1
|
Rocha GDS, Souza Rodrigues MF, Rocha YV, Beckman de Lima H, Ramos FR, Teixeira E, Monteiro W, Sachett JDAG. Perceptions of nurses regarding the management of snakebite envenomations: Limits and possibilities. Toxicon 2023; 223:106995. [PMID: 36566992 DOI: 10.1016/j.toxicon.2022.106995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/06/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
Snakebites can be caused by harmless or venomous snakes and, according to their severity and frequency, can be considered events of medical importance. In health facilities in remote areas, nurses work in the first line of care of patients that are victims of these envenomations. The aim was to discover the perception of nurses regarding the management of snakebites, its limitations and possibilities, with a view to professional empowerment in the context of primary health care. This is exploratory and descriptive research, with a qualitative approach, developed at FMT-HVD in Manaus, Amazonas state, Brazil, in the year 2021. The participants were nurses who work in basic health units in the municipalities of Careiro da Várzea, Ipixuna and Boa Vista do Ramos in the state of Amazonas. For data collection, the focus group strategy was adopted. Thematic content analysis was employed, which was carried out in the stages of pre-analysis; exploration or coding of the material; treatment of the results, inference and interpretation. After processing the data obtained, four topics emerged from the coding: Topic 1 - limitations in the primary care. Topic 2 - the need for infrastructure and personnel. Topic 3 - the need for continuing education. Topic 4 - the perception of training regarding the management of snakebite envenomations. The results showed a lack of antivenom in the healthcare units where nurses work. Another aspect highlighted by the nurses is the absence of a doctor in situ to perform the primary care or out of hours care in the units. The nurses' perceptions regarding the management of snakebite envenomations revealed the existence of failures in relation to the subject, such as the lack of antivenom, poor infrastructure in the units and the lack of a doctor, which must be solved, since the nurses are the most active professionals in primary health care, in addition to the high incidence of snakebite envenomations in the Brazilian Amazon.
Collapse
Affiliation(s)
- Gisele Dos Santos Rocha
- School of Health Sciences, State University of Amazonas, Manaus, Brazil; Directorate of Teaching and Research, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | | | - Yasmim Vieira Rocha
- School of Health Sciences, State University of Amazonas, Manaus, Brazil; Directorate of Teaching and Research, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Huxlan Beckman de Lima
- School of Health Sciences, State University of Amazonas, Manaus, Brazil; Directorate of Teaching and Research, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Flávia Regina Ramos
- School of Health Sciences, State University of Amazonas, Manaus, Brazil; Postgraduate Program in Nursing, Federal University of Santa Catarina, Florianópolis, Brazil
| | | | - Wuelton Monteiro
- School of Health Sciences, State University of Amazonas, Manaus, Brazil; Directorate of Teaching and Research, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Jacqueline de Almeida Gonçalves Sachett
- School of Health Sciences, State University of Amazonas, Manaus, Brazil; Directorate of Teaching and Research, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil; Education and Research Directorate, Alfredo da Matta Foundation, Manaus, Brazil.
| |
Collapse
|
2
|
Validation of a Culturally Relevant Snakebite Envenomation Clinical Practice Guideline in Brazil. Toxins (Basel) 2022; 14:toxins14060376. [PMID: 35737037 PMCID: PMC9229773 DOI: 10.3390/toxins14060376] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/17/2022] [Accepted: 05/26/2022] [Indexed: 11/17/2022] Open
Abstract
Snakebite envenoming (SBE) is a neglected tropical disease with significant global morbidity and mortality. Even when antivenom is available in low-resource areas, health workers do not receive adequate training to manage SBEs. This study aims to develop and validate a clinical practice guideline (CPG) for SBE management across Brazil. A panel of expert judges with academic and/or technical expertise in SBE management performed content validation. The content validity index (CVI) score was 90% for CPG objectives, 89% for structure and presentation and 92% for relevance and classified the CPG as valid. A semantic validation was performed by analyzing focus group discussions with doctors and nurses from three municipalities of the Brazilian Amazon, after a 5-day meeting during which the CPG was presented. Two central themes emerged: knowledge acquired during the meeting and recommendations for improving the CPG. Based on these results, the CPG was revised into a final version. This study presents the successful development and validation process of a CPG for SBE management, which is targeted to a specific low-resource, high-burden setting. This development and validation process can be adapted to other settings and/or other neglected tropical diseases.
Collapse
|
3
|
Snakebite Treatment in Tanzania: Identifying Gaps in Community Practices and Hospital Resources. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084701. [PMID: 35457571 PMCID: PMC9024466 DOI: 10.3390/ijerph19084701] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/09/2022] [Accepted: 04/11/2022] [Indexed: 01/18/2023]
Abstract
Snakebite envenoming causes more than 140,000 deaths annually and at least triple this number of disabilities. The World Health Organization classified snakebite as a Neglected Tropical Disease in 2017 and developed a strategy to halve death and disability from snakebite by 2030. To achieve this goal, snakebite victims need to receive safe and effective treatment. This descriptive, cross-sectional study surveyed student health professionals (N = 312) in Dar es Salaam, Tanzania, and was designed to identify major gaps in community practices and hospital resources for snakebite treatment. Participants reported using traditional community practices (44%, 95% confidence interval (CI) = 39–50%), allopathic practices (7%, 95% CI = 5–11%), or a combination of both (49%, 95% CI = 43–54%) to treat snakebite. Harmful practices included tight arterial tourniquets (46%, 95% CI = 41–52%) and wound incisions (15%, 95% CI = 11–19%). Many participants (35%, 95% CI = 29–40%) also turned to traditional healers. Students who treated snakebite injuries within the last 5 years (N = 69) also reported their general experiences with snakebite in hospitals. Hospitals often lacked essential resources to treat snakebite victims, and 44% (95% CI = 30–59%) of snakebite victims arrived at a hospital only three or more hours after the bite. A significant percentage of snakebite victims experienced lasting damage (32%, 95% CI = 20–47%) or death (14%, 95% CI = 7–25%). Snakebite outcomes could likely be improved if hospitals were universally and consistently equipped with the essential resources to treat snakebite victims, such as antivenoms. Educational interventions aimed at communities should focus on discouraging tourniquet use and tampering with the wound. Collaboration between the allopathic and traditional health system could further boost snakebite outcomes because traditional healers are often the first health workers to see snakebite victims.
