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PubMed1997

The painful experience of inappropriate therapy of snake bites: a report of two cases.

Recognizing the exact species of snake and specific antivenin administration are the most important modality of treatment for poisonous snake bites. In Taiwan, there are six kinds of medically important snakes--two species of Elapidae and four species of Viperidae. Two kinds of polyvalent antivenins and one monovalent antivenin are available. But for snake bites, questions about the prescription of antivenins are still the major problems addressed to the Poison Control Center. Improper use of antivenin may delay a patient's recovery from snake poisoning and even lead to mortality. Here, two cases of snake bites are presented. Each had severe complications and mortality as a result of inappropriate therapy, and the most rational management of snake bite in Taiwan is discussed, too.

Adult↗
PubMed1987

Past, present, and future immunotherapy of snake venom poisoning.

Management of snake venom poisoning with antivenin has been the time-proven and medically accepted standard in virtually every country, including the United States. All antivenins are equine in source, and administration to patients exposes them to all the adverse effects of heterologous antisera. The purity and specificity of neutralizing antibody titers in antivenin products vary among manufacturers. Research in the early 1980s demonstrated that immunosorbent affinity chromatography could purify a highly specific IgG(T) from equine hyperimmune antisera. This IgG(T) provided superior efficacy and reduced adverse effects as compared to commercial antivenin. The advent of newer biotechnical processes has now opened the doors for novel antibody and antibody fragment treatment of snake venom poisoning.

Animals↗
PubMed1989

Preliminary observations on the effects of hyperbaric oxygen therapy on western diamondback rattlesnake (Crotalus atrox) venom poisoning in the rabbit model.

Intermittent hyperbaric oxygen therapy has been shown to reduce skeletal muscle necrosis in a compartment syndrome animal model. To study whether intermittent exposure to hyperbaric oxygen augments antivenin therapy in reducing muscle necrosis, we injected sublethal doses of Western Diamondback rattlesnake (Crotalus atrox) venom intramuscularly into the hind legs of New Zealand White rabbits. In this pilot study, the animals were divided into three treatment groups. The first group received one vial of antivenin intravenously, the second group received one vial of antivenin intravenously plus three hyperbaric oxygen treatments, and the third group received no treatments. There were no statistically significant differences among the groups. These preliminary observations suggest that muscle necrosis secondary to Crotalus atrox venom poisoning is not significantly altered either by Antivenin [Crotalidae] Polyvalent at the dose level we used or in combination with intermittent hyperbaric oxygen treatments in this rabbit model.

Animals↗
PubMed1997

Naja naja cobra bite.

Most venomous snakes in the United States are of the Crotalidae family. Another family of snakes, the Elapidae, are not so common, but their bites may be a threat to zoo keepers and persons who have exotic snakes as pets. Because Elapidae envenomation is not common, signs and symptoms of such envenomation may not be recognized. Elapidae venom, because of a curare-like property, can produce respiratory compromise followed by death within 10 minutes. Antivenin, cholinesterase inhibitors, and mechanical ventilation are treatments to consider in such envenomations. Unlike Crotalidae antivenin, Elapidae antivenin may not confer protection against species not used in its preparation. Identification of the involved snake, by family and specie, should be an early priority. Correct management of the envenomated patient is dependent on the prompt administration of the most specific antivenin available when indicated.

Adult↗
PubMed1998

Prognostic factors of green pit viper bites.

Clinical features of green pit viper bites vary from asymptomatic to fatal bleeding. Antivenin promptly reverses the coagulopathy but has considerable adverse side effects. In this study, potential clinical predictors of severe outcomes (wound necrosis, wound infection, and systemic bleeding) and antivenin allergy were determined in 271 moderate to severe cases of green pit viper bites by multivariate analysis. The incidences of systemic bleeding, wound necrosis, secondary infection, and antivenin allergy were 17.3%, 6.6%, 5.5%, and 20.8% respectively. The predictors of systemic bleeding were the combination of thrombocytopenia and prolonged venous clotting time and bite sites away from digits. A bite on the fingers or toes was a risk factor for skin necrosis (P = 0.03). Systemic absorption of the venom from digits may be poor, resulting in severe local but mild systemic effects. The presence of blisters often led to necrosis and secondary infections (P = 0.0037 and P = 0.0006, respectively). Although negative skin test results do not exclude the possibility of antivenin allergy, positive results indicate a high risk (P = 0.016) requiring special precautions.

