Ouch! Something bit me!
By: Lisa Mathis MSN, FNP-BC
As healthcare providers we encourage patients to enjoy the beautiful outdoors. Sunshine, fresh air, and swimming can be as therapeutic as many medications we prescribe. However, danger can loom in the form of the hairy legged spider, the flying insect and the creepy crawlers who live in lush green grass. APPs are a first line to educate patients on what to look for and how to avoid these uncomfortable and often painful creatures.
First, use of a safe bug spray while outdoors is imperative, preferably one FDA approved. Products containing DEET are the most effective mosquito repellants currently available. DEET is also effective for a variety of other insects, including ticks. DEET should be used in locations where the risk for tick or mosquito-borne illness is elevated. DEET product concentration affects the amount of time the product repels insects. For example, 10% DEET provides protection for about 2 hours; 30% DEET protects for about 5 hours.1 In office samples may be beneficial to hand out in summer care packages.
However, even with the best protection some insects are successful, resulting in an itchy welt from the thirsty mosquito or a painful sting from a bee. In most cases it is uncomfortable but harmless with only short term consequences. However, some bites can have long term effects, and life-threatening sequela.
Any anaphylactic reaction to an insect is an emergency requiring prompt treatment and subsequent education and use of epinephrine pens. Review use yearly and limit assumptions that parents, guardians or patients know how to use auto-inject devices. Demonstrate in your office with demonstrator pens.
Ticks are very common and can be a very devious adversary causing multiple illnesses such as Rocky Mountain Spotted Fever, Alpha Gall syndrome, Lyme disease and other vector infections. Many tickborne diseases can have similar signs and symptoms. Be sure to inquire about recent tick bites when the patient comes in with vague symptoms. Examine the patient for rashes and treat aggressively as some of these illnesses can be quite devastating long term. Common symptoms of tick-related illnesses include fever, chills and arthralgias along with headache, fatigue, and myalgias. Persons infected with Lyme disease may also have joint pain or rash. Rash can also be associated with Southern tick-associated rash illness (STARI), Rocky Mountain spotted fever (RMSF), ehrlichiosis, and tularemia can cause distinctive rashes.2
Beyond itching at the site of bite, mosquitos can also carry several vector diseases. West Nile is one of the most common mosquito-borne diseases in the continental United States. One in 5 infected persons develop fever with concomitant symptoms such as headache, body aches, joint pains, vomiting, diarrhea, or rash. Most people with febrile illness due to West Nile virus recover completely, but fatigue and weakness can last for weeks to months.3
Malaria was common in the United States into the 20th century. Local U.S. mosquito-borne spread resulted in more than 150 locally acquired cases and more than 60 limited outbreaks in the United States over the past 50 years. In addition, more than 2,000 cases of malaria are reported annually in the United States, with most cases occurring in returned travelers.3 Evaluation of vague patient symptoms, fever, or lingering fatigue in areas where outbreak is possible, mosquito-borne illness should be considered in differential diagnosis.
In addition to ticks and mosquitos, spider bites can be life threatening and are a year-round risk, particularly in attics, barns, and basements. In insect bite assessment, local species distribution and activity maps may be helpful. Patient activity like working outside and in mulch or reaching under wood piles consider the Brown Recluse. This bite can result in severe pain and tissue necrosis. Medical treatment is advised as soon as possible if the spider is recognizable at time of bite.
Black widow spiders can also cause bite treatment urgency. This spider is well known for the red hourglass on its back. A black widow spider bite causes a sharp, pinprick-like, pain and can be followed by numbness in the bite area. Black widow spider venom interferes with chemicals transmission in nerve endings, producing severe pain, stiffness and muscle spasms throughout the body, including the abdomen, shoulders, chest and back. Treatment may include muscle relaxers and sedatives, to help relieve muscle pain and spasms and analgesics to help reduce pain. Antivenom can be given to help reverse the effects of the venom, including body wide muscle cramping. These bites are serious, children younger than 16 and people older than 60 may need hospitalization to treat beathing issues, heart problems, hypertension and severe muscle pain and cramping.4
Insects aren’t the only thing that can put a halt on summer fun. Watch out for slithery serpents lurking at dusk under leaves or in the shade. Avoiding the sun, they will often come out in the cooler parts of the day and like certain insects, encounters can have grave consequences. Depending on region, deadly bites can happen. Although at least one species of venomous snake is found in every state except Hawaii, Maine, and Alaska. In the U.S. roughly 7,000–8,000 people are bitten by venomous snakes yearly, with up to five deaths. Without seeking medical care, the death count would be higher.
Snake bite symptoms vary based on reptile type. Around the wound there may be puncture marks, bleeding, redness, swelling, bruising, or blistering. Severe pain and tenderness may occur. Patients can also suffer from nausea, vomiting, diarrhea, and visual or respiratory disturbance. In extreme cases, respiratory arrest, along with tachycardia and hypotension can occur. Numbness or tingling around face and/or limbs along with muscle twitching may also can occur.5 Snake bite victims should seek emergency medical attention as soon as possible to start antivenom (if needed) and stop irreversible damage. Do not advise a patient to drive themselves to the hospital because the snakebite can make the patient dizzy or pass out. Advise them to take a photograph from a safe distance to identify the snake if possible, which may aid in faster treatment. The main thing is to stay calm.
Education of these outside threats can make outdoor activities safe and fun. Have an area dedicated in your office to outdoor activities, risks and warning signs. These simple reminders will help keep your patients safe and happy during the summer months.
"Deep Summer is when Laziness finds respectability."- Sam Keen
2-https://www.cdc.gov/ticks/about/index.html
3-https://www.cdc.gov/mosquitoes/about/about-mosquitoes-in-the-united-states.html
4-https://my.clevelandclinic.org/health/diseases/black-widow-spider-bite
5-https://www.cdc.gov/niosh/outdoor-workers/about/venomous-snakes.html