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PubMed1990

[Preparation of toxoid from Taiwan cobra (Naja naja atra) venom].

Potency of sixty antitoxic unit was reached after two immunizations in 2-week intervals of rabbits and horses with 10-25 mg Taiwan cobra (Naja naja atra) venom which was detoxified by 0.125% glutaraldehyde. Now this procedure has become a routine antivenine-producing method by which snake bivalent neurotropic antivenine is produced. The stability test showed that Taiwan cobra toxoid kept at 37 degrees C for 40 days, the antigenicity increased by 24% and toxicity decreased by 10% as compared to the toxoid maintained at 4 degrees C.

Animals↗
PubMed1978

Poisonous snakebite treatment in the United States.

This is retrospective report of 107 cases of poisonous snakebites treated in south Georgia and north Florida. Sixty-seven percent of the cases required intensive treatment. Intravenous antivenin therapy, if indicated, should be given early and over a short time. Steroids are of use primarily for allergic phenomena. Fasciotomies were not necessary unless cooling or inadequate antivenin had been administered. A grading system that matches the species of snake with the severity of the bite was used to classify the cases.

Adult↗
PubMed1996

The black widow: is she deadly to children?

Pediatric cases of black widow spider envenomation (BWSE) were reviewed in order to assess the morbidity and mortality in children with BWSE, and to make recommendations for optimal therapy. The methodology includes a retrospective chart review in an urban pediatric tertiary care hospital. Included were all pediatric patients admitted with the BWSE diagnosis in the last 10 years (1984-1994). The results are based on 12 children with ages ranging from 15 months to 18 years. The BWSE syndrome is characterized by several common systemic effects. Our cases revealed abdominal pain (100%), hypertension (92%), muscle complaints (75%), a target lesion (75%), and irritability/agitation (66%) as the most common symptoms. Treatments used included antivenin, calcium gluconate, benzodiazepines, and opioids. Eight of 12 patients recovered (had relief of symptoms) within 24 hours, often by 12 hours. Antivenin did appear to bring quicker relief of symptoms. Hypertension was severe but asymptomatic in all patients. There were no complications or deaths resulting from BWSE.

Abdominal Pain↗
PubMed2003

Are there teratogenic risks associated with antidotes used in the acute management of poisoned pregnant women?

OBJECTIVE: We reviewed evidence suggesting teratogenic risk associated with the use of antidotes in the acute management of poisoned pregnant women. METHODS: Medline, Toxline, and DART/ETIC searches; references of retrieved articles, pertinent databases and textbooks were also searched. RESULTS: There are case reports or case series of women who received antidotes for poisoning during (*) or after (+) the period of organogenesis who showed no fetal adverse effects. Some antidotes, however, have no teratogenic risk: atropine (cohort/surveillance studies)+, calcium (oral supplement: cohort study)+ and pyridoxine (Bendectin studies). Also, ethanol+, methylene blue (intra-amniotic injection but not oral) and penicillamine* can be considered teratogens but their risks in the treatment of poisonings are unknown. There is no epidemiologic study evaluating the risk of the following antidotes during pregnancy: N-acetylcysteine(*+), BAL (dimercaprol)+, black widow spider antivenin+, calcium EDTA+, crotalidae antivenin, crotalidae polyvalent immune FAB, cyanide antidote kit (amyl and sodium nitrate, sodium thiosulfate), deferoxamine(*+), digoxin immune FAB+, DMSA+, flumazenil+, fomepizole, methylene blue (IV), naloxone, physostigmine, pralidoxime+, protamine+; and parenteral pharmacologic doses of calcium+, folinic acid*, glucagon+, hydroxycobalamin, phytonadione (vitamin K), and pyridoxine. CONCLUSIONS: Despite the limited evidence supporting the risk of antidote use during pregnancy, antidotes should be used when there is a clear maternal indication to decrease the morbidity or mortality associated with poisoning. The only exception may be penicillamine, which is a teratogen. Better antidotes exist for most poisonings that penicillamine could potentially treat. At this time, there is no known fetal indication for all antidotes. Reporting the use of an antidote during pregnancy should be encouraged, especially if used during the critical period of organogenesis.

