Stings, Bites, Blisters, & Rashes

by Herman Ellemberger, M.D.
Wright State Department of Emergency Medicine

Stings:

• Bees, Wasps, Yellow Jackets, etc. can produce minimal symptoms from the pain of a pinprick to major symptoms of trouble breathing and subsequent death.

If you have had an anaphylactic reaction to these stings (shortness of breath) you should have an epipen at home, in your car, and backpack if going hiking (auto injector of epinephrine, prescribed by your physician)


If you get stung, and have local inflammation & redness/swelling, pain, or itching, take Benadryl (available over the counter, 25 mg. every four hours, can take up to 50 mg every four hours)


If swelling & warmth develops at the site two days after the sting, go to your physician as this is an infection and will require antibiotics

• Fire Ants: pretty much the same thing goes, except that fire ant events usually occur with multiple stings/bites when someone lies down on a patch of grass/ground where a colony resides, thus if you have multiple sites affected you may want to head to your physician


• Scorpions: Unless you live in (or visit) the Southwest United States, this will not be that helpful. There are two types, venomous and not venomous. Just go to the closest Emergency Department if you get stung, since you won't know which type it is unless you kill it and then look at its external features. Death can result in a minimum of 5 hours with the venomous type.

Rashes:

• Poison Oak, Sumac, and of course Ivy.

Protection: Clothing; long pants and shirt; Ivy Block, sold in pharmacies over the counter; apply prior to being outdoors and exposure

NOT CONTAGIOUS! Contrary to myth, the rash is a result of the oil of the plant that causes an allergic reaction in most humans. If someone comes in skin-to-skin contact with an area that has this oil on it, then it will also be transmitted to them. Once the area has been cleaned with soap and water, then there is no more possible transmission. The liquid in the vesicles (blisters) that will form does not transmit the rash. To prevent spreading, don't itch yourself unless you have washed your body.

Vesicles that have popped can get infected. If any pus starts draining from the affected site or there is increasing surrounding redness or warmth, go see your physician.

Treatment at home: Benadryl (OTC, up to 50 mg every four hours) and 1 percent Hydrocortisone Cream (OTC) applied topically to affected areas. This works for some people but not me. If this doesn't work for you, your doctor can prescribe either an oral steroid or a stronger topical steroid. If prescribed, you should use these for at least seven days because the symptoms may flare up if you stop sooner.

Any involvement of the genitals or eyes should probably be seen by your doctor to make sure there is not infection brewing.

Blisters:

• Protection:

If going for an extended hike or backpacking trip, make sure your footwear is broken in. This is not the time to break shoes in, it will only serve to break you in!

DO NOT wear cotton socks! They lack the ability to 1) keep your feet warm, and 2) dry efficiently once wet. You can purchase wool socks or synthetic socks. Wool is warmer but will not dry as quickly, which is okay for a one day outing; or if out for multiple days, a synthetic liner can be used. Synthetic socks (polyester) work well at wicking moisture away from the skin and dry very quickly (one drawback, synthetic clothing will start to smell quickly if used repeatedly).

• If a hot spot is brewing:

Mole skin, cut in the shape of a donut with the hot spot in the middle; if I do this I usually make multiple layers, one usually doesn't work. -
Duct tape! Yes, I have read that applying the tape over the hot spot works great (no need for a donut)-
Change your socks often if wet. Wet feet will destroy you quicker then you know it! Hang the socks from your bag to dry-
Baby powder your feet prior to putting socks on (socks and feet must be dry prior to application)-
There are several other alternatives out there, but if your shoes are broken in, that's half the battle!-
Whenever you stop (and it's going to be over 10 minutes till you start up again) take off your shoes and socks and allow them to air out and dry.

• If a blister forms:

if it is filled with clear fluid, you may "pop" it with a sterile needle (heated with a flame) and the area should be cleaned as thoroughly as possible - if it is filled with blood, DO NOT POP IT! It may continue bleeding and will not stop.

If any pus begins to drain out or there is increased warmth with surrounding redness, go see a doctor for a probable infection

Bites:

• Brown Recluse: body 8-15 mm long; usually has a dark violin shaped spot on it's body

Venom: will cause hemolysis (breaking of red blood cells) and dermonecrosis (something you don't want). A stinging bite sensation is not always present, but if it is it will start to go away in 6-8 hours and then local aching and itching will commence

What to do:

Local cold compresses, elevation of the extremity, and go to an emergency department (not life threatening and usually managed on an outpatient basis)

• Black Widow: only the female has venom, 2-2.5 cm body length, shiny black with a red hourglass on it's abdomen

They usually bite as a defense mechanism to protect their webs; so they won't be creeping into your sleeping bag.