Collapse
|
4
|
Potet J, Beran D, Ray N, Alcoba G, Habib AG, Iliyasu G, Waldmann B, Ralph R, Faiz MA, Monteiro WM, de Almeida Gonçalves Sachett J, di Fabio JL, Cortés MDLÁ, Brown NI, Williams DJ. Access to antivenoms in the developing world: A multidisciplinary analysis. Toxicon X 2021; 12:100086. [PMID: 34786555 PMCID: PMC8578041 DOI: 10.1016/j.toxcx.2021.100086] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 11/21/2022] Open
Abstract
Access to safe, effective, quality-assured antivenom products that are tailored to endemic venomous snake species is a crucial component of recent coordinated efforts to reduce the global burden of snakebite envenoming. Multiple access barriers may affect the journey of antivenoms from manufacturers to the bedsides of patients. Our review describes the antivenom ecosystem at different levels and identifies solutions to overcome these challenges. At the global level, there is insufficient manufacturing output to meet clinical needs, notably for antivenoms intended for use in regions with a scarcity of producers. At national level, variable funding and deficient regulation of certain antivenom markets can lead to the procurement of substandard antivenom. This is particularly true when producers fail to seek registration of their products in the countries where they should be used, or where weak assessment frameworks allow registration without local clinical evaluation. Out-of-pocket expenses by snakebite victims are often the main source of financing antivenoms, which results in the underuse or under-dosing of antivenoms, and a preference for low-cost products regardless of efficacy. In resource-constrained rural areas, where the majority of victims are bitten, supply of antivenom in peripheral health facilities is often unreliable. Misconceptions about treatment of snakebite envenoming are common, further reducing demand for antivenom and exacerbating delays in reaching facilities equipped for antivenom use. Multifaceted interventions are needed to improve antivenom access in resource-limited settings. Particular attention should be paid to the comprehensive list of actions proposed within the WHO Strategy for Prevention and Control of Snakebite Envenoming.
Collapse
Affiliation(s)
- Julien Potet
- Médecins Sans Frontières Access Campaign, Geneva, Switzerland
| | - David Beran
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Nicolas Ray
- GeoHealth Group, Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Institute for Environmental Sciences, University of Geneva, Geneva, Switzerland
| | - Gabriel Alcoba
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Médecins Sans Frontières, Medical Department, Operational Center Geneva, Geneva, Switzerland
| | - Abdulrazaq Garba Habib
- Infectious Disease and Tropical Medicine Unit, Department of Medicine, College of Health Science, Bayero University Kano, Nigeria
| | - Garba Iliyasu
- Infectious Disease and Tropical Medicine Unit, Department of Medicine, College of Health Science, Bayero University Kano, Nigeria
| | | | - Ravikar Ralph
- Department of Internal Medicine & Poisons Information Center, Christian Medical College, Vellore, 632004, Tamil Nadu, India
| | | | - Wuelton Marcelo Monteiro
- Department of Research, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
- School of Health Sciences, Universidade Do Estado Do Amazonas, Manaus, Brazil
| | | | | | | | - Nicholas I. Brown
- Global Snakebite Initiative, 19 Haig Street, Ashgrove, Qld, 4060, Australia
- University of Queensland, Australia
| | - David J. Williams
- Global Snakebite Initiative, 19 Haig Street, Ashgrove, Qld, 4060, Australia
| |
Collapse
|
5
|
Costa TND, Silva AMD, Souza RMD, Monteiro WM, Bernarde PS. Efficacy of the 20-minute whole blood clotting test (WBCT20) in the diagnosis of coagulation alteration related to snakebites in a Western Brazilian Amazon hospital. Rev Soc Bras Med Trop 2021; 54:e00912021. [PMID: 34105627 PMCID: PMC8186896 DOI: 10.1590/0037-8682-0091-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/30/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction: The efficacy of 20-minute whole blood clotting (WBCT20) and the Lee-White clotting time (LWCT) tests in diagnosing coagulation alterations from snakebites were compared. Methods: We evaluated 89 snakebite cases treated at the Hospital Regional do Juruá em Cruzeiro do Sul, Acre, Brazil. Results: WBCT20 results were normal in 33.7% and unclottable in 66.3% of cases, while LWCT results were normal in 23.6% and altered (prolonged or unclottable) in 76.4% of cases, with no significant differences. Conclusions: The WBCT20 is important for rapidly diagnosing coagulation alterations from snakebites. Furthermore, it is efficient, inexpensive, and can be deployed in isolated hospitals.
