What is an

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What is an anaphylactic reaction?
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Symptoms of Anaphylaxis

• May occur within seconds to more than an hour
• Flushing, itching, hives
• Rapid, irregular pulse
• Feelings of anxiety
• Swelling of the throat and tongue with breathing
  difficulty
• Symptoms of rhinitis or asthma
• Runny nose, sneezing, wheezing
• Vomiting, diarrhea, stomach cramps
• Low blood pressure, light-headedness, loss of
  consciousness

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Incidence of Anaphylaxis

• About 10,000 cases per year in North America
• Underreported
• Less severe cases may mistaken for asthma or
  simple hives
• Approximately 50 deaths per year from insect
  stings

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PrescriptionAnaphylactic Medication

• EpiPen
• Adults and children gt 30 kg
• 0.3 mg epinephrine
• EpiPen Jr
• Children lt 30 kg
• 0.15 mg epinephrine
• EpiPen 2-Pak and EpiPen Jr. 2-Pak

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EpiPens Important Notes

• Protect from extreme heat or cold
• Be aware of the expiration date
• Examine contents of the auto-injector
  periodically to make sure that solution is clear
  and does not contain any particulates
• Make sure that family and friends of patient are
  instructed on use
• Consider requesting multiple pens, for home,
  school, work etc.

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EpiPensDirections For Use
Unless completely unavoidable, someone other than
the individual experiencing anaphylaxis should
administer the injection.

• 1. Remove cap (yellow or green)
• 2. Grasp in fist with black tip pointing
  downward
• 3. Pull off grey safety release
• 4. Hold black tip near thigh
• 5. Swing and jab firmly into outer thigh
• 6. Hold firmly against the thigh for 10 seconds
  
• The window will be red when injection is complete
  
• 7. Remove from thigh and massage area of
  injection for 10 seconds
• 8. Note time of injection
• 9. Call 911 or go to Emergency Department
• 10. Put used EpiPen back into storage holder and
  take with patient to ED
• 11. Give used EpiPen to attending physician for
  examination and tell them when injection was given

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Mosquito
Which diseases can they transmit?
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• West Nile virus
• Malaria

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Mosquito bites
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Flea
Which diseases can they transmit?
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• Bubonic plague
• Endemic typhus

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Flea Bite
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Sarcoptes scabiei scabies
How are they transmitted?
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Physical contact from an infected person
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Scabies infection on abdomen
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Bedbugs
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Ticks
Which diseases can they transmit?
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Rocky Mountain Spotted fever Lyme disease
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Chiggers
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Chigger bites
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Spiders
Brown recluse
Black widow
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Brown recluse bite
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When do you refer a patient with an insect bite?
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• Systemic symptoms
• lt 2 years of age
• History of tick bite and
• possible infection/systemic
• effects
• Signs of infection

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What is the nonpharmacologic treatment for an
insect bite patient?
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• Avoidance of insects
• Use of insect repellents

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Insect Repellents

• Most contain DEET
• n,ndiethyl-m-toluamide
• Most in concentrations of 7 - 40
• Some up to 100
• Adverse effects skin rashes, burning/tingling
  sensation, some rare cases of central nervous
  system reactions including seizures, ataxia and
  encephalopathy
• Apply to skin and clothing
• Wash skin (especially face) after going inside
• Picaridin is a new repellent
• Better safety profile than DEET
• Length of action similar to long acting DEET
  products
• Less odor/lighter feeling
• Comparable price

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What is the pharmacologic treatment for insect
bites?
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OTC Pharmacologic Treatment

• Topical Anesthetics
• Benzocaine
• Dibucaine
• Phenol
• 3-4 times daily
• Up to 7 days
• Topical Antihistamines
• Diphenhydramine
• 3-4 times daily
• Up to 7 days
• Systemic Antihistamines
• Not specifically indicated but used for this
• Diphenhydramine, chlorpheniramine, loratadine

• Counterirritants
• Camphor
• Menthol
• 3-4 times daily
• Up to 7 days
• Hydrocortisone
• 3-4 times daily
• Up to 7 days
• Skin Protectants
• Zinc oxide
• Calamine
• Titanium dioxide

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Insect Stings

• Signs and Symptoms
• Localized pain, itching, irritation, swelling
• Often caused by
• Hornets, bees, yellow jackets

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When do we refer an insect sting?
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Refer Insect Stings If.

