Deaths resulting from animal attacks in the United States

Management Strategies for Common Animal Bites in Pediatrics: A Narrative Review on the Latest Progress

Animal bites are a common reason for children to visit primary care and emergency departments. Dog bites are the most prevalent, followed by cat bites at 20-30%. Other animals such as bats, monkeys, snakes, and rats collectively contribute less than 1% of cases. Hospitalization is necessary in only 4% of animal bite incidents. The main aim of this narrative review is to summarize the main protocols currently followed in pediatrics in cases involving the most common bites from different animal species. Analysis of the literature showed that the management of common animal bites in children presents a multifaceted challenge requiring a comprehensive understanding of the epidemiology, clinical presentation, and treatment modalities associated with each specific species. Effective wound management is paramount in reducing the risk of infection and promoting optimal healing outcomes. Additionally, tetanus vaccination status should be assessed and updated as necessary, and prophylactic antibiotics may be indicated in certain cases to prevent secondary infections. Furthermore, the role of rabies prophylaxis cannot be overstated, particularly in regions where rabies is endemic or following bites from high-risk animals. In addition to medical management, psychosocial support for both the child and their caregivers is integral to the overall care continuum. Future studies exploring the efficacy of novel treatment modalities, such as topical antimicrobial agents or advanced wound dressings, may offer new insights into optimizing wound healing and reducing the risk of complications.

Studying the Tonkean macaques of Strasbourg, a tale full of sound and fury

In this paper, I chronicle the Strasbourg population of Tonkean macaques (Macaca tonkeana) over a period of half a century. In 1972, Tonkean macaques were imported from Sulawesi, Indonesia, to eastern France, leading to the establishment of two social groups in the Strasbourg region several years later. Our research team studied the social behavior and cognitive abilities of these Tonkean macaques for four decades. The species is characterized by a high degree of social tolerance. This has proven to be very informative in comparative studies of macaque social behavior, opening a new perspective on the evolution of primate societies. Over the years, the population has grown, and more social groups have been formed. However, the fact that some of the Tonkean macaques were healthy carriers of the herpes B virus led to disagreements over their management and eventually to the elimination of the positive individuals. Many individuals from the Strasbourg population are now kept in sanctuaries, and the number of captive breeding groups is limited. We still have much to learn about Tonkean macaques and there is a need for studies carried out in their native habitat in Sulawesi.

Predictors of FabAV use in copperhead envenomation

CONTEXT

Crotaline snake envenomation is a serious medical condition affecting thousands of Americans each year. Variation in the treatment of Crotaline snakebites exists among physicians in the United States. Management of copperhead snakebites is controversial with some experts advocating minimal intervention, rarely necessitating antivenom use and, even more rarely, surgical intervention. This study assessed the use of Crotaline Polyvalent Immune Fab antivenom (Ovine) (FabAV) and explored factors influencing the decision to prescribe antivenom for copperhead envenomation in patients in Northeastern Oklahoma.

METHODS

A retrospective cohort study examining electronic medical records of patients with copperhead snakebites from July 1, 2014 to August 31, 2019. Data collected included: patient demographics, transfer information, snake species, bite site, progression of local tissue effects, additional clinical and lab results, patient comorbidities, and treatment strategy. Associations between patient variables and treatment were evaluated using the chi-square test of independence, median test, and logistic regression analysis. Associations were statistically significant if p < 0.05.

DISCUSSION

Of the 130 patients bitten by a copperhead, a majority (75%) received FabAV. Symptoms of copperhead envenomation were mostly limited to the progression of tissue damage. Predictors of treatment with FabAV included progression of venom effects across major joints, younger age, comorbidities, and upper extremity bites.

CONCLUSIONS

Patients who have multiple comorbidities, upper extremity bites and progression of venom effects across major joints are more likely to be treated with FabAV. The high usage of FabAV at the study site underscores the need for continued work to optimize the use of antivenom for copperhead envenomations.

Anaphylactic shock with pulmonary eosinophilic infiltration due to honeybee attack in a donkey: case report

ABSTRACT A case of a donkey attacked by Africanized honeybee is reported here with clinical signs of agitation, dehydration, congestion of the ocular mucous membranes, tongue edema, tachycardia and inspiratory dyspnea, and progression to death. At necropsy, diffuse, severe subcutaneous edema at face and cervical regions and severe diffuse pulmonary hyperemia with abundant edema without parenchymal collapse were observed. Microscopically, marked, diffuse deep dermis and panniculus carnosus edema and marked diffuse alveolar edema, with moderate population of eosinophils predominantly around larger caliber vessels were noted. The final diagnosis of anaphylactic shock was supported by history, clinical signs, and anatomic pathology findings. This is the first report of a honeybee attack with pulmonary eosinophilic infiltration in a mammal.

