does occur, it can be rapidly life-threatening. Snake venom is a complex mixture of toxins and enzymes, each of which may be responsible for one or more distinct toxic actions.

Classification of venemous snakes can be done on the basis of constituent of venom & assosiated clinical signs:

NEUROTOXIC HAEMOTOXIC MYOTOXIC CARDIOTOXIC etc…………..

SNAKE VENOMS

Venom is the toxic saliva that is produced by the PAROTID GLAND of the poisonous snakes.

POISON GLANDS – are salivary glands of the snake and are situated behind the eyes, one on each side of head above the upper jaw.

Quantity of venom injected at a bite This is very variable, depending on the

species and size of the snake, the mechanical efficiency of the bite, whether one or two fangs penetrated the skin and whether there were repeated strikes.

Although large snakes tend to inject more venom than smaller specimens of thesame species, the venom of smaller, younger vipers may be richer in some dangerous components, such as those affecting haemostasis.

ThereforeBites by small snakes should not be ignored or dismissed. They should be taken just as seriously as bites by large snakes of the same species

Composition of venom Snake venoms contain more than 20

different constituents, mainly proteins, including enzymes and polypeptide toxins.

COMPOSITION OF SNAKE VENOM

SIGNS AND SYMPTOMS The most common symptoms of all snakebites are

overwhelming fear, which may cause symptoms such as nausea and vomiting, diarrhea, vertigo, fainting, tachycardia, and cold, clammy skin.

Dry snakebites, and those inflicted by a non-venomous species, can still cause severe injury. There are several reasons for this: a snakebite may become infected with the snake's saliva and fangs sometimes harboring pathogenic microbial organisms, including Clostridium tetani. Infection is often reported with viper bites whose fangs are capable of deep puncture wounds. Bites may cause anaphylaxis in certain people.

Local symptoms and signs in the bitten part

fang marks local pain local bleeding bruising lymphangitis lymph node enlargement Inflammation (swelling, redness, heat) blistering local infection, abscess formation necrosis

Local bleeding from fang marks

Local swelling and bruising along with blistering

Tissue necrosis

MANAGEMENT

First aid treatment Transport to hospital Rapid clinical assessment and resuscitation Detailed clinical assessment and species

diagnosis Investigations/laboratory tests Antivenom treatment Observation of the response to antivenom:

decision about the need for further dose(s) of antivenom

Supportive/ancillary treatment

Treatment of the bitten part Rehabilitation Treatment of chronic complications

FIRST AID TREATMENT Protect the person and others from further bites.

While identifying the species is desirable in certain regions, risking further bites or delaying proper medical treatment by attempting to capture or kill the snake is not recommended.

Keep the person calm. Acute stress reaction increases blood flow and endangers the person.

Call for help to arrange for transport to the nearest hospital emergency room, where antivenom for snakes common to the area will often be available.

Make sure to keep the bitten limb in a functional position and below the person's heart level so as to minimize blood returning to the heart and other organs of the body.

Do not give the person anything to eat or drink. This is especially important with consumable alcohol, a known vasodilator which will speed up the absorption of venom. Do not administer stimulants or pain medications, unless specifically directed to do so by a physician.

Remove any items or clothing which may constrict the bitten limb if it swells (rings, bracelets, watches, footwear, etc.)

The bitten limb should be immobilized with a makeshift splint or sling, and kept below the level of heart.

Keep the person as still as possible. Walking is contraindicated, because muscular contractions promote venom absorption.

Tight (arterial) tourniquets are not recommended!

Traditional tight (arterial) tourniquets. To be effective, these had to be applied around the upper part of the limb, so tightly that the peripheral pulse was occluded. This method was extremely painful and very dangerous if the tourniquet was left on for too long (more than about 40 minutes), as the limb might be damaged by ischaemia.

Constriction bands can be applied if there is no nearby medical facility. Constriction bands can be used but loose enough that a finger can slide beneath.

Ideally, compression bandages should not be released until the patient is under medical care in hospital, resuscitation facilities are available and antivenom treatment has been started.

