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What is an anaphylactic reaction? 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 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 Prescription Anaphylactic Medication • EpiPen – Adults and children > 30 kg – 0.3 mg epinephrine • EpiPen Jr – Children < 30 kg – 0.15 mg epinephrine • EpiPen 2-Pak and EpiPen Jr. 2-Pak 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. EpiPens Directions 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 Mosquito Which diseases can they transmit? West Nile virus Malaria Mosquito bites Flea Which diseases can they transmit? Bubonic plague Endemic typhus Flea Bite Sarcoptes scabiei “scabies” How are they transmitted? Physical contact from an infected person Scabies infection on abdomen Bedbugs Ticks Which diseases can they transmit? Rocky Mountain Spotted fever Lyme disease Chiggers Chigger bites Spiders Brown recluse Black widow Brown recluse bite When do you refer a patient with an insect bite? • Systemic symptoms • < 2 years of age • History of tick bite and possible infection/systemic effects • Signs of infection What is the nonpharmacologic treatment for an insect bite patient? • Avoidance of insects • Use of insect repellents 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 What is the pharmacologic treatment for insect bites? OTC Pharmacologic Treatment • Topical Anesthetics – – – – • Counterirritants – Camphor – Menthol – 3-4 times daily Benzocaine Dibucaine Phenol 3-4 times daily • Up to 7 days • Up to 7 days • • • Up to 7 days • – 3-4 times daily Topical Antihistamines – Diphenhydramine – 3-4 times daily Systemic Antihistamines – Not specifically indicated but used for this – Diphenhydramine, chlorpheniramine, loratadine Hydrocortisone • Up to 7 days • Skin Protectants – Zinc oxide – Calamine – Titanium dioxide Insect Stings • Signs and Symptoms – Localized pain, itching, irritation, swelling • Often caused by – Hornets, bees, yellow jackets When do we refer an insect sting? 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) • < 2 years of age Nonpharmacologic Treatment of Insect Stings • Remove stinger – scrape • Cold compresses – Reduces inflammation, swelling and pain • Avoid attracting insects – Don’t wear perfume, scented lotions, brightly colored clothing – Change clothes if they get soiled with food – Use caution when picnicking OTC Pharmacologic Treatment • Topical Anesthetics – – – – • Counterirritants – Camphor – Menthol – 3-4 times daily Benzocaine Dibucaine Phenol 3-4 times daily • Up to 7 days • Up to 7 days • • • Up to 7 days • – 3-4 times daily Topical Antihistamines – Diphenhydramine – 3-4 times daily Systemic Antihistamines – Not specifically indicated but used for this – Diphenhydramine, chlorpheniramine, loratadine Hydrocortisone • Up to 7 days • Skin Protectants – Zinc oxide – Calamine – Titanium dioxide How do you differentiate between scabies, head lice body lice and pubic lice and What treatment do you recommend for each? 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 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. 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 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, machinewash those washable items that the infested person used during the 2-3 days before treatment. Use the hot water cycle (130°F). 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. 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 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 < 2 Alternatives to Pyrethrin and Permetherin Products • Rid Pure Alternative – Dimethicone • Licefreee – Sodium Chloride