Social and environmental factors influencing contemporary cases of wolf aggression towards people in Poland

Understanding factors and mechanisms causing large carnivore aggression towards people is crucial for their conservation in modern human-dominated landscapes. We present detailed descriptions of wolf attacks on people in early summer 2018 in two areas of Poland, analysis of behaviour, fitness and origin of individuals responsible for the attacks and management actions undertaken by local communities as well as governmental bodies and non-governmental organisations. We show that attacks were caused by yearling wolves (13-month-old male and 14-month-old female) originating from local packs, which appeared near households several months prior to incidents. Both individuals were positively food-conditioned and showed increasing habituation caused by irresponsible behaviour of people such as long-lasting intentional feeding or illegal keeping. Post mortem necropsy revealed obesity and serious abnormality of spleen (polysplenia) in the problem female wolf that negatively impacted her fitness and was the most likely reason for her presence near households and feeding on leftovers. Despite prolonged observations of these wolves very close to human settlements (less than 30 m), no mitigation actions were undertaken until the attacks, after which both individuals were killed. We provide several recommendations to avoid aggressive human-carnivore encounters.

Pediatric Snakebites: Comparing Patients in Two Geographic Locations in the United States

BACKGROUND

Management of children with snakebites may vary based on subjective criteria, geographic, and climatic factors. We reviewed the incidence and management of snakebite injuries in children at two tertiary referral centers in separate geographic and climatic location to assess differences in management and outcomes of these patients.

METHODS

After institutional review board approval, a retrospective chart review was performed for patients ≤18 years with snakebite injuries at emergency departments (ED) of two American College of Surgeons verified trauma centers (2006-2013). One center is in southeast US and experiences a sub-tropical climate whereas the other is in southwest US and experiences a semi-arid climate. Demographic and clinical parameters were extracted.

RESULTS

A total of 108 patients (59% male), median age of 9 y (1 y-17 y), were included. Snake type was identified by bystanders in 55.5% cases; copperhead was the most common (37%) subtype. Approximately 30% of patients received antivenom. One quarter of all patients were discharged from the ED. Two patients received surgical intervention in the first 48 hours after presentation. Compared to patients who sustained a snakebite in semi-tropical regions, patients in semi-arid areas had shorter bite-to-ED time, presented directly to the referral center, were more frequently bitten by a rattlesnake, had longer lengths of hospital stay, required antivenom more frequently and at higher doses, and were more frequently admitted to the ICU. No differences were seen in gender, age at presentation, severity of wound, location of bite, abnormalities in coagulation profile or rate of admission to hospital amongst the two sites.

CONCLUSIONS

Patients sustaining snakebites in semi-arid climates were more commonly exposed to dangerous snake types, resulting in higher antivenom requirement, as well as longer hospital stays and need for intensive monitoring. Although no fatalities were reported in our study, our data supports early transfer of snakebite victims to higher levels of care, especially in semi-arid or high-risk areas.

Exotic Snakebites Reported to Pennsylvania Poison Control Centers: Lessons Learned on the Demographics, Clinical Effects, and Treatment of These Cases

Exotic snakebites (i.e. from non-native species) are a rare occurrence, but they present a unique challenge to clinicians treating these patients. Poison control centers are often contacted to assist in the management and care of these medical emergencies. In this study, we analyzed case records of the two Pennsylvania poison control centers from 2004 to 2018 to describe clinical features reported as a result of exotic snakebite envenomation. For the 15-year period reviewed, 18 exotic snakebites were reported with effects ranging from mild local tissue injury to patients who were treated with mechanical ventilation due to respiratory failure. The mean age of the patients was 35 years and males accounted for 83% of the cases. Antivenom, the only specific treatment, was administered in seven of 18 patients within an average of four h of envenomation. The procurement of antivenom against these exotic species may require substantial logistical efforts due to limited stocking of this rarely used treatment. Newer, targeted, small molecule treatments that are being currently investigated may aid in the treatment of snakebites in general. However, people should be cautious when handling these exotic species, and clinicians should be aware of these bites and relevant clinical effects in order to manage these when reported.

National Estimates of Noncanine Bite and Sting Injuries Treated in US Hospital Emergency Departments, 2011-2015

OBJECTIVES

Injuries resulting from contact with animals are a significant public health concern. This study quantifies and updates nonfatal bite and sting injuries by noncanine sources using the most recent data available (2011-2015) from the National Electronic Injury Surveillance System-All Injury Program with the purpose of using these updates to better understand public health consequences and prevention techniques. Increased rates of bites and stings can be expected in this study's time frame, possibly caused by the increasing human population expanding into animal territories, as well as changes in animal geographic distribution and pet ownership.

