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PubMed1998

[Acute management of patients bitten by poisonous snakes].

The management of poisonous snake bites includes first aid and clinical medical treatment. First aid consists of reassurement of the patient, immobilisation of the bitten limb and rapid transport to the nearest hospital to monitor the vital functions. In no case suction, incision or tight bandages should be applied. The degree of envenomation can be classified in three categories depending on the spread of the symptoms: no symptoms, only local non-progressive symptoms, and systemic or local rapidly progressive symptoms (severe envenomation). Antivenin therapy is indicated in severe envenomation. Because of the risk of anaphylactic reactions or serum sickness, antivenin should be given with great caution. Antibiotic therapy and tetanus prophylaxis are advised in all cases. Immediate consultation with the National Intoxication Centre of the Rijksinstitut voor Volksgezondheid en Milieu (RIVM) is always warranted; telephone: 030-2748888. In a national protocol, which is available at the RIVM, the Harbour Hospital Rotterdam, the Academic Medical Centre and Artis Zoo Amsterdam, the correct management of snake bites is described. An overview of all antivenins available in the Netherlands is also given in this protocol.

Anaphylaxis↗
PubMed2000

Recurrent coagulopathy after antivenom treatment of crotalid snakebite.

BACKGROUND: We studied whether recurrence of coagulopathy, defined as the return of a coagulation abnormality after initial normalization, occurred after the use of antivenin (Crotalidae) polyvalent. METHODS: A retrospective, blinded, descriptive analysis of 354 consecutive cases of North American crotalid snake envenomation was done. Inclusion criteria were documented clinical evidence of crotalid snakebite, presence of a coagulopathy (platelet count <150,000/mm3, prothrombin time above normal, or fibrinogen level <150 mg/dL), and treatment with antivenin (Crotalidae) polyvalent. RESULTS: Of 112 cases with a coagulopathy extending beyond 6 hours after envenomation, 31 had sufficient coagulopathy testing to detect recurrence. Fourteen of these patients (45%) had recurrence of coagulopathy, and two cases were severe (fibrinogen level 29 mg/dL; platelet count 36,000/mm3). CONCLUSION: Recurrence of coagulopathy after envenomation by North American crotalid snakes may occur after use of antivenin (Crotalidae) polyvalent and can result in severe coagulation abnormalities.

Adult↗
PubMed1986

Echis colorata bites: clinical evaluation of 42 patients. A retrospective study.

A retrospective study of 42 patients bitten by Echis colorata in the last 26 years is reported. Twenty-eight patients received and 14 patients did not receive specific antivenin. The clinical findings, laboratory studies, and course of hospitalization revealed hemostatic disturbances in most of the patients. One of the untreated patients died in the period when antivenin was not available. We recommend that antivenin be given, following appropriate clinical and laboratory assessment, to patients bitten by E. colorata who have progressive local signs and major alterations in the clotting mechanism. The usual precautions against allergic reactions should be taken.

Adolescent↗
PubMed1994

Evaluation and treatment of poisonous snakebites.

Snakebite victims should be transported immediately to the nearest emergency department. Incision and suction are contraindicated unless performed by experienced personnel within five minutes of the bite, or unless transport of the patient to definitive medical care will take more than 30 minutes. Cryotherapy is contraindicated. All bites should be graded for severity of envenomation. The wound should be cleaned and broad-spectrum antibiotics administered. Tetanus status should be determined and tetanus toxoid administered if necessary. Antivenin is indicated in certain mild cases and in all moderate and severe cases of envenomation. Patients with a mild case of envenomation may require up to five vials of antivenin; patients with moderate bites may require 10 to 15 vials, and patients with severe bites may require 15 to 20 vials. Antivenin is effective only when administered intravenously; skin testing to predict the possibility of anaphylactic reaction is mandatory before administration. Diphenhydramine and epinephrine should be readily available in case of anaphylaxis. Fasciotomy is only indicated in rare cases involving elevated intracompartment pressures.

Antivenins↗
PubMed1998

Venomous snakebite in Thailand. II: Clinical experience.