Suction and incision are dangerous and should not be done.

RAPID CLINICAL ASSESMENT Check for - Airway - Breathing - Circulation - Disability

Cardiopulmonary resuscitation may be needed, including administration of oxygen and establishment of intravenous access.

DETAILED CLINICAL ASSESSMENT & SPECIES DIAGNOSIS History - In what part of your body have you

been bitten? Evidence of snake bite, Assess nature & extent of local

signs -When were you bitten? Assess the severity -Where is the snake that bit you? Identification of snake

 

•Non Poisonous Snakes Head - RoundedFangs - Not presentPupils - RoundedAnal Plate - Double row of platesBite Mark - Row of small teeth. 

 

•Poisonous Snakes Head - Triangle - except CobraFangs - PresentPupils - Elliptical pupilAnal Plate - Single row of platesBite Mark - Fang Mark 

Identification of snake

Physical examination

1.Examination of the bitten part - Extent of swelling, extent of tenderness to

palpation noted, Lymph nodes draining the limb should be palpated.If possible, intracompartmental pressure should be measured and the blood flow and patency of arteries and veins assessed.

- Early signs of necrosis may include blistering, demarcated darkening or paleness of the skin, loss of sensation and a smell of putrefaction (rotting flesh).

2.General examination - Measure the blood pressure and heart rate. - Examine the skin and mucous membranes for evidence of petechiae, purpura, ecchymoses

and, in the conjunctivae, chemosis. - Examine the gingival sulci -may show the

earliest evidence of spontaneous systemic bleeding. - Examine the nose for epistaxis. - Abdominal tenderness may suggest gastrointestinal or retroperitoneal bleeding.

- Loin (low back) pain and tenderness suggests acute renal ischaemia (Russell’sviper bites).

- Intracranial haemorrhage is suggested by lateralising neurological signs,asymmetrical pupils, convulsions or impaired consciousness (in the absence ofrespiratory or circulatory failure).

- To exclude early neurotoxic envenoming, ask the patient to look up and observe whether the upper lids retract fully.

- Test eye movements for evidence of early external ophthalmoplegia. Check the size and reaction of the pupils.

Check the muscles innervated by the cranial nerves(facial muscles, tongue, gag reflex etc). The muscles flexing the neck may be paralysed,giving the “broken neck sign”.

Broken Neck Sign in Russel”s Viper Bite

INVESTIGATIONS/ LABORATORY DIAGNOSIS 20 minute whole blood clotting test (20WBCT) -Very useful and informative bedside test

requires very little skill and only one piece of apparatus - a new, clean, dry, glass vessel (tube or bottle).

-Place a few mls of freshly sampled venous blood in a small glass vessel & Leave undisturbed for 20 minutes at ambient temperature

-Tip the vessel once.If the blood is still liquid (unclotted) and runs out, the patient has hypofibrinogenaemia(“incoagulable blood”) as a result of venom-induced consumption coagulopathy.

Haemoglobin concentration/haematocrit: a transient increase indicates

haemoconcentration resulting from a generalised increase in capillary permeability(eg in Russell’s viper bite). More often, there is a decrease reflecting blood loss or, in the case of Russell’s viper bite, intravascular haemolysis.

Platelet count: this may be decreased in victims of viper bites.

White blood cell count: an early neutrophil leucocytosis is evidence of systemic envenoming from any species.

Bleeding Time should be done to rule out any bleeding abnormalities.

Plasma/serum may be pinkish or brownish if there is gross haemoglobinaemia or myoglobinaemia.

Arterial blood gases and pH may show evidence of respiratory failure (neurotoxic envenoming) and acidaemia (respiratory or metabolic acidosis).

Desaturation: arterial oxygen desaturation can be assessed non-invasively in patients with respiratory failure or shock using a finger oximeter.

Urine examination: the urine should be tested by dipsticks for blood/haemoglobin/myoglobin. Massive proteinuria is an early sign of the generalised increase in capillary permeability in Russell’s viper envenoming.

