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Title: Venomous Arthropod Handbook - Envenomization Symptoms/Treatment, Identification, Biology and Control
Author: Biery, Terry L.
Language: English
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                           VENOMOUS ARTHROPOD

 Envenomization Symptoms/Treatment, Identification, Biology and Control

                   Terry L. Biery, Captain, USAF, BSC

                      Disease Surveillance Branch
                         Epidemiology Division
                   USAF School of Aerospace Medicine
                   Aerospace Medical Division (AFSC)
                   Brooks Air Force Base, Texas 78235

 For sale by the Superintendent of Documents. U.S. Government Printing
                         Washington, DC. 20402

         Stock No. 008-070-00397-0/Catalog No. D 301,35: 161/43
            U.S. GOVERNMENT PRINTING OFFICE: 1977 O—251-048


The purpose of this handbook is to provide Air Force medical personnel
with a quick reference on the problems caused by the more important
venomous arthropods found in the United States. An attempt has been made
to include the latest information available in the scientific

The author would like to acknowledge the valuable assistance of Mr.
Orville V. Anderson, USAFSAM Photographer; Captain Robert W. Clegern,
USAF, BSC, Medical Entomologist; and Lieutenant Colonel John C. Moseley,
USAF, MC, Dermatologist.


  INTRODUCTION                                                          1
  BITING/PIERCING ARTHROPODS                                            4
      1. Black Widow Spider (_Latrodectus mactans_)                     4
      2. Brown Recluse Spider (_Loxosceles reclusa_)                    6
      3. Centipedes (Class: Chilopoda)                                  8
      4. Conenose or Kissing Bugs (_Triatoma_ spp.)                    10
      5. Wheel Bug (_Arilus cristatus_)                                12
  STINGING ARTHROPODS                                                  14
      1. Ants (Order: Hymenoptera; Family: Formicidae)                 14
      2. Bees (Order: Hymenoptera; Family: Apidae)                     17
      3. Scorpions (Class: Arachnida; Order: Scorpionida)              20
      4. Velvet Ants (Order: Hymenoptera; Family: Mutillidae)          22
      5. Wasps (Order: Hymenoptera; Family: Vespidae)                  24
  URTICATING/VESICATING ARTHROPODS                                     26
      1. Blister Beetles (Order: Coleoptera; Family: Meloidae)         26
      2. Urticating Caterpillars                                       28
          a. Io Moth Caterpillar (_Automeris io_)                      28
          b. Puss Caterpillar (_Megalopyge opercularis_)               30
          c. Saddleback Caterpillar (_Sibine stimulea_)                32
  BIBLIOGRAPHY                                                         34
      Chart 1: Antihistamines                                          48
      Chart 2: Treatment of Anaphylaxis—Shock                          49


Although most residents of the United States are aware of the pain and
discomfort associated with contacting a venomous arthropod, many are not
aware that these arthropods (such as ants, bees, wasps, spiders, and
scorpions) are responsible for more human deaths in the United States
each year than any other group of venomous animals, including snakes. In
fact, a study by Parrish[15] showed that venomous arthropods accounted
for more than 65% of the reported human fatalities caused by venomous
animals in the United States from 1950 through 1959. His findings are
summarized as follows:

        _Venomous animal group_          _Human fatalities

  Hymenoptera (bees, wasps, and ants)      229/460 or  49.8%
  Poisonous snakes                         138/460 or  30.0%
  Spiders                                   65/460 or  14.1%
  Scorpions                                  8/460 or   1.7%
  Others                                    20/460 or   4.4%

It would be incorrect, however, to assume from the above information
that a high percentage of arthropod envenomizations are fatal. In
actuality, the opposite is true. Of the estimated millions of people
envenomized by arthropods in the United States each year, about 25,000
have severe reactions; and of these, approximately 30 result in reported
deaths.[19] Therefore, the high number of fatalities caused by venomous
arthropods, relative to other venomous animals, can be attributed to the
high incidence of arthropod envenomizations rather than the efficient
killing power of their venoms. This high-incidence rate is accounted for
by the tremendous abundance of venomous arthropods and their ability to
live in close proximity to man.

Air Force personnel stationed in the continental United States face a
greater risk of contacting a venomous arthropod than the average United
States resident because: (1) a large portion of bases are located in the
southern half of the United States, where venomous arthropods are most
numerous; (2) many facilities (such as radar, communications, security,
and missile sites) are located in remote areas where venomous arthropods
are not controlled; (3) numerous Air Force training and work activities
must be performed outside; and (4) many military structures (such as
older wooden buildings, storage buildings, and field training
facilities) provide excellent habitats for venomous arthropods. It is
important, therefore, that Air Force medical facilities have current
information available concerning the most important venomous arthropods
in their areas.

The venomous arthropods discussed in this handbook were selected for
inclusion due to the relative severity of their envenomizations and/or
the high frequency of their contact with humans. It should be stressed
that other arthropods found in the United States are capable of
producing envenomization reactions in humans. Regardless, all venomous
arthropods found in the United States can be categorized under one of
the three types of envenomization methods described in this handbook:
(1) biting/piercing, (2) stinging, and (3) urticating/vesicating. The
biting/piercing arthropods inject a toxin through an apparatus
associated with or near their mouthparts; and the stinging arthropods,
through a stinger located at the posterior end of the abdomen.
Urticating and vesicating arthropods are grouped together because they
both release their toxins on contact. They differ in that the urticating
arthropods usually release their toxin through venomous hairs; and
vesicating arthropods carry a toxic substance within their system, which
is released through small body openings.

To facilitate the utilization of this handbook, each venomous arthropod
presentation has been organized into the following information

• Identification. Bringing the arthropod causing an envenomization to
the medical facility treating the victim is most helpful. In most cases,
an identification must be made before the proper form of treatment can
be determined. To assist personnel with identification, the key
characteristics and representative color photographs are provided for
the venomous arthropods discussed.

• Distribution. Most arthropod envenomizations occur during the warm
plant-growing season when venomous arthropods are most numerous. Since
the Southern United States has the longest growing season, venomous
arthropods are abundant for a longer period of time in this region.
Also, the moderate climate of the Southern States, with fewer weather
extremes, permits a greater variety of venomous arthropods to survive,
propagate, and produce multiple generations each year. Specific regional
occurrences are indicated.

• Biology/Behavior. Pertinent biological information is provided to help
increase the reader’s awareness and understanding of venomous
arthropods. These factors are essential in developing a good avoidance
and control program.

• Avoidance/Control. To assist in preventing envenomization accidents,
several means of avoidance are listed for each venomous arthropod. Since
the status of insecticide recommendations is constantly changing, few
specific recommendations are included. When insecticide control is
necessary, an Air Force, County Extension Service, or United States
Department of Agriculture entomologist should be consulted for current
recommendations. Any insecticide must be applied according to the
instructions on the container label.