We reviewed a total of 2,525 snakebite patients in Bangkok. Of these, 1,415 were bitten by venomous snakes, 91 by neurotoxic snakes of genus Naja or Bungarus and 1,324 by snakes of family Viperidae or Crotalidae. Seventy-one percent of bites were on the lower extremity. There were two fatal cobra bites; both patients were dead on arrival at the hospital. Bites from vipers caused morbidity but no deaths. Species-specific antivenins are effective in reversing respiratory failure from cobra bites and coagulopathies from bites by Viperidae and Crotalidae snakes. However, early respiratory and wound care will save lives even in the absence of specific cobra and krait antivenin. Care of a snakebite victim should consist of immobilization and bandaging of the bitten limb with elastic bandages during transport to the hospital, early surgical debridement of necrotic tissue, appropriate infusion of antivenin, aggressive respiratory support, management of shock and infection, and peritoneal dialysis or hemodialysis. Incision of bite wounds, suctioning, application of ice, and tourniquets are of no proven value and may be dangerous. All snakebite victims in southeast Asia should survive if they receive early competent care.

Adult↗
PubMed2004

Marine Neurotoxins: Envenomations and Contact Toxins.

Familiarity with the appearance and habitat of venomous sea creatures, the location of their stinging apparatus, and surveillance of population concentrations within recreational waters are essential in avoiding envenomations. Compared with the thermo-stable low molecular weighted ingestible seafood toxins, venomous toxins are often large molecular weight proteins and many are heat labile, which provides opportunity for therapeutic intervention. Heat therapy may denature the toxins, and provide immediate relief of pain in coelenterate and venomous fish envenomations. Injections of local anesthetic agents may also be used. First aid measures at the seashore may limit the spread of venom, and include immobilization of the affected sites, compression bandaging, and venous-lymphatic occlusive bandages. Measures to limit continued envenomation by attached stinging cells include topical vinegar for jellyfish tentacles and irrigation with debridment for spines of venomous fish. Antivenins are of limited availability and may be used for envenomations with sea snakes, Chironex box jellyfish, and some venomous fish. Sea snakes bites may be treated with antivenin from land snakes or with hemodialysis when antivenin is not available. Neuromuscular paralysis occurs with bites by sea snakes, cone snails, blue octopuses, and some jellyfish. Supportive treatment includes attention to cardiopulmonary resuscitation and intubation. Exposure to Pfeisteria may result in cognitive and behavioral abnormalities. Treatment with cholestyramine may be helpful in binding the toxin and improve recovery.

Journal Article↗
PubMed1983

Detection of antibodies to myotoxin a and prairie rattlesnake (Crotalus viridis viridis) venom in three antisera using enzyme-linked immunosorbent assay and immunodiffusion.

Immunodiffusion and enzyme-linked immunosorbent assay (ELISA) were used to compare three antisera for their content of antibodies against myotoxin a and C. v. viridis venom. No antibodies were detected in Wyeth's polyvalent (Crotalidae) antivenin against myotoxin a using immunodiffusion, whereas ELISA indicated a low titer of such antibodies. However, antimyotoxin a serum and anti-C. v. viridis venom both had higher titers than antivenin when tested against myotoxin a and crude venom in the ELISA. These results correlate well with previous data which indicated that antiserum to myotoxin a was more effective than antivenin in neutralizing the myotoxicity of C. v. viridis venom. The high content of antibodies to myotoxin a in anti-C. v. viridis venom supports the hypothesis that this monovalent antiserum might be effective in neutralizing rattlesnake (C. v. viridis) venom-induced myonecrosis.

Animals↗
PubMed2001

Antigenic cross-reactivity of venoms from medically important North American Loxosceles spider species.