ANTIVENOM TREATMENT The first antivenom was developed in 1895 by

French physician Albert Calmette for the treatment of Indian cobra bites.

Antivenom is immunoglobulin (usually the enzyme refined F(ab)2 fragment of IgG)purified from the serum or plasma of a horse or sheep that has been immunised with the venoms of one or more species of snake.

Antivenom is injected into the person intravenously, and works by binding to and neutralizing venom enzymes. It cannot undo damage already caused by venom, so antivenom treatment should be sought as soon as possible.

They can be either monovalent or polyvalent, depending on the number of species (single or multiple, respectively) whose venoms are used for immunization. Although monovalent antivenom has often been considered more efficacious, the production of polyvalent antivenom is preferred in many countries as snake species identification is generally not possible for the attending physician.

Local administration & Intramuscular Injection of antivenom is not recommended!

Snakes inject the same dose of venom into children and adults. Children must therefore be given exactly the same dose of antivenom as adults.

Epinephrine (adrenaline) should always be drawn up in readiness before antivenom is administered to counter the reactions such as:

-Early anaphylactic reactions: usually within 10-180 minutes of starting antivenom , the patient begins to itch (often over the scalp) and develops urticaria, dry cough , fever, nausea, vomiting, abdominal colic, diarrhea and tachycardia.

-Pyrogenic (endotoxin) reactions usually develop 1-2 hours after treatment .Symptoms include shaking chills (rigors), fever, vasodilatation and a fall in blood pressure. Febrile convulsions may be precipitated in children.

Late (serum sickness type) reactions develop 1-12 (mean 7) days after treatment . Clinical features include fever, nausea, vomiting, diarrhea, itching, recurrent urticaria , arthralgia, myalgia, lymphadenopathy, periarticular swellings, mononeuritis multiplex,proteinuria with immune complex nephritis and rarely encephalopathy.

Criteria for repeating the initial dose of antivenom:

-Persistence or recurrence of blood incoagulability after 6 hr of bleeding after1-2 hr.

-Deteriorating neurotoxic or cardiovascular signs after 1-2 hr.

SUPPORTIVE/ANCILLARY TREATMENT The management of envenomed snake bites is

not limited to the administration of antivenoms. In the case of neurotoxic envenoming, artificial

ventilation and careful airway management are crucial to avoid asphyxiation in patients with respiratory paralysis.

Anticholinesterase drugs such as edrophonium can partly overcome blockade by postsynaptic neurotoxins and have shown good efficacy in cobra bite envenoming.

A booster dose of tetanus toxoid should be administered but only in the absence of coagulopathy.

Bacterial infections can develop at the bite site, especially if the wound has been incised or tampered with nonsterile instruments, and may require antibiotic treatment.

Necrosis on the bitten limb may require surgery and skin grafts, particularly in the case of cobra bites.

Tensed swelling, pale and cold skin with severe pain may suggest increased intracompartmental pressure in the affected limb. A clear proof of significant compartment syndrome by measurement of substantially elevated intracompartmental pressures is a prerequisite. However, fasciotomy is rarely justified. In particular, it can be disastrous when performed before coagulation has been restored.

PREVENTION Many bites could be avoided by educating

the population at risk. Sleeping on a cot (rather than on the floor) and under bed nets decreases the risk of nocturnal bites.

Rubbish, termite mounds, and firewood, which attract snakes, can be removed from the vicinity of human dwellings.

Attempts can be made to prevent the proliferation of rodents in the domestic and peridomestic area.

Thatched roofs, and mud and straw walls are favoured hiding places for snakes and should be checked frequently.

Using a torch/flashlight while walking on footpaths at night, and wearing boots and long trousers during agricultural activities, could significantly reduce the incidence of bites.

Snakes are most likely to bite when they feel threatened, are startled, are provoked, or have no means of escape when cornered. Leave the area of a snake is recommended.

When dealing with direct encounters it is best to remain silent and motionless. If the snake has not yet fled it is important to step away slowly and cautiously.

