Antivenom surveillance: An audit of antivenom stock within South Australia

OBJECTIVES

Antivenoms are important emergency medications to be held within Australia, particularly in regional and remote locations. We audited current antivenom holdings in hospitals and health services across South Australia (SA) and compared to recommendations in the 'Snakebite and Spiderbite Management Guidelines' from the State's Toxinology service. The process also assessed the feasibility of 'real-time' remote stock monitoring.

METHODS

Fifty-three sites listed in the guideline were recommended to hold antivenom, though only 49 are currently operational. Interrogation of antivenom stock for 29 sites was possible using electronic reports generated from the State Pharmacy database. The 20 remaining centres had their stock levels confirmed by calling the centres directly. Data obtained were then compared to recommended levels of antivenom holdings in the guideline with discrepancies and associated costs documented. A separate report verification process was used to determine 'real-time' accuracy of the electronic reports.

RESULTS

Thirty-seven sites (75%) held more than the recommended number of antivenom vials, totalling 129 vials in excess with an approximate total cost of $110 000. Twelve sites (24%) held inadequate stock to deliver a treatment dose for 19 envenoming events. The report verification revealed variances in the electronic reports.

CONCLUSIONS

This audit has demonstrated a significant disparity between recommended and actual antivenom holdings across most sites in SA and has also revealed that 'real-time' remote monitoring of state antivenom holdings is not currently feasible. Correction of stock levels to that recommended may result in financial benefit for State Health while also addressing inequity in regional and remote healthcare provision.

Neurological and neuro-ophthalmological manifestations of snake bite: a systematic review

Objective

Snakebites, a major health concern in developing countries, affect rural farming communities. Venom, primarily neurotoxin, injected during a snake bite disrupts the nervous system, causing symptoms like muscle weakness, paralysis, altered sensation, and coordination issues. This review focuses on evaluating neurological and neuro-ophthalmological manifestations associated with snakebites.

Methods

A database search was conducted in EMBASE and PubMed for studies published from 2000 to 2023. The investigation centered on examining neurological and neuro-ophthalmological symptoms and signs, treatment approaches, treatment outcomes, and long-term complications of snake bites.

Results

Neurological and neuro-ophthalmological symptoms were common in both neurotoxic and hemotoxic snake bites, especially in neurotoxic cases. Ptosis was a prevalent manifestation across various snake bites, along with respiratory paralysis, limb weakness, dysphasia, and visual disturbances in some instances. However, most patients improved without residual neurological symptoms after treatment.

Conclusions

Understanding patterns of neurological manifestations contributes valuable insights for the comprehensive management of snakebite.

Exploring the ex vivo effects of Naja mossambica venom on the ultrastructure and viscoelastic properties of human blood

Background

Venomous snake bites have been listed as a neglected tropical disease by the World Health Organization. The Mozambique spitting cobra (Naja mossambica) is found in Sub-Saharan African countries, and its venom has been identified to predominantly result in cytotoxic effects. However, there is limited evidence on the possible hemotoxic effects of this venom on human blood.

Objectives

In this cross-sectional study, we investigated how Mozambique spitting cobra venom affects blood clot formation.

Methods

Cell morphology and clot architecture were studied by using microscopy techniques. We also studied the effects of the venom on platelets by measuring platelet activity with the global thrombosis test, followed by analyzing the viscoelasticity with thromboelastography using a 0.025 ng/μL venom concentration.

Results

The most prominent findings indicated that the viscoelastic profile in the venom-treated blood samples formed an unstable and elastic clot. The clot architecture seen with the scanning electron microscopy analysis showed an altered fibrin network and red blood cells, confirmed by the increased axial ratios, and aggregated platelets with spreading.

Conclusion

These findings may offer insights into the species-specific effects of snake venom on human blood and add value to the clinical workup in confirming envenomation. Further research is needed to correlate the 20 minute whole blood clotting test with measurable values from the thromboelastography within the context of snake envenomation. This may offer a bridge between cost, early diagnosis, and treatment of snake envenomation in resource-constrained countries.

