FIRST AID - Insect Bites and Stings

Most stings from bees, wasps and hornets cause pain and slight swelling, but have little other effect. But, some people are allergic to stings and can develop reactions that can be life-threatening. Call an ambulance immediately if you suspect an allergic reaction soon after being stung. If you are stung by a bee and the stinger remains in the skin, then scrape out the stinger as quickly as possible. Do not pluck it out as this may squeeze more venom into the skin. Insect bites (not stings) rarely cause serious allergic reactions but can cause small itchy lumps to appear on the skin. Itch may be eased by a soothing ointment, antihistamine tablets, or steroid cream. Some insects infest pets, furniture, etc, and can cause repeated bites.

Insects, stings and bites

• Stinging insects that are common in the UK include wasps, bees and hornets. The sting is due to venom (like a poison) which the insect 'injects' into the skin.
• Biting insects that are common in the UK include midges, gnats, mosquitoes, flies, fleas, mites, ticks, and bedbugs.

What may happen after an insect sting or bite?

A small local skin reaction - most cases

Most people will be familiar with the common local skin reactions caused by insects.

• An insect sting - typically causes an intense, burning pain. This is quickly followed by a patch of redness and a small area of swelling (up to 1 cm) around the sting. This usually eases and goes within a few hours.
• An insect bite - you may not notice the bite (although some can be quite painful, particularly from a horsefly). However, saliva from the insect can cause a skin reaction such as:
  • Irritation and itch over the site of the bite.
  • A small itchy lump (papule) which may develop up to 24 hours after a bite. This typically lasts for several days before fading away. Sometimes some redness (inflammation) surrounds each papule.
  • A weal which is like a small fluid-filled lump and is very itchy. It may develop immediately after being bitten. A weal lasts about two hours, but is often followed by a small itchy solid lump which develops up to 24 hours later. This can last for several days before fading away.

Occasionally, small skin reactions following an insect bite persist for weeks or months. A persistent skin reaction is particularly likely following a tick bite. Severe allergic reactions (described below) are rare after insect bites - they are more common after insect stings.

A localised allergic skin reaction - occurs in some cases

Some people have an allergic reaction to the venom in a sting. A localised reaction causes swelling at the site of the sting. This becomes larger over several hours, and then gradually goes away over a few days. The size of the swelling can vary, but can become many centimetres across. The swelling may even extend up an entire arm or leg. The swelling is not dangerous unless it affects your airway. However, if it is severe, the skin may break out in blisters.

A generalised (systemic) allergic reaction - rare but serious

The venom can cause your immune system to react more strongly. This may cause one or more of the following:

• Itchy skin in many parts of the body, followed by an itchy blotchy rash that can appear anywhere on the body.
• Swelling of your face which may extend to the lips, tongue, throat, and upper airway.
• A sense of impending doom.
• Abdominal cramps and feeling sick.
• Dilation of the blood vessel, which can cause:
  • General redness of your skin.
  • A fast heart rate.
  • Low blood pressure, which can make you feel faint, or even to collapse.
• Wheezing or difficulty in breathing due to an asthma attack or throat swelling.

A generalised reaction will usually develop within 10 minutes of a sting. It can be fairly mild; for example, a generalised itchy rash and some mild facial swelling. In some cases it is severe and life-threatening; for example, severe difficulty breathing and collapse. A severe generalised allergic reaction is called anaphylaxis and is a medical emergency.

If you have many bee or wasp stings at the same time, this can also cause serious illness. This is usually directly due to the high dose of venom, rather than to an allergy.

Skin infection

Occasionally, a skin infection develops following a bite, particularly if you scratch a lot, which can damage the skin and allow bacteria (germs) to get in. Infection causes redness and tenderness around the bite. Over a period of several days, this may spread and, sometimes, can become serious.

Transmitted diseases

Most insects in the UK do not transmit other diseases. The main exception is a type of tick which carries a germ called Borrelia burgdorferi which causes Lyme disease. If this germ gets into your skin it can travel to various parts of your body and cause arthritis, meningitis, and other problems. (See separate leaflet called Lyme Disease.) In hot countries, mosquito bites transmit certain germs which can cause diseases such as malaria.

What is the treatment for an insect sting or bite?

If stung by a bee and the stinger is still in place - scrape it out:

• Scrape out a bee sting left in the skin as quickly as possible. Use the edge of a knife, the edge of a credit card, a fingernail, or anything similar.
• The quicker you remove the sting the better, so use anything suitable to scrape out the sting quickly.
• Do not try to grab the sting to pluck it out, as this may squeeze more venom into the skin. Scraping it out is better.

