Burns and Bites and Stings, Oh My!

A Western Diamondback is seen in this undated file photo.
A Western Diamondback is seen in this undated file photo. (Photo/Joseph P Bruton)

Kaitlyn O’Malley, NRP, examines some not-so-common injuries EMS providers may encounter in the field.

In the world of EMS, first responders are faced with a number of different types of calls, during all of which their priorities remain patient care and safety. This can prove difficult when facing a patient presenting with a unique type of burn, bite or sting. Providers may not know the best course of action or even what symptoms to anticipate. There is a national requirement for first responders to keep up to date by completing continued education, because knowledge is one of the most important things utilized in the field. Providers should be aware if priorities of patient care, timing of interventions, or goals for symptom treatment have changed in order to ensure the most optimal patient outcome. When it comes to rare types of injuries, like those from certain animals, well-informed providers can make a huge difference in the quality of patient care and could be potentially lifesaving.

The number one priority on a call involving an animal attack is scene safety. EMS may need to call animal control (some states – if not all – require police intervention) or use the assistance of people on scene to ensure that the offending creature does not pose a threat. Once that is taken care of, patient contact can be made. Patient assessment should proceed as usual, following the MARCH assessment and treating any life threatening symptoms immediately. EMS should look for signs and symptoms of impending anaphylaxis that   may compromise the patient’s airway, as well as control any gross bleeding, as these are the aspects of the MARCH assessment most common to be seen in animal attacks. However, that is not to say a secondary event might have taken place and vigilant patient assessment should aid in identifying evidence of any underlying issues alongside the animal attack.

Related: Assessing, Treating and Preventing Snake Envenomation

Once life-threatening symptoms have been addressed, a secondary assessment can take place. The bite should be thoroughly washed for several minutes with warm water or copious amounts of normal saline solution. An antibiotic ointment should be applied with clean gloves to all areas of the wound, and then covered with a sterile dressing. Patients may develop symptoms such as redness, swelling, nausea, vomiting, and dizziness as time after the incident increases. These can develop into worsening conditions, and frequent reassessment of patient presentation is recommended. For patients who are suspected to have been injected with some sort of toxin, treat them as if the assailant is poisonous. Start by immobilizing areas of injection, do not apply ice to the area.² If the patient becomes hypotensive you may also place a constricting band proximal to the injury to further decrease the amount of blood from the wound site circulating. Choosing an appropriate receiving facility is important in the treatment of most envenomations and stings, as not all hospitals are equipped with toxicology departments.

A patient may be bit by creatures both small and large. Dependent upon the amount of bleeding present, the first step in patient care may be quite obvious. In instances such as shark attacks, whether a patient’s limb has been amputated or a large piece of flesh removed, a tourniquet will be necessary. Any appendages that have been removed and are retrievable should be placed in a bag and on ice for transport. Flesh should not be in direct contact with ice, and the receiving facility should be made aware that the limb is in transport as well. With patients who have experienced severe blood loss, EMS should first consider type of fluid administration as well as location of the nearest hospital. It may be appropriate to take a patient to a lower-tier hospital for blood administration before they can be transferred to a more appropriate facility. In the case of smaller animal bites, a pressure bandage may be sufficient enough to stop the bleeding. If possible, the wounds should be cleansed with a normal saline solution before bandages are applied, in order to avoid infection down the line. However, not all animal bites are handled with such little effort.

Snake bites are on the rise in the U.S. due to the increasing popularity of breeding and keeping these reptiles as pets. Unfortunately, this increase in popularity has also led to an increase in venomous snakes being let out into the public by incapable owners. The state of Florida houses a Fire Rescue Venom Response Team equipped with an anti-venom bank capable of providing antidotes for every venomous snake alive many zoos in large cities do the same. This is important because treatment is snake specific and dependent on the amount of venom injected into the patient. They recommend to the public that in the instance of a snake bite, they either photograph the snake or bring its dead body with them to the hospital if possible.⁵ First responders should be aware of this due to the fact that a patient’s recovery is greatly influenced by the ability to identify and treat the type of snake bite acquired.

Every type of snake venom requires their own antidote, which puts a great responsibility for patient care on being able to identify the offending snake. The receiving facility may also be able to estimate the amount of venom given to the patient by the reported size of the snake, as well as the patient’s presenting symptoms. An important consideration when it comes to snake bites is whether the reptile is hemotoxic or neurotoxic. Hemotoxic snakes will cause local swelling and necrosis, while neurotoxic snakes raise the risk of nerve paralysis, respiratory arrest or death. Patients suspected of hemotoxic envenomation should not walk to the ambulance. Rather, the affected limb should be secured to the body, in line with the heart, to encourage as little movement as possible.² Cold packs and tourniquets are not indicated.

However, in the event of hypotension, a constricting band can be placed proximal to the injection site. First responders should anticipate the need to control the airway and manually ventilate patients who have been injected with neurotoxic venom.³ Cardiac monitoring is also recommended, as eventual cardiac arrest is common in these types of envenomation. When it comes to life at sea, things are not always as they seem. Unfortunately, a large majority of patients who have been stung, bit or burned while in the water have very little insight about what attacked them. This can hinder a first responder’s ability to anticipate patient presentation and symptoms.