It is also important to avoid snakes that appear to be dead, as some species will actually roll over on their backs and stick out their tongue to fool potential threats. A snake's detached head can immediately act by reflex and potentially bite. The induced bite can be just as severe as that of a live snake. Dead snakes are incapable of regulating the venom they inject, so a bite from a dead snake can often contain large amounts of venom.

MYTHS IN SNAKE BITE TREATMENT IN KERALA

Visha Vaidya -one branch of traditional healing, popular in

Kerala, mostly in Palakad and Trichur. -deals with management of poisonous bites,

poisonous substances and their action, Antidotes and Understanding of poisonous creatures.

-Treatment include herbals, administered as nasal drops, eye drops and oral medicine, strict food regulations, Abstaining from alcohol and non vegetarian foods , rituals and offerings to God.

Kani tribe of the Western Ghats of Kerala apply ‘Vishakallu’, a medicated stone with anti - poisoning properties to the affected area (snake bite) which is administered only by experienced tribal healers.

It is directly applied to the bitten part. It sticks there and absorbs the venom from the wound. During this operation, Lord Siva is propitiated by chanting mantras.

When all the venom is absorbed the stone falls away automatically. The stone is immersed in cow’s milk for detoxification for 2 hours.It is again dried and stored in cow dung ash. It is believed from experience that it can be used 20 times.

DOG BITE

In 2010, an estimated 26,000 people died from rabies, down from 54,000 in 1990.The majority of the deaths occurred in Asia and Africa.

India has the highest rate of human rabies in the world, primarily

-because of stray dogs,whose number has greatly increased since a 2001 law forbade the killing of dogs.

-a form of mass hysteria or group delusion known as puppy pregnancy syndrome (PPS). Dog bite victims with PPS (both male and female) become convinced that puppies are growing inside them, and often seek help from faith healers rather than from conventional medical services. In cases where the bite was from a rabid dog, this decision can prove fatal.

Dog bites account for more than 90% of all animal bites.

Infections, including tetanus and rabies, need to be considered.

Wound cleaning decreases the risk of infection.

Skin repair increases the risk of infection, and the decision to suture the skin balances the risk of infection versus the benefit of a better appearing scar.

The risk of being bitten by a dog increases if there is a dog in the home; the more dogs there are, the greater the risk. Men are more frequent victims than women.

Dogs have rounded teeth, and it is the pressure exerted by their jaws that can cause significant damage to the tissues under the skin, including bones, muscles, tendons, blood vessels, and nerves.

The dog bite victim needs to be taken to a safe place away from the assailant dog to prevent further attack and injury. Since dog bites can cause significant damage beneath the skin, a type of injury that cannot always easily be appreciated, medical care should be accessed by a health care practitioner.

Wounds should be kept elevated and, if possible, washing the wound with tap water may be attempted.

Information should be obtained from the dog's owner about the dog's rabies immunization status, but if this is not possible, hospital, animal control centers, or law enforcement personnel will help gather any required information.

Medical care should be accessed if the dog bite disrupts the skin causing a puncture, laceration, or tear. As well, if there is pain at or near the injury site, underlying structures may have been damaged and medical care may be needed.

If the skin is not disturbed, or if there is a minimal abrasion present, it may be reasonable to watch for signs of infection (pain, redness, warmth, swelling, and drainage of pus or fluid) before seeking medical care.

RABIES

Rabies ( from Latin: rabies, "madness") is a viral disease that causes acute inflammation of the brain in humans and other warm-blooded animals.

Exposure to a rabid animal does not always result in rabies. If treatment is initiated promptly following a rabies exposure, rabies can be prevented. If a rabies exposure is not treated and a person develops clinical signs of rabies, the diseased almost always results in death.

Early symptoms may include fever and tingling at the site of exposure. This is then followed by either violent movements, uncontrolled excitement, and fear of water or an inability to move parts of the body and confusion followed by loss of consciousness.

In both cases once symptoms appear it nearly always results in death.

The period between infection and the first flu-like symptoms is typically 2 to 12 weeks. Incubation periods as short as four days and longer than six years have been documented, depending on the location and severity of the inoculating wound and the amount of virus introduced . The time is dependent on the distance the virus must travel to reach the central nervous system.