METHODS

The National Electronic Injury Surveillance System-All Injury Program is an ongoing nationally representative surveillance system used to monitor all types and causes of injuries treated in US hospital emergency departments (EDs). Cases were coded by trained hospital coders using information from medical records on animal sources of bite and sting injuries being treated. Data from 2011-2015 were weighted to produce national annualized estimates, percentages, and rates based on the US population.

RESULTS

An estimated 1.17 million people visited EDs for noncanine bite and sting injuries annually. This translates to a rate of 371.3/100,000 people. Insects accounted for 71.0% of noncanine bite and sting injuries, followed by arachnids (19.2%) and mammals (7.8%). The estimated annual total lifetime medical and work cost of unintentional noncanine injuries was $5,755,581,000.

CONCLUSIONS

Various sources of bite and sting injuries had an outsized effect on injury rates and identify potential areas of focus for education and prevention programs to reduce the burden of these injuries on health and healthcare costs. The study describes the diversity of animal exposures based on a national sample of EDs. Noncanine bite and sting injuries significantly affect public health and healthcare resources. Priorities can be focused on animal sources with the most impact on bite and sting injury rates, healthcare costs, and disease burden.

Mortality, hospital admission, and healthcare cost due to injury from venomous and non-venomous animal encounters in the USA: 5-year analysis of the National Emergency Department Sample

Background

Injuries due to encounters with animals can be serious, but are often discussed anecdotally or only for isolated types of encounters. We sought to characterize animal-related injuries presenting to US emergency departments (ED) to determine the impact of these types of injuries.

Methods

All ED encounters with diagnosis codes corresponding to animal-related injury were identified using ICD-9-CM codes from the 2010 2014 National Emergency Department Sample (NEDS). Outcomes assessed included inpatient admission, mortality, and healthcare cost. Survey methodology was applied to univariate and multivariate analyses. Weighted numbers are presented.

Results

There were 6 457 534 ED visits resulting from animal-related injuries identified. Bites from non-venomous arthropods (n=2 648 880; 41%), dog bites (n=1 658 295; 26%) and envenomation from hornets, wasps or bees (n=812 357; 13%) constitute the majority of encounters. There were 210 516 patients (3%) admitted as inpatients. Inpatient admission was most common for those suffering from venomous snakes or lizard bites (24%, n=10 332). Death was infrequent occurring in 1162 patients (0.02% of all ED presentations). The greatest number of deaths was due to bites from non-venomous arthropods (24% of deaths, n=278) whereas rat bites proved the most lethal (6.5 deaths per 10 000 bites). Among persons aged 85 years or greater, odds of hospital admission for any animal-related injury was 6.42 (95% CI 5.57 to 7.40) and the OR for death was 27.71 (95% CI 10.38 to 73.99). Female sex was associated with improved survival (OR 0.55, 95% CI 0.41 to 0.73) and lower rates of hospital admission (OR 0.77, 95% CI 0.75 to 0.79). The total healthcare cost for these animal encounters during the observed time period was $5.96 billion (95% CI $5.43 to $6.50 billion).

Conclusion

The morbidity, mortality, and healthcare cost due to animal encounters in the USA is considerable. Often overlooked, this particular mechanism of injury warrants further public health prevention efforts.

Level of Evidence

Level IV.

Fatal deer attack in a rutting season

Animal inflicted fatal or near fatal injuries are well described in the forensic literature, with the most frequently described cases involving dogs, large cats and bears. To our knowledge, a deer inflicted fatality has not been described in the forensic literature previously. This article reports a case of a 64-year-old male, who was found lying in a pool of blood near an enclosure for stags and hinds at the end of October. There were mechanical defects on his jacket and trousers, which appeared to be torn or penetrated, as well as multiple lacerations and stab wounds in different parts of his body. The type and location of the injuries the man had sustained strongly suggested that another person had been involved in the incident that had led to his death. The cause of death was deemed as external exsanguination due to multiple stab wounds to large vessels. After evaluating all of the information regarding the circumstances around the death, the case was classified as a deer attack related fatality, and the manner of death was determined to be accidental. The man was most probably attacked by one of the deer while he was refilling the animal feeder. A substantial increase in the levels of selected hormones, especially testosterone, during the rutting season explains the increased levels of aggression shown by the deer that led to a fatal outcome for the decedent.

Prophylactic Antibiotics Are Not Needed Following Rattlesnake Bites

BACKGROUND

Antibiotics are sometimes administered to victims of rattlesnake bites in the hope of preventing infections. Experts in the field recommend that prophylactic antibiotics not be used because secondary infections are rare. Current recommendations are based on a small number of studies conducted in the United States. We decided to reexamine the issue by taking advantage of a large database on snakebites in Arizona. This allowed us to determine how often prophylactic antibiotics were used and whether or not they were effective.

