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Abstract
SNAKE ENVENOMATION REPRESENTS AN IMPORTANT HEALTH PROBLEM IN much of the world. In 2009, it was recognized by the World Health Organization (WHO) as a neglected tropical disease, and in 2017, it was elevated into Category A of the Neglected Tropical Diseases list, further expanding access to funding for research and antivenoms. However, snake envenomation occurs in both tropical and temperate climates and on all continents except Antarctica. Worldwide, the estimated number of annual deaths due to snake envenomation (80,000 to 130,000) is similar to the estimate for drug-resistant tuberculosis and for multiple myeloma., In countries with adequate resources, deaths are infrequent (e.g., <6 deaths per year in the United States, despite the occurrence of 7000 to 8000 bites), but in countries without adequate resources, deaths may number in the tens of thousands. Venomous snakes kept as pets are not rare, and physicians anywhere might be called on to manage envenomation by a nonnative snake. Important advances have occurred in our understanding of the biology of venom and the management of snake envenomation since this topic was last addressed in the Journal two decades ago. For the general provider, it is important to understand the spectrum of snake envenomation effects and approaches to management and to obtain specific guidance, when needed.
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Affiliation(s)
- Steven A Seifert
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - James O Armitage
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
| | - Elda E Sanchez
- From the Department of Emergency Medicine and the New Mexico Poison and Drug Information Center, University of New Mexico Health Sciences Center, Albuquerque (S.A.S.); the Department of Internal Medicine, University of Nebraska Medical Center, Omaha (J.O.A.); and the National Natural Toxins Research Center and the Department of Chemistry, Texas A&M University-Kingsville, Kingsville (E.E.S.)
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Cocchio C, Johnson J, Clifton S. Review of North American pit viper antivenoms. Am J Health Syst Pharm 2020; 77:175-187. [PMID: 31974558 DOI: 10.1093/ajhp/zxz278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE For the first time in nearly 20 years, 2 antigen-binding fragment (Fab) antivenoms are available to treat patients who incur North American pit viper snakebites: Crotalidae polyvalent immune Fab (ovine), or simply FabAV; and Crotalidae immune F(ab')2 (equine), or simply F(ab')2. Pharmacists are in a key position for the selection, dosing, reconstitution, administration, and monitoring of antivenom therapy; however, they encounter inconsistent exposure and experience with these drugs. Thus, an updated review of the literature is necessary. METHODS The search strategy and selection incorporated both controlled vocabulary terms and keywords to describe concepts relevant to the search. Retrieval was limited to literature published from 1997 to the present in English, Portuguese, or Spanish. RESULTS Given the paucity of available prospective literature, the authors elected to include all prospective evidence to best describe the role of antivenom. For the primary literature review, manuscripts were excluded if they were observational studies, conference abstracts, narrative or opinion articles, letters to the editor, or in-progress studies. CONCLUSION While there is limited evidence-based guidance on the superiority of F(ab')2 to FabAV, or vice versa, individual and regional considerations should contribute to formulary decisions. Pharmacists must play a role in the development of clinical pathways to ensure appropriate evaluation, supportive care, and antivenom procurement, administration, and monitoring.
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Affiliation(s)
| | - Jami Johnson
- Oklahoma Center for Poison and Drug Information, Oklahoma City, OK, and University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Shari Clifton
- Reference & Instructional Services, Robert M. Bird Health Sciences Library, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Angioedema and Dual Nurse Flight Crew Cricothyrotomy After Envenomation by a Severed Rattlesnake Head. Air Med J 2020; 39:417-420. [PMID: 33012483 DOI: 10.1016/j.amj.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/05/2020] [Accepted: 06/17/2020] [Indexed: 11/21/2022]
Abstract
Crotalid envenomation may result in airway compromise from angioedema, anaphylaxis, or an anaphylactoid reaction. A 57-year-old man was transported by helicopter to the emergency department (ED) after a bite to his hand from a severed rattlesnake head. He rapidly developed facial and oropharyngeal edema that did not respond to standard treatment. After 2 unsuccessful attempts at intubation, the dual flight nurse team performed a cricothyrotomy. They notified the ED team en route, and antivenom was prepared before arrival. Angioedema was suspected because there was no concomitant urticaria, bronchoconstriction, or persistent hypotension. Edema and ecchymosis of the affected extremity were mild. Severe coagulopathy ensued, which was treated with bolus doses of antivenom and continuous infusion. This case report is significant for several reasons. It is the first detailing a prehospital cricothyrotomy performed by flight crew nurses for life-threatening airway edema caused by snakebite envenomation. In-flight notification enabled the ED staff to prepare and administer antivenom immediately after arrival. Despite the use of antivenom in bolus dosing, crotalid envenomation may be complicated by persistent or recurring coagulopathy, and continuous antivenom infusion may be useful. Finally, it highlights the danger of snakebite envenomation even after the death and decapitation of a snake.