In addition to the information presented in the text, a table on
envenomization reactions and treatment is included as an appendix. The
reactions listed in this table are “typical” and do not necessarily
represent the entire range of reactions which might occur.

                       BITING/PIERCING ARTHROPODS

(Latrodectus mactans)

    [Illustration: (unlabelled)]

Identification. The female black widow has a shiny black body,
approximately 1.5 cm (0.6 in) long, and usually a red hourglass-shaped
marking on the underside of her globose abdomen. On some individuals the
distinct hourglass marking is replaced with several triangles or spots
or an irregular longitudinal blotch. She has slim black legs with a span
of 4 cm (1.5 in). The male is considerably smaller than the female,
usually a patterned brown color, and is not a threat to man.

Distribution. _Latrodectus mactans_ is found in every state except
Alaska; however, most reported human fatalities have occurred in the
Southeastern States.[14, 15]

Biology/Behavior. The black widow is generally found in its
irregular-shaped web near the ground. Common web sites are under stones,
loose bark, or water faucets or in wood piles, rodent burrows, garages,
storage buildings, outhouses, and barns. Most human envenomizations
occur when the spider is inadvertently trapped against part of the body
or when the web is accidentally touched.

Avoidance/Control. Frequent cleaning to remove spiders and their webs
from buildings and outdoor living areas will decrease the possibility of
accidental bites. Routine hose washings of potential spider habitats,
such as under steps and around windows and doors, will discourage the
black widow from locating in these places. When working in
spider-infested areas, wear gloves and a long-sleeved shirt. If
warranted, the outside or inside of a building may be sprayed with an
approved insecticide. Apply the spray around windows, stairs, closets,
or other spider habitats in accordance with instructions on the
manufacturer’s label.

Envenomization Reaction/Treatment. (See appendix.)

(Loxosceles reclusa)

    [Illustration: (unlabelled)]

Identification. The brown recluse is a medium-sized spider with a 2- to
4-cm (0.8-1.6 in) legspan and a color range from yellow tan to dark
brown. The most distinguishing characteristics are six eyes (most
spiders have eight eyes) arranged in a semicircle of three pairs on top
of the head, and a violin-shaped marking extending from the area of the
eyes to the abdomen.

Distribution. Brown recluse spiders occur throughout an area of the
Southcentral States, including Alabama, Arkansas, Georgia, Illinois,
Indiana, Iowa, Kansas, Kentucky, Louisiana, Ohio, Oklahoma, Mississippi,
Missouri, Tennessee, and Texas. Localized populations of this spider,
probably imported from the Southcentral States, have been reported from
Arizona, Wyoming, California, Florida, New Jersey, North Carolina,
Pennsylvania, and Washington, D.C. Due to the mobility of the United
States citizenry, specimens can be easily transported in household goods
from the spider’s home range in the Southcentral United States to any
other area of the country. Under favorable conditions the relocated
spiders can survive for an extended period of time and possibly become

Biology/Behavior. Within its range, the brown recluse spider will
readily establish populations inside parts of buildings which are
generally dry, littered, and undisturbed for long periods of time. The
spider also can be found outside in protected areas (under rocks and
loose bark). Members of this species are nonaggressive and normally
attempt to escape whenever they are threatened. Thus, most instances of
bites occur when the spider is inadvertently trapped, such as when the
victim puts on clothing in which the spider is hiding, steps on a
wandering spider at night, or cleans closets or other storage areas
where the spider resides.

Avoidance/Control. Any of the following actions will help prevent
contact with the brown recluse spider: shake out clothing and bedding
before use; eliminate collections of papers and unused boxes; thoroughly
clean beneath and behind furniture; remove spiders, webs, and egg cases
from living and storage areas; and properly use appropriate

Envenomization Reaction/Treatment. (See appendix.)

(Class: Chilopoda)

    [Illustration: (unlabelled)]

Identification. Centipedes are multisegmented elongate arthropods with a
distinct head and one pair of legs, or appendages, per segment. Size is
species dependent, with body length ranging from approximately 2.5 to 25
cm (1-10 in) or more. The number of legs can therefore vary from 15 to
100 pairs or more, depending upon the species.

Distribution. The range of centipedes varies with the species; however,
these arthropods are most numerous in the southern half of the United

Biology/Behavior. Throughout the day, centipedes hide under rocks,
boards, or bark and in cracks, crevices, closets, basements, and other
moist, protected locations. At night, they come out of hiding to hunt
for prey which usually consists of insects and other small arthropods.
Centipedes inject venom through two powerful claws located on the
ventral side of the body immediately behind the head. Contrary to
popular belief, centipedes cannot inject venom through their numerous
legs. The majority of centipedes found in the United States are small
and not a threat to man. Human centipede envenomizations occur when a
relatively large centipede is accidentally picked up, stepped on, or
otherwise trapped against the body.

Avoidance/Control. When camping in a centipede-infested area, carefully
invert and shake out sleeping bags, clothes, or other items left in
contact with the ground. Always wear shoes when walking about at night,
and wear leather gloves when moving rocks or trash from the ground.
Usually centipedes are not sufficiently numerous in any one location to
warrant chemical control.

Envenomization Reaction/Treatment. (See appendix.)

(_Triatoma_ spp.)

    [Illustration: (unlabelled)]

Identification. Species of the genus _Triatoma_ have the elongate
(cone-shaped) head which is characteristic of the family Reduviidae.
Hence, the name “conenose bugs” is often used to describe these insects.
Orange and black markings are usually present where the abdomen extends
laterally past the folded wings. These insects are flattened dorsally,
and this trait allows them to effectively hide in small cracks and
crevices. The size of mature adults varies from approximately 1 to 3 cm
(0.4-1.2 in) depending upon the species.

Distribution. _Triatoma_ species that attack humans are generally
located in the southern half of the United States.

Biology/Behavior. Conenose bugs are nocturnal insects. They take their
blood meals at night and hide in any available crack or crevice between
feedings. _Triatoma_, as a group, normally feed on small mammals; but in
the absence of their preferred hosts, several species will readily feed
on humans. They are commonly referred to as “kissing bugs” because their
blood meals are occasionally taken from the area around the human lips.
Some of the common sites of human attack, in order of frequency, are the
hands, arms, feet, head, and trunk. This feeding pattern can be expected
since kissing bugs have not been found to feed through clothing.[30]

Avoidance/Control. Since these bugs can feed undetected on a sleeping
victim, it is difficult to avoid their attack in heavily infested areas.
Exposure to kissing bugs can be minimized, however, by destroying
underbrush, rubbish, wood rats’ nests, and any other small-animal
habitat located near a residence.[27] When an infestation is detected
inside a house, two or three treatments with an appropriate insecticide
at 10-day intervals should provide control. To obtain the best results,
thoroughly treat all windows, baseboards, walls, cracks, crevices, and

Envenomization Reaction/Treatment. (See appendix.)