METHODS

We obtained data from the Arizona Poison and Drug Information Center electronic medical record, Toxicall. Rattlesnake bites occurring over 18 years (1999-2016) were analyzed according to the descriptors: infection, pus, isolation of bacteria, and antibiotic use.

RESULTS

There were 2748 evaluable patients identified as having rattlesnake bites. The mean number of bite victims was 153 per year. Most (72%) were male. Their ages ranged from 8 months to 91 years. Prophylactic antibiotics were administered to 120 of 2748 (4.4%) victims. There were 27 postbite infections (0.98%) but no deaths. Victims sometimes manipulated the wound sites. Microorganisms were isolated from only 9 patients. Only a Salmonella sp. was of certain reptilian origin; the others were likely of human origin.

CONCLUSIONS

This large study supports recommendations that prophylactic antibiotics not be used following rattlesnake bites in the United States. The incidence of postbite infections was low, <1%. All but 1 of the bacteria isolated from the wounds were common inhabitants of human skin and not found in oral secretions of rattlesnakes.

Systemic toxic reaction due to multiple honeybee stings in equine: Case report

ABSTRACT Accidents caused by insects of the Hymenoptera are rarely described in large animals. The attacks caused by honeybee (Apis mellifera) may cause severe consequences and its intensity changes according to the number of stings. Local and systemic reactions can occur, including progression to death. This report describes a case of honeybee attack on an equine, which took place in the city of Lages, in the state of Santa Catarina, Brazil. In the clinical assessment the horse showed apathy, anorexia, head and pectoral edemas, dyspnea, icteric mucosa, increased mandibular lymph nodes and darkened urine. The blood count showed anemia and serum biochemical tests suggested, muscular and hepatic lesions. The urinalysis test indicated hemoglobinuria and increased clotting time. Treatment included lactate Ringer’s solution fluid therapy, furosemide, promethazine, corticosteroids and 20% mannitol solution. Hot and cold compresses were applied alternately on areas with edema. There was a satisfactory response to treatment and the animal was discharged after 30 days in veterinary hospital. The description of honeybee sting accidents in large animals is important because of the evolution that can lead to death. The early approach associated with appropriate treatment, avoiding the worsening of the lesions is fundamental for the recovery of the patient.

Incidence and mortality due to snakebite in the Americas

BACKGROUND

Better knowledge of the epidemiological characteristics of snakebites could help to take measures to improve their management. The incidence and mortality of snakebites in the Americas are most often estimated from medical and scientific literature, which generally lack precision and representativeness.

METHODOLOGY/PRINCIPAL FINDINGS

Authors used the notifications of snakebites treated in health centers collected by the Ministries of Health of the American countries to estimate their incidence and mortality. Data were obtained from official reports available on-line at government sites, including those of the Ministry of Health in each country and was sustained by recent literature obtained from PubMed. The average annual incidence is about 57,500 snake bites (6.2 per 100,000 population) and mortality is close to 370 deaths (0.04 per 100,000 population), that is, between one third and half of the previous estimates. The incidence of snakebites is influenced by the abundance of snakes, which is related to (i) climate and altitude, (ii) specific preferences of the snake for environments suitable for their development, and (iii) human population density. Recent literature allowed to notice that the severity of the bites depends mainly on (i) the snake responsible for the bite (species and size) and (ii) accessibility of health care, including availability of antivenoms.

CONCLUSIONS/SIGNIFICANCES

The main limitation of this study could be the reliability and accuracy of the notifications by national health services. However, the data seemed consistent considering the similarity of the incidences on each side of national boundaries while the sources are distinct. However, snakebite incidence could be underestimated due to the use of traditional medicine by the patients who escaped the reporting of cases. However, gathered data corresponded to the actual use of the health facilities, and therefore to the actual demand for antivenoms, which should make it possible to improve their management.

Human fatalities caused by animal attacks: A six-year autopsy study

Deaths caused by animal attacks in urban as well as rural areas are rising. With dwindling forest cover and with more interaction of animals with humans in day-to-day life, we need to understand the reasons, manner and causes of these fatal events. We studied 151 cases of fatal animal/human conflicts and in particular, the manner and mechanism of causation of injuries with respect to different types of animals. In this region there were more fatal snake bites followed by cattle attacks. Humans are at some risk while in the vicinity of animals whether in the wild or in human settlements. Human/animal conflicts occur due to reducing habitat for animals and the demands of humans. One must be aware of the potential dangers from animals and as a health care provider it is our duty to educate the public at large. They need to be cautious when around animals, seek medical care after an animal injury and wear protective equipment when working around or with animals.