Collapse
Affiliation(s)
- Tamires Nascimento da Costa
- Universidade Federal do Acre, Campus Floresta, Laboratório de Herpetologia, Cruzeiro do Sul, AC, Brasil.,Universidade Federal do Acre, Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde na Amazônia Ocidental, Rio Branco, AC, Brasil
| | - Ageane Mota da Silva
- Instituto Federal do Acre, Campus de Cruzeiro do Sul, Cruzeiro do Sul, Acre, Brasil
| | - Rodrigo Medeiros de Souza
- Universidade Federal do Acre, Campus Floresta, Laboratório de Microbiologia, Imunologia e Parasitologia, Cruzeiro do Sul, AC, Brasil
| | - Wuelton Marcelo Monteiro
- Universidade do Estado do Amazonas, Manaus, AM, Brasil.,Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brasil
| | - Paulo Sérgio Bernarde
- Universidade Federal do Acre, Campus Floresta, Laboratório de Herpetologia, Cruzeiro do Sul, AC, Brasil.,Universidade Federal do Acre, Programa de Pós-Graduação Stricto Sensu em Ciências da Saúde na Amazônia Ocidental, Rio Branco, AC, Brasil
| |
Collapse
|
6
|
Cristino JS, Salazar GM, Machado VA, Honorato E, Farias AS, Vissoci JRN, Silva Neto AV, Lacerda M, Wen FH, Monteiro WM, Sachett JAG. A painful journey to antivenom: The therapeutic itinerary of snakebite patients in the Brazilian Amazon (The QUALISnake Study). PLoS Negl Trop Dis 2021; 15:e0009245. [PMID: 33661895 PMCID: PMC7963098 DOI: 10.1371/journal.pntd.0009245] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/16/2021] [Accepted: 02/15/2021] [Indexed: 12/05/2022] Open
Abstract
Access to antivenoms is not guarranteed for vulnerable populations that inhabit remote areas in the Amazon. The study of therapeutic itineraries (TI) for treatment of snakebites would support strategies to provide timely access to users. A TI is the set of processes by which individuals adhere to certain forms of treatment, and includes the path traveled in the search for healthcare, and practices to solve their health problems. This study aims to describe TIs of snakebite patients in the Brazilian Amazon. This study was carried out at the Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, in Manaus, state of Amazonas, Brazil. The itinerary from the moment of the bite to the patient's admission to the reference unit was analyzed. Sample size was defined by saturation. After an exploratory survey to collect epidemiological variables, in-depth interviews were conducted following a semi-structured guide. Patients originated from rural areas of 11 different municipalities, including ones located >500 kilometers from Manaus. A great fragmentation was observed in the itineraries, marked by several changes of means of transport along the route. Four themes emerged from the analysis: exposure to snakebite during day-to-day activities, use of traditional therapeutic practices, and personal perception of the severity, as well as the route taken and its contingencies. Access to healthcare requires considerable effort on the part of snakebite patients. Major barriers were identified, such as the low number of hospitals that offer antivenom treatment, poor access to healthcare due to long distances and geographic barriers, low acceptability of healthcare offered in countryside, lack of use of personal protective equipment, common use of ineffective or deleterious self-care practices, late recognition of serious clinical signs and resistance to seeking medical assistance. Health education, promotion of immediate transport to health centers and decentralization of antivenom from reference hospitals to community healthcare centers in the Brazilian Amazon are more effective strategies that would to maximize access to antivenom treatment.
Collapse
Affiliation(s)
- Joseir Saturnino Cristino
- Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus, Brazil
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Brazil
| | - Guilherme Maciel Salazar
- Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus, Brazil
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Brazil
| | - Vinícius Azevedo Machado
- Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus, Brazil
| | - Eduardo Honorato
- Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus, Brazil
| | - Altair Seabra Farias
- Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus, Brazil
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Brazil
| | - João Ricardo Nickenig Vissoci
- Division of Emergency Medicine, Department of Surgery and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Alexandre Vilhena Silva Neto
- Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus, Brazil
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Brazil
| | - Marcus Lacerda
- Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus, Brazil
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Brazil
- Instituto Leônidas & Maria Deane, Fiocruz, Manaus, Brazil
| | - Fan Hui Wen
- Bioindustrial Centre, Butantan Institute, São Paulo, Brazil
| | - Wuelton Marcelo Monteiro
- Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus, Brazil
- Department of Teaching and Research, Dr. Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Brazil
| | - Jacqueline Almeida Gonçalves Sachett
- Department of Medicine and Nursing, School of Health Sciences, Amazonas State University, Manaus, Brazil
- Department of Teaching and Research, Alfredo da Matta Foundation, Manaus, Brazil
| |
Collapse
|
7
|
Clinical, hematobiochemical, and pathological findings and therapeutic management of viperine snake envenomation in zebu cattle. Trop Anim Health Prod 2020; 52:3425-3437. [PMID: 32939706 DOI: 10.1007/s11250-020-02376-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
Abstract
The present investigation was carried out to study the epidemiology, clinical signs, bleeding profile, kidney function, and pathology and to evaluate the therapeutic protocol for viperine snake envenomation in zebu cattle over a period of 14 years. A total of 98 cases of viperine bite were reported with the highest incidence during monsoon months in grazing male zebu cattle. Ascending swelling over the affected limb with lameness or asymmetrical swelling over the face with dyspnea was a consistent clinical finding. Increased bleeding tendency was invariably observed in ailing cattle with major bleeding from the site of the bite. Hematobiochemistry showed neutrophilic leukocytosis, thrombocytopenia, prolonged capillary blood clotting time, and elevation of BUN and creatinine. The characteristic gross pathological lesions observed were widespread petechial to ecchymotic hemorrhages in the lungs, liver, heart, spleen, abomasal mucosa, and intramuscular or subcutaneously at the site of bite. Histopathological examination revealed presence of necrohemorrhagic changes within the liver, heart, kidneys, skeletal muscles, and subcutaneously or intradermally at the site of bite. Diagnosis of viperine snakebite was made based on circumstantial evidence of bite, progressive swelling, and bleeding at the site of bite. The severity was assessed based on prolongation of capillary blood clotting time, thrombocytopenia, and kidney dysfunction. Therapeutic protocol comprising polyvalent anti-snake venom along with supportive therapy for 5-9 days showed encouraging results with 88.30% survival rate. In conclusion, the precise diagnosis of viperine snake envenomation in cattle can be made from history and typical clinical signs while severity and treatment can be monitored based on bleeding profile.
