Successful resuscitation after cardiac arrest following massive brown snake envenomation

Fatal Rattlesnake Envenomation in Northernmost Brazilian Amazon: A Case Report and Literature Overview

Snakebite envenomations are classified as Category A Neglected Tropical Diseases by the World Health Organization. In Brazil, 405 snake species are distributed among 11 families, with the genera Bothrops and Crotalus being the most studied and main responsible for severe and lethal envenomations. In the country, Crotalus genus (i.e., rattlesnakes) is represented by Crotalus durissus species, showing seven different subspecies distributed along the country, including Crotalus durissus ruruima, which inhabits Roraima, the Brazilian nothermost state from Amazon forest. Here, we report a fatal case of a severe envenomation following a rattlesnake bite. The patient presented classic crotalic neurological signs and symptoms such as ptosis, drooling of saliva, sluggishness, macroscopic hematuria, and oliguria, which evolved to acute kidney failure (AKF) and hemodynamic instability. Although the patient was treated with the specific antivenom therapy, the severe envenomation resulted in three cardiac arrests and death of the victim in less than 38 h. This study discusses the causes of the patient death, the features of rattlesnake venom-induced AKF, and shows evidences that the Brazilian crotalic antivenom should be improved to treat rattlesnake envenomations caused by C. d. ruruima venom in Roraima state.

An in vivo examination of the differences between rapid cardiovascular collapse and prolonged hypotension induced by snake venom

We investigated the cardiovascular effects of venoms from seven medically important species of snakes: Australian Eastern Brown snake (Pseudonaja textilis), Sri Lankan Russell’s viper (Daboia russelii), Javanese Russell’s viper (D. siamensis), Gaboon viper (Bitis gabonica), Uracoan rattlesnake (Crotalus vegrandis), Carpet viper (Echis ocellatus) and Puff adder (Bitis arietans), and identified two distinct patterns of effects: i.e. rapid cardiovascular collapse and prolonged hypotension. P. textilis (5 µg/kg, i.v.) and E. ocellatus (50 µg/kg, i.v.) venoms induced rapid (i.e. within 2 min) cardiovascular collapse in anaesthetised rats. P. textilis (20 mg/kg, i.m.) caused collapse within 10 min. D. russelii (100 µg/kg, i.v.) and D. siamensis (100 µg/kg, i.v.) venoms caused ‘prolonged hypotension’, characterised by a persistent decrease in blood pressure with recovery. D. russelii venom (50 mg/kg and 100 mg/kg, i.m.) also caused prolonged hypotension. A priming dose of P. textilis venom (2 µg/kg, i.v.) prevented collapse by E. ocellatus venom (50 µg/kg, i.v.), but had no significant effect on subsequent addition of D. russelii venom (1 mg/kg, i.v). Two priming doses (1 µg/kg, i.v.) of E. ocellatus venom prevented collapse by E. ocellatus venom (50 µg/kg, i.v.). B. gabonica, C. vegrandis and B. arietans (all at 200 µg/kg, i.v.) induced mild transient hypotension. Artificial respiration prevented D. russelii venom induced prolonged hypotension but not rapid cardiovascular collapse from E. ocellatus venom. D. russelii venom (0.001–1 μg/ml) caused concentration-dependent relaxation (EC₅₀ = 82.2 ± 15.3 ng/ml, R_max = 91 ± 1%) in pre-contracted mesenteric arteries. In contrast, E. ocellatus venom (1 µg/ml) only produced a maximum relaxant effect of 27 ± 14%, suggesting that rapid cardiovascular collapse is unlikely to be due to peripheral vasodilation. The prevention of rapid cardiovascular collapse, by ‘priming’ doses of venom, supports a role for depletable endogenous mediators in this phenomenon.