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Neri-Castro E, Bénard-Valle M, Paniagua D, V. Boyer L, D. Possani L, López-Casillas F, Olvera A, Romero C, Zamudio F, Alagón A. Neotropical Rattlesnake ( Crotalus simus) Venom Pharmacokinetics in Lymph and Blood Using an Ovine Model. Toxins (Basel) 2020; 12:toxins12070455. [PMID: 32708875 PMCID: PMC7405010 DOI: 10.3390/toxins12070455] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/10/2020] [Accepted: 07/10/2020] [Indexed: 02/06/2023] Open
Abstract
The most abundant protein families in viper venoms are Snake Venom Metalloproteases (SVMPs), Snake Venom Serine Proteases (SVSPs) and Phospholipases (PLA2s). These are primarily responsible for the pathophysiology caused by the bite of pit-vipers; however, there are few studies that analyze the pharmacokinetics (PK) of whole venom (WV) and its protein families. We studied the pathophysiology, PK profile and differential absorption of representative toxins from venom of Neotropical Rattlesnake (Crotalus simus) in a large animal model (ovine). Toxins studied included crotoxin (the main lethal component), which causes moderate to severe neurotoxicity; SVSPs, which deplete fibrinogen; and SVMPs, which cause local tissue damage and local and systemic hemorrhage. We found that Whole Venom (WV) was highly bioavailable (86%) 60 h following intramuscular (IM) injection, and extrapolation suggests that bioavailability may be as high as 92%. PK profiles of individual toxins were consistent with their physicochemical properties and expected clinical effects. Lymph cannulated animals absorbed 1.9% of WV through lymph during the first 12 h. Crotoxin was minimally detectable in serum after intravenous (IV) injection; however, following IM injection it was detected in lymph but not in blood. This suggests that crotoxin is quickly released from the blood toward its tissue targets.
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Affiliation(s)
- Edgar Neri-Castro
- Departamento de Medicina Molecular y Bioprocesos, Instituto de Biotecnologia, Universidad Nacional Autónoma de México, Av. Universidad 2001, Cuernavaca 62210, Mexico; (E.N.-C.); (M.B.-V.); (L.D.P.); (A.O.); (F.Z.)
- Programa de Doctorado en Ciencias Biomédicas, Universidad Nacional Autónoma de México, Unidad de Posgrado, Edificio B Primer Piso, Ciudad Universitaria, Ciudad de México 04510, Mexico
| | - Melisa Bénard-Valle
- Departamento de Medicina Molecular y Bioprocesos, Instituto de Biotecnologia, Universidad Nacional Autónoma de México, Av. Universidad 2001, Cuernavaca 62210, Mexico; (E.N.-C.); (M.B.-V.); (L.D.P.); (A.O.); (F.Z.)
| | - Dayanira Paniagua
- Facultad de Ingeniería, Arquitectura y Diseño, Universidad Autónoma de Baja California, Ensenada, Baja California 22860, Mexico;
| | - Leslie V. Boyer
- Venom Immunochemistry, Pharmacology, and Emergency Response (VIPER) Institute, University of Arizona,1501 N. Campbell Avenue, Tucson, AZ 85724, USA;
| | - Lourival D. Possani
- Departamento de Medicina Molecular y Bioprocesos, Instituto de Biotecnologia, Universidad Nacional Autónoma de México, Av. Universidad 2001, Cuernavaca 62210, Mexico; (E.N.-C.); (M.B.-V.); (L.D.P.); (A.O.); (F.Z.)