Collapse
|
8
|
Namal Rathnayaka RMMK, Ranathunga PEAN, Kularatne SAM. Venom-Induced Consumption Coagulopathy Following Hump-Nosed Pit Viper (Genus: Hypnale) Envenoming in Sri Lanka: Uncertain Efficacy of Fresh Frozen Plasma. Wilderness Environ Med 2020; 31:131-143. [PMID: 32336579 DOI: 10.1016/j.wem.2019.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 11/29/2019] [Accepted: 12/09/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Hump-nosed pit vipers (Hypnale spp) cause the highest number of venomous snakebites in Sri Lanka. Bites commonly cause local envenoming leading to local pain, swelling, and necrosis of the site of the bite. Acute kidney injury is the most common systemic manifestation, and some patients develop venom-induced consumption coagulopathy (VICC). Genus Hypnale comprises 3 species. Of them, H hypnale is found in Sri Lanka and the Western Ghats region of India. The other 2 (H nepa and H zara) are endemic species in Sri Lanka. METHODS This study included 500 patients with hump-nosed viper bites studied prospectively over 4.5 y starting June 2014. All patients were assessed and the data were collected by the principal investigator (primary data). A subgroup of patients who developed VICC is described. There were 2 groups, including proven (patients with the specimen of the snake) and probable (specimen of snake not available) bites. RESULTS Thirty (n=500; 6%) patients developed VICC; of them, 17 (3%) were proven cases, and 13 (2%) were probable cases. In both groups, 24 (80%) recovered, 2 (7%) progressed to chronic kidney disease, 1 (3%) died of severe hemostatic dysfunction, and 3 (10%) were lost to follow-up. Systemic bleeding was observed in 16 patients (53%), including hematuria (microscopic and gross) in 8 (27%) and venipuncture bleeding in 5 (17%). Eleven (37%) developed local bleeding at the site of the bite. Fresh frozen plasma was administered to 20 patients (67%), among whom only 11 (55%) experienced early correction of VICC. In both groups, 15 (50%) developed acute kidney injury, and 2 (7%) progressed to chronic kidney disease. Microangiopathic hemolysis was observed in 18 patients (60%) and thrombocytopenia in 16 (53%). Thrombotic microangiopathy was detected in 13 patients (43%), of whom 10 (33%) developed hemolytic uremic syndrome and 2 (7%) had thrombotic thrombocytopenic purpura. Of patients with VICC in the proven group, 94% (n=16) was caused by H hypnale and 1 (6%) was caused by H zara. In the proven group, median international normalized ratio was 3.7 (interquartile range 1.6-5.0); in the probable group, it was 5.0 (interquartile range 2.1-5.4). CONCLUSIONS We found that 6% of patients develop hemostatic dysfunction after hump-nosed viper bites. However, which patients will develop coagulopathy or die of envenoming is unpredictable. Reliable and accessible treatments are unmet essential needs because antivenoms for these bites are currently not available in the country. Therapy with fresh frozen plasma has doubtful efficacy in early correction of VICC and needs further evaluation.
Collapse
Affiliation(s)
- R M M K Namal Rathnayaka
- Department of Veterinary Pathobiology, Faculty of Veterinary Medicine and Animal Science, University of Peradeniya, Peredeniya, Sri Lanka; Intensive Care Unit/Anaesthesia, Teaching Hospital Ratnapura, Sri Lanka; Postgraduate Institute of Medicine (Clinical Pharmacology and Therapeutics), University of Colombo, Colombo, Sri Lanka.
| | | | - S A M Kularatne
- Faculty of Medicine, University of Peradeniya, Peredeniya, Sri Lanka
| |
Collapse
|
9
|
Gerardo CJ, Vissoci JRN, Evans CS, Simel DL, Lavonas EJ. Does This Patient Have a Severe Snake Envenomation?: The Rational Clinical Examination Systematic Review. JAMA Surg 2020; 154:346-354. [PMID: 30758508 DOI: 10.1001/jamasurg.2018.5069] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Venomous snakebite severity ranges from an asymptomatic dry bite to severe envenomation and death. The clinical evaluation aids in prognosis and is essential to determine the risks and potential benefits of antivenom treatment. Objectives To identify historical features, clinical examination findings, basic laboratory testing, and clinical grading scales that will risk-stratify patients with pit viper snake envenomation for severe systemic envenomation, severe tissue injury, and/or severe hematologic venom effects. Data Sources We conducted a structured search of PubMed (1966-October 3, 2017) and Embase database (1980-October 3, 2017) to identify English-language studies that evaluated clinical features predictive of severe envenomation. Study Selection We included studies that evaluated the test performance of at least 1 clinical finding with an acceptable reference standard of severe envenomation for venomous snakes of the Western Hemisphere. Only studies involving the most common subfamily, Crotalinae (pit vipers), were evaluated. Seventeen studies with data were available for abstraction. Data Extraction and Synthesis The clinical features assessed and severity outcome measures were extracted from each original study. We assessed severity in 3 categories: systemic toxicity, tissue injury, and hematologic effects. Differences were resolved by author consensus. Results The pooled prevalence of severe systemic envenomation was 14% (95% CI, 9%-21%). The pooled prevalence of severe tissue injury and severe hematologic venom effects were 14% (95% CI, 12%-16%) and 18% (95% CI, 8%-27%), respectively. Factors increasing the likelihood of severe systemic envenomation included the time from bite to care of 6 or more hours (likelihood ratio [LR], 3.4 [95% CI, 1.1-6.4]), a patient younger than 12 years (LRs, 3.2 [95% CI, 1.5-7.1] and 2.9 [95% CI, 1.3-6.2]), large snake size (LR, 3.1 [95% CI, 1.5-5.7]), and ptosis (LRs, 1.4 [95% CI, 1.0-2.1] and 3.8 [95% CI, 1.8-8.3]). Envenomation by the genus Agkistrodon (copperhead and cottonmouth), as opposed to rattlesnakes, decreased the likelihood of severe systemic envenomation (LR, 0.28 [95% CI, 0.10-0.78]). Initial hypofibrinogenemia (LR, 5.1 [95% CI, 1.7-15.0]) and thrombocytopenia (LR, 3.7 [95% CI, 1.9-7.3]) increased the likelihood of severe hematologic venom effects. Other clinical features from history, physical examination, or normal laboratory values were not discriminative. Conclusions Clinical features can identify patients at increased risk of severe systemic envenomation and severe hematologic venom effects, but there are few features that are associated with severe tissue injury or can confidently exclude severe envenomation. Physicians should monitor patients closely and be wary of progression from nonsevere to a severe envenomation and have a low threshold to escalate therapy as needed.