Adolescent↗
PubMed2000

Influential factors affecting prognosis of snakebite patients management: Kaohsiung Chang Gung Memorial Hospital experience.

BACKGROUND: The objective of this study was to determine the most influential factors affecting the prognosis of snakebite patients in Kaohsiung Chang Gung Memorial Hospital. METHODS: A thorough review of the medical records of poisonous snakebite from June 1986 to November 1999 was carried out in this retrospective study. RESULTS: Of the identified snakes in 39 bite victims, 70% of these cases were hemorrhagic type: Trimeresurus stejnegeri 20/27, T. mucrosquamatus 6/27, and Agkistrodon acutus 1/27; 28% were neurotoxic type: Naja naja atra 6/11 and Bungarus multicinctus 5/11; and 2% was mixed type: Vipera russelli formosensis 1/39. Three of four acute renal failure victims were bitten by T. mucrosquamatus. Two of the 5 victims bitten by B. multicinctus required endotracheal intubation to maintain their respiration. Five patients received skin grafting, 3 of whom were bitten by Naja naja atra. Most of our patients (55%) received only a single dose of antivenin, and 83% (29/35) of the antivenin was given within 6 hours after the bite; the antivenin infusion was finished in less than 2 hours in most cases (33/36). CONCLUSION: Bites from Trimeresurus stejnegeri are the most common poisonous snakebite recorded in our emergency department. T. mucrosquamatus is prominent in causing bleeding tendency and acute renal failure. Bungarus multicinctus is more prominent than Naja naja atra in causing acute respiratory failure. The dosage of antivenin used to treat patient bitten by cobra was less than that recommended by the poison control center, and the complication of skin necrosis requiring skin grafting was more severe than that of the other species.

Adolescent↗
PubMed1995

Snakebite treatment at a southeastern regional referral center.

Our objective was to determine the prevalence of poisonous snakebite victims admitted to a regional trauma center in Southeastern Georgia over a 10-year period, as well as the type of snake, grade of envenomation, treatment administered, morbidity and mortality, and outcome. Records of patients admitted to the center for snakebite from a 24-county catchment area during the 10-year period (January 1984 to January 1994) were retroactively reviewed. Sixty-three (63) bites in 62 victims of venomous snakebites were treated. The snake distribution was rattlesnake: 19 (30%), copperhead: 18 (29%), cottonmouth moccasin: 8 (12%), unknown: 18 (29%). Envenomation grades were Grade I: 20 (32%), Grade II: 24 (38%), Grade III: 10 (16%), and Grade IV: 9 (14%). Fourteen of 19 (74%) Grades III and IV envenomations were from rattlesnakes. Antivenin was used in all Grade IV and half of the Grade III envenomations. Antivenin was administered within 3 hours of injury in all but one case. Five patients had surgery. Two patients (both Grade I) developed anaphylaxes from antivenin given before hospitalization. All patients recovered. An average of 6 snakebites were treated each year. Expeditious transport, attention to the type of snake inflicting the bite, and judicious use of antivenin will result in a favorable outcome for the snakebite victim.

Adult↗
PubMedDate not supplied

Black widow spider bite.

These two cases illustrate many classical features of latrodectism. A subclinical bite followed by extensive systemic signs and symptoms in a recognizable pattern is strongly suggestive of the diagnosis. Pain and muscle spasms are refractory to standard therapy but are relieved by intravenous calcium. Finally, there should be complete resolution of the symptoms after only one vial of antivenin is administered. The common features of these cases form a recognizable constellation of signs and symptoms known as latrodectism. The specifics of these cases highlight the uncertainty of therapy. The older patient, because of the severity of his symptoms, warranted the use of antivenin perhaps earlier than it was given. The argument could be made, however, that because the patient was experiencing minimal morbidity and mortality, the calcium would have controlled his symptoms until the venom was cleared from his system. There would then have been no risk of anaphylaxis or serum sickness. One can only guess whether continued calcium use would have precipitated a hypercalcemic state and also would have been a health risk. The decision to provide antivenin therapy was made and the patient did well. The younger patient was not as severely affected as the older patient, so it could be argued that he was less in need of the antivenin. Still, his symptoms had not abated despite a reasonable length of time and might even have been considered to be worsening. No bite was found, but having discovered him playing with the spider certainly qualifies as circumstantial evidence. Also, the child was 11 months old and had greater risk of mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1997

[Snakes and scorpions: what are the risks for the traveler?].