| | - Fernando López-Casillas
- Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Ciudad Universitaria, Ciudad de México 04510, Mexico;
| | - Alejandro Olvera
- Departamento de Medicina Molecular y Bioprocesos, Instituto de Biotecnologia, Universidad Nacional Autónoma de México, Av. Universidad 2001, Cuernavaca 62210, Mexico; (E.N.-C.); (M.B.-V.); (L.D.P.); (A.O.); (F.Z.)
| | - Camilo Romero
- Centro Universitario UAEM Amecameca, Universidad Autónoma del Estado de México, Amecameca de Juárez 56900, Mexico;
| | - Fernando Zamudio
- Departamento de Medicina Molecular y Bioprocesos, Instituto de Biotecnologia, Universidad Nacional Autónoma de México, Av. Universidad 2001, Cuernavaca 62210, Mexico; (E.N.-C.); (M.B.-V.); (L.D.P.); (A.O.); (F.Z.)
| | - Alejandro Alagón
- Departamento de Medicina Molecular y Bioprocesos, Instituto de Biotecnologia, Universidad Nacional Autónoma de México, Av. Universidad 2001, Cuernavaca 62210, Mexico; (E.N.-C.); (M.B.-V.); (L.D.P.); (A.O.); (F.Z.)
- Correspondence:
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Sarmiento K, Rodríguez A, Quevedo-Buitrago W, Torres I, Ríos C, Ruíz L, Salazar J, Hidalgo-Martínez P, Diez H. Comparación de la eficacia, la seguridad y la farmacocinética de los antivenenos antiofídicos: revisión de literatura. UNIVERSITAS MÉDICA 2019. [DOI: 10.11144/javeriana.umed61-1.anti] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
En Colombia se presentan anualmente alrededor de 5000 casos de mordedura de serpiente y su tratamiento se basa en la neutralización con inmunoglobulinas completas purificadas, sin embargo, globalmente se utilizan antivenenos faboterápicos. Objetivo: Dar a conocer diferencias entre las generaciones de antivenenos, la importancia del veneno en la producción de anticuerpos, comparar aspectos farmacocinéticos y los efectos adversos en pacientes. Materiales Métodos: Se realizó una búsqueda de literatura en bases de datos utilizando combinaciones de los descriptores y términos Mesh, en inglés y español. Se cotejaron parámetros farmacocinéticos en estudios preclínicos y los efectos adversos en estudios clínicos. Resultados: Se encontraron diferencias debidas al tamaño de la fracción de la inmunoglobulina que la compone, así entre más pequeña es ésta, se observa mayor distribución a los tejidos y una vida media más corta, comparada con las moléculas más pesadas. Se encontraron estudios con disminución de efectos adversos con antivenenos faboterápicos
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Park KH, Shin H, Kang H, Kim C, Choi HJ, Yoo K, Oh J, Lim TH. Effectiveness of repeated antivenom therapy for snakebite-related systemic complications. J Int Med Res 2019; 47:4808-4814. [PMID: 31446819 PMCID: PMC6833386 DOI: 10.1177/0300060519870012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective This study aimed to determine the effect of repeated antivenom therapy compared with that of single antivenom therapy for treating snakebite-related systemic complications. Methods A retrospective medical record review from January 2008 to September 2016 was performed. Patients with snakebite injury who visited the Emergency Department in one tertiary center of Korea were included. The primary outcome was the survival rate. The secondary outcome was the effect of repeated antivenom therapy for treating snakebite-related systemic complications compared with that of single antivenom therapy on hospital length of stay. Results A total of 110 patients with snakebites were included. All patients survived to discharge. Twenty-nine (26.4%) patients had snakebite-related systemic complications. Of these, nine patients received repeated antivenom therapy and 20 patients received single antivenom therapy. The length of stay was significantly longer in those who received repeated antivenom therapy compared with those who received single antivenom therapy (10.0 [4.0–11.0] vs. 3.5 [0–7.0] days). Conclusion We were unable to demonstrate any superiority of repeated versus single antivenom therapy. However, repeated antivenom therapy is associated with a longer hospital stay. The reason for this finding is unknown.