(_Arilus cristatus_)

    [Illustration: (unlabelled)]

Identification. _Arilus cristatus_ has the small narrow head
characteristic of the Reduviidae family of Hemiptera (true bugs). This
insect is mouse gray in color and approximately 2.5 to 4 cm (1-1.6 in)
long. A cogwheel-like crest on the dorsal side of the prothorax is
distinctive to this insect and accounts for its popular name, “wheel

Distribution. Wheel bugs are generally found in the southern two-thirds
of the United States.

Biology/Behavior. Wheel bugs are predacious on soft-bodied insects.
Human envenomizations are usually the result of accidental contact while
handling vegetation, boards, or other objects. The bug penetrates the
skin with its “beak,” or proboscis, and injects a salivary fluid
normally used in killing its insect prey.[31]

Avoidance/Control. The best way to prevent wheel bug contact is to be
able to identify this unusual insect and avoid it. Children should be
instructed not to handle it. Wearing leather gloves while working
outside will prevent bites which occur when the wheel bug is
accidentally picked up with vegetation or other debris. Since wheel bugs
are predacious on many harmful insects and are generally considered
beneficial, control is not recommended.

Envenomization Reaction/Treatment. Wheel bug bites are characterized by
immediate intense pain which usually subsides in 3 to 6 hours. Since all
reported bite reactions have been localized and self-limiting, specific
treatment measures are not provided for _A. cristatus_ bites. However,
anaphylactic shock has resulted from the bite of other Hemiptera and
should be considered a possibility with wheel bug bites.[12]

                          STINGING ARTHROPODS

(Order: Hymenoptera; Family: Formicidae)

    [Illustration: Fire Ant Mound]

    [Illustration: Harvester Ant Mound]

Identification. Like other Hymenoptera, females of dangerous ant species
have a stinger at the posterior tip of the abdomen. Their constricted
“waist” between the thorax and posterior abdomen and their elbowed
antennae distinguish them from similar insects. The dangerous United
States species belong to genera _Solenopsis_ (fire ants) or
_Pogonomyrmex_ (harvester ants). The easiest way to distinguish these
ants is by their mounds. Fire ants build elevated earthen mounds 8-90 cm
(3-36 in) high, leaving the surrounding vegetation relatively
undisturbed. In contrast, harvester ant mounds are usually flat or
slightly elevated and are surrounded by a defoliated area 0.6-3 m (2-10
ft) or more in diameter. Also, harvester ants are 2 to 3 times larger
than fire ants.

Distribution. The Florida harvester ant, _P. badius_, distributed
throughout the Southeastern States, is the only harvester ant known to
occur east of the Mississippi River. West of the Mississippi, the red
harvester ant (_P. barbatus_), the California harvester ant (_P.
californicus_), and the western harvester ant (_P. occidentalis_) are
found in different individualized distribution areas. The two most
important fire ant species were introduced into the United States from
South America. The red imported fire ant (_S. invicta_) was introduced
about 1940 and is well established in the Southeastern States.
Currently, this ant infests Alabama, Arkansas, Florida, Georgia,
Louisiana, Mississippi, North and South Carolina, and Texas. The black
imported fire ant (_S. richteri_) was introduced about 1918; its
distribution is limited to an area in northeastern Mississippi and
northwestern Alabama. Two less important native species, _S. geminata_
(tropical or native fire ant) and _S. xyloni_ (southern fire ant), occur
in localized areas of a few southern states.

Biology/Behavior. Ants of the _Solenopsis_ and _Pogonomyrmex_ genera are
diurnal soil-inhabiting insects that prefer to nest in open areas. These
ants are social insects; their colonies consist of at least one
reproductive queen, several males, and many nonreproductive female
workers. Fire and harvester ants are particularly dangerous because
workers defending their nest can inflict repeated stings, and multiple
human envenomizations may occur when a victim comes in contact with a

Avoidance/Control. Familiarization with the appearance of the ant mounds
is necessary in order to avoid them and prevent accidental
envenomizations. Since small children are often the victims of multiple
stings, parents should insure that the mounds of dangerous ant species
are not present in play areas. This is particularly important where the
red imported fire ant occurs. Mound treatments with mirex have been
effective in controlling _Solenopsis_ and _Pogonomyrmex_ ants. The
Environmental Protection Agency limits the use of this insecticide, and
it must be applied in strict accordance with EPA and product label

Envenomization Reaction/Treatment. (See appendix.)

(Order: Hymenoptera; Family: Apidae)

    [Illustration: (unlabelled)]

Identification. Two families of bees are commonly associated with human
envenomization: Apidae (honey bees and bumble bees) and Halictidae
(sweat bees). Only the honey bees and bumble bees are considered
dangerous. Both are robust hairy insects with two pairs of membranous
wings which they hold at an angular position over the body when at rest.
Microscopic examination shows that bee thoracic hairs are individually
“feathered.” In contrast, wasp thoracic hairs are smooth.

Distribution. Dangerous species of bees are distributed throughout the
United States.

Biology/Behavior. 1. Honey Bees. Since these insects are not native to
this continent, north of Mexico, all original honey bee colonies in the
United States were imported. _Apis mellifera_, the cosmopolitan bee of
commerce, is responsible for most bee stings and many deaths.[10] This
species is separated into several races, with the gold Italian and the
black or gray Caucasian races making up the majority of the bees found
in this country.[5] The aggressive Brazilian (hybrid African) bee is
currently restricted to the South American continent. Honey bees are
highly social insects. Their colony consists of an egg-laying queen,
drones to fertilize the queen, and workers to gather food and care for
the young. Honey bees can release “alarm odors” associated with the
sting gland, which cause other bees in the vicinity of an odor-marked
victim to attack and inflict multiple stings. Unlike other hymenopterous
insects, the honey bee worker has a barbed stinger and can sting only
once; to escape, the bee must leave its entire stinging apparatus
attached to the skin of its victim. As important pollinators of crops,
honey bees are very beneficial to man.

2. Bumble Bees. The bumble bees are considered to be the most primitive
of the social bees. Their colonies lack much of the structure and highly
evolved behavior of the honey bees; however, like the honey bees, the
bumble bees are diurnal plant feeders and important pollinators of
crops. A typical colony consists of at least one queen, several males,
and numerous workers. Only young fertilized queens survive the winter to
establish new colonies the next spring. The nests are normally located
deep in undisturbed ground, like fence rows, and are supplied with a
mixture of pollen and honey. During late summer, a colony usually
contains between 100 and 500 bees. Although bumble bees are 2 to 3 times
larger than honey bees, they are neither as aggressive nor as abundant
as the honey bees, and therefore not as dangerous.