The use of serum protein analysis in the diagnosis of fatal envenomation via Crotalus horridus (timber rattlesnake)

Deaths occurring due to rattlesnake envenomization are extremely rare and must be thoroughly investigated in the same manner as any other type of death. Our research presents the case of an adult white male who suffered a fatal timber rattlesnake (Crotalus horridus) envenomation in northwest Florida in 2018. Blood samples were taken from the decedent's heart and vasculature of the chest and sent for serum proteomic analysis. Serum proteomic analysis was utilized in order to identify proteins from timber rattlesnake (C. horridus) found within the victim's blood. The confirmation of the presence of timber rattlesnake venom within the victim's blood allows the forensic pathologist to determine the cause of death most accurately and likewise, assists with the manner of death determination. Blood samples were separated into two groups: one with the abundant endogenous proteins depleted to facilitate detection of lower abundant proteins and one undepleted. In the depleted sample, a total of 712 proteins were identified, with 47 of the proteins (6.6%) occurring originating from timber rattlesnake (C. horridus). Likewise, a total of 742 proteins were identified in the undepleted sample, with 52 of the proteins (7.0%) occurring in timber rattlesnake (C. horridus). No timber rattlesnake (C. horridus) proteins were found in control human serum.

Completeness of notifications of accidents involving venomous animals in the Information System for Notifiable Diseases: a descriptive study, Brazil, 2007-2019

OBJECTIVE

to describe the completeness of notifications of accidents involving venomous animals held on the Notifiable Health Conditions Information System (SINAN), in Brazil and its macro-regions, from 2007 to 2019.

METHODS

we analyzed essential and non-mandatory fields for snakebite, spider bite and scorpion sting notifications, considering the following completeness categories: Excellent (≤5.0% incompleteness), Good (5.0% to 10.0%), Regular (10.0% to 20.0%), Poor (20.0% to ≤50.0%) and Very Poor (>50.0%). Proportional change in completeness between 2007 and 2019 was estimated.

RESULTS

1,871,462 notifications were investigated. The "localized manifestations", "systemic manifestations", "case classification", "case progression" and "zone of occurrence" fields had excellent or good completeness. Completeness was regular or poor for the "schooling" and "race/color" fields. The "occupation" field was predominantly poorly or very poorly filled in. There was a proportional worsening in completeness (PC<0) in most regions for the "zone of occurrence", "case progression" and "schooling" fields.

CONCLUSION

completeness of most fields improved, although socioeconomic and occupational fields require more attention.

Clinical characteristics and use of antibiotics in a group of patients with snake bites in Colombia

Introduction

Millions of snake bites occur worldwide each year. Clinical practice guidelines generally do not recommend the use of prophylactic antibiotics.

Objective

To determine the sociodemographic, clinical, and pharmacological variables and the use of antibiotics in a group of patients with snake bites in Colombia.

Methods

A retrospective cross-sectional study was carried out. Patients affiliated with a Colombian health insurer who presented with snake bites between 2015 and 2022 were included. The cases were identified from the National Public Health Surveillance System. Sociodemographic, clinical and pharmacological variables were identified. Descriptive and bivariate analyses were performed.

Results

A total of 643 patients were analyzed, with a median age of 30.8 years, and 74.7% were men. The most frequently identified genus of snake was Bothrops (88.8%), and most incidents were classified as mild ophidian accidents (61.6%). A total of 59.7% of patients received snake antivenom. A total of 13.8% and 2.2% of the patients had cellulitis or abscesses, respectively. A total of 63.5% received antibiotics (50.6% for prophylaxis and 12.9% for treatment), especially cephalexin (25.9%), and most of the antibiotic management was considered inappropriate (91.7%).

Conclusion

Most patients with snake bites received antibiotics, especially for prophylactic purposes, a clinical behavior that goes against current evidence. The use of antibiotics with an unsuitable spectrum for the microorganisms that are usually found in the wounds of these patients is frequent. The development of local clinical practice guidelines is required to help reduce the overprescription of antibiotics, as the excessive use of antimicrobials is the main determinant of antimicrobial resistance.

Computer-Aided Analysis of West Sub-Saharan Africa Snakes Venom towards the Design of Epitope-Based Poly-Specific Antivenoms

Snakebite envenomation is a neglected tropical disease that causes over 100,000 deaths each year. The only effective treatment consists of antivenoms derived from animal sera, but these have been deemed with highly variable potency and are usually inaccessible and too costly for victims. The production of antivenoms by venom-independent techniques, such as the immunization with multi-epitope constructs, could circumvent those drawbacks. Herein, we present a knowledge-based pipeline to prioritize potential epitopes of therapeutic relevance from toxins of medically important snakes in West Sub-Saharan Africa. It is mainly based on sequence conservation and protein structural features. The ultimately selected 41 epitopes originate from 11 out of 16 snake species considered of highest medical importance in the region and 3 out of 10 of those considered as secondary medical importance. Echis ocellatus, responsible for the highest casualties in the area, would be covered by 12 different epitopes. Remarkably, this pipeline is versatile and customizable for the analysis of snake venom sequences from any other region of the world.