The risk of being bitten by a snake or stung by a scorpion is low for the ordinary, non-thrill-seeking traveler. Travelers who plan hazardous outdoor activities should be advised to be careful and bring along adequate protective clothing (boots, long trousers, and gloves). If envenomation occurs, the victim should be immobilized and rushed to a treatment center. Administration of antivenin using massive doses in severe cases is the best therapy. For quickest and most efficient results, antivenins should be administered by the intravenous route. Packing antivenins is necessary only under special circumstances when high-risk activities are scheduled. In this case contingency planning may also be necessary taking into account health care facilities in the destination country and the availability of antivenins.

Animals↗
PubMed1984

A new method for quantitating hemorrhage induced by rattlesnake venoms: ability of polyvalent antivenom to neutralize hemorrhagic activity.

Polyvalent (Crotalidae) antivenin was tested for its ability to neutralize the hemorrhagic activity of two crotaline venoms when mixed with them prior to injection. Hemorrhage was measured by two methods. In the first method an intradermal injection of venom produced a hemorrhagic spot which was quantitated by measuring diameters. In the second method the amount of hemoglobin in a muscle extract was measured after i.m. injection of venom. The results show that both methods are useful for quantitating hemorrhage induced by Crotalus viridis viridis and Crotalus atrox venoms. Antivenin neutralized the hemorrhagic activity of 240 micrograms C. v. viridis venom and 120 micrograms C. atrox venom per 0.05 ml. The question remains, can antivenin neutralize this amount of venom when injected independently of venom.

Animals↗
PubMed1983

Venomous snakebite in a patient allergic to horse serum.

The management of snake envenomation is a clinical challenge. The definitive therapy, antivenin, is potentially harmful and should not be used indiscriminately. However, the morbidity and mortality from the envenomation usually outweigh any adverse reactions to the antivenin therapy. Most reactions can be divided into two general categories: type I (immediate hypersensitivity) reaction, which may be life-threatening, and the more common type III (immune complex) reaction characterized by serum sickness. It is vital to evaluate the patient's potential for developing adverse reactions from antivenin and to be prepared to provide appropriate therapy. The administration of epinephrine and antihistamines can be lifesaving in type I reactions, while steroids and antihistamines can ameliorate type III reactions.

Animals↗
PubMed1987

Biotoxicology of sea snake venoms.

Sea snakes are the most abundant venomous reptiles, found throughout the Indian and Pacific Oceans. Divided into two subfamilies, Laticaudinae and Hydrophiinae, all sea snakes are poisonous. Venoms are highly toxic, as indicated by low LD50 values in test animals. Toxic compounds include presynaptic and postsynaptic neurotoxins. Similarities in phylogeny are reflected in immunodiffusion patterns, immunoelectrophoresis, cross-neutralization by antivenin against heterologous venoms, and amino acid composition. The clinical syndrome following a bite is largely neurotoxic and myotoxic, with rare hepatotoxicity and nephrotoxicity. Proper emergency field therapy and timely administration of antivenin can be lifesaving. Hemodialysis may be useful when antivenin is not available.

Animals↗
PubMed2002

Respiratory compromise in patients with rattlesnake envenomation.

Respiratory compromise after rattlesnake envenomation (RSE) is an uncommon yet potentially lethal complication. We were interested in determining the frequency of respiratory compromise in patients treated for RSE. The incidence and indications for intubation were also determined. A retrospective chart review was conducted of all patients treated by medical toxicologists at a tertiary referral hospital between July, 1994 and November, 2000. Out of 294 total patients, 289 charts were reviewed. Of all 289 patients, 214 (74%) received Crotalidae Polyvalent Antivenin (Wyeth-Ayerst) and 23 (8%) had clinical evidence of respiratory compromise. Thirteen of 289 patients (4.4%) were intubated following RSE. No one was intubated for antivenin-induced complications. There were no deaths among studied patients during acute hospitalization. Respiratory compromise following RSE is rare, occurring in only 8% of studied patients. Only 2 patients (0.7%) required intubation as a direct consequence of RSE. No one required intubation for antivenin-induced hypersensitivity reactions.