Avoidance/Control. The best way to avoid Hymenoptera stings is to
prevent human contact with these insects. This is especially important
for persons hypersensitive to bee venom. Some preventive steps are:

  1 Avoid outdoor activities in unfamiliar areas where stinging insects
  are known to occur.

  2 When outdoors, don’t use floral-scented cosmetic products or leave
  sweet beverages or foods exposed in areas where they might attract

  3 Avoid garbage collection areas, which attract Hymenoptera.

  4 When outdoors, always wear shoes and, if possible, a long-sleeved
  shirt, long pants, or other protective clothing. Don’t wear clothing
  with a bright floral print or loose-fitting clothing in which stinging
  insects may be trapped.

  5 Don’t make rapid movements around stinging insects or intentionally
  disturb either the insects or their nests.

  6 Eliminate all Hymenoptera nests around inhabited areas (wild honey
  bee colonies may be removed by a local beekeeper). When necessary, an
  insecticide such as 5% carbaryl dust may be applied in a nesting area
  within a building to eliminate the nuisance colony.

  7 Educate young children on the hazards of venomous arthropods.

Envenomization Reaction/Treatment. (See appendix.)

(Class: Arachnida; Order: Scorpionida)

    [Illustration: (unlabelled)]

Identification. Scorpions are crablike in appearance, with pincers
attached to their two front appendages. They also possess a
five-segmented “tail” terminating in a bulbous structure with a
prominent stinger. The body size of mature scorpions varies from 2 to 10
cm (0.8-4 in) or more, depending upon the species.

Distribution. Scorpions are most prevalent in warmer climates. In the
United States the two most dangerous scorpion species, _Centruroides
sculpturatus_ and _C. gertschi_, have been found only in Arizona.

Biology/Behavior. During daylight hours scorpions hide under objects or
debris on the ground. At night, they come out of hiding to search for
food, which consists primarily of ground-inhabiting arthropods. The prey
is grasped with the pincers and stung by rapidly bringing the stinger
forward directly over the head. This quick stinging motion is also used
for defense, as is usually the case with human envenomizations.

Avoidance/Control. To avoid stings in scorpion-infested areas: remove
accumulations of boards, rocks, and other debris; wear leather gloves to
remove any item from the ground; inspect and shake out clothing or shoes
before donning them; and when moving about at night, turn on lights to
avoid contacting these nocturnally active arthropods. Insecticides that
are commonly used for household cockroach control are also useful for
controlling scorpions. Special care should be taken to treat around all
baseboards thoroughly.

Envenomization Reaction/Treatment. (See appendix.)

(Order: Hymenoptera; Family: Mutillidae)

    [Illustration: (unlabelled)]

Identification. Female velvet ants, wingless and antlike in appearance,
are actually wasps that only resemble ants. The males are winged and
usually larger than the females. Both male and female are covered with a
velvety pubescence which is normally bright red, orange, or yellow. The
female has a formidable stinger at the posterior end of her abdomen
which she can use to inflict a painful envenomization. The length of a
mature mutillid wasp varies from 1 to 2.5 cm (0.4-1 in). In some
localities, mutillids are commonly referred to as cow killers, mule
killers, or wooly ants.

Distribution. The Mutillidae is a large family with most species
distributed in the southern and western parts of the United States.[2]
However, one species, _Dasymutilla occidentalis_, is commonly found on
the sandy beaches of Lake Erie and during the summer months causes
barefoot bathers much distress.[5]

Biology/Behavior. Female velvet ants are solitary, diurnal, parasitic
wasps. An efficient stinging apparatus and an extremely thick
exoskeleton allow the female mutillid to conspicuously, yet safely, run
about in the open searching for a suitable place to lay her eggs. Most
cases of human envenomization occur when the female wasp is accidentally
touched while roaming about on the ground or is trapped against the body
in clothing or bedding.

Avoidance/Control. The solitary and roaming nature of velvet ants makes
it very difficult to predict or designate ways to avoid contacting them.
In areas like the beaches of Lake Erie where mutillids are known to
frequent, however, potential victims should be made aware of the velvet
ant hazard and how to avoid accidental envenomization. Since mutillids
are not gregarious and do not congregate in accessible places, chemical
control is not feasible.

Envenomization Reaction/Treatment. (See appendix.)

(Order: Hymenoptera; Family: Vespidae)

    [Illustration: Bald-Faced Hornet]

    [Illustration: Yellow Jacket]

Identification. This information applies to all dangerous wasps found in
the United States except the mutillids (previously discussed). Wasps are
elongate insects with three distinct body parts and four wings. As with
all winged forms of Hymenoptera, the front pair of wings is larger than
the hind pair. Only the female wasps are equipped with a stinger at the
posterior end of the abdomen. To distinguish wasps from
similar-appearing bees, the specimen’s thoracic hairs should be examined
microscopically to determine if they are smooth (a wasp) or feathered (a
bee). In the United States, members of the paper-wasp family (Vespidae)
are generally considered to be the most dangerous because of their
social nesting habits, aggressive behavior, and abundance. Two
representative members of the Vespidae family found in North America are
the bald-faced hornet, _Vespula maculata_, and a common yellow jacket,
_V. pennsylvanica_. Although it takes an expert to identify most wasps
according to species, the paperlike nests of the vespids make their
identification easy. Another important group of dangerous wasps easily
distinguished by their nests are the mud daubers. These wasps usually
build their mud nests in the corners of man-made structures. Besides
their distinctive nests, mud daubers are identified by their dark shiny
color and long narrow waist.

Distribution. Dangerous species of wasps can be found throughout the
United States.

Biology/Behavior. Most vespids are social insects that feed primarily on
other arthropods. These wasps build paperlike nests by masticating wood
fiber into pulp. In addition to the social wasps, many types of solitary
wasps are capable of envenomization; but these wasps are easy to avoid
since they are neither abundant nor aggressive. Female members of the
dangerous wasp species will readily attack and inject their venom if
someone disturbs or annoys them. Wasp stingers do not become detached,
and a single wasp can sting a victim several times before retreating.
Social wasps are particularly dangerous because a disturbance of their
nest may result in attack by numerous wasps.