Collapse
Affiliation(s)
- Charles J Gerardo
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - João R N Vissoci
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina
| | - C Scott Evans
- Kaiser Permanente South San Francisco, South San Francisco, California
| | - David L Simel
- Department of Medicine, Durham VA Medical Center, Durham, North Carolina.,Department of Medicine, Duke University Health System, Durham, North Carolina
| | - Eric J Lavonas
- Department of Emergency Medicine and Rocky Mountain Poison and Drug Center, Denver Health, Denver, Colorado.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
| |
Collapse
|
10
|
Benjamin JM, Abo BN, Brandehoff N. Review Article: Snake Envenomation in Africa. CURRENT TROPICAL MEDICINE REPORTS 2020. [DOI: 10.1007/s40475-020-00198-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
11
|
Williams HF, Layfield HJ, Vallance T, Patel K, Bicknell AB, Trim SA, Vaiyapuri S. The Urgent Need to Develop Novel Strategies for the Diagnosis and Treatment of Snakebites. Toxins (Basel) 2019; 11:E363. [PMID: 31226842 PMCID: PMC6628419 DOI: 10.3390/toxins11060363] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/18/2019] [Accepted: 06/18/2019] [Indexed: 01/09/2023] Open
Abstract
Snakebite envenoming (SBE) is a priority neglected tropical disease, which kills in excess of 100,000 people per year. Additionally, many millions of survivors also suffer through disabilities and long-term health consequences. The only treatment for SBE, antivenom, has a number of major associated problems, not least, adverse reactions and limited availability. This emphasises the necessity for urgent improvements to the management of this disease. Administration of antivenom is too frequently based on symptomatology, which results in wasting crucial time. The majority of SBE-affected regions rely on broad-spectrum polyvalent antivenoms that have a low content of case-specific efficacious immunoglobulins. Research into small molecular therapeutics such as varespladib/methyl-varespladib (PLA2 inhibitors) and batimastat/marimastat (metalloprotease inhibitors) suggest that such adjunctive treatments could be hugely beneficial to victims. Progress into toxin-specific monoclonal antibodies as well as alternative binding scaffolds such as aptamers hold much promise for future treatment strategies. SBE is not implicit during snakebite, due to venom metering. Thus, the delay between bite and symptom presentation is critical and when symptoms appear it may often already be too late to effectively treat SBE. The development of reliable diagnostical tools could therefore initiate a paradigm shift in the treatment of SBE. While the complete eradication of SBE is an impossibility, mitigation is in the pipeline, with new treatments and diagnostics rapidly emerging. Here we critically review the urgent necessity for the development of diagnostic tools and improved therapeutics to mitigate the deaths and disabilities caused by SBE.
Collapse
Affiliation(s)
| | | | - Thomas Vallance
- School of Pharmacy, University of Reading, Reading RG6 6AH, UK.
| | - Ketan Patel
- School of Biological Sciences, University of Reading, Reading RG6 6AH, UK.
| | - Andrew B Bicknell
- School of Biological Sciences, University of Reading, Reading RG6 6AH, UK.
| | | | | |
Collapse
|
12
|
Benjamin JM, Chippaux JP, Sambo BT, Massougbodji A. Delayed double reading of whole blood clotting test (WBCT) results at 20 and 30 minutes enhances diagnosis and treatment of viper envenomation. J Venom Anim Toxins Incl Trop Dis 2018; 24:14. [PMID: 29796013 PMCID: PMC5956810 DOI: 10.1186/s40409-018-0151-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 04/27/2018] [Indexed: 12/28/2022] Open
Abstract
Background The whole blood clotting test (WBCT) is a simple test of coagulation that is often used in the assessment, diagnosis, and therapeutic monitoring of snakebite patients in sub-Saharan Africa. WBCT requires only a clean glass tube and several milliliters of venous blood and is ideal for use in poorly equipped health centers throughout the rural areas where 95% of snakebites occur. However, questions surrounding the accuracy and reliability of the test remain unanswered due to variations in testing conditions and a lack of comparative research with which to validate them. This is the first study to evaluate WBCT results at both 20-min (WBCT20) and 30-min (WBCT30) reading times in the same group of snakebite patients. Methods In order to define the best reading time, the authors compared the results of serial WBCT evaluation at both 20 and 30 min after collection in 23 patients treated for snake envenomation in Bembèrèkè, northern Benin. Results WBCT results were identical at both reading times in patients without coagulopathy or when coagulation was restored permanently following a single dose of antivenom. Out of 17 patients with coagulopathy, 14 showed discrepancies between WBCT20 and WBCT30 results in at least one pair of serial evaluations. These could be completely contradictory results (e.g. normal clot at WBCT20 and no clot at WBCT30) or a marked difference in the quality of the clot (e.g. no clotting activity at WBCT20 and an unstable partial clot at WBCT30). WBCT discrepancies were encountered most frequently in three situations: initial normalization of hemostasis following antivenom therapy, detection of a secondary resumption of coagulopathy, or final restoration of hemostasis after a secondary resumption had occurred. Conclusions This study suggests that the WBCT is robust and that a sequential reading should improve the diagnosis and monitoring of venom-induced coagulopathies. It also indicates the possibility of discrepancies in the sensitivity of WBCT20 and WBCT30 for detecting the resolution or reoccurrence of coagulopathy and identifies how these findings, if confirmed, may be used to increase the efficacy and efficiency of antivenom treatment in the field.