Antidote Use in the Critically Ill Poisoned Patient

The proper use of antidotes in the intensive care setting when combined with appropriate general supportive care may reduce the morbidity and mortality associated with severe poisonings. The more commonly used antidotes that may be encountered in the intensive care unit ( N-acetylcysteine, ethanol, fomepizole, physostigmine, naloxone, flumazenil, sodium bicarbonate, octreotide, pyridoxine, cyanide antidote kit, pralidoxime, atropine, digoxin immune Fab, glucagon, calcium gluconate and chloride, deferoxamine, phytonadione, botulism antitoxin, methylene blue, and Crotaline snake antivenom) are reviewed. Proper indications for their use and knowledge of the possible adverse effects accompanying antidotal therapy will allow the physician to appropriately manage the severely poisoned patient.

Human attacks by large felid carnivores in captivity and in the wild

Whereas those who live in the native ranges of the large feline carnivores are well aware of the risks of cat and human encounters, North Americans and Europeans are increasingly exposed to exotic animals through travel, ecotourism, leisure pursuits in rural areas, occupational exposure, zoo and animal park visits, wild habitat encroachment at the urban-wildlands interface, and contact with exotic pets. In encounters during which persons have been severely injured, lapses in animal management protocols, lack of appropriate adult supervision, and intoxication have been reported. Unlike common domestic pets that have lived in close association with humans for thousands of years, no matter where individual large felines may have been raised, they remain wild carnivores with strong prey-drive and territorial instincts. The emergency management of large felid attacks is similar to that of other major trauma: stabilization; management of significant orthopedic, neurologic, vascular, and soft tissue injuries; antibiotic coverage provided for the number of organisms that inhabit their mouths and the potential for tetanus and rabies; and early management in survivors of likely posttraumatic stress disorder. We must actively explore responsible measures globally that can be taken to ensure biologically appropriate, ethical, safe, and sustainable conservation of these large carnivores in both their natural habitats and captivity.

Comparison of F(ab')2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial

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.

Management of pediatric snake bites: are we doing too much?

BACKGROUND

The optimal management of children with snake bite injuries is not well defined. The purpose of this study was to review the use of antivenom, diagnostic tests, and antibiotics in children bitten by venomous snakes in a specific geographic region (Southeast Texas).

METHODS

This is a retrospective single-center review of all patients with snake bite injury from 1/2006 to 6/2012. An envenomated bite was defined as causing edema, discoloration of the skin, necrosis, or systemic effects. The severity of injury was scored using a novel 4-point scale based on initial physical examination alone.

RESULTS

One hundred fifty-one children (mean age 8.4±4.3years) were treated for a snake bite. There were no mortalities. Lower extremity injuries were most common (60%). Most bites were from copperheads (43%). Envenomation was evident in 82% (average wound score: 2.61±0.81). The median hospital stay for admitted patients (79%) was 2days (range 1-7). Four patients required surgery for complications of the snake bite. Fifty-two children (34%) received CroFab, with one allergic reaction. 22/135 (16%) had evidence of coagulopathy. Seventy-two children (48%) received IV antibiotics.

CONCLUSION

Despite a high rate of envenomated bites in Southeast Texas, significant morbidity is rare. Children with an envenomation score of 1 or 2 are unlikely to be coagulopathic, suggesting that laboratory investigation should be reserved for patients with higher scores. The indications for the administration of CroFab deserve further prospective study.

Safety and cost-effectiveness of a clinical protocol implemented to standardize the use of Crotalidae polyvalent immune Fab antivenom at an academic medical center

STUDY OBJECTIVE

To evaluate the safety and cost-effectiveness of a clinical protocol adopted in June 2006 that included a comprehensive, objective assessment of snake bite envenomations and standardized the use of Crotalidae polyvalent immune Fab antivenom (FabAV).

DESIGN

Retrospective medical record review.

SETTING

Academic medical center that serves as the regional level I trauma center.

PATIENTS

Seventy-five adults treated with FabAV for snake envenomations in the emergency department between June 1, 2003, and June 1, 2009; 30 patients received treatment according to the protocol (treatment group), and 45 patients received treatment that did not adhere to the protocol (control group).

MEASUREMENTS AND MAIN RESULTS

Demographic and envenomation characteristics, as well as treatment details, were collected for all patients. In addition, information on quantity of FabAV vials required, length of hospital stay, and length of intensive care unit stay were compared between the treatment and control groups. In the treatment group, significantly fewer vials of FabAV were used (2.5 vs 4.727 vials, p=0.007). This decreased in usage correlated to a cost savings of approximately $2000/patient. Despite no significant difference in the severity of the envenomations between the two groups (p=0.379), the treatment group experienced a significantly shorter hospital length of stay (1.933 vs 2.791 days, p=0.030). No significant difference in the progression to fasciotomy or the development of allergic reactions was noted between the two groups.