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Affiliation(s)
- Kyung Hoon Park
- Department of Emergency Medicine, College of Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - Hyungoo Shin
- Department of Emergency Medicine, College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Hyunggoo Kang
- Department of Emergency Medicine, College of Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - Changsun Kim
- Department of Emergency Medicine, College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Hyuk Joong Choi
- Department of Emergency Medicine, College of Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Kyunghun Yoo
- Department of Emergency Medicine, College of Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - Jaehoon Oh
- Department of Emergency Medicine, College of Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University Seoul Hospital, Seoul, Republic of Korea
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Persistent pit viper envenomation in three dogs. Toxicon 2019; 166:83-87. [PMID: 31129161 DOI: 10.1016/j.toxicon.2019.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 05/15/2019] [Accepted: 05/20/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION North Central Florida is the home to several venomous snakes. The most clinically significant pit vipers include the Eastern Diamondback Rattlesnake, the Water Moccasin, and less commonly the Timber Rattlesnake. Many of the dogs and cats that become envenomated by these particular snakes have moderate to severe clinical signs requiring the use of antivenom in doses that can range from 1 to 20 vials with the average case requiring two vials. Oftentimes, the pet owners' financial limitations restrict the amount of antivenom that can be administered initially to severely envenomed cases. Most of these patients will become clinically stable after the first 48 hours of treatment, but there are rare instances where some patients will follow this same initial course, and then revert back to the initial signs of envenomation associated with delayed absorption of redistributed venom from other tissue sites in addition to the bite site. This report describes three dogs that showed signs of persistent and/or recurrent envenomation requiring additional doses of antivenom. METHODS The medical records of three dogs showing signs of persistent envenomation were reviewed by the author who was available and provided assistance during the course of the dogs' respective hospitalizations. The dog's signalment, time of year of the envenomation, clinical signs, treatment, and outcome are provided in each case. RESULTS Each of these three dogs showed severe signs of envenomation characterized by marked mental depression, prostration, hemorrhagic lymphedema, and evidence of prolonged coagulation times. Initial treatment in each consisted of intravenous crystalloid solution and polyvalent crotalid antivenom that exceeded the usual average dose as reported in the literature. After the coagulation test normalized during the first three days, all of them reverted to abnormal prolonged clotting times with signs of clinical deterioration requiring additional doses of antivenom. Clinical stability was eventually reached and all dogs survived to be discharged. CONCLUSIONS The clinical course of the three dogs described in this study showed that veterinary patients can experience persistent envenomation in a similar manner as described in humans. It behooves the veterinary practitioner to be aware of this complication and to be prepared to extend antivenom treatment as deemed necessary.
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Paniagua D, Vergara I, Román R, Romero C, Benard-Valle M, Calderón A, Jiménez L, Bernas MJ, Witte MH, Boyer LV, Alagón A. Antivenom effect on lymphatic absorption and pharmacokinetics of coral snake venom using a large animal model. Clin Toxicol (Phila) 2019; 57:727-734. [PMID: 30773936 DOI: 10.1080/15563650.2018.1550199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Context: Historically, administration and dosing of antivenom (AV) have been guided primarily by physician judgment because of incomplete understanding of the envenomation process. As demonstrated previously, lymphatic absorption plays a major role in the availability and pharmacokinetics (PK) of coral snake venom injected subcutaneously, which suggests that absorption from subcutaneous tissue is the limiting step for venom bioavailability, supporting the notion that the bite site is an ongoing venom depot. This feature may underlie the recurrence phenomena reported in viperid envenomation that appear to result from a mismatch between venom and AV PK. The role of lymphatic absorption in neutralization of venom by AV administered intravenously remains unclear. Methods: The effect of AV on systemic bioavailability and neutralization of Micrurus fulvius venom was assessed using a central lymph-cannulated sheep model. Venom was administered by subcutaneous injection in eight sheep, four with and four without thoracic duct cannulation and drainage. Two hours after venom injection, AV was administered intravenously. Venom and AV concentrations in serum and lymph were determined by ELISA assay from samples collected over a 6-h period and in tissues harvested post-mortem. Results: After AV injection, venom levels in serum fell immediately to undetectable with a subsequent increase in concentration attributable to non-toxic venom proteins. In lymph, AV became detectable 6 min after treatment; venom levels dropped concurrently but remained detectable 4 h later. Post-mortem samples from the venom injection site confirmed the presence of venom near the point of injection. Neither venom nor AV was detected at significant concentrations in major organs or contralateral skin. Conclusions: Intravenous AV immediately neutralizes venom in the bloodstream and can extravasate to neutralize venom absorbed by lymph but this neutralization seems to be slow and incomplete. Residual venom in the inoculation site demonstrates that this site functions as a depot where it is not neutralized by AV, which allows the venom to remain active with slow delivery to the bloodstream for ongoing systemic distribution.