Collapse
Affiliation(s)
- Jordan Max Benjamin
- Center for the Study and Research of Malaria Associated with Pregnancy and Childhood (CERPAGE), 08 BP 841 Cotonou, Bénin.,2Whitman College, Department of Biology, Walla Walla, WA 99362 USA
| | - Jean-Philippe Chippaux
- 2Whitman College, Department of Biology, Walla Walla, WA 99362 USA.,3IRD UMR216, Mère et enfant face aux infections tropicales, 75006 Paris, France.,4PRES Sorbonne Paris Cité, Université Paris Descartes, Faculté de Pharmacie, 75270 Paris, France
| | - Bio Tamou Sambo
- 5Département de chirurgie et spécialités, Faculté de Médecine, Université Parakou, Parakou, Bénin
| | - Achille Massougbodji
- Center for the Study and Research of Malaria Associated with Pregnancy and Childhood (CERPAGE), 08 BP 841 Cotonou, Bénin
| |
Collapse
|
13
|
de Brito Sousa JD, Sachett JAG, de Oliveira SS, Mendonça-da-Silva I, Marques HO, de Lacerda MVG, Fan HW, Monteiro WM. Accuracy of the Lee-White Clotting Time Performed in the Hospital Routine to Detect Coagulopathy in Bothrops atrox Envenomation. Am J Trop Med Hyg 2018; 98:1547-1551. [PMID: 29611503 DOI: 10.4269/ajtmh.17-0992] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Snake envenomation is a major public health problem in Brazil. Systemic complications that may arise from snakebites are mainly related to coagulopathy. The Lee-White clotting time (LWCT) is a simple and inexpensive test and available even in remote health facilities. However, the diagnostic value of such test needs to be evaluated to accurately diagnose coagulopathy in the clinical practice. This study aimed to assess the reliability of the LWCT performed in hospital routine to diagnose venom-induced coagulopathy. We studied 186 patients admitted at the Tropical Medicine Foundation Dr. Heitor Vieira Dourado in Manaus, Amazonas, Brazil, with Bothrops envenomation diagnosis. At admission, blood samples were collected for performing LWCT and the concentration of fibrinogen. Sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, diagnostic odds ratio, and accuracy were calculated with 95% confidence intervals. From the total, 85.5% had hypofibrinogenemia. The sensitivity of the LWCT to the diagnosis of hypofibrinogenemia was 78.0% and the specificity 40.7%. The accuracy of the test was 72.6%, and patients with a prolonged LWCT had 2.4 higher odds of developing hypofibrinogenemia. In addition, the LWCT was also compared with venom antigen levels and systemic hemorrhage. The LWCT showed moderate sensitivity to detect consumption coagulopathy and constitutes a valuable tool for the diagnosis of Bothrops snake envenomation and indication of antivenom therapy.
Collapse
Affiliation(s)
- Jose Diego de Brito Sousa
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil.,Instituto de Pesquisa Clinica Carlos Borborema, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Jacqueline Almeida Gonçalves Sachett
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil.,Instituto de Pesquisa Clinica Carlos Borborema, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Sâmella Silva de Oliveira
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil.,Instituto de Pesquisa Clinica Carlos Borborema, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | - Iran Mendonça-da-Silva
- Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil.,Instituto de Pesquisa Clinica Carlos Borborema, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | | | - Marcus Vinicius Guimarães de Lacerda
- Instituto de Pesquisas Leônidas e Maria Deane, Fundação Oswaldo Cruz, Manaus, Brazil.,Instituto de Pesquisa Clinica Carlos Borborema, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil
| | | | - Wuelton Marcelo Monteiro
- Instituto de Pesquisa Clinica Carlos Borborema, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil.,Programa de Pós-graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| |
Collapse
|
14
|
Deschepper P, Aerts R. An Iconic Pit Viper of the Central American Rainforests. Wilderness Environ Med 2018. [DOI: 10.1016/j.wem.2017.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
15
|
Weinstein SA, Everest E, Purdell-Lewis J, Harrison M, Tavender F, Alfred S, Marrack L, Davenport-Klunder C, Wearn N, White J. Neurotoxicity with persistent unilateral ophthalmoplegia from envenoming by a wild inland taipan (Oxyuranus microlepidotus, Elapidae) in remote outback South Australia. Toxicon 2017; 137:15-18. [PMID: 28694006 DOI: 10.1016/j.toxicon.2017.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 07/03/2017] [Accepted: 07/05/2017] [Indexed: 11/26/2022]
Abstract
INTRODUCTION A case of life threatening envenoming by a wild specimen of the inland taipan, Oxyuranus microlepidotus, is described. There have been 11 previously well-documented envenomings by O. microlepidotus, but only 2 were inflicted by wild snakes. Envenomed patients have presented predominantly with defibrinating coagulopathy and neurotoxicity. CASE REPORT The victim was seeking to observe members of an isolated population of this species and was envenomed while attempting to photograph an approximately 1.5 m specimen. He reported feeling "drowsiness" and blurred vision that progressed to ptosis; he later developed dysphagia and dysarthria. The patient was treated with 1 vial of polyvalent antivenom, which was later followed with an additional two vials of taipan monovalent. He was intubated during retrieval, and recovered after 3 days of intensive care. He had a right ophthalmoplegia that persisted for approximately 1 week post-envenoming. Despite a positive 20-min whole blood clotting test, defibrination coagulopathy was absent, and there was no myotoxicity, or acute kidney injury. DISCUSSION Physicians presented with a patient envenomed by O. microlepidotus should remain cognizant of the possible variability of medically important venom toxins in some populations of this species. Some patients seriously envenomed by this species may develop persistent cranial nerve palsies. When clinically indicated, prompt provision of adequate antivenom is the cornerstone of managing O. microlepidotus envenoming. Rapid application of pressure-bandage immobilization and efficient retrieval of victims envenomed in remote locales, preferably by medically well-equipped aircraft, probably improves the likelihood of a positive outcome.