Animals↗
PubMed1996

Pit viper bites: rational management in locales in which copperheads and cottonmouths predominate.

The management of pitviper bites remains controversial. In order to better assess the efficacy of different treatment modalities, charts of 107 patients hospitalized for pitviper bites at University of North Carolina Hospitals between 1952 and 1992 were retrospectively reviewed. The series included 68 copperhead bites (64%), 8 cottonmouth bites (7%), 3 rattlesnake bites (3%), and 28 bites (26%) in which the snake could not be identified. First aid measures taken prior to hospitalization included cryotherapy (21%), incision and suction (22%), tight or loose tourniquets (32%), and moist heat (2%). After hospitalization, 29 patients (27%) underwent wound excision and 4 patients (4%) required fasciotomy. Antivenin was administered to 34 patients (32%) and 9 patients (26%) developed serum sickness. No patients died as a result of a bite injury and 84 patients (79%) recovered uneventfully. Complications of the injuries included coagulopathies (4%), infections (13%), tissue loss (12%), and permanent physical deformities (8%). No first aid measure significantly affected the outcome, although there was a trend toward increased complication rates in bites with moderate (grade II) or greater envenomation if cryotherapy or tourniquets were utilized. Wound excision after hospitalization was associated with a decreased complication rate in these significantly envenomated bites. Antivenin utilization did not improve outcome and there was a significantly higher incidence of tissue loss associated with its use. Therefore, no first aid measures are recommended for pitviper bites due to copperheads and cottonmouths except immobilization and elevation. Excision is efficacious for patients seen within 1 to 2 hours of bite injury. The risk of complications and questionable efficacy of antivenin outweigh any potential benefit for these patients. Data from the current series were insufficient to make definitive recommendations regarding rattlesnake bites.

Animals↗
PubMed2001

Crotalid envenomation: the southern Arizona experience.

OBJECTIVE: To review a regional experience with the treatment of snakebites. SETTING: Five major southern Arizona hospitals, including two Level I trauma centers. DESIGN: A review of all snakebite admissions over a five-year period was performed. RESULTS: During the period reviewed, 164 patients were admitted for snakebites. Rattlesnakes were responsible for 98 percent of identified envenomations. Thirty-six percent of the patients were transported by air to the admitting facility. Eighty percent of patients were admitted to the intensive care unit for an average of 1.6 days. Total hospital stays averaged 2.8 days. Ninety percent of patients received antivenin, usually only on the day of admission. Of those receiving antivenin, 20 percent had an anaphylactoid reaction, and 1 percent required readmission for serum sickness. Laboratory evaluation indicated abnormalities in platelet count, coagulation parameters, and fibrinogen levels, but these rarely required treatment. Thirteen percent of patients underwent surgical intervention, including a 4 percent fasciotomy rate, and a single amputation. CONCLUSION: The use of field treatment, including "cut and suck," tourniquets, and cryotherapy, increased the likelihood of surgery. The authors concluded that the intensive care unit and helicopter transport system were overused. They recommend that established objective envenomation severity scores be used to dictate patient treatment, specifically the use of antivenin.

Adolescent↗
PubMed2001

Epidemiology and hospital course of rattlesnake envenomations cared for at a tertiary referral center in Central Arizona.