Hypotensive and vascular relaxant effects of phospholipase A2 toxins from Papuan taipan (Oxyuranus scutellatus) venom

Phospholipase A2 (PLA2) toxins are common and abundant components of Australasian elapid venoms. These toxins are associated with a range of activities including neurotoxicity, myotoxicity and coagulation disturbances. We have recently reported that sudden cardiovascular collapse induced by Papuan taipan (Oxyuranus scutellatus) venom involves a combination of the release of dilator autacoids and a direct effect on the smooth muscle. In this study, we aimed to isolate PLA2 components from Papuan taipan venom and investigate their contribution to the hypotensive action of this venom. O. scutellatus venom was fractionated using size-exclusion high performance liquid chromatography (HPLC), and fractions screened for activity in anaesthetized rats. Fraction three from O. scutellatus venom (i.e. OSC3, 14.2±1.0% of whole venom) produced a 64% decrease in mean arterial pressure. Reverse-phase HPLC indicated that OSC3 consisted of two major components (i.e. OSC3a and OSC3b). OSC3a and OSC3b produced a significant hypotensive response in anaesthetized rats which were attenuated by prior administration of indomethacin or the combination of mepyramine and heparin. N-terminal analysis indicated that OSC3a and b displayed sequence homology to PLA2 toxins isolated from coastal taipan (O. scutellatus scutellatus) venom. These findings indicate that PLA2 components may play an important role in the development of hypotension and vascular relaxation which may contribute to the effects observed after envenoming by these Australasian elapids.

An examination of cardiovascular collapse induced by eastern brown snake (Pseudonaja textilis) venom

The Pseudonaja genus (Brown snakes) is widely distributed across Australia and bites account for significant mortality. Venom-induced consumption coagulopathy (VICC) and, less often, early cardiovascular collapse occur following envenoming by these snakes. We have previously examined possible mechanism(s) behind the early cardiovascular collapse following Papuan taipan (Oxyuranus scutellatus) envenoming. In the present study, we investigate early cardiovascular collapse in anaesthetized rats following administration of eastern brown snake (Pseudonaja textilis) venom, and prevention of this effect with prior administration of 'priming' doses (i.e. doses of venom which caused a transient hypotensive response) of venom. P. textilis venom (5-10 μg/kg, i.v.) induced cardiovascular collapse in anaesthetized rats, characterized by a rapid decrease in systolic blood pressure until non recordable. Prior administration of 'priming' doses of P. textilis venom (2 and 3 μg/kg) or, at least, 4-5 doses of O. scutellatus (2 μg/kg, i.v.) or Daboia russelii limitis (20 μg/kg, i.v.) venoms prevented cardiovascular collapse induced by P. textilis venom. Moreover, early collapse was also inhibited by prior administration of 2 discrete doses of Acanthophis rugosus venom. Prior administration of commercial polyvalent snake antivenom (500-3000 units/kg, i.v.) or heparin (300 units/kg, i.v.) also inhibited P. textilis venom-induced cardiovascular collapse. Our results indicate that P. textilis venom-induced cardiovascular collapse can be prevented by prior administration of sub-lethal doses of venom from P. textilis, O. scutellatus, A. rugosus and D. russelii limitis. This suggests that sudden cardiovascular collapse following envenoming is likely to involve a common mechanism/pathway activated by different snake venoms.

In vivo and in vitro cardiovascular effects of Papuan taipan (Oxyuranus scutellatus) venom: Exploring "sudden collapse"