Note: wasps, hornets or yellow jackets do not leave a stinger in the skin when they sting.

If any symptoms of a generalised allergic reaction develop (see above) then:

• Call an ambulance immediately.
• If you have been issued with an adrenaline pen, use it as directed straightaway.
• You may be given oxygen, and injections of adrenaline, steroids and antihistamines in hospital to counter the allergic reaction.
• Some people require a fluid 'drip' and other intensive resuscitation.

If there is a localised allergic reaction (swelling around the site of the sting) then:

• Take an antihistamine tablet as soon as possible. You can buy these at pharmacies, or get them on prescription. (Antihistamines block the action of histamine, which is a chemical that is released by certain cells in the body during allergic reactions.)
• Use a cold compress to ease pain and to help reduce swelling. For example, use a cold flannel or an ice pack.
• Painkillers such as paracetamol or ibuprofen can help to ease the pain.
• Continue with antihistamines until the swelling eases. This may be for a few days.
• See a doctor if the swelling is severe. Your doctor may prescribe a short course ofsteroid tablets to counter the inflammation.

If there is no allergic reaction (most cases) then:

• A cold compress will ease any pain and help to minimise any swelling -for example, use a cold flannel or an ice pack.
• A painkiller such as paracetamol or ibuprofen may help if you have any pain.
• If it is itchy, you may not need any treatment, as itching often soon fades. However, sometimes an itch persists for hours or days. No treatment will take the itch away fully, but the following may help:
  • Crotamiton ointment (which you can buy at pharmacies) is soothing when rubbed on to itchy skin.
  • A steroid cream may be useful - for example, hydrocortisone which you can buy at pharmacies or get on prescription. A doctor may prescribe a stronger steroid cream in some cases.
  • Antihistamine tablets may be useful if you have lots of bites. In particular, a sedative antihistamine at night may help if the itch is interfering with sleep. A pharmacist can advise on which types of antihistamine are sedative and can help with sleep.

Tick bites

The tick usually clings to the skin. Remove the tick as soon as possible after the bite, using fine tweezers or fingernails to grab the tick as close to the skin as possible. Pull it gently and slowly straight out, and try not to squeeze the body of the tick. Clean the site of the bite with disinfectant. (Traditional methods of tick removal using a burned match, petroleum jelly, or nail polish do not work well and are not recommended.)

See a doctor if you develop a rash which spreads out from a tick bite over the next week or so. Also, if you develop an unexplained high temperature (fever) within a month of the tick bite. These symptoms may be the first sign of Lyme disease and need checking out.

Infection

If the skin around a bite or sting becomes infected then you may need a course ofantibiotics. This is not commonly needed.

What are my chances of having a serious allergic reaction?

• Most people do not have an allergic reaction to insect bites or stings.
• About a quarter of people who are stung by a wasp or bee have some kind of allergic reaction. Only in a small proportion of these is the reaction severe.

Some points about allergies to insect stings

• In the UK most allergic reactions are caused by wasp stings.
• You do not get an allergic reaction after a first sting by a particular type of insect. You need one or more stings to 'sensitise' your immune system.
• Sometimes it takes many stings to sensitise you. This is why some beekeepers who have had many previous stings may suddenly develop an allergic reaction to a bee sting.
• Bee and wasp venoms are different. People who are sensitised and 'allergic' to wasp venom are rarely allergic to bee venom.
• About 1 in 5 people who have had a previous generalised allergic reaction to a sting have no such reaction, or only a milder reaction, to a further sting. Therefore, if you have a generalised reaction to a sting, it does not necessarily mean it will happen again if you are stung again.
• However, the course can be variable. A series of stings may result in a generalised allergic reaction, no reaction, and then another generalised allergic reaction. The reason why some people have variable reactions to a series of stings is not clear.

In short, if you have an allergic reaction to a sting, you cannot predict what will happen next time you are stung. Therefore, your doctor may refer you to an allergy clinic.

Advice and treatment following an allergic reaction

Your doctor may refer you to an allergy clinic if:

• A sting or bite has caused a generalised allergic reaction.
• A sting or bite has caused a large local skin reaction with redness and swelling over 10 cm.

An allergy clinic will be able to do tests to confirm which type of venom or insect you are allergic to. There are then two possible options which may be considered.

To give you a supply of emergency medication to use when necessary

Some people are given a preloaded syringe of adrenaline together with a written treatment plan to cope with any future reactions. You (and relatives) can be taught how and when to use the treatments provided.