The disease is spread to humans from another animal, commonly by a bite or scratch. Infected saliva that comes into contact with any mucous membrane is also a risk.

Globally most cases are a result of dog bite.

DIAGNOSIS Rabies can be difficult to diagnose because,

in the early stages, it is easily confused with other diseases or aggressiveness.

The reference method for diagnosing rabies is the Fluorescent Antibody Test (FAT) which is recommended by World Health Organization (WHO).

The FAT relies on the ability of a detector molecule (usually fluorescein isothiocyanate) coupled with a rabies specific antibody forming a conjugate to bind to and allow the visualization of rabies antigen using fluorescent microscopy techniques.

The diagnosis can also be made from saliva, urine, and cerebrospinal fluid samples, but this is not as sensitive and reliable as brain samples.[

Cerebral inclusion bodies called Negri bodies are 100% diagnostic for rabies infection but are found in only about 80% of cases.

If possible, the animal from which the bite was received should also be examined for rabies.

DIFFERENTIAL DIAGNOSIS Encephalitis, in particular infection with

viruses such as herpesviruses, enteroviruses, and arboviruses( West Nile virus).

The most important viruses to rule out are herpes simplex virus type one, varicella zoster virus, and (less commonly) enteroviruses, including coxsackieviruses, echoviruses, polioviruses, and human enteroviruses 68-71.

PREVENTION Do not approach a stray or unfamiliar dog,

especially if its owner is not present. If a confrontation occurs, do not make eye

contact and do not run or scream. Do not approach an unfamiliar dog while it is

eating, sleeping, or caring for puppies. Do not leave young children or infants

unsupervised with a dog. Contacting an animal control officer upon

observing a wild animal or a stray, especially if the animal is acting strangely

If bitten by an animal, washing the wound with soap and water for 10 to 15 minutes and contacting a healthcare provider to determine if post-exposure prophylaxis is required

Vaccinating dogs, cats, rabbits, and ferrets against rabies

Keeping pets under supervision

TREATMENT

Almost all human cases of rabies were fatal until a vaccine was developed in 1885 by Louis Pasteur and Émile Roux. Their original vaccine was harvested from infected rabbits, from which the virus in the nerve tissue was weakened by allowing it to dry for five to 10 days.

Treatment after exposure can prevent the disease if administered promptly, generally within 10 days of infection.

Thoroughly washing the wound as soon as possible with soap and water for approximately five minutes is very effective in reducing the number of viral particles.

Patients should receive one dose of human rabies immunoglobulin (HRIG) and four doses of rabies vaccine over a 14-day period.The immunoglobulin dose should not exceed 20 units per kilogram body weight.

The rabies vaccine is available as: - Human diploid cell vaccine (HDCV) - Purified chick embryo cell vaccine (PCECV) The first dose may be given at any time.The

second dose should be given seven days later.The third dose should be given 21 or 28 days after the first dose.Booster doses of vaccine are recommended every two years.

Patients who have previously received pre-exposure vaccination do not receive the immunoglobulin, only the postexposure vaccinations on days 0 and 2.

As much as possible of this dose should be infiltrated around the bites, with the remainder being given by deep intramuscular injection at a site distant from the vaccination site.

Intramuscular vaccination should be given into the deltoid, not gluteal area, which has been associated with vaccination failure due to injection into fat rather than muscle.In infants, the lateral thigh is used as for routine childhood vaccinations.

BEE & WASP STING

WASP BEE

Bee Sting in most of the situations is potentially serious. The spectrum of bee sting disease ranges from mild local reaction to death.

A bee sting is strictly a sting from a bee (honey bee, bumblebee, sweat bee, etc.). In the vernacular it can mean a sting of a bee, wasp, hornet, or yellow jacket.

Bee stings differ from insect bites, and the venom or toxin of stinging insects is quite different. Therefore, the body's reaction to a bee sting may differ significantly from one species to another.

