Problems for Discussion - 4 - Other Venomous Arthropods

• Describe the first aid management of common insect stings
• Understanding of the clinical effects of common insects in particular bees, wasps, caterpillars, centipedes, scorpions and ticks.
• Identification of allergic reactions.
• Management of these stings.

30 year old male presents to ED 2 hours following a painful sting to his left forearm which woke him from his sleep. On his forearm he has an erythaematous area the approximate size of a 50c coin. He rates his pain as 7 out of 10. There are no other local effects and he has no associated systemic effects. His vital signs are all normal.

1. What are possible insect(s) that could cause this presentation?
2. What would be medically important envenomations to exclude? What features would you look for to exclude this?
3. What would be your management be of this patients symptoms?

Mum brings in her 2 year old daughter to ED who is crying and pointing to her right foot. Mum gives a history of her daughter playing in the yard with caterpillars. On examination of the child you note that her left foot is erythaematous and on closer inspection you note hundreds of tiny black spines embedded into the foot. The child is crying but is able to be settled by mum. Rest of examination is unremarkable.

1. What is the most likely culprit?
2. How would you manage this child? Would you attempt removal of the spines?
3. What would advise would you give mum in terms of what to expect and what to watch for?

50 year old female presents to her GP 1 hour following a bee sting to her left hand. She has moderate pain and on examination of her hand you notice the sting area to be erythaematous and there is associated swelling. There is no sting embedded. There are no other local effects. She is otherwise feeling well. In particular she has no breathing difficulties and no urticaria. She has never been stung by a bee previously.

1. What would be important clinical features to look for and rule out early?
2. What first aid would you provide this patient? What is the evidence for this information?
3. Would you monitor this patient? If you were sending this patient home what would you advise her to watch for?

A previously well 33 month-old girl presented after a day of abdominal pain, lethargy, falls, lower limb weakness and ataxic gait. A tick was found above the hair line and removed. It was not formally identified. The child was discharged home. She returned in 12 hours with increasing peripheral weakness and respiratory distress. On examination stridor is audible, she is lethargic, has bilateral opthalmoplegia and globally diminished power and reflexes.

1. Outline your immediate management
2. What are the indications for ventilatory support?
3. How would you proceed with intubation if this is necessary?
4. Is Paralysis Tick antivenom indicated? If so how much?
5. What is the expected progress of this patient?
6. What is the prognosis?

(Adapted from Cameron RJ, Rowley MP. Tick paralysis requires prolonged observation. Med J Aust. 1999;171:334-335