Massive acute ischemic stroke after Bothrops spp. envenomation in southwestern Colombia: Case report and literature review

Bothrops spp. envenomation and its relationship with ischemic stroke has complex pathogenesis. Local effects such as edema, pain, redness, necrosis, and systemic manifestations like coagulation disorders, thrombosis, renal failure, and hemorrhage have been reported. Hemorrhagic stroke is a common neurological complication but ischemic stroke is poorly understood. We present here the case of a 50-year-old male with no comorbidities referred from a rural area in southwest Colombia with a Bothrops spp. snakebite on the left hand. On admission, the patient presented with a deterioration of consciousness and required mechanical ventilation assistance. The MRI showed multiple ischemic areas in the bilateral frontaltemporal and occipital regions. Two months later, the patient had a favorable resolution, although central paresis in the III and VI cranial nerves and positive Babinski's sign persisted. As already mentioned, the pathophysiology of ischemic stroke due to snakebite is complex but the procoagulant activity of the venom components, the hypovolemic shock, the endothelial damage, and the thromboinflammation can explain it, and although it rarely occurs, it should be considered as a complication of ophidian accidents caused by Bothrops spp.

Temporal trend and epidemiological profile of accidents involving venomous animals in Brazil, 2007-2019

OBJECTIVE

to analyze the temporal trend of accidents involving venomous animals in Brazil from 2007 to 2019.

METHODS

this was a cross-sectional study carried out with data from the Notifiable Health Conditions Information System (SINAN). Prais-Winsten linear regression was used for the temporal analysis. We calculated incidence rates according to sex and age group, relative risk and case fatality ratio.

RESULTS

during the study period there were 2,102,657 cases of accidents involving venomous animals. With the exception of snakebite, the remaining accidents showed a rising temporal trend in most regions of the country. Scorpion stings, snake bites and spider bites were responsible for 86% of accidents, mainly affecting male people of working age. Accidents involving snakes (0.4%) and bees (0.3%) had the highest case fatality ratios. Children were the main victims of accidents involving bees, caterpillars and "others".

CONCLUSION

accidents involving venomous animals showed a rising temporal trend for most conditions, as well as different epidemiological profiles.

Snakebite and local envenomation by Boiruna maculata treated without antivenom

Background

When snake breeders are bitten by rare snakes, deciding whether to administer snake antivenom can be challenging.

Case Presentation

A 50‐year‐old man was bitten on the right finger by Boiruna maculata. The next day, his right upper limb exhibited pronounced local manifestations of envenomation. At the first consultation, a dark purple bleeding spot and a necrotic site were present under the fang marks at the bitten finger and his affected limb showed extensive swelling and redness. Snake antivenom was not administered because it was difficult to identify the snake and obtain the antivenom. We performed the pressure immobilization technique to his limb. The patient’s symptoms peaked in severity on the second day of illness. He was discharged with marked improvement.

Conclusions

We have experienced a case of snakebite envenomation by Boiruna maculata.

The clinical course and treatment of black mamba (Dendroaspis polylepis) envenomations: a narrative review

CONTEXT

The black mamba (Dendroaspis polylepis) is, due to its extremely toxic venom, one of the most dangerous snake species in Sub-Saharan Africa. A D. polylepis bite is a medical emergency and requires adequate action to prevent severe complications. However, there are no comprehensive reviews available based on clinical cases, and no readily accessible guidelines for standardized treatment. Therefore, we aim to provide an overview regarding the currently available clinical literature on D. polylepis envenomations; in order to promote knowledge on symptomatology and treatment options.

METHODS

We searched for cases reporting humans bitten by D. polylepis in PubMed, Embase, Scopus, and Sabinet. We searched the reference lists of all eligible articles for additional articles. After quality assessment, 29 cases were included in this review. We used descriptive analysis to create an overview of the collected parameters.