There is minimal or no local irritation at the site

But within as few as 30-60 minutes, victims will start experiencing involuntary muscle spasm and rigidity of the abdomen, legs, and lower back. May feel like a really bad "tummy ache." Then increasing shortness of breath, and then respiratory paralysis, which leads to death

If you see this spider and it bites you, waste no time and go to an Emergency Department. This is a life threatening emergency! Not all cases lead to respiratory failure, and some cases are managed with minimal intervention.

If you develop severe abdominal pain in the woods and remember having felt a bite earlier that you might have dismissed as mosquito, go to an Emergency Department. Make sure you let the physician know that you were outdoors and you felt a bite.

• Ticks: Very simple, pull the tick off (applying alcohol to the tick will help get it off) and keep it. Take it and yourself to an Emergency Department. If you never noticed the tick bite, but then notice a bulls eye lesion on your body, go to your doctor. Also search yourself and children after time in the woods (mainly during spring and summer); and search your dogs too as they can carry them indoors.


• Squirrels: Do not fret. Wash the area with a copious amount of water and soap. If it is large and deep go to the Emergency Department. If it is a nick on the skin, just watch it. Go to your doctor if there is any evidence of increasing warmth or surrounding redness or pus draining. SQUIRRELS ARE NOT VECTORS FOR RABIES! (other mammals like skunks and raccoons are though)


• Cats and dogs: If you are bitten on the hand and the bite is semi-deep, go to the Emergency Department or your doctor. Infections of the hand can get nasty. If you know the animal and there is proof of rabies vaccination, then don't worry. Just clean the site with copious amounts of water and soap. If you don't know its vaccination status and this dog or cat appeared very viscous with frothing or saliva coming from the mouth, then go to your doctor. If it is a homeless animal and managed to get killed after the attack, contact your local health department as the brain will then be biopsied (this is THE ONLY way of telling whether an animal is rabid)


• Bears: GOOD LUCK, if you can drag yourself and all your parts to the closest Emergency Department!


• Snakes: Two main types Elapids (coral snakes) and Crotalids (pit vipers). GO TO AN EMERGENCY DEPARTMENT ASAP AFTER BEING BITTEN BY ONE OF THESE! The majority of snake bites are by pit vipers (the snake will have a "pit" between and below the level of the eye and nostril on each side).



Vipers: Elliptical eyes, not round ones. On its ventral side (the side against ground), it will have a single row of scales. (Non-venomous snakes have a double row, however Elapids also have a double row.) Vipers will also have fangs (fangs are shorter on Elapids). Triangular head, not round. Babies are capable of producing a fatal bite. Venom of pit vipers is meant to destroy tissue locally and then spread systemically to cause organ failure. You will get local irritation, followed by necrosis, and increased bleeding ability. Preliminary symptoms include weakness, nausea and vomiting, numbness, pain and swelling.

Coral Snakes: "Red on yellow, kill a fellow; red on black, venom lack" (ONLY IN UNITED STATES!) Venom of coral snakes does not cause a local reaction and has little if no pain associated with the bite. The venom is a neurotoxin. Will start to get muscle twitching and paresthesias (numbness) at site, followed by increased salivation, tremors, drowsiness, slurred speech. Respiratory failure can develop over a several hours. All these symptoms have been known to be delayed for up to 12 hours.

What to do:

1) Don't panic, it will only delay definitive care. Keep your cool and use your head.

2) Call 911 if you have the resources. This is a medical emergency! If not, have someone drive you. If you are alone, walk but do it slowly, and use a makeshift crutch if a leg is involved, and take breaks. Any increased exertion of that body part will increase blood flow, thus providing a means of transportation for the venom. PIT VIPER VICTIMS RARELY DIE IN 24 HOURS!

3) If the snake was killed, take it with you in a closed container. But don't go chase the snake to try and kill it so you can take it with you. You are asking for death if you do so! If the snake was decapitated, the head can still envenom a person up to 20-60 minutes after decapitation!

4) Immobilize the extremity (splint it) and reduce physical activity to a minimum

5) If you cannot be evacuated ASAP (in the back country) stay put while someone goes for help, and drink plenty of fluids

6) DO NOT USE A TOURNIQUET or PRESSURE BANDAGE! North American viper's venom will cause significant local damage when such measures are employed (this method only works on certain Crotalidae, like Australian ones, whose venom has no local effects)

7) Making an incision and sucking out the venom has not been proven to help (despite what you have seen on MacGyver!)

8) AND MOST IMPORTANT OF ALL, BEING DRUNK OR EXTREMELY DUMB AND WANTING TO PROVOKE REPTILES IS BAD FOR YOUR HEALTH!

Last of all: some of the medical problems explained above are true emergencies and medical attention must be sought out. There are several problems in this handout that are not emergencies and can be handled by your primary care physician, unless you are away from home, and then an Emergency Department is appropriate.

ENJOY THE WILDERNESS!!