• Hives, swelling, dizziness, nausea, vomiting,
  difficulty breathing
• Significant allergic response away from the local
  site of the sting
• Previous severe reaction to bite or sting
• Personal or family history of significant
  allergic reaction (eg. hayfever)
• lt 2 years of age

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Nonpharmacologic Treatment of Insect Stings

• Remove stinger scrape
• Cold compresses
• Reduces inflammation, swelling and pain
• Avoid attracting insects
• Dont wear perfume, scented lotions, brightly
  colored clothing
• Change clothes if they get soiled with food
• Use caution when picnicking

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OTC Pharmacologic Treatment

• Topical Anesthetics
• Benzocaine
• Dibucaine
• Phenol
• 3-4 times daily
• Up to 7 days
• Topical Antihistamines
• Diphenhydramine
• 3-4 times daily
• Up to 7 days
• Systemic Antihistamines
• Not specifically indicated but used for this
• Diphenhydramine, chlorpheniramine, loratadine

• Counterirritants
• Camphor
• Menthol
• 3-4 times daily
• Up to 7 days
• Hydrocortisone
• 3-4 times daily
• Up to 7 days
• Skin Protectants
• Zinc oxide
• Calamine
• Titanium dioxide

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How do you differentiate between scabies, head
lice body lice and pubic lice and What treatment
do you recommend for each?
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Scabies

• Signs and Symptoms
• Pimple-like irritations, burrows or rash of the
  skin, especially the webbing between the fingers
  the skin folds on the wrist, elbow, or knee the
  penis, the breast, or shoulder blades.
• Intense itching, especially at night and over
  most of the body.
• Sores on the body caused by scratching. These
  sores can sometimes become infected with
  bacteria.
• May take 4-6 weeks to see signs after infestation
• Treatment
• Needs prescription medication for eradication
• Topical hydrocortisone and topical antihistamines
  for itching
• Wash all clothing and bedding in the house

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Head Lice

• Signs and Symptoms
• Tickling feeling of something moving in the hair.
  
• Itching, caused by an allergic reaction to the
  bites.
• Irritability.
• Sores on the head caused by scratching. These
  sores can sometimes become infected.
• Treatment
• Wash all bedding, clothing, spray treat cushions,
  headrests
• Pyrethrins (retreat after 7-10 days) or
  permethrin
• Before applying treatment, remove all clothing
  from the waist up.
• Do not use a creme rinse or combination
  shampoo/conditioner before using lice medicine.
  Do not re-wash hair for 1-2 days after treatment.
  
• Have the infested person put on clean clothing
  after treatment.
• If a few live lice are still found 8-12 hours
  after treatment, but are moving more slowly than
  before, do not retreat. Comb dead and remaining
  live lice out of the hair. The medicine may take
  longer to kill lice.
• Nit (head lice egg) combs, often found in lice
  medicine packages, should be used to comb nits
  and lice from the hair shaft. Many flea combs
  made for cats and dogs are also effective.
• After treatment, check hair and comb with a nit
  comb to remove nits and lice every 2-3 days.
  Continue to check for 2-3 weeks until you are
  sure all lice and nits are gone.

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Body Lice

• Signs and Symptoms
• Itching and rash
• Long term infection would lead to thickened skin,
  especially around the groin, waist and upper
  thighs
• Sores from scratching
• Treatment
• Wash all clothing in VERY HOT water
• Pyrethrins and permethrin are effective, but
  usually not necessary

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Pubic Lice (Crabs)

• Signs and Symptoms
• Itching in the genital area
• Visible nits or crawling lice
• Treatment
• Wash the infested area towel dry.
• Thoroughly saturate hair with lice pyrethrin.
  Leave medication on for 10 minutes. Thoroughly
  rinse off medication with water. Dry off with a
  clean towel.
• Following treatment, most nits will still be
  attached to hair shafts. Nits may be removed with
  fingernails.
• Put on clean underwear and clothing after
  treatment.
• To kill any lice or nits (attached to hairs) that
  may be left on clothing or bedding, machine-wash
  those washable items that the infested person
  used during the 2-3 days before treatment. Use
  the hot water cycle (130F). Use the hot dryer
  cycle for at least 20 minutes.
• Dry-clean clothing that is not washable.
• Inform any sexual partners that they are at risk
  for infestation.
• Do not have sex until treatment is complete.
• Repeat treatment in 7-10 days if lice are still
  found.

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Pyrethrin

• Indicated for head lice and pubic lice
• Available in foams, shampoos, solutions and gels
• Use with lice comb
• Retreat after 7-10 days
• Adverse effects
• Irritation, erythema, itching
• May be used on infants
• Individuals allergic to chrysanthemums or ragweed
  should not use

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Permethrin

• Indicated for head lice
• Available as a cream rinse
• Re-treatment not required
• Adverse effects
• Itching, burning, stinging, scalp irritation
• Individuals allergic to chrysanthemums or ragweed
  should not use
• Do not use on children lt 2

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Alternatives to Pyrethrin and Permetherin Products

• Rid Pure Alternative
• Dimethicone
• Licefreee
• Sodium Chloride