Abnormalities, Drug-Induced↗
PubMed2001

Analysis of antibody-antigen interactions in mixtures containing reactive and nonreactive components using size-exclusion high-performance (pressure) liquid chromatography.

Analysis of antibody-antigen interactions using size-exclusion high-performance (pressure) liquid chromatography was applied to a polyvalent system composed of both reactive and nonreactive components. Mixtures containing varying concentrations of antivenin (Crotalidae) polyvalent (equine origin) and either Crotalus atrox (Western diamondback rattlesnake) venom (CV) or isolated C. atrox phospholipase A2 (PLA2) were separated using a Bio-Sil SEC 250-5 size-exclusion column (300 x 7.8 mm). Major regions containing high-molecular-weight aggregates, antivenin IgG, and CV components or PLA2 could be identified from the elution profiles. Changes in elution profile areas could be modeled by equations derived from the law of mass action that included values for the maximum fraction of reactivity, antigen valence, apparent binding constants, profile area proportionality constants, and nonreactive profile area. The analysis was simple, fast, and readily interpretable and may be applicable to a variety of situations in which stable antigen-antibody complexes are formed in the presence of nonreactive components.

Animals↗
PubMed1980

Comparative studies on Egyptian elapid venoms.

The immunological properties of Naja haje from Western Desert, Naja haje of the Nile Delta, Naja nigricollis from Upper Egypt and Walternnesia aegyptia from Sinai Desert were compared using horse serum antivenin prepared from the Delta Naja haje venom. All elapid venoms showed very similar precipitin lines with immunodiffusion or immunoelectrophoresis on agar gel. Results of cellulose-acetate electrophoresis showed either different concentration of certain similar protein components or the absence of some major protein fractions. However, different migration and localization of protein components were observed. LD50 of the 4 elapids and their degree of lethality was determined. Naja haje (Delta) antivenin had different degree of neutralization capacity on the investigated elapid venoms. No correlation between immunodiffusion similarities and the degree of neutralization could be deducted.

Animals↗
PubMed1988

Clinical and laboratory features of South American rattlesnake (Crotalus durissus terrificus) envenomation in children.

The venom of the South American rattlesnake Crotalus durissus terrificus was first reported to have mainly haemolytic and neurotoxic physiopathological activities. Later studies demonstrated the systemic myotoxic action of the venom, characterized by the release of myoglobin from damaged skeletal muscle into serum and urine, and a recent report ruled out the presence of intravascular haemolysis in 3 patients, one child and 2 adults. The present paper describes the clinical-laboratory evolution of 10 children bitten by C. durissus terrificus; 2 developed acute renal failure and one died. The myotoxic activity of the venom was evaluated by measuring serum lactic dehydrogenase, creatine kinase and aspartate aminotransferase, by detection of myoglobin in serum and urine, and by muscle biopsy. Haemolytic activity was evaluated by serial measurements of serum haemoglobin and haptoglobin and by detection of urine haemoglobin. We conclude that the signs and symptoms exhibited by patients bitten by C. durissus terrificus are due only to the myotoxic and neurotoxic action of the venom. The only patients with major morbidity were those who initially received subcutaneous antivenin and did not receive definitive antivenin therapy until later.

Acute Kidney Injury↗
PubMed2004

[Risks posed by venomous animals -- accidents due to snakebite envenomation].

In regions where poisonous animals are widely distributed, the management of injuries due to these animals is part of the routine medical care. Personnel e. g. deployed for humanitarian aid missions in these areas have to be prepared to face these challenges as well. Beside this group zoo personnel and snake charmers here in Europe are also endangered. The most common form of animal poisoning is due to snake bites. There are approximately 600 different species of poisonous snakes, commonly found in the warm climatic regions. But poisoning from spiders, scorpions and some marine animals can also be life threatening. There are different kinds of snake venoms, which result into different clinical presentations depending on the components of the venom. The venom may be cytotoxic, hematotoxic, neurotoxic, rhabdomyolytic, cardiotoxic, renotoxic or may cause an autoimmune reaction by complement activation. In the management of injuries following animal poisoning, besides the first aid measures taken, the injured is supposed to be managed according to the poison component in the venom with specific antivenin treatment and supportive therapeutic care. There are mono- and polyvalent antivenins available. Noneffective first-aid measures or measures which can cause further trauma must always be avoided. In general adapted behaviour in the field can prevent envenomation. Education on preventive measures with the aim of behaviour change are central components for pre-deployment preparations.