DISCUSSION

Among the included case reports and case series, D. polylepis envenomations most frequently resulted in decreased respiratory function, sweating and paralysis. The onset of symptoms usually occurred within 60 minutes. Neurological symptoms occurred more often than symptoms of autonomic dysfunction. In the reported cases most patients (26/29) received antivenom and most survived (25/29). We recommend the reporting of additional structured case reports to improve future analyses on the clinical course of envenomations, in order to improve public health response to D. polylepis envenomations.

Biochemical characterization of Bothrops roedingeri Mertens, 1942 snake venom and its edematogenic, hemorrhagic, and myotoxic activities

Introducción.

El envenenamiento por mordedura de serpiente es considerado por la Organización Mundial de la Salud (OMS) una enfermedad tropical desatendida. Si bien los venenos de otras serpientes Bothrops se vienen estudiado ampliamente, poco se conoce del de Bothrops roedingeri.

Objetivos.

Caracterizar bioquímicamente el veneno total de la serpiente B. roedingeri y evaluar su actividad miotóxica, edematógena y hemorrágica.

Materiales y métodos.

Se hizo la caracterización enzimática del veneno de B. roedingeri determinando la actividad de la fosfolipasa A₂ (PLA₂) y de las enzimas proteolíticas, así como su acción fibrinogenolítica mediante electroforesis en gel de poliacrilamida con duodecilsulfato sódico (sodium dodecyl sulfate polyacrylamide gel electrophoresis, SDS-PAGE), y la caracterización tóxica del veneno estableciendo la dosis hemorrágica mínima, la dosis edematógena mínima y el efecto miotóxico local y sistémico.

Resultados.

La actividad de las PLA₂ del veneno total de B. roedingeri fue de 3,45 ± 0,11 nmoles/minuto, la proteolítica, de 0,145 ± 0,009 nmoles/minuto, en tanto que el índice de coagulación del fibrinógeno fue de 6,67 ± 1,33 segundos. Por otro lado, el veneno produjo una dosis hemorrágica mínima de 24,5 µg, una dosis edematógena mínima de 15,6 µg y un pronunciado efecto miotóxico local evidenciado por la elevación de los niveles plasmáticos de creatina cinasa después de la inoculación por vía intramuscular. No se registró miotoxicidad sistémica.

Conclusiones.

El veneno de B. roedingeri tiene efectos hemorrágicos, edematógenos y miotóxicos locales, así como una elevada actividad de la PLA₂, que sería responsable de los efectos miotóxico y edematógeno. También presentó actividad proteolítica, la cual podría afectar la coagulación, dada su capacidad para degradar el fibrinógeno y producir hemorragia por acción de las metaloproteasas.

Fatal brain hemorrhage after Bothrops asper bite in the Catatumbo region of Colombia

Las mordeduras de serpientes son un problema de salud pública en regiones tropicales y subtropicales del mundo. Ocurren, especialmente, en trabajadores rurales, y son una importante fuente de discapacidad y mortalidad.

Se presenta el caso de un hombre de 59 años, agricultor de la región del Catatumbo (Colombia), quien sufrió la mordedura de una serpiente Bothrops asper, la cual le produjo una hemorragia cerebral fatal.

Se llama la atención sobre el grave trastorno hemorrágico en contraste con los leves cambios en el sitio de la mordedura, así como sobre la necesidad del tratamiento temprano de la intoxicación con el suero antiofídico, incluso, en ausencia de manifestaciones cutáneas significativas.

Optic Neuritis After a Snakebite: A Diagnostic Dilemma

Background: Snakebite is one of the major causes of morbidity and mortality in India, particularly in rural regions. Of the 57 known venomous species of snakes in India, the 4 most dangerous snakes are the cobra, the common krait, the Russell viper, and the saw-scaled viper. Of these, the snakes commonly implicated with neurotoxicity are the cobra and the common krait-both elapidae. Acute neuromuscular weakness with respiratory system involvement is the most lethal neurotoxic effect. Case Report: A 24-year-old female was brought to the emergency department in an unresponsive state with a history of snakebite on the left foot. The patient was intubated, mechanically ventilated, and promptly started on snake antivenom and anticholinesterase agents. The patient improved significantly and was extubated. On day 6, she developed blurred vision and slurred speech. She was diagnosed with bilateral optic neuropathy and treated with repeat snake antivenom and steroids. She improved significantly and was discharged on day 14. Conclusion: When a person is bitten by a venomous snake, antivenom is the mainstay of treatment, but clinicians must also consider possible reactions and complications. Optic neuritis following a snakebite is rare but does occur. The prognosis is generally good if clinical suspicion for such a complication is strong, the snake is identified, and the patient receives timely treatment with steroids.