'Sudden collapse' following envenoming by some Australasian elapids is a poorly understood cause of mortality. We have previously shown that Oxyuranus scutellatus venom causes cardiovascular collapse in anaesthetized rats. Prior administration of a sub lethal dose of venom attenuated the response to subsequent administration of higher (lethal) venom doses. In this study, we investigated the possible mechanisms mediating this 'protective effect'. Papuan taipan venom (5μg/kg, i.v.) produced a small transient hypotension in anaesthetized rats, while 10μg/kg resulted in a 73±12% decrease in arterial pressure. Venom (20μg/kg or 50μg/kg) produced cardiovascular collapse in all animals tested (n=12). Cardiovascular collapse by 50μg/kg venom was prevented by prior administration of 'priming' doses of venom (5, 10 and 20μg/kg). Also, prior administration of indomethacin (30mg/kg, i.v.) or heparin (300units/kg, i.v.) prevented sudden collapse induced by venom (20μg/kg). Venom was without effect in isolated hearts indicating that a direct cardiac effect was unlikely to be responsible for 'sudden collapse'. Venom induced endothelium-dependent and -independent relaxation in pre-contracted rat mesenteric artery rings which was inhibited by indomethacin, IbTx and Rp-8-CPT-cAMPs. This relaxation was markedly reduced upon second exposure. Our results indicate that cardiovascular collapse induced by O. scutellatus venom may be due to a combination of release of dilator autacoids and to direct relaxation of vascular smooth muscle involving the cAMP/protein kinase A cascade. Further work will involve identification of the venom component(s) responsible for this action and may provide insight into the management of envenomed patients.

Venom variation in hemostasis of the southern Pacific rattlesnake (Crotalus oreganus helleri): isolation of hellerase

Envenomations by the southern Pacific rattlesnake (Crotalus oreganus helleri) are the most common snakebite accidents in southern California. Intraspecies venom variation may lead to unresponsiveness to antivenom therapy. Even in a known species, venom toxins are recognized as diverse in conformity with interpopulational, seasonal, ontogenetic and individual factors. Five venoms of individual C. oreganus helleri located in Riverside and San Bernardino counties of southern California were studied for their variation in their hemostatic activity. The results demonstrated that Riverside 2 and San Bernardino 1 venoms presented the highest lethal activity without hemorrhagic activity. In contrast, San Bernardino 2 and 3 venoms had the highest hemorrhagic and fibrinolytic activities with low lethal and coagulant activities. Riverside 1, Riverside 2 and San Bernardino 1 venoms presented a significant thrombin-like activity. San Bernardino 2 and 3 venoms presented an insignificant thrombin-like activity. In relation to the fibrinolytic activity, San Bernardino 3 venom was the most active on fibrin plates, which was in turn neutralized by metal chelating inhibitors. These results demonstrate the differences amongst C. oreganus helleri venoms from close localities. A metalloproteinase, hellerase, was purified by anionic and cationic exchange chromatographies from San Bernardino 3 venom. Hellerase exhibited the ability to break fibrin clots in vitro, which can be of biomedically importance in the treatment of heart attacks and strokes.

Venomous snakebite in mountainous terrain: prevention and management

The prevention and management of venomous snakebite in the world's mountains present unique challenges. This paper presents a series of practical, clinically sound recommendations for management of venomous snakebite in a mountain environment. The authors performed an extensive review of current literature using search engines and manual searches. They then fused the abundant knowledge of snakebite with the realities of remote first aid and mountain rescue to develop recommendations. A summary is provided of the world's most troublesome mountain snakes and the mechanisms of toxicity from their bites. Preventive measures are described. Expected symptoms and signs are reviewed in lay and medical terms. A review of currently recommended first-aid measures and advanced medical management for physicians, paramedics, and other clinicians is included. Venomous snakebites in mountainous environments present unique challenges for management. This paper offers practical recommendations for managing such cases and summarizes the approach to first aid and advanced management in 2 algorithms.

Snake venoms and coagulopathy

Snakebite affects around 2.5 million humans annually, with greater than 100,000 deaths. Coagulopathy is a significant cause of both morbidity and mortality in these patients, either directly, or indirectly. This paper reviews clinical aspects of snakebite coagulopathy, including types of coagulopathy (procoagulant, fibrinogen clotting, fibrinolytic, platelet-active, anticoagulant, thrombotic, haemorrhagic), diagnosis and treatment. Examples of clinical laboratory findings in selected types of snakebite coagulopathy are presented. Where available, antivenom is the most effective treatment, while standard treatments for other forms of coagulopathy, such as factor replacement therapy and heparin, are either ineffective or dangerous in snakebite coagulopathy, except in specific situations.