Cell Survival↗
PubMed2000

Combined evidence-based literature analysis and consensus guidelines for stocking of emergency antidotes in the United States.

STUDY OBJECTIVE: To develop guidelines for the stocking of antidotes at hospitals that accept emergency admissions using combined evidence-based and consensus methods. METHODS: Study participants were 12 medical care providers from disciplines that are affected by insufficient stocking of emergency antidotes (clinical pharmacology, critical care, clinical pharmacy, emergency medicine, hospital pharmacy, internal medicine, managed care pharmacy, clinical toxicology, pediatrics, poison control centers, pulmonary medicine, regulatory medicine). Selection of individuals for the study panel was based on evidence of previous antidote research or perspective regarding the purchase and use of antidotes. The literature regarding each antidote was systematically amassed using pre-1966 literature files, current MEDLINE searches, the reference lists of major medical textbooks, and citations solicited from the consensus panel. Articles relevant to 4 defined core questions were included. These articles formed the basis of an evidence-based analysis performed by the principal investigator. After literature analysis, a literature summary and proposed guidelines for antidote stocking were submitted to the panel. Consensus was formed by electronic iterative presentation of alternatives to each panel member using a modified Delphi method. All panel members participated in 5 rounds of guideline analysis of 20 antidotes. RESULTS: Of the 20 antidotes, 16 antidotes were ultimately recommended for stocking (N -acetylcysteine, atropine, Crotalid snake antivenin, calcium gluconate and chloride, cyanide antidote kit, deferoxamine, digoxin immune Fab, dimercaprol, ethanol, fomepizole, glucagon, methylene blue, naloxone, pralidoxime, physostigmine, sodium bicarbonate), 2 were not recommended for stocking (black widow antivenin, ethylenediamine tetraacetic acid), and consensus could not be reached for 2 antidotes (flumazenil, physostigmine). CONCLUSION: These guidelines provide a tool to be used in revising or creating policies and procedures with regard to the stocking of antidotes in hospitals that accept emergency patients.

Antidotes↗
PubMed1978

Hand deformities in patients with snakebite.

Over the past 25 years, 83 patients have been treated at our hospitals for poisonous snakebites of the hand. Prior to 1970, polyvalent antivenin was used, either alone or in conjunction with cryotherapy, steroids, or incision and suction methods. Hand deformities, due to tissue necrosis, were encountered in 15 of 22 patients (68%) treated by these methods. In contrast, excisional therapy, without the use of polyvalent antivenin, was the sole method of treatment in 61 patients seen since 1970. The incidence of hand deformity in them was 8.2%. We have concluded that early excision of the envenomated tissues will not only curtail systemic toxicity from the injected venom, but will also minimize the extent of local tissue damage.

Hand Deformities, Acquired↗
PubMedDate not supplied

[Epidemiological and clinical aspects of snake bites in the municipalities of the state of Amazonas, Brazil].

In the State of Amazonas, accidents with snakes are a public health problem. For this reasons, the objective of this work was to carry out a descriptive study of the snake accidents attended in the health units of 34 municipalities, one district and two border platoons in the State of Amazonas. The characteristics most commonly observed among those involved in snake accidents were: farmers (50. 4%), male (81.3%), belonging to the working age-group (72.1%), bitten on an upper limb (88.5%) by a "jararaca" (48.6%) or a "surucucu" (46.8%) in the rural part of the municipality (70.2%). The local signs and symptoms most frequently observed in those who received medical care more than 6 hours after the accident (57.3%) were edema (76.9%), pain (68.7%), erithema (10.2%) and hemorrhage (9. 3%). The systemic manifestation most frequently observed was hemorrhage (18.8%). Serotherapy was administered in only 65.9% of patients, the intravenous route being the route most commonly used to administer the antivenin (52.3%), while other non- recommended routes were widely used. In the majority of patients the antivenin given was antibotropic. The most frequent complications were: abscess 13.7%, necrosis 12.3%, secondary infection 8.3%, renal insufficiency 2.5% and gangrene 2.5%. The medical procedures most used in the treatment of these complications were drainage 52.6%, debridement 28.9%, amputation 10.5%, surgical cleaning 5.3% and peritoneal dialysis 2.6%. The fatality rate was 1%.