SnakeMap: four years of experience with a national small animal snake envenomation registry

SnakeMap is a national cloud-based, veterinary snakebite registry. It was designed to prospectively collect data of the clinical circumstances and temporospatial information on cases of snake envenomation in dogs and cats. We herein introduce the project and summarise the data from the first 4 years of SnakeMap. The registry is a veterinary community-based online database allowing case entry from veterinary hospitals across Australia. Registry data comprise hospital characteristics, patient characteristics, envenoming snake type, treatment and outcome variables, including time and geolocation of the snake bite. We present summative information on select key variables from the SnakeMap registry (1 July 2015 to 30 June 2019). Twenty-eight hospitals from 6 states/territories entered 624 cases into the registry, including 419 dogs (67%) and 205 cats (33%). Bite time was available in 216 animals of which 90 (42%) were reported to be bitten in the 3 hours between 03:00 pm and 05:59 pm; median bite to presentation interval was 60 (interquartile range [IQR] 30, 211) minutes in dogs and 95 (IQR 41, 238) minutes in cats. Bites occurred in the owner's yard in 356 dogs (85%) and 53 cats (26%). A snake venom detection kit was used in 172 cases (28%) and antivenom was administered in 523 cases (85%). Most animals (n = 534, 88%) survived to discharge (median hospitalisation of 25 [IQR 16, 62] hours). SnakeMap effectively collects relevant clinical data from dogs and cats with presumed snake bite and provides locally specific information on the epidemiology of snake envenomation in small animals.

Delayed-onset sinus node dysfunction in a child victim of Russell's viper bite

Cardiac complications following envenomation by Russell's viper venom are uncommon. We describe a 14-year-old girl who developed delayed-onset sinus node dysfunction. She presented with mucosal bleeding, ptosis, and muscle weakness. Her 20-min whole blood clotting time and international normalized ratio were prolonged. The initial electrocardiogram showed sinus tachycardia. Her systemic manifestations responded to antivenom serum. After 24 h, she developed bradycardia and electrocardiography showed sinus node dysfunction with sinus arrest and an atrial escape rhythm. This case shows that arrhythmias can have a delayed onset even after resolution of other systemic manifestations, and even after treatment with antivenom serum.

Snakebite in the department of Nariño, Colombia: a retrospective analysis, 2008-2017

Introducción.

El ofidismo es un relevante problema de salud pública y, en Colombia, se incluyó como un evento de notificación obligatoria desde el año 2004. Por ser un país tropical con gran diversidad ecosistémica, ocupa el tercer puesto en Latinoamérica, después de México y Brasil, en presentar el mayor número de accidentes ofídicos.

Objetivo.

Realizar un análisis retrospectivo del accidente ofídico en el departamento de Nariño, con base en los eventos notificados entre los años 2008 y 2017 al Instituto Departamental de Salud de Nariño y al Sistema de Vigilancia en Salud Pública de Colombia.

Materiales y métodos.

Se hizo un análisis de tipo descriptivo y retrospectivo a partir de la recopilación e interpretación de la información consignada en las fichas de notificación para accidente ofídico del Instituto Departamental de Salud de Nariño, entre los años 2008 y 2017. Se representó la frecuencia del accidente ofídico a nivel municipal mediante la elaboración de un mapa y se identificaron los géneros responsables del mismo.

Resultados.

Se reporta un total de 1.110 casos. El 78,13 % de los municipios hizo alguna notificación. Se observa un patrón de aumento constante en el número de casos durante los 10 años, a excepción de 2017. Las características sociodemográficas se mantuvieron durante el periodo de estudio.

Conclusiones.

El municipio de San Andrés de Tumaco, el sexo masculino y las áreas rurales son los principales afectados por el ofidismo causado, en mayor medida, por el género Bothrops. La mayor incidencia se presentó en el mes de julio.