Desensitisation

This is where you are given injections of tiny amounts of venom from the type of insect that causes your allergic reaction. Repeated doses of venom over several weeks can 'desensitise' your immune system, and so you will not react severely next time you are stung. This treatment involves some risk of causing a severe reaction, so it is not undertaken lightly. It is only available in certain specialised centres.

Preventing insect bites and stings

When out and about

Bites and stings most commonly occur when outside, particularly in the countryside.

The following measures are recommended to reduce the risk of stings from bees and wasps:

• Wear light-coloured clothing.
• Avoid strong fragrances, perfumes and highly scented shampoos.
• Wear shoes while outdoors and cover body with clothing and a hat, and use gloves while gardening.
• Avoid picking fruit from the ground or trees.
• Avoid drinking out of opened drink bottles or cans to prevent being stung inside the mouth.
• Wash hands after eating or handling sticky or sweet foods outdoors (especially children).
• Keep uneaten foods covered, especially when eating outdoors.
• Always contact professionals to remove bee or wasp nests.
• Wear full protective clothing while handling bees.

Ways to avoid bites include:

• Wear long-sleeved clothing and long trousers in places where insects are common.
• Avoid brightly coloured clothes, cosmetics, perfumes or hair sprays, which attract insects.
• Rub an insect repellent on to exposed areas of skin.
• A complete head covering with a plastic viewer. Where midges are common, some people wear these when out - for example, when camping next to lakes and rivers. Many camping shops sell them.

There is no evidence that eating garlic, vitamin B1 or other foods will repel insects.

Infestations

Various types of fleas, mites, and bedbugs can infest (live on) pets, furniture, bedding, etc. These can cause recurring bites. You may realise that if you develop itchy spots or weals they are due to insect bites. However, some people do not realise that their 'skin rash' is caused by insect bites. They think they have some other skin disease. It may come as a surprise to find that their itchy spots are due to fleas living on their favourite pet!

If you have recurring insect bites, you should try to identify the source of the infestation and deal with it - for example, have pets checked for fleas. Your pet and/or your soft furnishings may need treatment with insecticide. See a vet for advice if you suspect that your pet is infested with fleas.

Source: http://www.patient.co.uk/

FIRST AID - Insect bites and stings

By Mayo Clinic Staff

Signs and symptoms of an insect bite result from the injection of venom or other substances into your skin. The venom causes pain and sometimes triggers an allergic reaction. The severity of the reaction depends on your sensitivity to the insect venom or substance and whether you've been stung or bitten more than once.

Most reactions to insect bites are mild, causing little more than an annoying itching or stinging sensation and mild swelling that disappear within a day or so. A delayed reaction may cause fever, hives, painful joints and swollen glands. You might experience both the immediate and the delayed reactions from the same insect bite or sting. Only a small percentage of people develop severe reactions (anaphylaxis) to insect venom.

Signs and symptoms of a severe reaction include:

●  Nausea

●  Facial swelling

●  Difficulty breathing

●  Abdominal pain

●  Deterioration of blood pressure and circulation (shock)

Bites from bees, wasps, hornets, yellow jackets and fire ants are typically the most troublesome. Bites from mosquitoes, ticks, biting flies, ants, scorpions and some spiders also can cause reactions. Scorpion and ant bites can be very severe. Although rare, some insects also carry disease such as West Nile virus or Lyme disease.

For mild reactions

●  Move to a safe area to avoid more stings.

●  Remove the stinger, especially if it's stuck in your skin. This will
    prevent the release of more venom. Wash the area with soap and
    water.

●  Apply a cold pack or cloth filled with ice to reduce pain and
    swelling.

●  Try a pain reliever, such as ibuprofen (Advil, Motrin, others) or
    acetaminophen (Tylenol, others), to ease pain from bites or stings.

●  Apply a topical cream to ease pain and provide itch relief. Creams
    containing ingredients such as hydrocortisone, lidocaine or
    pramoxine may help control pain. Other creams, such as calamine
    lotion or those containing colloidal oatmeal or baking soda, can
    help soothe itchy skin.

●  Take an antihistamine containing diphenhydramine (Benadryl,
     others) or chlorpheniramine maleate (Chlor-Trimeton, others).

Allergic reactions may include mild nausea and intestinal cramps, diarrhea, or swelling larger than 4 inches (about 10 centimeters) in diameter at the site, bigger than the size of a baseball. See your doctor promptly if you experience any of these signs and symptoms.