Avoidance/Control. Avoid garbage accumulation sites, which attract
wasps. To avoid wasp stings, recognizing the nests of the dangerous
species in the local area, is important. If possible, remove and destroy
all nests found around inhabited areas. Wasps can be controlled by
treating their nests with insecticide—preferably at night, when the
wasps are least active. Treat nests found above the ground with a
commercial wasp spray or other insecticide recommended by an
entomologist. To treat wasp nests in the ground or in houses, a 5%
carbaryl dust may be used.[38]

Envenomization Reaction/Treatment. (See appendix.)


(Order: Coleoptera; Family: Meloidae)

    [Illustration: (unlabelled)]

Identification. The Meloidae are narrow elongate beetles characterized
by a “neck” (pronotum) which is distinctly narrower than its head or
wings. Adult beetles range in body length from 1 to 2 cm (0.4-0.8 in)
and vary considerably in their coloration.

Distribution. In general, blister beetles are found in greater numbers
in the western half of the United States.[5]

Biology/Behavior. The immature stages of the blister beetle are usually
predacious on other insects and are not harmful to man. Adult blister
beetles release a clear amber fluid by rupture of thin membranes in the
leg joints or other segmented areas of the body. The release of this
fluid, which contains a vesicating agent called cantharidin, is
triggered by pressure against the body of the beetle. Light pressure
exerted by clothing or by brushing off a beetle is usually sufficient to
cause the release of its vesicating fluid. The adult blister beetles are
readily attracted to bright white light, and many cases of human
exposure occur at night around such lights. Since the adults are plant
feeders, some cases of human vesication occur as persons move through
vegetation infested with blister beetles.

Avoidance/Control. In areas with an abundance of blister beetles, use
yellow light bulbs for outdoor lighting. If a meloid beetle lands on the
skin, blow it off, do not crush it. Since cantharidin is distributed
throughout the beetle’s body, crushing the beetle against exposed skin
would result in maximum cantharidin exposure. Dermatoses resulting from
blister beetle contact are seasonal, with the greatest number of
vesicating incidents in the United States occurring in July, August, and
September. Chemical control usually is not recommended because of the
mobility and wide distribution of blister beetles.

Envenomization Reaction/Treatment. This information is not included in
the appendix because the envenomization reaction generally consists of a
superficial linear bulla which does not require emergency treatment.


(_Automeris io_)

    [Illustration: (unlabelled)]

Identification. The _Automeris io_ caterpillar is the larva of the Io
moth, which belongs to the moth family Saturniidae. A full-grown
caterpillar is about 5 to 8 cm (2-3 in) long, pale green, with lateral
strips of red or maroon over white running the length of the body. Near
the center of each body segment is a partial row of tubercles armed with
radiating green and black spines. Many of these spines are venomous, and
their tips are connected to rather large individualized poison glands.

Distribution. In the United States, the Io moth is found in the states
east of the Rocky Mountains.[68]

Biology/Behavior. Io moth larvae feed on the leaves of a variety of
plants, including corn and willow.[17] In most areas they produce only
one annual generation, emerging as a moth in the spring or summer and
overwintering as a pupa. In south Texas, however, two generations occur,
with one developing in May-July and the second in October-December.
Therefore, the urticating larval stages can be found anytime from early
spring to late fall, depending upon the area of the country and climatic
conditions. As with most urticating caterpillars, _A. io_
envenomizations normally occur when the victim inadvertently contacts
caterpillar-infested vegetation. At the instant the victim’s skin
touches this caterpillar, the spine tips break off in the skin, thus
allowing toxin to flow out of the hollow spines and onto the skin.

Avoidance/Control. Wear gloves, a long-sleeved shirt, and long pants
when working in an infested area. Children should be warned not to
handle caterpillars. If necessary, infested vegetation may be treated
with an appropriate insecticide.

Envenomization Reaction/Treatment. (See appendix.)

(Megalopyge opercularis)

    [Illustration: (unlabelled)]

Identification. The puss caterpillar is the larva of a lepidopterous
group commonly referred to as “flannel moths.” In some parts of the
United States the larva is incorrectly referred to as an “asp.” When
fully mature, the larvae are near white to dark gray in color, 2 to 3 cm
(0.8-1.2 in) long, and completely covered dorsolaterally with hairs that
cause them to resemble elongate tufts of cotton. Some of the hairs are
venomous, and when they penetrate the skin a “toxin” passes from an
underlying gland through the hairs at the points of contact. The color
variation of the larvae in this species is dependent upon larval age,
locality, and time of year. In Texas, where this species is most
abundant, the spring/summer generation of caterpillars is usually
lighter in color than the fall generation.

Distribution. This species has been recorded primarily from the
Southeastern States, including Alabama, Arkansas, Florida, Georgia,
Louisiana, Maryland, Mississippi, Missouri, North Carolina, South
Carolina, Texas, and Virginia.

Biology/Behavior. In most of the southern area of its range, the puss
caterpillar is thought to have two generations per year. The first
generation develops in the spring and early summer, while the second
generation develops in the fall. After emerging from a cocoon and
mating, the female moth lays her eggs on a suitable host plant. In a few
days the eggs hatch into larvae, which develop by feeding on the leaves
of a wide range of trees and shrubs. The natural enemies of the puss
caterpillar usually keep its numbers under control; however, every 4 or
5 years the caterpillars become more numerous, and the number of
envenomizations associated with them increases.[66]

Avoidance/Control. Always wear protective clothing such as gloves and a
long-sleeved shirt when working in areas heavily infested with puss
caterpillars. During periods of _M. opercularis_ abundance, children
should be instructed to stay away from infested trees and shrubs and not
to handle caterpillars. If necessary, heavy puss caterpillar
infestations may be treated with an appropriate insecticide.

Envenomization Reaction/Treatment. (See appendix.)

(_Sibine stimulea_)

    [Illustration: (unlabelled)]

Identification. The saddleback caterpillar is easy to recognize since
its brown sluglike body is covered mid-dorsally with markings that
resemble a brown or purplish saddle sitting on a green and white saddle
blanket. Upon close examination, stout spines can be observed along the
caterpillar’s lateral body margin and on its four tubercles. Many of
these spines are hairs that are connected at their bases with individual
poison glands. Just prior to pupation and subsequent development into a
moth, the caterpillar is 2-3 cm (0.8-1.2 in) long.

Distribution. In general, the saddleback caterpillar in the United
States is distributed southeast of a diagonal line drawn from
Massachusetts through the middle of Texas.[68]

Biology/Behavior. From May to November, _Sibine stimulea_ caterpillars
may be found feeding on the leaves of a large variety of trees, shrubs,
and other plants. Envenomization usually occurs when the victim
accidentally contacts vegetation infested with these caterpillars. At
the instant the victim’s skin contacts the caterpillar, the spine tips
break off, thus allowing toxin to flow out of the hollow spines and into
or onto the skin.