CONCLUSION

Use of a clinical protocol related to snake envenomations resulted in approximately two fewer vials of FabAV required for each patient. In addition, the treatment group experienced a shorter hospital length of stay without a corresponding increase in adverse events or envenomation progression. Data show that use of the protocol was cost-effective. The development of institution-specific multidisciplinary protocols regarding snake bite envenomations is recommended. Clinical pharmacists can play a vital role in the protocol development to ensure that optimal care is provided for this distinct patient population.

On the venom system of centipedes (Chilopoda), a neglected group of venomous animals

Centipedes are among the oldest extant terrestrial arthropods and are an ecologically important group of soil and leaf litter predators. Despite their abundance and frequent, often painful, encounters with humans, little is known about the venom and venom apparatus of centipedes, although it is apparent that these are both quite different from other venomous lineages. The venom gland can be regarded as an invaginated cuticle and epidermis, consisting of numerous epithelial secretory units each with its own unique valve-like excretory system. The venom contains several different enzymes, but is strikingly different to most other arthropods in that metalloproteases appear to be important. Myotoxic, cardiotoxic, and neurotoxic activities have been described, most of which have been attributed to high molecular weight proteins. Neurotoxic activities are also unusual in that G-protein coupled receptors often seem to be involved, either directly as targets of neurotoxins or indirectly by activating endogenous agonists. These relatively slow responses may be complemented by the rapid effects caused by histamines present in the venom and from endogenous release of histamines induced by venom cytotoxins. The differences probably reflect the ancient and independent evolutionary history of the centipede venom system, although they may also be somewhat exaggerated by the paucity of information available on this largely neglected group.

Management of venomous snakebite injury to the extremities

Pit vipers (subfamily Crotalinae) are responsible for most venomous snakebites in the United States. The mixture of proteins with cytotoxic, proteolytic, and/or neurotoxic enzymes in snake venom varies by species. Treatment in the field consists of safe identification of the species of snake and rapid transport of the patient to the nearest health care facility. Swelling, bruising, and systemic symptoms are seen following snakebite. Most patients respond to elevation of the affected extremity and observation. Some require the administration of antivenin. Crotalidae Polyvalent Immune Fab (Ovine) (CroFab, BTG International, West Conshohocken, PA) antivenin is safe and effective for the management of local and systemic effects of envenomation. Rarely, compartment syndrome may develop in the affected limb because of edema and tissue necrosis. Close monitoring of the extremity via serial physical examination and measurement of compartment pressure is a reliable method of determining whether surgical intervention is required.

Evidence-Based, Multidisciplinary Approach to the Development of a Crotalidae Polyvalent Antivenin (CroFab) Protocol at a University Hospital

Background:

Several thousand people are bitten annually by venomous snakes in the US. While the development of ovine Crotalidae polyvalent immune Fab antivenin (FabAV) for Crotalinae snakebite envenomations has greatly changed the way this clinical presentation is treated, multiple issues complicate its use. From patient assessment and evaluation, to medication preparation and administration, to the management of adverse drug reactions, the use of this antidote carries with it multiple points of possible medication variances. The inappropriate use of this agent can result in adverse patient consequences and a significant financial burden for both the hospital and the patient.

Objective:

To describe an evidence-based, multidisciplinary approach that was taken to ensure optimal, safe, and cost-effective treatment of patients with FabAV.

Methods:

Following an analysis of the available literature, a multidisciplinary committee was formed to construct a protocol for use of FabAV. This group included clinical pharmacists, pharmacy administrators, emergency medicine physicians who specialized in wilderness medicine and pharmacy residents.

Results:

A multidisciplinary FabAV usage protocol was constructed and implemented to ensure appropriate patient evaluation, FabAV use and preparation, monitoring, and follow-up. This protocol was based on the available literature and the expert opinion of the committee. Through the use of a 24-hour in-house pharmacy resident on-call system, clinical pharmacy services were provided to ensure a multidisciplinary approach to the care of these patients emergently. Although limited, initial data show that this approach is effective and may result in substantial cost savings.

Conclusions:

Initial results from implementation of a protocol for use of FabAV have limited inappropriate use, reduced medication wastage, and decreased costs.

Recurrent coagulopathy with delayed significant bleeding after crotaline envenomation

OBJECTIVES

Report of delayed significant coagulopathy, thrombocytopenia, and bleeding after Crotaline envenomation.

METHODS

Recurrent coagulopathy and thrombocytopenia have been described after treatment of Crotaline envenomation with Crotalidae polyvalent immune Fab (CroFab). Until now, there have been no reports of significant spontaneous bleeding despite these abnormalities.

RESULTS

Crotalidae polyvalent immune Fab has a relatively short half-life compared with previous antivenoms used to treat snake bite. This shorter half-life allows for recurrence of venom effects. Therefore, patients with Crotaline envenomation should undergo close monitoring for recurrence of coagulopathy or thrombocytopenia after treatment with CroFab.

