Complex regional pain syndrome following southern pacific rattlesnake (C. oreganus helleri) envenoming

Complex regional pain syndrome (CRPS) has rarely been reported in the setting of snakebite but might be more common than previously reported. We present the third case of CRPS reported in North America and the first resulting from a pit‐viper''s bite.     

Correlations between rotational thromboelastometry (ROTEM) and standard coagulation tests following viper snakebites

BackgroundA high prevalence of venom-induced consumption coagulopathy has been reported in individuals with viper snakebites. Rotational thromboelastometry (ROTEM) is a rapid technique that could be advantageous in assessing and monitoring coagulation disorders.PurposeTo explore correlations between ROTEM and standard coagulation tests.Patients and methodsThis prospective observational study was performed among 41 patients with viper envenomation admitted to the Vietnam Poison Control Center from April 2016 to October 2017. Standard coagulation measurements [platelet count, prothrombin time (PT), activated partial thromboplastin time (aPTT), and fibrinogen level] and ROTEM indicators [clotting time (CT), amplitude (at set time: 5 and 10 minutes), clot information time (CFT) and maximum clot firmness (MCF) for extrinsic (EXTEM), intrinsic (INTEM), and fibrin based (FIBTEM) ROTEM] were obtained.ResultsFor INTEM, EXTEM, the FIBTEM, proportions of patients with prolonged CT were 34.1%, 63.4%, and 61.0% respectively and the proportions of patients with decreased MCF were 62.2%, 62.2%, and 35.5%, respectively. Moderate correlations were observed between PT and EXTEM CT (r = 0.627), aPTT and INTEM CT (r = 0.626), fibrinogen and FIBTEM MCF (r = 0.723), and platelet count and EXTEM MCF (0.60).ConclusionROTEM indicated a hypocoagulation state in patients with viper snakebite and was moderately correlated with standard coagulation parameters.     

In Vitro Immunological Cross-Reactivity of Thai Polyvalent and Monovalent Antivenoms with Asian Viper Venoms

The intravenous administration of polyclonal antibodies known as antivenom is the only effective treatment for snakebite envenomed victims, but because of inter-specific variation in the toxic components of snake venoms, these therapies have variable efficacies against different snake species and/or different populations of the same species. In this study, we sought to characterize the in vitro venom binding capability and in vitro cross-neutralizing activity of antivenom, specifically the Hemato Polyvalent antivenom (HPAV; The Queen Saovabha Memorial Institute (QSMI) of the Thai Red Cross Society, Thailand) and three monovalent antivenoms (QSMI) specific to Daboia siamensis, Calloselasma rhodostoma, and Trimeresurus albolabris venoms, against a variety of South Asian and Southeast Asian viper venoms (Calloselasma rhodostoma, Daboia russelii, Hypnale hypnale, Trimeresurus albolabris, Trimeresurus purpureomaculatus, Trimeresurus hageni, and Trimeresurus fucatus). Using ELISA and immunoblotting approaches, we find that the majority of protein components in the viper venoms were recognized and bound by the HPAV polyvalent antivenom, while the monospecific antivenom made against T. albolabris extensively recognized toxins present in the venom of related species, T. purpureomaculatus, T. hageni, and T. fucatus. In vitro coagulation assays using bovine plasma revealed similar findings, with HPAV antivenom significantly inhibiting the coagulopathic activities of all tested viper venoms and T. albolabris antivenom inhibiting the venoms from Malaysian arboreal pit vipers. We also show that the monovalent C. rhodostoma antivenom exhibits highly comparable levels of immunological binding and in vitro venom neutralization to venom from both Thailand and Malaysia, despite previous reports of considerable intraspecific venom variation. Our findings suggest that Thai antivenoms from QSMI may by useful therapeutics for managing snake envenomings caused by a number of Southeast Asian viper species and populations for which no specific antivenom currently exists and thus should be explored further to assess their clinical utility in treating snakebite victims.     

自制蛇伤中药对蝮蛇咬伤患者凝血功能的影响

目的:观察蝮蛇咬伤患者凝血功能的变化情况和自制中药(外用蛇肿散及内服蛇毒消)对其的影响。方法:把93例蝮蛇咬伤患者,随机分为两个组,治疗组47例,对照组46例,均给予常规治疗,治疗组加服中药蛇毒消,均以7天为1个疗程。分别于治疗前及治疗后1天、3天、7天抽血观察并比较两组患者凝血功能指标(PT、TT、APTT、FIB、DD、PLT)的变化情况。结果:入院治疗前和治疗1天后两组凝血功能变化无明显差异性;治疗3天后,两组FIB、TT比较具有明显差异性(分别为P0.05,P0.05),其他指标两组比较无明显差异性;治疗7天后,两组指标FIB、TT比较具有明显差异性(分别为P0.01,P0.05),其他指标两组比较无明显差异性。结论:蝮蛇咬伤患者的凝血功能指标FIB、TT变化明显,中药能明显减轻蝮蛇咬伤患者凝血功能异常。     

竹叶青蛇咬伤血液学指标动态变化的研究

目的研究竹叶青蛇咬伤后患者血液学指标的动态变化特征。方法收集2011-01～2013-12在广州医科大学附属第一医院急诊科确诊为竹叶青蛇咬伤的患者49例，按照咬伤后不同的时间段对PLT、PT、APTT、INR、Fg及D-二聚体6项血液学指标进行统计分析。结果竹叶青蛇咬伤后，6项血液学指标在24 h内均呈现不同程度的异常变化。 PLT和Fg随发病时间的延长呈进行性下降，分别在第4天和第3天达最低值。 PT、APTT、INR及D-二聚体在咬伤后的24 h内明显升高；PT和APTT均在第3天达最高值，而INR和D-二聚体升高较快，在第2天已达最高值。上述6个血液学指标基本在第7～9天恢复正常。结论竹叶青蛇咬伤能引起凝血功能异常，血液学指标随时间不同呈动态变化；了解该规律有助于评估竹叶青蛇咬伤的预后和指导其临床治疗。     