We characterized the antigenic cross-reactivity of two medically important North American Loxoxceles species: L. reclusa (native to southeastern US) and L. deserta (native to southwestern US). Dermonecrosis resulting from bites from these two North American spider species are indistinguishable clinically. Polyclonal IgG antivenins directed against L. reclusa and L. deserta were raised in rabbits and used to develop specific enzyme immunoassays (EIAs). Antigenic differences in the two venoms were evaluated as follows: (1) Comparison of the sensitivities and correlation coefficient (R(2)) of anti-L. reclusa (alpha LoxR) and anti-L. deserta antibodies (alpha LoxD) in the detection of varying concentrations of the two venoms; (2) separation and western blot comparison of venom components; (3) protein sequence analysis of L. desertavenom and comparison to the L. reclusa protein sequence analysis present in a US national database; and (4) in vivo evaluation of alpha LoxR and alpha LoxD antivenins in attenuating dermal lesions (rabbit model). Correlation coefficients for alpha LoxR (R(2)=0.99) and alpha LoxD (R(2)=0.99) polyclonal antibodies in the measurements of standard concentrations of venoms were virtually identical. Western blot analysis revealed multiple common bands between the two venoms. Amino acid data (amino acids 1-35, N-terminal) of the active venom components of the two venoms revealed only three non-identical amino acids. alpha LoxR and alpha LoxD antivenins were similarly effective in blocking the development of rabbit skin lesions (ANOVA p<0.05). In summary, L. reclusa and L deserta spider venoms possess several common protein bands as identified by western blot, greater than 90% amino acid sequence identity, and marked antigenic cross-reactivity.

Amino Acid Sequence↗
PubMed2000

Black widow spider (Latrodectus mactans) envenomation in a term pregnancy.

Description of a black widow spider (Latrodectus mactans) envenomation in a term pregnancy.Case report conducted at an Air Force tertiary care hospital of a 27-year-old primigravida at 38 1/7 weeks pregnancy.Latrodectus mactans antivenin can be given to treat symptoms of black widow envenomation.Black widow envenomations can cause symptoms associated with acute intra-abdominal processes. In pregnancy, envenomations can result in symptoms and signs similar to those seen in preeclampsia (abdominal pain, headache, hypertension, and proteinuria). Latrodectism should be considered in patients complaining of these symptoms in association with a spider bite. If latrodectism is considered to be the underlying origin for these symptoms, appropriate treatment should be administered. In cases of pregnancy, treatment should include L. mactans antivenin if believed to be clinically indicated. There is no current evidence that this antivenin is contraindicated in pregnancy. (Curr Surg 57:346-348)

Journal Article↗
PubMed1987

Venomous snakebites in the United States.

Venomous snakebite treatment is controversial. Venomous snakebites are known to occur in all but a few states. Approximately 10 to 15 individuals die from snakebites each year, with bites from diamondback rattlesnakes accounting for 95 percent of fatalities. The identification of the two endogenous classes of venomous snakes are discussed in detail to aid in determining the proper treatment for each class. Approximately 25 percent of all pit viper bites are "dry" and result in no envenomation. The best first aid is a set of car keys to get the victim to a facility where antivenin is obtainable. Incision and suction should be limited to very special situations; cryotherapy and use of tourniquets applied by laymen should be avoided. Proper medical management at a health care facility requires establishing whether envenomation has occurred and to what extent, followed by appropriate dosing of antivenin. The use of corticosteroids and antibiotics is controversial. Tetanus immunization should be updated, if necessary. Although research in developing a more purified antivenin is under way, the best treatment for snakebite is prevention.

Animals↗
PubMed2003

Persistent coagulopathy in snake bite.

Bleeding diathesis is a cardinal feature of viperine bite, which has been thought to last not more than 24 hours. There is scarcity of literature about prolonged bleeding disorder in snake envenomation. Various explanations suggested in the literature include-temporary decrease in antivenin levels, rapid elimination of antivenin from circulation or continuous release of unneutralised venom from the envenomated site. Two children with prolonged coagulopathy lasting for more than a week, correction of which required more than 300 ml of antisnake venom are reported here.

Antivenins↗
PubMed1983

Producers of antivenom sera.

A list of the producers of antivenom sera in presented along with a listing of the venomous species against which the antivenin is prepared. Some characteristics of the antivenins are specified, such as polyvalence or monovalence, animal source, etc.

Africa↗
PubMed1989

Crotalid envenomation in children: selective conservative management.