Avoidance/Control. When working in infested areas, wear gloves, a
long-sleeved shirt, and long pants to prevent accidental envenomization.
During periods of local heavy infestations, children should be
instructed to avoid trees, shrubs, and other vegetation commonly
infested with these caterpillars. Local entomologists may be contacted
to obtain information on the most effective insecticide for saddleback
caterpillar control in a given area.

Envenomization Reaction/Treatment. (See appendix.)



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9. Infections and bites: Parasites, arthropods and animals, Section 18.
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11. Lyon, J.B. Insect bites and stings. Practitioner 200: 670-677

12. Micks, D.W. Insects and other arthropods of medical importance in
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13. Millikan, L.E., and R.S. Berger. Clinical and laboratory diagnosis
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14. Parrish, H.M. Deaths from bites and stings of venomous animals and
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15. Parrish, H.M. Analysis of 460 fatalities from venomous animals in
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18. Russell, F.E. Injuries by venomous animals. Am J Nurs 66:1322-1326

19. Scott, H.G. Envenomization. DHEW CDC Publ No. (HSM) 72-8121, 1972.

Blister Beetles

20. Lehmann, C.F., et al. Blister beetle dermatosis. Arch Dermatol
71:36-38 (1955).

21. Rosin, R.D. Cantharides intoxication. Br Med J 4:33 (1967)


22. Cloudsley-Thompson, J.L. Spiders, scorpions, centipedes and mites.
New York: Pergamon, 1958.

23. Pineda, E.V. A fatal case of centipede bite. J Philipp Med Assoc
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24. Remington, C.L. The bite and habits of a giant centipede
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30:453-455 (1950).


25. Hall, M.C. Lesions due to the bite of the wheel-bug, _Arilus
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26. Marks, M.B. Stinging insects: Allergy implications. Pediatr Clin
North Am 16:177-191 (1969).

27. Nichols, N., and T.W. Green. Allergic reactions to “kissing bug”
bites. Calif Med 98:267-268 (1963).

28. Parsons, D.J. Bedbug bite anaphylaxis misinterpreted as coronary
occlusion. Ohio Med J 51:669 (1955).

29. Readio, P.A. Studies on the biology of the Reduviidae of America
north of Mexico. Univ Kans Sci Bull 17:5 (1927).

30. Shields, T.L., and E.N. Walsh. “Kissing bug” bite. Arch Dermatol
74:14-21 (1956).

31. Smith, F.D., et al. Insect bite by _Arilus cristatus_, a North
American Reduviid. Arch Dermatol 77:324-330 (1958).

32. Wray, D.L. Two cases of Hemiptera biting humans (Hemiptera,
Reduviidae). Entomol News 82:228 (1971).


33. Barnard, J.H. Studies of 400 hymenoptera sting deaths in the United
States. J Allergy Clin Dermatol 52:259-264 (1973).

34. Barr, S.E. Allergy to hymenoptera stings. JAMA 228:718-720 (1974).

35. Busse, W., et al. Protection following honeybee venom immunotherapy
in a case of beesting anaphylaxis. (Abstract) J Allergy Clin Immunol
53:104 (1974).

36. Busse, W.S., et al. Immunotherapy in bee-sting anaphylaxis: Use of
honeybee venom. JAMA 231:1154-1156 (1975).

37. Charavejasarn, C.C., et al. Stinging insect hypersensitivity. II.
Studies of bee venom antigenicity. (Abstract) J Allergy Clin Immunol
53:104 (1974).

38. Controlling wasps. U.S. Department of Agriculture, Home and Garden
Bull No. 122, 1972.

39. Favorite, F.G. The imported fire ant. Public Health Rep 73:445-448

40. Insect-sting allergy: Questionnaire study of 2,606 cases. JAMA
193:109-114 (1965).

41. Lichtenstein, L.M., et al. Treatment of honeybee anaphylactic
sensitivity with honeybee venom: A case report. (Abstract) J Allergy
Clin Immunol 53:104-105 (1974).

42. Majeski, J.A., et al. Acute systemic anaphylaxis associated with an
ant sting. South Med J 67:365-366 (1974).

43. McCormick, W.F. Fatal anaphylactic reactions to wasp stings. Am J
Clin Pathol 39:485-491 (1963).

44. McLean, J.A. Management of insect sting reactions. Mod Treat
5:814-824 (1968).

45. Morse, R.A., et al. Protective measures against stinging insects. NY
State J Med 59:1546-1548 (1959).

46. Reisman, R.E. Stinging insect allergy—treatment failures. J Allergy
Clin Immunol 52:257-258 (1973).

47. Spencer, J.T. Treatment of yellow jacket stings. JAMA 206:649

48. Torsney, P.J. Treatment failure: Insect desensitization. J Allergy
Clin Dermatol 52:303-306 (1973).

49. Valentine, M.D., et al. Blocking antibody to bee venom: Induction by
venom and not by whole body extracts. (Abstract) J Allergy Clin Immunol
53:105 (1974).


50. Masco, H.L. Scorpion bite treatment with chlorpromazine. JAMA
212:2122 (1970).

51. Stahnke, H.L. Scorpions. Tempe, Ariz.: Arizona State College
Bookstore, 1949.

52. Vachon, M. The biology of scorpions. Endeavor April:80-89 (1953).


53. Anderson, P.C. What’s new in loxoscelism? Mo Med 70:711, 712, 718

54. Atkins, J.A., et al. Probable cause of necrotic spider bite in the
Midwest. Science 126:73 (1957).

55. Auer, A.I., and F.B. Hershey. Surgery for necrotic bites of the
brown spider. Arch Surg 108:612-618 (1974).

56. Cheng, A.K. USAF School of Aerospace Medicine, San Antonio, Tex.
Personal communication, 1974.

57. Gladney, W.J. Controlling the brown recluse spider. U.S. Department
of Agriculture Leaflet No. 556, 1972.

58. Hammon, P.J., and W.H. Newton. The brown recluse and the black widow
spiders. Texas A&M Univ, Fact Sheet L-623 (1970).

59. Hershey, R.B., and C.E. Aulenbacher. Surgical treatment of brown
spider bites. Ann Surg 170:300-308 (1969)

60. Horen, W.P. Arachnidism. Clin Med (Aug):41-43 (1966)

61. Russell, F. E., et al. Bites of spiders and other arthropods,
Section 16, pp. 865-867. _In_ H.F. Conn (ed.). Current therapy.
Philadelphia: W.B. Saunders, 1974.

62. Taylor, E.H., and W.F. Denney. Hemolysis, renal failure and sudden
death, presumed secondary to bite of brown recluse spider. South Med J
59:1209-1211 (1966).