Early pathology in venom-induced consumption coagulopathy by Rhabdophis tigrinus (Yamakagashi snake) envenomation

Objective: Rhabdophis tigrinus (Yamakagashi in Japanese) is a venomous non-front-fanged colubroid snake capable of inflicting envenoming with life-threatening defibrinating coagulopathy. However, because of the uncommon incidence of bites and tendency for late development of symptoms/signs, the early effects of the venom on the coagulation system are poorly known. Case report: We describe a boy bitten by a wild R. tigrinus and report his clinical course starting at 30 min after the bite. Results: At 30 min after envenomation, only the thrombin-antithrombin complex (TAT) level was elevated. At 90 min after envenomation, laboratory data revealed a prolonged activated partial thromboplastin time (APTT) and increased prothrombin time international normalized ratio (PT-INR) with elevated fibrinogen degeneration product (FDP). At 5.5 h after envenomation, APTT and PT-INR increased beyond a measurable range, and fibrinogen levels dropped below the detection limit. We administered recombinant human soluble thrombomodulin and antivenom prepared against R. tigrinus antivenom. Venom-induced consumption coagulopathy (VICC), which is sometimes reported as disseminated intravascular coagulation (DIC), subsequently improved rapidly. Discussion: We found that TAT is the earliest marker to detect R. tigrinus envenomation and subsequent VICC occurrence. Although rTM was effective in this case, further studies are necessary to prove its safety and efficacy.

Incidence of allergic reactions to Crotalidae polyvalent immune Fab

CONTEXT

The administration of Crotalidae polyvalent immune Fab (FabAV) currently requires close observation, so patients can be monitored for hypersensitivity reactions. The objective of this study was to evaluate the occurrence of hypersensitivity reactions to FabAV.

METHOD

This was a retrospective cohort study utilizing data from a statewide poison center database in the United States. Records of all patients envenomated by a rattlesnake and treated with FabAV between January 2002 and December 2014 were evaluated. Patients with acute hypersensitivity reactions were identified, and reactions were evaluated descriptively.

RESULTS

A total of 1340 adult and pediatric patients received FabAV during the study period. Of these, 19 (1.4%) patients had a potential reaction to FabAV, with 10 requiring a reduction in infusion rate, but none requiring discontinuation of the antivenom. Reactions occurred during the loading dose (n = 10), maintenance doses (n = 4), or were delayed reactions (n = 6). Symptoms recorded included pruritus (n = 8), hives (n = 8), rash (n = 7), vomiting (n = 7), nausea (n = 6), dyspnea or wheezing (n = 4), diaphoresis (n = 3), throat irritation (n = 2), and mild hypotension (n = 2). One patient was given a concomitant administration of low dose epinephrine infusion until completion of the antivenom course. However, none of the reactions were considered to be life-threatening.

CONCLUSION

FabAV appears to be associated with a low incidence of acute hypersensitivity reactions. Patients may not require placement in a location capable of detecting and rapidly responding to hemodynamic and/or airway issues for FabAV monitoring alone.

Early administration of Fab antivenom resulted in faster limb recovery in copperhead snake envenomation patients

BACKGROUND

No previous research has studied whether early snake antivenom administration leads to better clinical outcomes than late antivenom administration in North American pit viper envenomation.

METHODS

A secondary analysis of data from a clinical trial of Fab antivenom (FabAV) versus placebo for copperhead snake envenomation was conducted. Patients treated before the median time to FabAV administration were classified as receiving early treatment and those treated after the median time were defined as the late treatment group. A Cox proportional hazards model was used to compare time to full recovery on the Patient-Specific Functional Scale (PSFS) instrument between groups. Secondary analyses compared estimated mean PSFS scores using a generalized linear model and the estimated proportion of patients with full recovery at each time point using logistic regression. To evaluate for confounding, the main analysis was repeated using data from placebo-treated subjects.

RESULTS

Forty-five subjects were treated with FabAV at a median of 5.47 h after envenomation. Patients in the early treatment group had a significantly shorter time to full recovery than those treated late (median time: 17 versus 28 days, p = .025). Model-estimated PSFS scores were numerically higher at each time point in the early group. No difference was found between patients treated early versus late with placebo.

CONCLUSIONS

In this secondary analysis of trial data, recovery of limb function was faster when Fab antivenom was administered soon after envenomation, as opposed to late administration.

Retrospective evaluation of cats with elapid snake envenomation associated neurotoxicity requiring mechanical ventilation: 12 cases (2005-2014)

OBJECTIVE

To retrospectively determine the population and outcome characteristics of a cohort of Australian elapid snake envenomed cats requiring mechanical ventilation (MV).

DESIGN

Retrospective observational study (2005-2014).

SETTING

Academic veterinary emergency and critical care service.