Adolescent↗
PubMed1983

[Snake bites and coagulation disorders].

Within a period of 6 years 8 patients with 12 bites by potentially hemotoxic snakes (crotalids, viperids) were hospitalised in various clinics of the Basle area. All the patients were snake owners. One patient was hospitalized 3 times, 2 patients twice and the others once. In two cases no signs of envenomation were noted after an observation period of 12 hours. Ten bites were followed by local cytotoxic symptoms e.g. oedema and suffusions. Among this group only 6 cases had further signs of systemic, hemotoxic envenomation with decrease of the activity of various coagulation factors. Complete defibrination was seen in 4 patients, but only in 2 cases with additional thrombopenia did overt clinical symptoms of bleeding complications (urological bleeding) occur. Bleeding complications of the central nervous system or of the gastrointestinal tract were not seen. Antivenin was used in three patients and coagulation mechanisms recovered within 24 hours. One patient with complete defibrination, thrombopenia and overt bleeding (macrohematuria) refused antivenin. His coagulation parameters started to improve after 7 days and became normal on day 11.

Adult↗
PubMed1997

Acute renal failure after snakebite: a report of four cases.

There is risk of acute renal failure (ARF) after snakebite. Four patients are reported who developed ARF after bites by Vipera russelli formosensis. The four patients were all male, of ages ranging from 26 to 55 years old. Their clinical features were mainly hemorrhage including hemoptysis, hematemesis, gross hematuria and hypotension. The abnormal laboratory data were thrombocytopenia, prothrombin time (PT) and activated partial thromboplastin time (APTT) prolongation, disseminated intravascular coagulation (DIC), hemolysis and rhabdomyolysis. The onset of ARF occurred within 24 hours after the snakebite, and lasted for 17 to 26 days. All patients received conservative treatment including hemodialysis and antivenin therapy. One patient, with massive gastrointestinal bleeding, died. It was concluded that the factors contributing to ARF following Vipera russelli formosensis bit are hemorrhage, hypotension, DIC, hemolysis and rhabdomyolysis. To prevent development of ARF, the early administration of antivenin cannot be too strongly emphasized.

Acute Kidney Injury↗
PubMed1964

NATURE AND TREATMENT OF BITES OF VENOMOUS SNAKES IN CANADA: A REVIEW.

A review of literature on snakebites was undertaken to evaluate the various recommended and practised methods of treatment used over the years, and to choose the most effective and least mutilating therapy for snakebite victims. Descriptions and photographs of pit vipers indigenous to Canada are included for identification purposes. The only proved adequate treatment of snakebite was shown to be Antivenin administration. A complete description of the use of this substance, which is prepared from horse serum, is given, as well as precautions to be taken prior to its administration, in the event of sensitivity to the serum. Supporting therapy is described and brief comments are made on less satisfactory means of treatment.

Animals↗
PubMed1964

COUNTING CALIFORNIA'S SNAKEBITES.

Poisonous snakebites happen in all sections of California, but they are especially frequent in Southern California. An estimated 221 (138 in-patients and 83 out-patients) people were bitten by snakes annually, an incidence of 1.41 bites per 100,000 people. However, the estimated case-fatality rate was less than one-half of one per cent. Of 135 in-patients reported in detail by California hospitals during 1958 and 1959, 123 (91 per cent) were bitten by rattlesnakes, one (1 per cent) by a foreign snake, and 11 (8 per cent) by unidentified poisonous snakes. "Seasonal epidemics" of snakebites occurred, 90 per cent of the bites being inflicted from April through October. Males had higher bite rates than females and Caucasians had higher rates than non-whites. Fifty per cent of the cases were among children and young adults less than 20 years of age. Ninety-nine per cent of the bites were on the extremities-65 per cent on the upper extremities and 34 per cent on the lower extremities. The recommended treatment of poisonous snakebites included incision and suction and the 3 A's (antivenin, antibiotics and antitetanus treatment).