63. The brown recluse. Public Health Service Publ No. 2062, 1970.

Urticating Caterpillars

64. Daly, J.A., and B.L. Derrick. Puss caterpillar sting in Arkansas.
South Med J 68:893-894 (1975).

65. Kendall, R.O. San Antonio, Tex. Personal communication, 1975.

66. McGovern, J.P., et al. _Megalopyge opercularis_: Observations of its
life history, natural history of its sting in man, and report of an
epidemic. JAMA 175: 121-124 (1961).

67. Micks, D.S. Clinical effects of the sting of the “puss caterpillar”
(_Megalopyge opercularis_ S. & A.) on man. Tex Rep Biol Med 10:399-405

68. Mitchell, R.T., and H.S. Zim. Butterflies and moths. New York:
Golden Press, 1964.


The material presented in this appendix was prepared by Lt Col John C.
Moseley, USAF, MC, Dermatologist, Wilford Hall USAF Medical Center,
Lackland AFB, Texas.

                           BLACK WIDOW SPIDER


_IMMEDIATE:_ Pinprick sensation from the bite

_LOCAL:_ Dull numbing pain; two red puncture marks at bite site. Pain
peaks at 1-3 hours and persists 12-48 hours


  1. Severe muscular pain and spasm
  2. Rigid boardlike abdomen
  3. Tightness in chest and pain on inspiration


  1. Rigidity and spasm of all large muscle groups; excruciating
          abdominal pain
  2. Convulsions, paralysis
  3. Shock

_DEATHS:_ 4-5% of untreated cases due to neurotoxic effect of the venom


_LOCAL FIRST AID:_ Ineffective and unnecessary


  1. Antivenin—1 vial IM (carefully follow package insert instructions)
          after testing for horse-serum sensitivity
  2. Calcium gluconate—10 ml of 10% solution given IV immediately and
          prn to control muscle pain
  3. Muscle relaxants—Give continuously over 8-16-hr period to relieve
          intensity of muscle spasm and pain
  4. Treat for shock as necessary (Chart 2)

                          BROWN RECLUSE SPIDER


_IMMEDIATE:_ Very little pain, if any


  1. 2-8 Hours—Mild to severe pain with redness and vesiculation at bite
          site, followed by ischemia
  2. 3-4 Days—Star-shaped firm area of deep-purple color with necrosis
  3. 7-14 Days—Central area of depression and ulceration
  4. 21 Days—Healing and scar formation. May not heal sufficiently and
          may require skin grafting


  1. Fever, chills, nausea, vomiting, weakness, joint pain
  2. Morbilliform or petechial generalized eruption
  3. Occasionally serious hematological disturbances—hemolytic anemia,

_DEATHS:_ Reported; usually in children, due to renal failure and
hematological abnormalities.


_LOCAL FIRST AID:_ None effective or necessary

_LOCAL:_ Within 4 hours of the bite, locally excise bite site


  1. Systemic corticosteroids is the treatment of choice and must be
          administered immediately—methylprednisolone (Depo-Medrol) 80
          mg IM, followed by prednisone 60 mg a day for 3 days and
          gradually tapered over a 10-14-day course of therapy
  2. Heparin therapy may reduce the disseminated intravascular
          coagulation phenomenon
  3. Analgesics for pain



_IMMEDIATE:_ Pain, often intense

_LOCAL:_ 1-4 hours—A two-puncture wound at the site with redness,
swelling, and a burning aching pain that subsides in 4-5 hours

_REGIONAL:_ Rare—Purpura of an entire limb

_ANAPHYLAXIS AND DEATH:_ None reported in the United States



  1. Wash with soap and water
  2. Apply ammonia in 10% solution
  3. Apply cool wet dressings of a saturated magnesium sulfate solution

_SYSTEMIC:_ Analgesics for pain

                        TRUE BUGS (KISSING BUGS)


_IMMEDIATE:_ Usually no sensation, occasionally mild pain

_LOCAL:_ (Four distinct reactions depending on degree of sensitivity):

  1. Papule with a central punctum
  2. Small vesicles grouped around bite site with swelling and little
  3. Giant urticarial lesion with central punctum and surrounding brawny
  4. Hemorrhagic nodular-to-bullous lesions on hands and feet—the
          characteristic “kissing bug bites”

_ANAPHYLACTIC SHOCK:_ Rare, but reported

_DEATHS:_ None reported


_LOCAL FIRST AID:_ Wash with soap and water

_SYSTEMIC:_ Oral antihistamines (Chart 1)



_IMMEDIATE:_ Fierce burning pain lasting minutes

_LOCAL:_ (Fire Ants)

  Minutes—Wheal formation
  2-4 Hours—Clear fluid-filled vesicles
  8-10 Hours—Cloudy fluid-filled vesicles
  12-24 Hours—Umbilicated pustules on a red base, with pain and
  3-8 Days—Lesions resolve; may leave scars

_SYSTEMIC:_ Due to allergic sensitization; severity and speed of onset
related to degree of sensitivity. May see wheezing, urticaria, abdominal
cramps, generalized edema, nausea, vomiting, dizziness, confusion, shock

_ANAPHYLAXIS AND DEATH:_ Rare, but reported



  1. Wash sites with soap and water
  2. Apply ice packs or cold compresses
  3. Apply baking soda and water paste


  1. Epinephrine (1:1,000) subcutaneous injection (0.2-0.5 ml in adults
          and 0.1-0.3 in children). Repeat in 5-10 min if necessary
  2. Antihistamine (Benadryl, 50 mg IM)—Adult
  3. Oral antihistamines (Chart 1)
  4. Treat for shock as necessary (Chart 2)

                             BEES AND WASPS



_LOCAL:_ Within 1-4 hours—Appearance and subsidence of wheal and red
flare; may see intense local swelling in region of sting


  1. Mild reaction—Generalized urticaria, itching, malaise, anxiety
  2. Moderate reaction—Any of the above plus generalized edema,
          tightness in the chest, wheezing, abdominal pain, nausea,
          vomiting, dizziness
  3. Severe reaction—Any of the above plus labored breathing, difficulty
          in swallowing, hoarseness or thickened speech, marked
          weakness, confusion, feeling of impending disaster
  4. Shock—Cyanosis, fall in BP, collapse, incontinence, unconsciousness
  5. Delayed serum-sickness-like reaction (10-14 days after
          sting)—Fever, lymphadenopathy, malaise, headache, urticaria,

_ANAPHYLAXIS AND SUDDEN DEATH:_ Many cases reported, usually in adults



  1. Remove bee stinger from sting site by gently scraping with
          fingernail or blade to prevent further venom injection from
          attached venom sac
  2. Wash site with soap and water
  3. Apply ice packs or ammonia in 10% solution
  4. Apply baking soda and water paste
  5. Elevate and rest involved limb