For severe reactions Severe reactions affect more than just the site of the insect bite and may progress rapidly. Call 911 or emergency medical assistance if the following signs or symptoms occur:

●  Difficulty breathing

●  Swelling of the lips or throat

●  Faintness

●  Dizziness

●  Confusion

●  Rapid heartbeat

●  Hives

●  Nausea, cramps and vomiting

Take these actions immediately while waiting with an affected person for medical help:

1.   Check for medications that the person might be carrying to treat
      an allergic attack, such as an autoinjector of epinephrine (EpiPen,
      Twinject). Administer the drug as directed — usually by pressing
      the autoinjector against the person's thigh and holding it in place
      for several seconds. Massage the injection site for 10 seconds to
      enhance absorption.

2.   Loosen tight clothing and cover the person with a blanket. Don't
      give anything to drink.

3.   Turn the person on his or her side to prevent choking if there's
      vomiting or bleeding from the mouth.

4.   Begin CPR if there are no signs of circulation, such as breathing,
      coughing or movement.

If your doctor has prescribed an autoinjector of epinephrine, read the instructions before a problem develops and also have your household members read them.

Source: http://www.mayoclinic.org/

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FIRST AID - The simple medical error that can lead to elderly patients losing a limb

The simple medical error that can lead to elderly patients losing a limb

• - Ulcers have several causes and can therefore not be treated the same
• - When the cause is blockage, the artery needs to be cleared
• - Leg ulcers are common among elderly, affecting one in 50 over 80 
• 
  

By RACHEL ELLIS

PUBLISHED: 14:45 GMT, 27 August 2013 | UPDATED: 14:45 GMT, 27 August 2013

Wrong way: Treating an ulcer with a compression bandage can be the best - and worst

When the Rev Grahame Stephens developed leg ulcers earlier this year, staff at his GP surgery assumed the cause was problems with his veins.

That’s because 70 per cent of leg ulcers are venous, which means they’ve been caused when persistently high blood pressure in leg veins causes fluid to leak out, causing swelling and damage to the skin. 

Eventually, the skin breaks down and forms an ulcer, or open wound, typically just above the ankle.

But there are other causes of leg ulcers, including poor circulation in the arteries, diabetes, inflammatory conditions such as rheumatoid arthritis, injury and leg tumours. 

And because the mechanisms that lead to ulcers are different, they need different treatments.

Ulcers can also have a mixture of  causes. The problem is a misdiagnosis can lead to the wrong treatment, with bad results.

For example, if a leg ulcer is caused by a blocked artery, the cure is clearing the blockage and restoring a healthy blood supply to the foot and lower leg. 

Delay in doing so makes the ulcer worse (infection can set in, which can lead to blood poisoning, gangrene and amputation).

But if this kind of leg ulcer is treated with compression bandages (the ‘gold standard’ treatment for venous leg ulcers, as the pressure increases blood flow in the veins), it can make the problem worse, as the bandages can reduce blood flow in the artery still further.

Rev Stephens’ ulcers were dressed with ordinary bandages. But over the next three weeks, rather than improving, they got worse. When the 79-year-old, a married retired priest from Bexley, Kent, went back to have the ulcers dressed, the nurse called in the doctor for a second opinion.

‘They tested the pulse in my foot for the first time and it was very weak,’ says Rev Stephens. ‘They said it suggested a problem with blood supply to my foot, saying I needed to see a vascular surgeon.’

Until then, he’d had no problems linked to blocked arteries and had been very healthy, running marathons until the age of 63. Concerned about his left leg, which by then had three large open wounds just above the ankle, causing excruciating pain from infection, he decided to pay for an appointment with a private specialist that day rather than wait for an NHS appointment.

The specialist tested his pulse at the top of his leg and on his foot and diagnosed a blockage in the main artery supplying blood to the leg. 

‘He said the lack of blood in the lower part of my leg was causing the ulcer,’ says Rev Stephens. This is because when blood supply is poor, tissues are starved of oxygen and nutrients and so break down, forming an ulcer.

Risk group: Ulcers are more common among elderly people, affecting one in 50 over 80 years of age, and those with mobility issues, obesity and varicose veins

Rev Stephens was then referred to the NHS Royal London Hospital, where his consultant, vascular surgeon Constantinos Kyriakides, works (he is also in private practice at London Bridge Hospital). By this time, Rev Stephens had three large ulcers and half a dozen small ones.

Staff measured blood flow in his legs. The key test was a colour duplex ultrasound scan, which looks at leg arteries and veins using an ultrasound probe. Gel is spread on the skin and the probe is run along the legs, measuring blood flow.

