482 Emergency Medicine
antivenin is dependent on the severity of these symptoms. Venom itself has
a number of substances including proteolytic enzymes and polypeptides,
which promote coagulation, neuromuscular blockage, cell lysis, and death.
Anaphylaxis may also occur. Airway, breathing, and circulation (ABCs) must
always be initially assessed.
Tetanus prophylaxis (b)should be given at some point in treatment,
but it is not the initial treatment of choice. Antibiotic prophylaxis (c)is
not clinically indicated in these cases. Sedation (d)with benzodiazepines
may be used in other venomous bites, such as scorpions, as a result of the
extreme pain and neurologic manifestations but is not clinically indicated
here. Atropine (e)and pralidoxime are used in cases of organophosphate
exposure.
434.The answer is d.(Rosen, pp 793-794.)History-taking should include
prior bee stings in this child, as each successive sting increases the possibility
of anaphylaxis given sensitization. The ABCs must be initially addressed.
Stings most commonly present with localized burning, erythema, and
edema at the sting site lasting for about 24 hours. The patient is asymptomatic
and only warrants observationat this time. Toxicity and anaphylaxis are
evident soon after the sting and include vomiting, diarrhea, fever, and neuro-
logicmanifestations, such as seizures and altered mental status. This child
most likely sustained a sting from a honeybee or bumblebee, given the single
puncture wound. Aphids contain retroserrate-barbed stingers, which are
removed upon stinging, thereby eviscerating and killing the insect. Vespids,
such as wasps, hornets, and yellow jackets, do not contain this mechanism
and may sting many times. “Killer bees,” as popularized by the film industry,
contain the same amount of venom as other species. The difference is that
they are more aggressive, not more toxic.
Our patient’s condition at this time does not warrant epinephrine
(a and b)in any form. Steroids (c)and antihistamines (e)are usually given
in patients with systemic signs. β2-Agonists (eg, albuterol) may also be given
for respiratory symptoms.
435.The answer is b.(Rosen, pp 774-780, 1839-1840.)Given that the bite
was sustained by an unknown stray dogthat may be difficult to locate,
rabies immunizationshould be given promptly. If the dog could be found,
quarantining the animal for 10 days for observation may be a valid option and
could save the patient from the rigorous postexposure prophylaxis schedule.
It is important to note the powerful effects of water and soap irrigationin