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Poisonous animals
 
Cnidarians (Jellyfish, Corals and Anemones)
 
Venomous fish
 
Scorpions
 
Spiders
 
Hymenopterans (Bees, Wasps and Ants)
 
Sea snakes
 
Terrestrial snakes
 
Miscellaneous animals
 
 
 
 
 
 
 
 

Diagnosis & Treatment — Hospital

 

General problems

Which patients need to be monitored in hospital?

S  Signs & Symptoms
  • All patients with a known Hymenoptera allergy and systemic reaction following re-exposure.
  • All patients with progressive systemic symptoms.

Autopharmacological effects

(following single and multiple stings)

D  Diagnostics

See Therapy phase: General practitioner / health post.

In addition in the case of anaphylactic shock:

  • ECG,
  • continuous monitoring of blood pressure,
  • central venous pressure,
  • blood gases.
T  Treatment

See Therapy phase: General practitioner / health post.

In addition in the case of anaphylactic shock:

  • pH correction (sodium bicarbonate);
  • adrenergics, continuous i.v. infusion: e.g. adrenaline 5–20 µg/min, dopamine 100–1,000 µg/min, noradrenaline 8–20 µg/min.

Resuscitation in the event of cardiorespiratory failure (Müller et al. 1991).

C  Comments

Uncommon reactions (Müller 1988, Reisman and Livingston 1989):

  • Anaphylactic reactions that appear after a period of days.
  • Serum sickness (generalised vasculitis) 1–2 weeks after the sting: fever, joint pain, swelling, lymphadenopathy, exanthem, vasculitic purpura (hypersensitivity reaction type III?).
  • Renal effects: glomerulonephritis, nephrotic syndrome (hypersensitivity reaction type III?).
  • Neurological effects: peripheral neuritis (toxic or mechanical nerve damage due to extensive local reactions?), polyradiculitis, epileptiform seizures, reversible and irreversible central nervous system deficits (hypoxic damage in the context of severe anaphylactic shock?).
  • Haematological effects: thrombocytopaenia, haemolytic anaemia, disseminated intravascular coagulation.
  • Cardiac effects: angina pectoris, myocardial infarction, cardiac dysrhythmias (local release of mediators from mast cells that are found at increased levels in the coronary arteries of patients with coronary heart disease) (Wassermann 1986).
  • Anaphylactic reactions following a Hymenoptera sting without detectable venom-specific IgE antibodies in the serum (from this it is concluded that a non-IgE-mediated process may be the cause of a small group of reactions to insect stings) (Clayton et al. 1985, Reisman and Osur 1987).

How long should the patient be monitored in hospital following an allergic reaction?

D  Diagnostics

Monitoring in hospital until the patient is free of symptoms or for at least 24 h.

C  Comments

Due to the possibility of a biphasic course of anaphylaxis, it is necessary to monitor the patient for a sufficiently long period of time even after the patient is free of symptoms (Stark and Sullivan 1986).

Local effects

(toxic venom effects from multiple stings)

S  Signs & Symptoms
  • Local swelling of the cutis and subcutis,
  • haemorrhagic skin necrosis.
D  Diagnostics

Extent of the swelling.

T  Treatment
  • Fluid replacement if there is extensive and/or rapidly progressive swelling,
  • wound treatment.
C  Comments

Fluid sequestration in the region of the swelling can lead to hypovolaemic shock (Müller 1988). See also Apoidea: Clinic: Recommendations (Franca et al. 1994).

Haemostatic effects

(toxic venom effects from multiple stings)

S  Signs & Symptoms
  • Icterus,
  • systemic bleeding.
D  Diagnostics
  • Clinical signs of haemolysis, 
  • laboratory parameters: Hb, Hct, LDH, haptoglobin, clotting time test, PT/aPTT, TT, fibrinogen, FSP, D-dimers, platelets.
T  Treatment
  • Blood transfusions,
  • symptomatic treatment of the haemostatic defect if there is critical systemic bleeding or the risk of such bleeding,
  • prevention of haemoglobinuric nephropathy.
C  Comments

Coagulation disorders are caused in part by the fall in liver-dependent coagulation factors in the context of toxic liver damage. However, patients with disseminated intravascular coagulation have also been described (Müller 1988). See also Apoidea: Clinic: Recommendations (Franca et al. 1994).