Snake bites in children remain an uncommon injury. In general, there is a wide disagreement by knowledgeable authorities on a uniform approach to therapy. In the last 5 years, 29 children have been treated in our institution for snake bites, all with signs of envenomation. Treatment consisted of diagnostic laboratory studies, intravenous fluids, tetanus prophylaxis, antibiotics, bed rest, elevation, and observation. There were no deaths. A fasciotomy was required in three children. Cryotherapy initiated elsewhere resulted in tissue loss. Seven children received antivenin. All developed signs and symptoms to serum sickness. From this experience, it appears that the majority of snake bites in children, especially copperhead bites, can be treated selectively and conservatively. Care must be exercised in using antivenin as it is associated with a high rate of serum sickness. Cryotherapy adds to the morbidity of the bite and is not to be used.

Adolescent↗
PubMed1991

Snake venom coagulopathy: use and abuse of blood products in the treatment of pit viper envenomation.

Coagulopathies are commonly encountered in victims of pit viper envenomation. In the majority of patients these defects improve with administration of antivenin. However, blood products are often transfused based on arbitrary criteria and with significant risk to the patient. This article documents the effectiveness and risks of antivenin administration and the risks of blood product transfusion. We recommend that blood products not be used except for clearly defined clinical indications.

Aged↗
PubMed1991

Failure of electric shock treatment for rattlesnake envenomation.

The use of high-voltage electric shock therapy for the treatment of snake venom poisoning has recently gained popularity in the United States. We present a case that documents the dangerous, ineffective application of electric shock to the face of a patient envenomated by a Great Basin rattlesnake (Crotalus viridis lutosus). The successful use of antivenin in this critically ill, antivenin-allergic patient is described.

Adult↗
PubMed1996

Neostigmine for the treatment of neurotoxicity following envenomation by the Asiatic cobra.

Envenomation by the monocellate cobra (Naja kaouthia) is usually manifested clinically as neurotoxicity and local tissue necrosis. Treatment often requires administration of large quantities of antivenin, resulting in a high incidence of serum reactions. In cases where antivenin administration may be delayed for several hours or administration is contraindicated, the use of the anticholinesterase drug neostigmine may temporarily reverse the potentially lethal neurological effects of the venom. Detailed in this report is the case of immediate and dramatic reversal of envenomation symptoms following the administration of the anticholinesterase neostigmine methyl sulfate.

Adult↗
PubMed1998

Successful treatment of neurotoxic king cobra envenomation in Myrtle Beach, South Carolina.

The growing trend toward the collection of exotic snakes by private collectors increases the likelihood that emergency physicians will face the challenge of treating an exotic envenomation. We report a case involving a professional reptile handler who sustained an extremity bite from a king cobra (Ophiophagus hannah ). Rapid, progressive neurotoxicity developed as manifested clinically by bulbar and respiratory paralysis requiring endotracheal intubation and mechanical support. After infusion of Thai Red Cross Society monospecific king cobra antivenin, all neurologic sequelae rapidly resolved within 7 hours after the bite. In treating an exotic envenomation, the emergency physician should contact personnel at the regional poison control center or local zoo. Both are prepared to assist the physician by facilitating the timely acquisition of exotic antivenins and by arranging consultation with experts experienced in the management and treatment of exotic envenomations.

Accidents, Occupational↗
PubMed1980

The management of upper extremity pit viper wounds.

In a series of 56 rattlesnake bites, there were 31 injuries involving the upper extremity and hand with a clinical complication rate of 32% that ranged from Volkmann's contracture to coagulopathies. The most frequent was tissue necrosis with functional joint stiffness and loss of sensibility. Because these patients were treated with a variety of regimens, an animal model was developed to determine the efficacy of the individual treatments. Sublethal intramuscular injections of Crotalus atrox venom were made in the extremity of New Zealand white rabbits. Tissue reaction monitored by swelling and hemorrhage was decreased significantly (P less than 0.05) with antivenin and antivenin-steroids, but no treatment modality prevented tissue necrosis. Clinical and laboratory experience indicates that one cannot rely on injectable medications to prevent tissue necrosis in pit viper envenomations and that operative treatment should be used in conjunction with other forms of therapy.

Adolescent↗