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Affiliation(s)
- D Paniagua
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - I Vergara
- b Department of Chemical and Biological Sciences, Sciences School , Universidad de las Américas Puebla , Cholula , México
| | - R Román
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - C Romero
- c Centro Universitario UAEM Amecameca, Universidad Autónoma del Estado de México , Amecameca de Juarez , México
| | - M Benard-Valle
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - A Calderón
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - L Jiménez
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
| | - M J Bernas
- d Department of Medical Education , TCU and UNTHSC School of Medicine , Fort Worth , TX , USA.,e Department of Surgery , University of Arizona , Tucson , AZ , USA
| | - M H Witte
- e Department of Surgery , University of Arizona , Tucson , AZ , USA
| | - L V Boyer
- f Venom Immunochemistry, Pharmacology, and Emergency Response (VIPER) Institute, University of Arizona , Tucson , AZ , USA
| | - A Alagón
- a Departamento de Biología Molecular y Bioprocesos , Instituto de Biotecnología Universidad Nacional Autónoma de México , Cuernavaca , México
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Fry BG. Snakebite: When the Human Touch Becomes a Bad Touch. Toxins (Basel) 2018; 10:E170. [PMID: 29690533 PMCID: PMC5923336 DOI: 10.3390/toxins10040170] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 01/08/2023] Open
Abstract
Many issues and complications in treating snakebite are a result of poor human social, economic and clinical intervention and management. As such, there is scope for significant improvements for reducing incidence and increasing patient outcomes. Snakes do not target humans as prey, but as our dwellings and farms expand ever farther and climate change increases snake activity periods, accidental encounters with snakes seeking water and prey increase drastically. Despite its long history, the snakebite crisis is neglected, ignored, underestimated and fundamentally misunderstood. Tens of thousands of lives are lost to snakebites each year and hundreds of thousands of people will survive with some form of permanent damage and reduced work capacity. These numbers are well recognized as being gross underestimations due to poor to non-existent record keeping in some of the most affected areas. These underestimations complicate achieving the proper recognition of snakebite’s socioeconomic impact and thus securing foreign aid to help alleviate this global crisis. Antivenoms are expensive and hospitals are few and far between, leaving people to seek help from traditional healers or use other forms of ineffective treatment. In some cases, cheaper, inappropriately manufactured antivenom from other regions is used despite no evidence for their efficacy, with often robust data demonstrating they are woefully ineffective in neutralizing many venoms for which they are marketed for. Inappropriate first-aid and treatments include cutting the wound, tourniquets, electrical shock, immersion in ice water, and use of ineffective herbal remedies by traditional healers. Even in the developed world, there are fundamental controversies including fasciotomy, pressure bandages, antivenom dosage, premedication such as adrenalin, and lack of antivenom for exotic snakebites in the pet trade. This review explores the myriad of human-origin factors that influence the trajectory of global snakebite causes and treatment failures and illustrate that snakebite is as much a sociological and economic problem as it is a medical one. Reducing the incidence and frequency of such controllable factors are therefore realistic targets to help alleviate the global snakebite burden as incremental improvements across several areas will have a strong cumulative effect.
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Affiliation(s)
- Bryan G Fry
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St. Lucia, QLD 4072, Australia.