  1. Epinephrine (1:1,000) subcutaneous injection (0.2-0.5 ml in adults
          and 0.1-0.3 ml in children). Repeat in 5-10 min if necessary
  2. Analgesics (ASA, Tylenol) for pain
  3. Antihistamines (Chart 1)—Useful only for urticarial and pruritic
  4. Treat for shock as necessary (Chart 2)

_LONG-TERM MANAGEMENT:_ (for hypersensitive patients)

  1. Medic-alert tag or bracelet
  2. Emergency treatment kit and instructions for use
  3. Program for desensitization



_IMMEDIATE:_ Severe sharp pain


  1. Dangerous neurotoxic species—Pins-and-needles sensation with no
          local swelling or discoloration (found in Arizona only)
  2. Comparatively harmless species (not neurotoxic)—Local swelling and
          discoloration at sting site

_SYSTEMIC_ (neurotoxic species only—within 1-3 hours):

  1. Hypoesthesia and numbness or drowsiness
  2. Itching of nose and throat
  3. Impaired speech and tightness of jaw muscles
  4. Restlessness and muscle twitching
  5. Muscle spasms with pain, nausea, vomiting, incontinence,
  6. Respiratory and/or circulatory distress

_ANAPHYLAXIS:_ Rare, but reported with non-neurotoxic species

_DEATHS:_ Occasional; due to neurotoxic species



  1. Apply ice packs
  2. Apply tourniquet if possible and as near sting site as possible.
          Loosen briefly every 10-15 minutes
      WARNING: Do _not_ use morphine or opiates since they increase
          toxic effects


  1. Specific antivenin available for many dangerous species;
          administered early, may be lifesaving
  2. Calcium gluconate—10 ml of 10% solution IV immediately and prn to
          control muscle pain
  3. Phenobarbital—30-60 mg orally for sedation and control of
  4. Treat for shock as necessary (Chart 1)

                        URTICATING CATERPILLARS


_IMMEDIATE:_ Severe burning pain


  1. Numbness and swelling of area inflicted with severe radiating pain
  2. Possible double row of parallel red punctuate marks forming a
          gridlike tract along the path of the caterpillar
  3. Swelling of regional lymph nodes
  4. Late foreign-body reaction to unremoved spines


  1. Nausea, vomiting, fever
  2. Headaches
  3. Shock and convulsions (rare)

_DEATHS:_ None reported



  1. Repeated stripping using adhesive or cellophane tape to remove
  2. Apply ice packs
  3. Apply baking soda and water paste


  1. For severe pain give meperidine hydrochloride (Demerol, 50-100 mg
          PO or IM), morphine sulfate (0.25 subcutaneous), codeine
          phosphate (0.5 g PO)
      NOTE: Aspirin is generally not effective
  2. Shock (Chart 2)

                                CHART 1

GROUP                          TRADE NAME        AVERAGE ORAL BASE      SEDATION
   GENERIC NAMES                                ADULT         CHILD

   diphenhydramine•HCl       Benadryl        50 mg q 4-6h  25 mg q 4-6h   ++++
   diphenhydramine           Dramamine       50 mg q 4h    25 mg q 4h     ++++
   tripelennamine            Pyribenzamine   50 mg q 4-6h  25 mg q 4-6h   +++
   chlorpheniramine maleate  Chlor-Trimeton  4 mg q 6h     2 mg q 6h       ++
   brompheniramine maleate   Dimetane        8 mg q 6h     4 mg q 6h       +
   triprolidine•HCl          Actidil         2.5 mg q 8h   1.25 mg q 8h    ++
   hydroxyzine•HCl           Atarax          25-100 mg q   10-25 mg q      +
                                             6h            6h
   cyproheptadine•HCl        Periactin       4 mg q 6h     2 mg q 6h      +++
   promethazine              Phenergan       25-50 mg q    12.5-25 mg     ++++
                                             6-8h          q 6-8h

                                Chart 2
                     Treatment of Anaphylaxis—Shock

 REACTION: Conjunctivitis, Rhinitis, Urticaria, Pruritus, Erythema

 Epinephrine•HCl 0.3 ml     Diphenhydramine•HCl 50 mg
 (1:1,000) IM               PO q 6h
 Diphenhydramine•HCl 50 mg

 REACTION: Laryngeal edema

 Epinephrine•HCl 0.3 ml     Diphenhydramine•HCl 50 mg  Oxygen
 (1:1,000) IM               q 6h IM or PO              Diphenhydramine•HCl 50 mg
 Diphenhydramine•HCl 50 mg  Ephedrine sulfate 25 mg q  q 6h
 IV                         6h                         Ephedrine sulfate 25 mg q
                                                       Monitor blood gases

 REACTION: Bronchospasm

 Epinephrine•HCl 0.3 ml     Epinephrine•HCl 0.3 ml     Oxygen
 (1:1,000) IM               (1:1,000) IM               Aminophylline 500 mg IV q
 Diphenhydramine•HCl 50 mg  Aminophylline 250 mg IV    6h
 IV                         over 10-min period of time Hydrocortisone
                                                       IV fluids
                                                       Monitor blood gases
                                                       Observe for respiratory

 REACTION: Hypotension

 Epinephrine•HCl 0.3 ml     Metaraminol bitartrate,    Oxygen
 (1:1,000) IM               100 mg in 1,000 ml 5%      Metaraminol bitartrate IV
 Diphenhydramine•HCl 50 mg  dextrose in water          IV fluids

                          Transcriber’s Notes

—Retained publication information from the printed edition: this eBook
  is public-domain in the country of publication.

—Corrected a few palpable typos.

—Generated a spine image from elements of the cover image.

—Reformatted several charts for better text flow on narrow screens.

—In the text versions only, text in italics is delimited by

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ensuring that what you are doing is legal. Do not assume that just because
we believe a book is in the public domain for users in the United States,
that the work is also in the public domain for users in other countries.
Whether a book is still in copyright varies from country to country, and we
can't offer guidance on whether any specific use of any specific book is
allowed. Please do not assume that a book's appearance in Doctrine Publishing
ISYS search  means it can be used in any manner anywhere in the world.
Copyright infringement liability can be quite severe.

About ISYS® Search Software
Established in 1988, ISYS Search Software is a global supplier of enterprise
search solutions for business and government.  The company's award-winning
software suite offers a broad range of search, navigation and discovery
solutions for desktop search, intranet search, SharePoint search and embedded
search applications.  ISYS has been deployed by thousands of organizations
operating in a variety of industries, including government, legal, law
enforcement, financial services, healthcare and recruitment.