ANIMALS

Twelve cats undergoing MV for elapid snake envenomation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The medical records were searched to identify cats requiring MV as part of treatment for elapid snake envenomation. Signalment, the indication for, duration of and complications associated with MV, duration of hospitalization, and survival to hospital discharge were recorded for each of the enrolled cases. Seven cats (58.3%) underwent MV because of presumed unsustainable respiratory effort and 5 cats (41.7%) for respiratory arrest. Eleven cats (91.7%) were successfully weaned from MV and survived to hospital discharge. No cats developed ventilator associated pneumonia or pneumothorax. The median duration of MV was 19.5 hours for the survivors (range 7.0-37.0 hours) and median duration of hospitalization was 3.5 days (range 2.4-14.9 days).

CONCLUSIONS

Cats requiring MV for elapid snake envenomation have a favorable outcome and require a relatively short period of MV. Complications encountered are unlikely to influence outcome.

Prospective study of recovery from copperhead snake envenomation: an observational study

BACKGROUND

Although much is known about signs, symptoms, and management in the acute phase of crotaline snake envenomation, little is known about signs, symptoms, function, and quality of life during the recovery phase. The purpose of this observational pilot investigation is to evaluate the utility of several clinical outcome instruments in the setting of copperhead snakebite, and to characterize the clinical course of recovery.

METHODS

This is a multi-center prospective, open-label, observational study of patients envenomated by copperhead snakes. We administered the Disabilities of the Arm, Shoulder, and Hand (DASH), Lower Extremity Functional Scale (LEFS), Patient-Specific Functional Scale (PSFS), Work Productivity and Ability Impairment: Special Health Problem (WPAI: SHP), Patients' Global Impression of Change (PGIC), Patient's Global Assessment of Recovery (PGAR), and SF-36 instruments, obtained numeric pain rating scales, and measured grip strength, walking speed, and swelling prior to hospital discharge and 3, 7, 14, 21, and 28 days after envenomation.

RESULTS

20 subjects were enrolled; none were lost to follow-up. Most (80%) had moderate severity swelling, and most (75%) received antivenom. Across the broad range of measures, abnormalities of pain, swelling, impairments of physical and role function, and quality of life persisted for 7-14 days in most subjects. Validated self-reported outcome measures, such as the DASH, LEFS, PSFS, PGIC, SF-36, and the daily activities impairment portion of the WPAI: SHP were more responsive than measurements of swelling or walking speed. Data quality issues limited the utility of the work impairment portion of the WPAI: SHP. Residual signs, symptoms, and impairment in some subjects lasted through the 28-day study period. The study design precluded any assessment of the effectiveness of antivenom.

CONCLUSIONS

Signs, symptoms, impaired function, and decreased quality of life typically last 7 - 14 days after copperhead envenomation. Several tools appear responsive and useful in studying recovery from pit viper envenomation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01651299.

Shewanella infection of snake bites: a twelve-year retrospective study

OBJECTIVE

Infections of snake bite wounds by Shewanella are rarely discussed in the medical literature. This study aims to characterize the presentation and management of Shewanella infections in snake bite wounds.

METHOD

We retrospectively investigated the microbiology, clinical features, and outcomes of patients with Shewanella infected snake bite wounds admitted to a tertiary medical center from January 1998 to December 2009.

RESULTS

Ten patients with Shewanella-infected snake bite wounds were identified. All of the snake bites were caused by cobras. The majority of patients had moderate to severe local envenomation and polymicrobial infections. Shewanella isolates are susceptible to ampicillin-sulbactam, piperacillin-tazobactam, third-and fourth-generation cephalosporins, carbapenems, aminoglycosides, and quinolones but are resistant to penicillin and cefazolin. All of the patients examined had favorable outcomes.

CONCLUSION

It is recommended that Shewanella infection be considered in snake bite patients, especially when patients present with moderate to severe local envenomation.

Anticholinesterase therapy for patients with ophthalmoplegia following snake bites: report of two cases

Although ophthalmoplegia following snake bites is not indicative of a serious neurotoxic complication, symptoms of diplopia, dizziness and ocular discomfort can be emotionally devastating for patients. The authors experienced two cases of ophthalmoplegia following snake bites in Korea. The patients complained of diplopia that had developed several hours after the snake bites. The diplopia did not improve with antivenom treatment, but resolved completely after several injections of neostigmine.