Adolescent↗
PubMed2001

A randomized multicenter trial of crotalinae polyvalent immune Fab (ovine) antivenom for the treatment for crotaline snakebite in the United States.

BACKGROUND: Current therapy for crotaline snakebite includes antivenin (Crotalidae) polyvalent, an antivenom with numerous adverse effects. We compared the efficacy and safety of 2 dosing regimens with a new antivenom, Crotalinae polyvalent immune Fab (Fab AV). METHODS: A single dose of Fab AV alone (as-needed [PRN] group) was compared with an initial dose plus repeated treatments during 18 hours (scheduled group) in a multicenter randomized trial. The study included patients with minimal or moderate envenomation by a crotaline snake within the preceding 6 hours, aged 10 years or older, in whom worsening of the envenomation syndrome was observed before Fab AV treatment. After treatment with Fab AV to achieve initial control, patients were randomized to the scheduled or PRN treatment group. Scheduled group patients received additional doses of Fab AV every 6 hours for 3 doses. The PRN group received no planned additional doses of antivenom. RESULTS: The mean severity score of the 31 patients decreased from 4.35 to 2.39 points (P<.001); there was no difference between scheduled and PRN groups. No patient in the scheduled group received unplanned Fab AV doses, but 8 of 16 patients in the PRN group received unplanned doses (P =.002). Acute reactions occurred in 6 patients (19%), and serum sickness occurred in 6 (23%) of 26 patients who returned for follow-up. CONCLUSIONS: In the first randomized trial of antivenom in the United States, Fab AV effectively terminated venom effects. Since the unplanned use of Fab AV in the PRN group was common, the treatment regimen may require more than 1 initial dose.

Adolescent↗
PubMed1983

Mechanism of defibrination in humans after envenomation by the Eastern diamondback rattlesnake.

We prospectively studied the hemostatic system of ten persons bitten by the Eastern diamondback rattlesnake (Crotalus adamanteus) during 1978-1980. Blood was drawn when the patients arrived in the emergency room and every 6 hr thereafter. All envenomated victims developed incoagulable blood (defined by a thrombin time greater than or equal to 120 sec, normal less than 20 sec). Platelet counts and plasma levels of antithrombin III and factors II and VIII were not drastically altered, which distinguished this disorder from classic disseminated intravascular coagulation. Fibrinogen levels were markedly decreased (mean coagulable level of 0 mg/dl and antigenic levels of 99 mg/dl). Plasminogen levels were 20% of normal, alpha-2-plasminogen inhibitor was 17% of normal, and plasminogen activator was 20 times normal. Levels of fibrin degradation products peaked at a mean of 7,680 micrograms/ml. The magnitude and duration of the coagulopathy were proportional to the clinical severity of envenomation. Treatment with antivenin blunted the coagulopathy. Because venom from the Eastern diamondback rattlesnake does not directly activate plasminogen, we conclude that coagulopathy following envenomation by that reptile appears to be due to partial proteolysis of fibrinogen with secondary activation of plasminogen by released plasminogen activator, probably of endothelial origin.

Antivenins↗
PubMed2004

Surgical implications of snakebites.

OBJECTIVE: Snakebites are a common problem in the pediatric age group. Local complications such as necrosis and compartment syndrome threaten limb survival even after control of systemic manifestations. Few recommendations exist about the nature and timing of surgical treatment. METHODS: A retrospective review of all children with snakebites presenting to the hospital was undertaken over a 6-year period. Records were reviewed with special emphasis on the type of surgical lesions seen and the treatment offered and their results. RESULTS: 44 of the 58 children required some form of local therapy. In the majority conservative treatment was successful. 28% of the patients needed debridement for local necrosis, and only 5 needed a skin graft, with good functional results over a period of 1 to 45 days. One child underwent an above knee amputation. Patients who required surgical intervention received significantly more vials of antivenin. CONCLUSION: Local complications of snakebite are frequent, but can be managed conservatively. Delayed excision of the resultant local necrosis is associated with good outcomes. The need for fasciotomy is rare.

Adolescent↗