不同护理干预方法对蝮蛇咬伤肢体肿痛的疗效比较

目的 比较中西医护理干预对蝮蛇咬伤患者肢体肿痛的效果。方法 将2015年6月至2016年8月收治的96例蝮蛇咬伤所致肢体肿痛的患者随机分为对照组和干预组各48例,分别采取常规护理和中西医结合护理干预,分别于干预的第3天及第7天评价患肢的周径及予患者疼痛评分,同时统计患肢肿胀消退总时间及不良反应发生率。结果 采用中西医结合护理干预的患者在第3天及第7天患肢周径、疼痛评分、患肢肿胀消退总时间及不良反应发生率均显著低于对照组（P＜0.05）。结论 在蝮蛇咬伤患者救治中,采用中西医结合护理干预能够有效的缓解患者肢体肿痛及降低不良反应的发生,是一种切实可行的护理手段。     

Epidemiology and outcome of acute kidney injury due to venomous animals from a subtropical region of India

Aim: To study the epidemiology and outcome of acute kidney injury (AKI) caused by venomous animals.

Methods: A retrospective study of patients admitted at Indira Gandhi Medical College Hospital, Shimla, with AKI due to venomous animals over a period of 15 years (January 2003–December 2017). Medical records were evaluated for patient information on demographic factors, clinical characteristics, complications, and outcome. Outcomes of requirement for intensive care unit (ICU) support, treatment with dialysis, survival, and mortality were analyzed. The survival and non-survival groups were compared to see the difference in the demographic factors, laboratory results, clinical characteristics, and complications.

Results: One hundred and eighty-one patients were diagnosed with AKI caused by venomous creatures. Mean age was 44?±?15.4 years, and the majority (54.1%) was women. Snakebite (77.9%) and wasp stings (19.9%) were the leading causes of AKI. Clinical details were available in 148 patients. The median duration of arrival at hospital was two days. 81.8% had oliguria, and 54.7% had a history of hematuria or having passed red or brown colored urine. The hematological and biochemical laboratory abnormalities were as follows: anemia (75%), leukocytosis (75.7%), hyperkalemia (35.8%), severe metabolic acidosis (46.6%), hepatic dysfunction (54.7%), hemolysis (85.8%), and rhabdomyolysis (65.5%). Main complications were as follows: gastrointestinal bleed (9.5%), seizure/encephalopathy (10.8%), and pneumonia/acute respiratory distress syndrome (ARDS) (11.5%). 82.3% of the patients required dialysis. 154 (85.1%) patient survived, and 27 (14.9%) patients died. As compared to the survival group, the white blood cell count, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, creatine kinase, and lactate dehydrogenase were significantly higher, and serum albumin levels were significantly lower in patients who died. The proportion of patients with leukocytosis, hyperkalemia, metabolic acidosis, pneumonia/ARDS, seizure/encephalopathy, need for ICU support, and dialysis was significantly higher in patients who died.

Conclusions: Snakebite and multiple Hymenoptera stings (bees and wasps) were the leading causes of AKI due to venomous animals. AKI was severe, a high proportion required dialysis, and the mortality was high.     

Severe envenomation with convulsion following multiple bites by a common brown snake, Pseudonaja textilis

Abstract A case report of envenomation by a common brown snake, Pseudonaja textilis , in a 3.3 year old boy is presented. He suffered a brief grand mal convulsion 10 min after the bite which was shortly after removal of a compression bandage. A severe coagulopathy of the defibrination type required administration of five ampoules of brown snake monovalent antivenom (CSL). The association of envenomation by snakes and convulsions is discussed, as is the management of severe defibrination due to envenomation.     

Suspected snakebite: One year prospective study of emergency department presentations

Aim: Snakebite is an uncommon, but potentially life‐threatening condition. The more common clinical scenario is suspected snake‐bite. Our aim was to characterise the epidemiology, diagnosis and management of patients with suspected snakebites. Methods: Prospective cohort study of patients presenting with suspected snakebites to a tertiary referral hospital serving a large rural region in tropical northern Australia where a standard admission protocol for suspected snakebites is used. Results: Of 70 suspected snakebite cases, there were 45 definite bites: three severe envenomings (two western brown snakes [Pseudonaja nuchalis] and one mulga snake [Pseudechis australis]); seven mild/moderate envenomings by other snakes, two non‐envenomings by identified P. nuchalis, five bites by identified non‐venomous snakes and 28 definite bites without envenoming. The remaining 25 cases were either suspected bites (8), unlikely bites (15) and two people hit by snakes. Definite snake‐bites occurred throughout the year, peaking in May and December. There were three severe envenomings (mainly coagulopathy), requiring antivenom treatment, but no deaths or major complications. Most patients had appropriate investigations. Of 47 venom detection kit swabs collected, 34 were not tested, venom was not detected in nine and was positive in the three envenomings with one false‐positive tiger snake. Whole blood clotting time was highly sensitive for procoagulant coagulopathy and envenoming in this study. Median length of time from the bite to discharge was 20 h (interquartile range: 12–27). Conclusions: The study shows that although suspected snakebite was common, severe envenoming occurred in less than 5% of cases. The study supports the proposition that a structured approach and admission policy of suspected snakebites leads to the appropriate management of severe envenoming, with no cases discharged early and no cases of non‐envenoming treated with antivenom.