Collapse
Affiliation(s)
- Scott A Weinstein
- Toxinology Department, Women's and Children's Hospital, 72 King William Street, North Adelaide, South Australia, 5006, Australia; Department of Paediatrics and Reproductive Medicine, University of Adelaide School of Medicine, 30 Frome Street, Adelaide, South Australia, 5005, Australia.
| | - Evan Everest
- Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, South Australia, 5042, Australia; MedSTAR Retrieval Service, South Australian Ambulance Service, 20 James Schofield Drive, Adelaide Airport, South Australia, 5950, Australia
| | - Jeremy Purdell-Lewis
- Royal Flying Doctor Service, Central Operations, 1 Tower Road, Adelaide Airport, South Australia, 5950, Australia
| | - Michael Harrison
- Royal Flying Doctor Service, Central Operations, 1 Tower Road, Adelaide Airport, South Australia, 5950, Australia
| | - Fiona Tavender
- MedSTAR Retrieval Service, South Australian Ambulance Service, 20 James Schofield Drive, Adelaide Airport, South Australia, 5950, Australia
| | - Sam Alfred
- Emergency Department, Royal Adelaide Hospital, North Terrace, Adelaide, 5000, Australia
| | - Liz Marrack
- Royal Flying Doctor Service, Central Operations, 1 Tower Road, Adelaide Airport, South Australia, 5950, Australia
| | - Chris Davenport-Klunder
- Royal Flying Doctor Service, Central Operations, 1 Tower Road, Adelaide Airport, South Australia, 5950, Australia
| | - Neralie Wearn
- MedSTAR Retrieval Service, South Australian Ambulance Service, 20 James Schofield Drive, Adelaide Airport, South Australia, 5950, Australia
| | - Julian White
- Toxinology Department, Women's and Children's Hospital, 72 King William Street, North Adelaide, South Australia, 5006, Australia; Department of Paediatrics and Reproductive Medicine, University of Adelaide School of Medicine, 30 Frome Street, Adelaide, South Australia, 5005, Australia
| |
Collapse
|
16
|
Doyle GS, Theodore AA, Hansen JN. Impact thromboelastometry (ITEM) for point-of-injury detection of trauma-induced coagulopathy: a pilot study. Trauma Surg Acute Care Open 2017; 2:e000049. [PMID: 29766077 PMCID: PMC5877890 DOI: 10.1136/tsaco-2016-000049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/05/2017] [Accepted: 01/24/2017] [Indexed: 01/24/2023] Open
Abstract
Background Acute coagulopathy of trauma is associated with high mortality and extensive use of blood products. Hemostatic resuscitation, the early administration of blood products with higher ratios of procoagulant components, may improve trauma outcomes in select cases, but can also worsen outcome if inappropriately used. Evolving approaches to hemostatic resuscitation utilize viscoelastic tests to provide a more rational basis for choosing blood component therapy regimens, but these tests are logistically rigorous. We hypothesized that coagulopathy could be detected by the failure of blood clots to remain intact when subjected to a predefined impact force. Methods We aim to develop a point-of-injury test for coagulopathy. We created coagulopathic blood using an ex vivo normal saline (NS) dilution model and allowed blood of varying dilutions to clot, then examined the behavior of the clotted blood when subjected to a uniform gravitationally induced sheer force. Results Clots created from coagulopatic blood (diluted to ≤50% with NS) failed under gravitational challenge at a significantly higher rate than non-coagulopathic blood dilutions. Discussion Impact thromboelastometry (ITEM) represents a simple, logistically lean method for detecting dilutional coagulopathy that may facilitate detection of trauma-induced coagulopathy. ITEM may thus function as a point-of-injury or point-of-care screening test for the presence of coagulopathy. Level of evidence Diagnostic studies, Level IV.
Collapse
Affiliation(s)
- Gerard S Doyle
- Division of Emergency Medicine, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Aristotle A Theodore
- Division of Emergency Medicine, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - J Nicholas Hansen
- Division of Emergency Medicine, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
17
|
Slusher T, Bjorklund A, Aanyu HT, Kiragu A, Philip C. The Assessment, Evaluation, and Management of the Critically Ill Child in Resource-Limited International Settings. J Pediatr Intensive Care 2016; 6:66-76. [PMID: 31073427 DOI: 10.1055/s-0036-1584677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 03/22/2016] [Indexed: 10/21/2022] Open
Abstract
Providing evidence-based care to the critically ill child including assessment, evaluation, and management in resource-limited settings provides unique challenges and limitless opportunities to significantly impact morbidity and mortality in these settings. Difficulties encountered include: determining which disease processes will benefit most from critical care in resource-limited settings, lack of triage tools and adjuncts to help with assessment, finite laboratory and radiological tests, limited understanding of key findings in critically ill/injured pediatric patients, (especially by those without pediatric focused training), and finally, lack of supplies, medicines, equipment, and training of health care providers to appropriately treat critically ill children in these resource-limited settings. In this review, the most common problems encountered and possible solutions to overcome these obstacles are discussed.