This test, which takes 45 minutes per leg, tells doctors whether valves in the veins are working properly, and whether blood is flowing freely in the arteries, pinpointing blockages. ‘The information is instantly available, and it’s totally non-invasive,’ says Mr Kyriakides. But the probe cannot be used reliably over areas where the skin is breached, such as ulcers. ‘Pressing a probe over an open wound can be painful,’ says Mr Kyriakides.

Another test is a CT angiogram, which is also non-invasive and takes a few minutes using a powerful X-ray machine to photograph the veins and arteries in the legs. It requires a dye to be injected, usually through a vein in the hand or arm, and the information can take up to an hour to become available.

The test results confirmed Rev Stephens had a major blockage in the main artery of his leg, caused by a furring up of the blood vessels, which needed urgent attention. He also had vein problems. He had an operation under local anaesthetic the next day.

‘It took almost an hour and involved guiding a tube into the artery through an incision in my groin, threading a balloon down the artery and inflating it at the problem area to clear the blockage. Then a good blood supply started flowing into my foot again.’

With the blockage cleared, Rev Stephens could have the ulcer treated in the normal way with a compression bandage.

His story underlines a serious issue about some leg ulcer patients failing to receive the right treatment. Between 1 and 2 per cent of Britons suffer from leg ulcers. The condition is more common in the elderly — affecting one in 50 people over 80 — and those with mobility issues, obesity and varicose veins because they are more likely to have vein and artery problems or diabetes.

Yet not everyone receives the same standard of treatment, as Wendy Hayes, a vascular nurse consultant and spokesperson for the Circulation Foundation explains. ‘Despite Royal College of Nursing guidelines and local policies, it depends how services are developed and delivered in your area,’ she says. ‘There’s an awful lot of good practice, but it’s patchy across the country.

‘In some cases hospital care of leg ulcers comes under vascular services; in others dermatology.’

Wrong treatment: If a leg ulcer is caused by a blocked artery, using compression bandages can make the problem worse

Treatment at a vascular unit is likely to be superior to that at a dermatology one, says Mr Kyriakides. At Worcestershire Acute Hospitals NHS Trust, where Ms Hayes is based, patients are seen by a vascular surgeon and specialist nurses ‘who undertake an assessment with the help of clinical vascular lab staff’.

Specially trained nurses should be able to tell quickly what is causing the leg ulcers from the patient’s medical history, looking for symptoms and undertaking simple tests that do not require a hospital visit.

Diabetes, injuries, varicose veins or deep vein thrombosis increase the risk, and the underlying cause needs to be treated.

A common test is the Ankle Brachial Pressure Index, which measures blood pressure in the arm and compares it with that at the ankle. If the readings are the same, this suggests the ulcer is venous (as the blood flow isn’t affected by a blockage). If the readings are different, it indicates a blocked artery. But not all nurses have been trained to do this test.

Venous leg ulcers appear as dark coloured skin near the ulcer, which can be exacerbated by eczema, and are usually around the ankle. Varicose veins, deep vein thrombosis, obesity and immobility can all contribute to venous leg ulcers. Arterial ulcers are more likely to be on the foot because they are the furthest point from the heart with the worst blood supply. The leg may also be cool, the pulse at the ankle weak or absent, the blood pressure ankle reading low and there is significant pain, even when lying down.

‘Unless patients are assessed properly, you can’t treat them properly,’ says Ms Hayes. ‘There are a lot of experienced nurses who care for patients with leg ulcers, but we should aspire for all nurses who care for patients with leg ulceration to have the necessary skills.

‘In some cases, the underlying cause will not be clear and patients will benefit from specialist input. This may involve procedures only available in hospitals.’

Mr Kyriakides adds: ‘The problem lies when there are mixed causes, which occur in ten to 20 per cent of cases. For example, part venous, part arterial. Some medical staff don’t know how to manage it. These patients need to have their circulation tested and, if necessary, undergo procedures such as angioplasty to improve blood flow.

‘If they don’t receive the appropriate care, it can make the problem worse. Limb loss is a real risk, although thankfully life loss from blood poisoning is rare.’

The National Institute for Health and Care Excellence (NICE) advises that anyone with a venous leg ulcer that has not healed after two weeks should be referred to a hospital vascular unit for assessment.

Mr Kyriakides says ideally all patients would go to a specialist vascular unit for assessment and planning. But this would have a huge cost impact and most patients can be treated in the community.

Since his operation in June, Rev Stephens has gone from strength to strength. ‘The ulcers are healing nicely and I’m so grateful for my treatment on the NHS. Everyone should have access to this level of care.’