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Williams KL, Woslager M, Garland SL, Barton RP, Banner W. Use of polyvalent equine anti-viper serum to treat delayed coagulopathy due to suspected Sistrurus miliarius streckeri envenomation in two children. Clin Toxicol (Phila) 2017; 55:326-331. [DOI: 10.1080/15563650.2017.1284334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Megan Woslager
- The Children’s Hospital at Saint Francis, Tulsa, OK, USA
- University of Oklahoma – Tulsa School of Community Medicine, Tulsa, OK, USA
| | | | - Roger P. Barton
- The Children’s Hospital at Saint Francis, Tulsa, OK, USA
- University of Oklahoma – Tulsa School of Community Medicine, Tulsa, OK, USA
| | - William Banner
- Oklahoma Center for Poison and Drug Information, Oklahoma City, OK, USA
- Integris Baptist Medical Center, Oklahoma City, OK, USA
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Boyer LV, Ruha AM. Pitviper Envenomation Guidelines Should Address Choice Between FDA-approved Treatments for Cases at Risk of Late Coagulopathy. Wilderness Environ Med 2016; 27:341-2. [PMID: 27079732 DOI: 10.1016/j.wem.2015.10.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 10/20/2015] [Accepted: 10/29/2015] [Indexed: 11/19/2022]
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Witham WR, McNeill C, Patel S. Rebound coagulopathy in patients with snakebite presenting with marked initial coagulopathy. Wilderness Environ Med 2015; 26:211-5. [PMID: 25758759 DOI: 10.1016/j.wem.2014.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 11/21/2014] [Accepted: 11/25/2014] [Indexed: 12/18/2022]
Abstract
OBJECTIVE An estimated 70% of patients with pit viper snakebites require antivenom to treat serious complications such as coagulopathy. Evidence-based guidance is limited for the appropriate administration of Crotalinae Polyvalent Immune Fab (FabAV) and the duration of laboratory follow-up. The objective of our study was to assess the incidence of marked and recurrent envenomation coagulopathy at our trauma center and identify practice patterns that may prevent serious complications. METHODS A retrospective case review was conducted over a 3-year period on patients treated for symptomatic snakebite injury. Case records were reviewed for the inclusion criteria of international normalized ratio (INR) greater than 2.0. The exclusion criterion was limited to patients receiving anticoagulant therapy. RESULTS In all, 61 patients were identified on retrospective chart review and 3 patients (4.9%) met inclusion criteria. Two of the 3 patients had marked rebound coagulopathy requiring readmission and additional treatment. In our small series, 2 patients presenting after crotaline envenomation with increased INR (>6.0), decreased fibrinogen (<60 mg/dL), and decreased platelet count (<100,000/mL) had recurrent coagulopathy and were asymptomatic, and recurrence was noted only with follow-up laboratory testing. All patients responded positively within a matter of hours to repeat FabAV administration, with resolution of rebound coagulopathy. CONCLUSIONS We recommend periodic monitoring of patients with increased INR, decreased fibrinogen, and decreased platelet count. Patients should be monitored for 10 to 14 days after envenomation to identify asymptomatic rebound coagulopathy. Prompt readministration of FabAV appears to correct the coagulopathy.
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Affiliation(s)
- Willam R Witham
- Trauma Department, Texas Health Harris Methodist Hospital Fort Worth (Dr Witham and Ms McNeill), Fort Worth, TX.
| | - Cathy McNeill
- Trauma Department, Texas Health Harris Methodist Hospital Fort Worth (Dr Witham and Ms McNeill), Fort Worth, TX
| | - Sunny Patel
- Clinical Research Master's Program, University of North Texas Health Science Center (Mr Patel), Fort Worth, TX
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Recurrent coagulopathy after rattlesnake bite requiring continuous intravenous dosing of antivenom. Case Rep Emerg Med 2015; 2015:719302. [PMID: 25664187 PMCID: PMC4309308 DOI: 10.1155/2015/719302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 12/20/2014] [Indexed: 11/26/2022] Open
Abstract
Context. Snakebite envenomation is common and may result in systemic coagulopathy. Antivenom can correct resulting laboratory abnormalities; however, despite antivenom use, coagulopathy may recur, persist, or result in death after a latency period. Case Details. A 50-year-old previously healthy man presented to the emergency department after a rattlesnake bite to his right upper extremity. His presentation was complicated by significant glossal and oropharyngeal edema requiring emergent cricothyrotomy. His clinical course rapidly improved with the administration of snake antivenom (FabAV); the oropharyngeal and upper extremity edema resolved within several days. However, over the subsequent two weeks, he continued to have refractory coagulopathy requiring multiple units of antivenom. The coagulopathy finally resolved after starting a continuous antivenom infusion. Discussion. Envenomation may result in latent venom release from soft tissue depots that can last for two weeks. This case report illustrates the importance of close hemodynamic and laboratory monitoring after snakebites and describes the administration of continuous antivenom infusion, instead of multidose bolus, to neutralize latent venom release and correct residual coagulopathy.