CONCLUSIONS

If coagulopathy or thrombocytopenia recurs, retreatment with CroFab should be considered to prevent significant bleeding.

Injuries and deaths occurring as a result of bull attack

Persons whose occupations are in animal husbandry may be seriously injured or killed while tending to animals. Bulls are among the most dangerous of these animals. In this study, seven deaths and 23 traumatic injury cases caused by bull attacks and treated in the General Surgery and Chest Surgery Department of Selcuk University Meram Medical Faculty Hospital are presented. Of the 30 total cases, 24 were male and 6 were female. The ages of the cases ranged from 33 to 86 years and the average age was 60.3 +/- 12.4 (mean +/- standard deviation). All of the death and injury cases occurred while engaged in the care of bulls. It was also determined that the injuries were in the chest region of five (71.4%) and in the head of two (18.6%) out of seven death cases; and in the abdominal region of 14 (60.9%) and in the chest region of nine (39.1%) out of 23 traumatic injury cases. Of the 14 cases that were in the abdominal region and treated surgically, 11 were perforation of small/large intestines, whereas hemorrhages involving the intestinal mesentery, intraabdominal hemorrhage due to perforation of the abdominal wall, and splenic laceration were determined in one case each. There were one or multiple costal fractures in all nine chest injury cases, flail chest in five cases, and hemothorax, pneumothorax, or hemopneumothorax were determined in six cases. Of the chest injury cases, tube thoracostomy was performed in six whereas the other three cases were discharged from the hospital after supportive care. It was concluded that animals such as bulls might be the cause of serious trauma ending with death for those working in the animal husbandry. For this reason, caution is required while feeding and working with bulls. Risk can be reduced by chutes, gates, restraints, special housing, and confinement facilities. Also, wearing protective helmets would be useful especially for preventing head injuries.

Reptile bite in pregnancy

Reptile bites are rarely seen cases in emergency departments. But particularly in the warm summer months, the prevalence is relatively higher in rural areas. Snakebites during pregnancy is little known and only a few cases have been reported in the literature. However, in case of pregnancy, the outcomes may be different both for mother and the fetus. Interestingly, there is limited number of reptile bite cases during pregnancy in the literature. We report here a woman who was bitten at her 28th week of gestation. Obstetric consultation with ultrasonography was performed and seen that fetus was normal according to a 28-week gestation. We infused four vials of antiserum in a period of 1 h in a saline solution. In all, 30 min after the initiation of the antiserum infusion, the lesion started to regress. Her obstetric consultation was repeated 1 h, 36 h, and before discharge were performed and seen that the fetus was normal. After a period of five days, the patient and fetus were evaluated once more, and nothing was abnormal for both.

Pediatric snakebites: lessons learned from 114 cases

PURPOSE

Evidence-based guidelines for the treatment of pediatric snakebite injuries are lacking because they occur infrequently in most centers.

METHODS

We reviewed our experience treating snakebites from January 1995 through December 2005. Demographic (eg, age, sex, geographic location) and clinical information (eg, location of bite, species of snake, vital signs, laboratories, treatment, hospital length of stay) were obtained.

RESULTS

Over the last decade, we have treated 114 children with confirmed snakebites. Mean age was 7.3 +/- 4.2 years (range, 1-17 years), and snakebites were more common in males (n = 68, 60%). All bites occurred on the extremities, and lower extremity bites were more common (n = 71, 62%). Copperheads inflicted the most bite injuries (n = 65, 57%), followed by rattlesnakes (n = 9, 8%) and cottonmouths (n = 7, 6%). The snake was not identified in 33 (29%) cases. Seven (6%) children were treated with Crotalidae antivenin. Of the children treated with antivenin, only 4 met criteria for treatment, and 1 had an anaphylactic reaction. If compartment syndrome was suspected based on neurovascular examination, compartment pressures were measured. Only 2 (1.8%) patients required fasciotomies. Over the last 2 years, we have stopped empiric treatment with antibiotics and have not observed any infectious complications. Average hospital length of stay was 30 +/- 25 hours.

CONCLUSIONS

Most children bitten by pit vipers can be managed conservatively with analgesics and elevation of the affected extremity. Treatment with Crotalidae antivenin, antibiotics, and fasciotomy is rarely indicated.

Animal-caused fatalities in New Mexico, 1993-2004

OBJECTIVE

To evaluate animal-caused fatalities in New Mexico using data collected during medicolegal death investigations, including toxicology, survival interval, and circumstances.

METHODS

A retrospective review of the computerized database and hard copies of files from a centralized, statewide medical examiner's office, excluding deaths due to zoonotic diseases and motor vehicle collisions involving animals.