Therefore, all patients who were attacked by an unknown creature and have requested EMS for concerning symptoms should be considered severe. An example of such circumstances is a sting from a jellyfish. The severity of a jellyfish sting depends on the type of jellyfish as well as the amount of exposure from the sting. On average, jellyfish span from one millimeter to seven feet long, which means the surface area on a human that they can sting varies greatly. Jellyfish tentacles are covered with hundreds of microscopic needles that inject venom into their target upon tactile stimulation.⁴ Household vinegar is a proven antagonist to these needles, and can be used in the likely event that a piece of the jellyfish has ripped off and is still attached to the patient. Contrary to popular belief, urine is not helpful to those who have been stung by a jellyfish. It has been proven that urine irritates the stingers and leads to an increase in venom release.⁴ However, jellyfish venom can be inactivated by the application of hot packs, as most jellyfish venom cannot withstand applied heat that is tolerable to humans. Cold packs, on the other hand, have been shown to increase the negative side effects of a sting and should not be used by first responders on victims of a jellyfish sting.

First responders should be on the lookout for Irukandji syndrome in patients who have been stung by a jellyfish. This is a delayed response to what presents initially as a minor sting that can result in cardiac arrest.¹ Prehospital management of these patients includes application of vinegar to the site, analgesics for pain management, and the administration of magnesium sulfate for analgesia as well as associated hypertension. Current research is being conducted in Australia involving magnesium sulfate as a treatment for Irukandji Syndrome related pain and hypertension.¹ Cardiac monitoring during transport is also recommended by physicians to monitor for impending heart failure. Although, one doesn’t need to travel all the way to the beach to find danger.

Approximately 7.5% of people will experience a severe reaction to common insect stings in their lifetime. Envenomation from honeybees, paper wasps and yellow jackets are all capable of initiating an anaphylactic response. However, most insect stings will only cause moderate symptoms of an allergic reaction. Most common symptoms include redness, swelling and itching. In patients experiencing an anaphylactic reaction to the sting wheezing, difficulty breathing, hypotension and swelling of the airway are all common. The stinger should be removed, if possible, and the area washed thoroughly before applying a cold compress. In cases of anaphylaxis, epinephrine can be given through an intramuscular injection. Diphenhydramine should be given afterwards to avoid resurgence of symptoms during transportation. For patients with continued wheezing, after albuterol treatments have been administered, methylprednisolone should be considered. There are also common insects with the ability to create life-threatening symptoms.

Spider bites are incredibly rare, as most arachnids lack the muscles necessary to puncture human flesh. However, the brown recluse, phoneutria, black widow, and funnel web spider are known to have quite dangerous bites. The black widow alone accounts for 2,500 patient admission to poison control centers yearly in the United States.⁷ Spider bites vary in symptoms and onset, so first responders should be vigilant in their assessment. Brown recluse spider bites are initially only mildly irritating, but can result in major tissue damage. Funnel web spider bites can cause tingling sensation, vomiting, dizziness and eventual heart failure resulting in fluid in the lungs. Black widow spider bites can result in significant muscular pain, cramping, and paralysis of the diaphragm. These patients may require advanced airway placement and manual ventilation. It is frequent for patients to put off treatment for a spider bite if they did not see the type of spider that bit them, or they believe the symptoms are not significant. Providers may encounter a patient with a spider bite at any time during the progression of their symptoms and should be familiar with what to anticipate and are encouraged to complete a full body system assessment.

Finally, first responders should be aware of plant life that can pose a serious risk to patients’ health. Gympie-Gympie is a plant that is known to cause anaphylaxis to those who even brush up against it. A Gympie-Gympie burn is often described as an electrical shock sensation before the onset of anaphylaxis. The Gympie-Gympie uses stingers that should be removed before the area is touched, otherwise the stingers can be broken off in the patient.⁶ The pain bush is well known in literature for its ability to “drive people to suicide” from the excruciating pain of its burns. Pain management will be first priority in these cases, as well as washing of the affected area. These burns will cause blackening of the skin, but should resolve in a few weeks.⁶

The manchineel tree has the capability of affecting patients in quite a few ways. Those who have ingested the apples from this poisonous tree are likely to experience esophageal burns and even death. Securing an airway and rapid transportation are important for these patients. However, even coming in contact with water that fell off a manchineel leaf can cause significant burns or allergic reactions. First responders should be aware of what types of poisonous fauna exist in the areas they serve.

Although these obscure related injuries are not very common in the world of EMS, it is important for first responders to be prepared. Quick thinking on scene and appropriate receiving facilities can mean life or death for a patient, so it is important to stay informed. Specific treatments can also help improve patient outcomes. Staying up-to-date on the new and improved ways of treating unique burns, bites and stings may save a life one day.

References

1. Barnett, F. I. (2005, September). Management of Irukandji syndrome in northern Australia. PubMed. https://pubmed.ncbi.nlm.nih.gov/16124840/

2. Daley, B. J. (2014, June 3). Assessing, Treating and Preventing Snake Envenomation. JEMS. https://www.jems.com/patient-care/assessing-treating-and-preventing-snake/

3. EMS World. (2005, March 31). Stings and Bites: What To Do About Envenomation Injuries. EMS World. https://www.emsworld.com/article/10324062/stings-and-bites-what-do-about-envenomation-injuries

4. Health Direct. (2010, June). Jellyfish stings. Types, Symptoms and Treatment | Healthdirect. https://www.healthdirect.gov.au/jellyfish-stings

5. Morelli, K. (2008, April 30). Florida Snakebites on the Rise. JEMS. https://www.jems.com/news/florida-snakebites-rise/

6. Petruzzello, M. (n.d.). 7 Dangerous Plants You Should Never Touch. Encyclopedia Britannica. Retrieved March 29, 2021, from https://www.britannica.com/list/7-plants-you-cant-even-touch

7. Rafferty, J. (n.d.). 9 of the World’s Deadliest Spiders. Encyclopedia Britannica. Retrieved March 29, 2021, from https://www.britannica.com/list/9-of-the-worlds-deadliest-spiders#:%7E:text=Phoneutria%20are%20poisonous%20to%20humans,erections%20(priapism)%20in%20men

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