OBJECTIVE: To describe the demographics and primary inpatient treatment of victims of rattle-snake bites (RSBs) referred to a teritiary referral poison treatment center in central Arizona, and to compare the frequency of local tissue complications and hematologic toxicity during hospitalization in children with those for adults. METHODS: This was a chart review of patients diagnosed as having RSB by a toxicology service between July 1994 and April 2000. Data collected included: age, sex, date, bite location, time to and length of hospitalization, time to and amount of antivenin, serial hematologic studies, and inpatient complications. RESULTS: Of 241 patients admitted, 236 charts met inclusion criteria. The majority of RSB victims were male (81%). Children (< or =13 years) represented 22%. Most RSBs (78%) occurred between April and September. Mean time (+/-SEM) to presentation was 1.7 +/- 0.2 hours. Antivenin was administered to 77% of patients, with an average (+/-SEM) of 28.5 +/- 0.9 vials administered. Hematologic abnormalities included: coagulopathy (60%), hypofibrinogenemia (49%), and thrombocytopenia (33%). No statistically significant difference in the above parameters was detected between upper- and lower-extremity envenomations, or between children and adults. Immediate antivenin reactions occurred in 36% of patients. Hemorrhagic bullae formation occurred in 22%, occurring most frequently in upper extremities. Operative procedures were required in 3.4% of patients. Hospitalization averaged 2.5 +/- 0.1 days. There was no fatality. CONCLUSIONS: In Arizona, RSB victims were typically adult males with upper-extremity bites. Hematologic abnormalities were common. Local tissue complications were more common with upper-extremity envenomations. No statistically significant difference was detected in frequency of hematologic disorders or local tissue complications when children were compared with adults.

Adolescent↗
PubMed2002

Clinical findings associated with prairie rattlesnake bites in dogs: 100 cases (1989-1998).

OBJECTIVE: To identify clinically relevant variables and treatments for dogs bitten by prairie rattlesnakes (Crotalus viridis viridis). DESIGN: Retrospective study. ANIMALS: 100 client-owned dogs. PROCEDURE: Records of dogs evaluated for rattlesnake envenomation from 1989 to 1998 were reviewed. Analysis was performed to test for significant associations among clinical variables or treatments and cell counts, costs, and duration of hospitalization. RESULTS: Most prairie rattlesnake bites occurred between May and September. Dogs were 3 months to 12 years old (median, 3.7 years); most were bitten on the head in the late afternoon. There was no sex predilection. Median time to evaluation was 1 hour (range, 15 minutes to 13 hours). Swelling in the area of the bite was the primary physical abnormality. Principal initial laboratory findings were echinocytosis, thrombocytopenia, leukocytosis, and prolonged activated clotting time. Ninety-four dogs were hospitalized; 48 were discharged the following day. Antimicrobials and crystalloid fluids, glucocorticoids, antihistamines, and antivenin administered i.v. were the most commonly used treatments. One dog died, and small dogs were hospitalized longer than large dogs. Antivenin administration was not significantly associated with duration of hospitalization but was associated with higher platelet counts after treatment and higher total hospital costs. CONCLUSIONS AND CLINICAL RELEVANCE: Prairie rattlesnake envenomation in dogs is associated with high morbidity rate but low mortality rate. The efficacy of administration of antivenin for dogs with bites from this snake species is questionable.

Age Distribution↗
PubMedDate not supplied

Reptile envenomations.

Venomous reptiles are distributed in select habitats in temperate and tropical areas of the world with few geographical exceptions, and have adapted to not only terrestial existence, but to arboreal and aquatic environments as well. Venomous snakes are found in the families Colubridae (fixed and rear fanged snakes), Elapidae (fixed and front fang snakes), Hydrophiidae (sea snakes), Viperidae (Old World vipers) and Crotalidae (pit vipers). Venomous lizards are found in the United States and Mexico, and comprise the family Helodermatidae. Venom delivery systems and venom components show diversity, and greater appreciation of interspecies clinical effect is apparent in modern literature. First aid care for the bitten individual remains controversial, but most authorities now tend to minimize field procedures, especially those endeavors which may potentially damage tissue. The weight of evidence in the area of definitive therapy lies with the use of antivenin, although proponents of primary surgical intervention in crotalid envenomations have followings, particularly in the United States. Recent developments in "purification" of existing antivenins are promising, and attention to species-specific antivenin production, especially to the venoms of the crotalid species of the New World, is encouraged. Due to a growing international traffic in venomous animals for the purposes of research and supply of zoos and private reptile collections, knowledge of resources for assistance in bites of non-indigenous reptiles is a growing consideration.

Animals↗