RESULTS

Between 1993 and 2004, 63 deaths caused by animals were reported in New Mexico. The majority of decedents were male (46/63, 73%) and non-Hispanic white (33/63, 52%). Horses were the most commonly implicated animals, with 43 (68%) deaths due to a person being thrown from, crushed, dragged, or kicked by a horse. Cattle caused 9 deaths (14%), dogs caused 3 (5%), and venomous animals caused 3, whereas a bear was responsible for 1 death. Ten decedents (16%) had alcohol present at the time of death, and 8 would have been over the legal blood alcohol concentration for driving (0.08%). Ten deaths (16%) were work-related and included deaths of jockeys and ranch workers. The majority of deaths (42/63, 67%) occurred in remote locations, potentially delaying access to treatment. Survival intervals ranged from 1 day to 33 years.

CONCLUSIONS

Whereas both human and animal behavior can be difficult to predict, a review of animal-caused fatalities investigated by a medical examiner revealed that in many cases, deaths could have been prevented by either the use of protective gear or alterations in human behavior.

Case studies in pediatric toxicology

Intentional and unintentional poisonings are encountered commonly in the pediatric population. Providers should be familiar both with the general approach to the poisoned child and with specific interventions required for certain toxic exposures.

Most lay people can correctly identify indigenous venomous snakes

We attempted to determine how accurately members of the public can identify venomous snakes. Six different snakes indigenous to southern California were displayed in cages for 265 people to view at a street fair. These included 4 nonvenomous snakes and 2 venomous snakes. People were asked whether the snake was venomous and the name of the snake, if they knew it. Overall, people recognized whether a snake was venomous or nonvenomous 81% of the time. They were most accurate at identifying rattlesnakes as being venomous (95%) but incorrectly identified nonvenomous snakes as being venomous 25% of the time. Men were more accurate than women, and adults were more accurate than children. Subjects were less well able to identify the exact species of snakes. The results suggest that there may be no need to capture, kill, or bring a snake to the hospital for identification, at least in this geographic area.

Sensitivity to Bee Venom Antigen Phospholipase A2: Association With Specific HLA Class I and Class II Alleles and Haplotypes in Beekeepers and Allergic Patients

Bee venom hypersensitivity is a clinical entity of outstanding importance because bee stings are a leading cause of mortality worldwide. Individuals with immediate-type bee venom hypersensitivity, beekeepers, and healthy controls were examined for HLA-DRB1, DQB1, and DQA1 alleles by sequence-specific oligonucleotide probe typing. Defined hypersensitivity to bee venom antigen phospholipase A2 (vbPLA2) is significantly associated with the presence of susceptible HLA class II alleles: DRB1*0101 (RR = 2.7, p < 3 x 10(-3)), DRB1*0103 (RR = 21.2, p < 7.5 x 10(-11)), DQA1*0101 (RR = 1.2, p < 38.52 x 10(-10)), and DQB1*0501 (RR = 4, p < 2.18 x 10(-10)). Some HLA class I alleles were also associated with risk to bee venom allergy: A*01 (RR = 2.4, p < 7.5 x 10(-4)), B*57 (RR = 35.1, p < 3.5 x 10(-7)), and B*5901 (p < 3.5 x 10(-5)), but they are probably of secondary significance. Three- (DRB1*0103-DQA1*0101-DQB1*0501) (RR = 21.24, p < 7.5 x 10(-11)) and five-loci (A*01-B*59-DRB1*0103-DQA1*0101-DQB1*0501) (p < 2.3 x 10(-6)) extended haplotypes are also significantly carried by vbPLA2 allergic patients. When HLA allele frequencies from patients are compared with those from beekeepers, only HLA-DRB1*0103 (RR = 11.7, p < 8.5 x 10(-5)) and HLA-DQA1*0101 (p < 0.02) were significantly increased in the former. These observations emphasize the importance of the DRB1*0103-DQA1*0101-DQB1*0501 haplotype as a strong candidate for susceptibility to vbPLA2 hypersensitivity, at least in our region.

Effectiveness of Delayed Use of Crotalidae Polyvalent Immune Fab (Ovine) Antivenom

Traditionally, horse-serum-based antivenom has been used in the United States for North American crotaline snake evenomation. Crotalidae polyvalent immune Fab (ovine) was approved in 2000 for use in mild to moderate envenomations. The manufacture recommends use within 6 h of envenomation. Published postmarketing retrospective reports describe its use up to 9 h after envenomation. We describe a case of effective use of FabAV 52 h after envenomation with resultant correction of coagulopathy and mild improvement of local symptoms.

North American snake envenomation: diagnosis, treatment, and management

A bite from a venomous snake is a medical emergency involving not only the affected site but also multiple organ systems. Rapid transport of a snakebite victim to a medical facility is paramount. Management decisions must be based on close clinical monitoring of the potentially erratic envenomation syndrome. Because of the many variables inherent in the management of snakebite victims, consultation with a physician specialist is recommended.