In people with insect sting allergy, a bee sting may trigger a dangerous anaphylactic reaction that is potentially deadly. Honey bee stings release pheromones that prompt other nearby bees to attack.

The larger drone bees, the males, do not have stingers. The female worker bees are the only ones that can sting, and their stinger is a modified ovipositor. The queen bee has a smooth stinger and can, if need be, sting skin-bearing creatures multiple times, but the queen does not leave the hive under normal conditions.

Although it is widely believed that a worker honey bee can sting only once, this is a partial misconception: When a honey bee stings a person, it cannot pull the barbed stinger back out. It leaves behind not only the stinger, but also part of its abdomen and digestive tract, plus muscles and nerves. This massive abdominal rupture kills the honey bee. Honey bees are the only species of bees to die after stinging

The sting's injection of apitoxin into the victim is accompanied by the release of alarm pheromones, a process which is accelerated if the bee is fatally injured.

The main component of bee venom responsible for pain in vertebrates is the toxin melittin.

Histamine and other biogenic amines may also contribute to pain and itching.

In one of the medical uses of honey bee products, apitherapy, bee venom has been used to treat arthritis and other painful conditions.

TREATMENT If the person does not have severe allergy

symptoms:1. Remove the Stinger -Scrape the area with a fingernail or use

tweezers to remove it. -Don't pinch the stinger -- that can inject more

venom.2. Control Swelling -Ice the area. -If stung on arm or leg, elevate it. -Remove any tight-fitting jewelry from the area

of the sting. As it swells, rings or bracelets might be difficult to remove.

3. Treat Symptoms -For pain, take an over-the-counter painkiller

like acetaminophen or ibuprofen. Do not give aspirin to anyone under age 18.

-For itchiness, take an antihistamine. You can also apply a mixture of baking soda and water or calamine lotion.

4. Follow-Up -It might take 2-5 days for the area to heal.

Keep it clean to prevent infection.

If the person does have severe allergy symptoms (anaphylaxis):

1. Seek emergency care if the person has any of these symptoms or a

history of severe allergic reactions (anaphylaxis), even if there are no symptoms:

-Difficulty breathing or wheezing -Tightness in the throat or a feeling that the

airways are closing -Hoarseness or trouble speaking -Nausea, abdominal pain, or vomiting -Fast heartbeat or pulse -Skin that severely itches, tingles, swells, or turns

red -Anxiety or dizziness -Loss of consciousness

2. Inject Epinephrine Immediately -If the person has an anaphylaxis action plan from a

doctor for injecting epinephrine and other emergency measures, follow it. Otherwise, if the person carries an epinephrine shot or one is available:

-If the person has a history of anaphylaxis, don't wait for signs of a severe reaction to inject epinephrine.Inject epinephrine into outer muscle of the thigh. Avoid injecting into a vein or buttock muscles.

-Do not inject medicine into hands or feet, which can cause tissue damage.

-The person may need more than one injection if there's no improvement after the first. For an adult, inject again after 10 to 20 minutes. For a child, inject again after 5 to 30 minutes.

-A person should always go to the ER after an epinephrine injection, even if the symptoms subside.

3. Do CPR if the Person Stops Breathing -For a child, start CPR for children. -For an adult, start adult CPR.4. Follow-Up -Make sure that someone stays with the

person for 24 hours after anaphylaxis in case of another attack.

-Report the reaction to the person's doctor. The sting may be painful for a few hours.

Swelling and itching may persist for a week. The area should not be scratched as it will only increase the itching and swelling.

If a reaction persists for over a week or covers an area greater than 7–10 cm (3 or 4 inches), medical attention should be sought.

Doctors often recommend a tetanus immunization.

For about 2 percent of people, a hypersensitivity can develop after being stung, creating a more severe reaction when stung again later.

People known to be highly allergic may carry around epinephrine in the form of a self-injectable EpiPen for the treatment of an anaphylactic shock.

MANAGEMENT OF ANAPHYLAXIS FIRST LINE THERAPY

Airway &oxygenationDecontaminationEpinephrineCrystalloids

SECOND LINE THERAPYCorticosteroidsAntihistamines