Collapse
Affiliation(s)
- Tina Slusher
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States.,Department of Pediatrics, Hennepin County Medical School, Minneapolis, Minnesota, United States
| | - Ashley Bjorklund
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States
| | - Hellen T Aanyu
- Department of Pediatrics, Mulago National Referral Hospital, Kampala, Uganda
| | - Andrew Kiragu
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, United States.,Department of Pediatrics, Hennepin County Medical School, Minneapolis, Minnesota, United States
| | - Christo Philip
- Department of Emergency and Intensive Care, Duncan Hospital, Raxaul, Bihar, India
| |
Collapse
|
18
|
Johnson T, Gaus D, Herrera D. Emergency Department of a Rural Hospital in Ecuador. West J Emerg Med 2016; 17:66-72. [PMID: 26823934 PMCID: PMC4729422 DOI: 10.5811/westjem.2015.11.27936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 10/29/2015] [Accepted: 11/11/2015] [Indexed: 11/16/2022] Open
Abstract
Introduction There is a paucity of data studying patients and complaints presenting to emergency departments (EDs) in low- and middle-income countries. The town of Pedro Vicente Maldonado (PVM) is located in the northwestern highlands of Ecuador. Hospital PVM (HPVM) is a rural teaching hospital providing family medicine residency training. These physicians provide around-the-clock acute medical care in HPVM’s ED. This study provides a first look at a functioning ED in rural Latin America by reviewing one year of ED visits to HPVM. Methods All ED visits between April 14, 2013, and April 13, 2014, were included and analyzed, totaling 1,239 patient visits. Data were collected from their electronic medical record and exported into a de-identified Excel® database where it was sorted and categorized. Variables included age, gender, mode of arrival, insurance type, month and day of the week of the service, chief complaint, laboratory and imaging requests, and disposition. We performed descriptive statistics, and where possible, comparisons using Student’s T or chi-square, as appropriate. Results Of the 1239 total ED visits, 48% were males and 52% females; 93% of the visits were ambulatory, and 7% came by ambulance. Sixty-three percent of the patients had social security insurance. The top three chief complaints were abdominal pain (25.5%), fever (15.1%) and trauma (10.8%). Healthcare providers requested labs on 71.3% of patients and imaging on 43.2%. The most frequently requested imaging studies were chest radiograph (14.9%), upper extremity radiograph (9.4%), and electrocardiogram (9.0%). There was no seasonal or day-of-week variability to number of ED patients. The chief complaint of human or animal bite made it more likely the patient would be admitted, and the chief complaint of traumatic injury made it more likely the patient would be transferred. Conclusion Analysis of patients presenting to a rural ED in Ecuador contributes to the global study of acute care in the developing world and also provides a self-analysis identifying disease patterns of the area, training topics for residents, areas for introducing protocols, and information to help planning for rural EDs in low- and middle-income countries.
Collapse
Affiliation(s)
- Tara Johnson
- Maricopa Medical Center, Department of Emergency Medicine, Phoenix, Arizona
| | - David Gaus
- University of Wisconsin School of Medicine and Public Health, Department of Family Medicine, Madison, Wisconsin
| | - Diego Herrera
- Central University of Ecuador, Catholic University of Ecuador, Department of Family Medicine, Santo Domingo, Ecuador
| |
Collapse
|
19
|
Monzavi SM, Salarian AA, Khoshdel AR, Dadpour B, Afshari R. Effectiveness of a clinical protocol implemented to standardize snakebite management in Iran: initial evaluation. Wilderness Environ Med 2015; 26:115-23. [PMID: 25698180 DOI: 10.1016/j.wem.2014.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 08/13/2014] [Accepted: 09/06/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This study was designed to evaluate the effectiveness of a new protocol implemented to standardize snakebite management in Iran. METHODS In this study, 27 patients treated according to the new protocol in 2012 (P+) were compared with 22 patients treated according to the previous modality in the year before implementation of the protocol (P-) in Mashhad Medical Toxicology Centre (MTC). Demographic characteristics and treatment details of all patients were recorded prospectively. Envenomation severity of each victim was assessed according to snakebite severity score (SSS). RESULTS After implementation of the protocol, a smaller percentage of patients received antivenom (AV) therapy (78% vs 95%; P=.079). In spite of no significant difference in baseline severity of envenomation between the 2 groups (SSS [mean±SD], 34.8±18.1 vs 35.5±17.4; P=.801), the P+ group received significantly fewer AV vials (8.4±6.8 vs 12.1±5.6 vials; P=.042) and had a significantly shorter length of hospital stay (2.2±1.5 vs 3.2±1.8 days; P=.027). Moreover, smaller proportion of P+ patients experienced recurrence of venom-induced effects; however, the difference was not significant (18.5% vs 36%; P=.159). The reduction in use of antiallergy treatments to prevent or treat acute hypersensitivity reactions approached statistical significance (41% vs 68%; P=.051). These findings denote a reduction in AV use of approximately 4 vials and a reduction in hospital stay of 1 day for each patient, which translates to approximately $196/patient in healthcare cost savings. CONCLUSIONS Implementation of a snakebite management protocol at MTC reduced overall antivenom usage, use of antiallergy interventions, and length of hospital stay.
Collapse
Affiliation(s)
- Seyed Mostafa Monzavi
- AJA University of Medical Sciences, Tehran, Iran (Drs Monzavi, Salarian, and Khoshdel); Addiction Research Center, Department of Internal Medicine, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran (Drs Monzavi, Dadpour, and Afshari)
| | - Amir Ahmad Salarian
- AJA University of Medical Sciences, Tehran, Iran (Drs Monzavi, Salarian, and Khoshdel)
| | - Ali Reza Khoshdel
- AJA University of Medical Sciences, Tehran, Iran (Drs Monzavi, Salarian, and Khoshdel)
| | - Bita Dadpour
- Addiction Research Center, Department of Internal Medicine, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran (Drs Monzavi, Dadpour, and Afshari)
| | - Reza Afshari
- Addiction Research Center, Department of Internal Medicine, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran (Drs Monzavi, Dadpour, and Afshari).
| |
Collapse
|
20
|
Laines J, Segura Á, Villalta M, Herrera M, Vargas M, Alvarez G, Gutiérrez JM, León G. Toxicity of Bothrops sp snake venoms from Ecuador and preclinical assessment of the neutralizing efficacy of a polyspecific antivenom from Costa Rica. Toxicon 2014; 88:34-7. [DOI: 10.1016/j.toxicon.2014.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 06/09/2014] [Accepted: 06/11/2014] [Indexed: 11/29/2022]
|