Neurological effects

(toxic venom effects from multiple stings)

S  Signs & Symptoms
  • Cerebral seizures
  • clouding of consciousness,
  • coma.

D  Diagnostics

Clinical.

T  Treatment
  • Treatment of cerebral seizures.
  • Treatment of cerebral oedema.
C  Comments

Peptides such as melittin, apamin and kinins can penetrate the blood-brain barrier and are probably responsible for central nervous symptoms. Such symptoms have been observed in particular following multiple stings to the head region (Müller 1988). However, central nervous signs and symptoms may also be the consequence of hypoxia in the context of hypovolaemic or anaphylactic shock, for example. See also Apoidea: Clinic: Recommendations (Franca et al. 1994).

Muscular effects

(rhabdomyolysis)
(toxic venom effects from multiple stings)

S  Signs & Symptoms
  • Muscle weakness,
  • muscle pain,
  • tenderness of the musculature on pressure,
  • resistance to passive stretch,
  • pseudotrismus,
  • dark-brown/red urine (differential diagnosis haemoglobinuria).
D  Diagnostics
  • Clinical,
  • laboratory parameters:
    • myoglobin in the serum/urine,
    • ↑ serum creatinine kinase (CK, CPK),
    • ↑ aspartate aminotransferase,
    • ↑ serum potassium,
    • ↑ phosphate,
    • ↑ serum calcium.
T  Treatment
  • Prevention of myoglobinuric nephropathy (see below).
  • Immobilisation (regeneration of the damaged musculature).

Renal effects

(toxic venom effects from multiple stings)

S  Signs & Symptoms
  • Flank pain, 
  • renal bed sensitive to percussion,
  • eyelid oedema.
D  Diagnostics
  • Clinical,
  • urine output (balance, hourly),
  • laboratory parameters:
    • serum creatinine,
    • serum potassium,
    • bicarbonate.
T  Treatment

Treatment of acute renal failure.

C  Comments

Renal effects may have an autopharmacological (allergic) cause (see Comments above). Acute renal failure is also possible in the context of renal hypoxia (arterial hypotension, microthrombosis) and renal effects of rhabdomyolysis or haemolysis (Müller 1988, Ward 1988). Renal failure may also occur after a delay (Bousquet et al. 1984). See also Apoidea: Clinic: Recommendations (Franca et al. 1994).

Other venom effects
(toxic venom effects from multiple stings)

S  Signs & Symptoms
  • Icterus,
  • arterial hypertension.
D  Diagnostics
  • Clinical;
  • laboratory parameters,
    • transaminases (increase may be very marked),
    • liver-dependent coagulation factors (decrease),
    • arterial blood pressure.
T  Treatment
  • Replacement of liver-dependent coagulation factors.
  • Prazosin, nifedipine for arterial hypertension (Franca et al. 1994).
C  Comments

The venom-induced release of catecholamines may be responsible for the arterial hypertension observed in some patients. See also Apoidea: Clinic: Recommendations (Franca et al. 1994).

How long should the patient be monitored in hospital following a toxic reaction?

≥4 days (Bousquet et al. 1984).

D  Diagnostics
  • Clinical, signs of
    • rhabdomyolysis,
    • haemolysis,
    • renal failure.
  • Laboratory parameters:
    • CPK, LDH,
    • Hb, Hct,
    • haptoglobin,
    • creatinine, serum potassium.
C  Comments

Rhabdomyolysis and acute renal failure may only become manifest after a period of days (Bousquet et al. 1984).

Follow-up
Wounds, in particular necrosis

D  Diagnostics
  • Inspection,
  • bacterial smears.
T  Treatment
  • Wound care,
  • possibly antibiotic treatment.