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Clark RF, O'Connell CW, Villano JH, Kim A, Ly BT, Minns AB. Severe recurrent coagulopathy following crotaline envenomation refractory to maintenance dosing of antivenom. Am J Emerg Med 2014; 33:856.e3-5. [PMID: 25524360 DOI: 10.1016/j.ajem.2014.11.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022] Open
Affiliation(s)
- Richard F Clark
- UCSD Department of Emergency Medicine; UCSD Division of Medical Toxicology.
| | - Charles W O'Connell
- UCSD Department of Emergency Medicine; UCSD Division of Medical Toxicology; Veteran Association San Diego Health System, San Diego, CA
| | - Janna H Villano
- UCSD Department of Emergency Medicine; UCSD Division of Medical Toxicology; Veteran Association San Diego Health System, San Diego, CA
| | - Andrew Kim
- UCSD Department of Pediatric Critical Care
| | - Binh T Ly
- UCSD Department of Emergency Medicine; UCSD Division of Medical Toxicology
| | - Alicia B Minns
- UCSD Department of Emergency Medicine; UCSD Division of Medical Toxicology
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Weinstein SA. The pharmacotherapy for pit viper envenoming in the United States: A brief retrospective on roots, recurrence, and risk. Clin Toxicol (Phila) 2014; 53:1-4. [DOI: 10.3109/15563650.2014.983240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bush SP, Ruha AM, Seifert SA, Morgan DL, Lewis BJ, Arnold TC, Clark RF, Meggs WJ, Toschlog EA, Borron SW, Figge GR, Sollee DR, Shirazi FM, Wolk R, de Chazal I, Quan D, García-Ubbelohde W, Alagón A, Gerkin RD, Boyer LV. Comparison of F(ab')2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial. Clin Toxicol (Phila) 2014; 53:37-45. [PMID: 25361165 PMCID: PMC4364250 DOI: 10.3109/15563650.2014.974263] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background. Crotalidae Polyvalent Immune Fab (Ovine) has been the only antivenom commercially available in the US since 2007 for treatment of Crotalinae envenomation. Late coagulopathy can occur or recur after clearance of Fab antivenom, often after hospital discharge, lasting in some cases more than 2 weeks. There have been serious, even fatal, bleeding complications associated with recurrence phenomena. Frequent follow-up is required, and additional intervention or hospitalization is often necessary. F(ab')2 immunoglobulin derivatives have longer plasma half life than do Fab. We hypothesized that F(ab')2 antivenom would be superior to Fab in the prevention of late coagulopathy following treatment of patients with Crotalinae envenomation. Methods. We conducted a prospective, double-blind, randomized clinical trial, comparing late coagulopathy in snakebitten patients treated with F(ab')2 with maintenance doses [F(ab')2/F(ab')2], or F(ab')2 with placebo maintenance doses [F(ab')2/placebo], versus Fab with maintenance doses [Fab/Fab]. The primary efficacy endpoint was coagulopathy (platelet count < 150 K/mm3, fibrinogen level < 150 mg/dL) between end of maintenance dosing and day 8. Results. 121 patients were randomized at 18 clinical sites and received at least one dose of study drug. 114 completed the study. Of these, 11/37 (29.7%) in the Fab/Fab cohort experienced late coagulopathy versus 4/39 (10.3%, p < 0.05) in the F(ab')2/F(ab')2 cohort and 2/38 (5.3%, p < 0.05) in the F(ab')2/placebo cohort. The lowest heterologous protein exposure was with F(ab')2/placebo. No serious adverse events were related to study drug. In each study arm, one patient experienced an acute serum reaction and one experienced serum sickness. Conclusions. In this study, management of coagulopathic Crotalinae envenomation with longer-half-life F(ab')2 antivenom, with or without maintenance dosing, reduced the risk of subacute coagulopathy and bleeding following treatment of envenomation.
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Affiliation(s)
- Sean P Bush
- East Carolina University Brody School of Medicine/Vidant Medical Center , Greenville, NC , USA
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Seifert SA, Cano DN. Late, new-onset thrombocytopenia in a rattlesnake envenomation treated with a Fab antivenom. Clin Toxicol (Phila) 2013; 51:911-2. [DOI: 10.3109/15563650.2013.843006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Affiliation(s)
- Hoon Lim
- Department of Emergency Medicine, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Hyung Goo Kang
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Kyung Hwan Kim
- Department of Emergency Medicine, Inje University College of Medicine, Goyang, Korea
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