- Email: [email protected]
238. Incidence and Management of Snakebite in Northern Central African Republic
Abstracts Toxins 2012 / Toxicon 60 (2012) 95–248
hospital stay >2days (aOR: 19.5; 95% CI: 2.0 – 192.3) as independent risk factors of high cost of care. Conclusion: Most cases of snake bite occur in young productive farmers and could impact local food production. Delay in presentation associated with unorthodox, harmful practices, could result in prolonged hospital stay and high cost of care.
Fig. 1. A. Haematoma from bite on the buttocks; B. Leg swelling; C. Cellulitis and gangrene; D. Bleeding diathesis. Keywords: Access, cost of care, Echis ocellatus, envenomation, Nigeria 10.1016/j.toxicon.2012.04.237
predominance (83% male victims). Upper extremity bites were more common (32/41 upper vs 10/42 lower extremity). One victim sustained bilateral bites to the hands. Thirty-five patients (85%) were admitted, with an average length of stay 2.12 days. The longest hospitalization was 15 days. There were no fatalities. The average time from bite to ED presentation was 164 minutes. Bites occurred during every month except November, with the majority occurring during spring and summer months and peaking in June (12/42 cases). Most bites occurred in the hours between noon and 8 pm. The amount of antivenom given ranged from 2 to 35 vials (average, 9 vials). Interfacility transfers were common in our study population: thirteen (32%) patients were transferred into our emergency department for a higher level of care, and 3 (7%) were transferred out (two because of insurance requirements, and one for higher level of Pediatric ICU care). There were no surgical interventions in our study group. Intoxication did not appear to play a major role in this population as only 3 patients (7%) were found to be acutely intoxicated: one with cannabis and amphetamines, 1 with alcohol, and 1 with opioids. Conclusions: In Central California, Crotaline envenomations occurred mainly in adult males. Dry bites, or bites not requiring antivenom administration, were uncommon, comprising only 10% of bites in this study population. Contrary to popular and clinical beliefs, substance abuse and/or alcohol intoxication did not appear to play a role in the majority of patients. Care providers and snakebite specialists should also be aware that snakebite patients are often transferred between facilities, a finding that may be useful in informing future first aid protocols and research. We hope these findings add concrete data and help correct some common misconceptions about snakebites in Central California. Keywords: Snakebites, epidemiology, interhospital transfers 10.1016/j.toxicon.2012.04.238
237. Snakebite Survivors Club: Ten-year, retrospective review of Crotaline envenomations in Central California
238. Incidence and Management of Snakebite in Northern Central African Republic
Susanne Spano 1, Fernando Macias 1, Brandy Snowden 1, Rais Vohra 1, 2
Séverine Gras 1, Gaëtan Plantefève 2, Jean-Philippe Chippaux 3
1
UCSF-Fresno Medical Center, Fresno, CA, USA California Poison Control System, Fresno-Madera Division, Madera, CA USA E-mail address: [email protected] (R. Vohra). 2
Objective: We investigated clinical patterns of Crotaline envenomation presenting to a tertiary-care academic hospital in Central California over a 10-year period. Methods: An IRB-approved, retrospective chart review was conducted on all patients diagnosed with snakebite from December 2000 to December 2010. Data abstracted: demographics, anatomic location of bite, comorbid conditions and intoxicants, length of stay, antivenom dose, laboratory results, and complications or procedures. Results: There were 46 snakebite cases admitted over the study period. Five were “dry bites;” the remaining cases (41/46) received antivenom. There was a male
217
1 Département d'Anesthésie - Réanimation, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France 2 Réanimation Polyvalente, CH Victor Dupouy, Argenteuil, France 3 UMR 216 “Mère et enfant face aux infections tropicales”, Institut de Recherche pour le Développement and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Pharmacie, Cotonou, Bénin E-mail address: [email protected] (J.-P. Chippaux).
Background: Snakebite represents a serious public health problem in sub-Saharan Africa. Methods: A retrospective study was conducted in Paoua hospital (northern CAR) for 27 months to assess the incidence and severity of snakebites. A team of Médecins Sans Frontières (MSF) is working in this hospital the resources of which are better than the average of sub-Saharan facilities. Results: 842 people were registered for snakebite of which 825 were included in the study. The seasonal
218
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distribution shows a slight increase during rainy season. Only 11 snakes were identified. The sex ratio was 1.56 (503 M/322 F) and the median age [IQ:25;75] was 17 [10;27.5] years. A third of the patients (174/523) reached the hospital within 6 hours after the bite, while 46.5% (243/523) arrived 12 hours after or more. Feet were involved in 70.7% of cases and hands in 24.6%. Immunotherapy was administered to 644 patients (78.1%) who received 1.9 0.06 [IC:95%] vials. Antivenom was renewed twice or more for 131 patients (20.3), owing to edema progression (40%), persistent bleeding (30%), abnormal coagulation test (30%) or persistence of neurological disorders (0.2%). Three patients did not benefit from immunotherapy due to lack of antivenom. The average stay was 4.03 0.28 days. Seven patients (0.8%) showed clinical signs consistent with envenoming by elapid. Viper-like envenomation was observed in 640 patients (77.6%). Edema was present in 681 of 812 patients for whom the data was specified (83.9%). Edema involving two joints was observed in 399 patients (49.1%) and edema reaching or exceeding the limb's root was present in 114 (14%). A clinical sign of hemorrhage (blisters, persistent local bleeding, epistaxis, gingival bleeding, hemoptysis, hematemesis) was reported in 145 patients (17.6%). Five deaths (0.6%) occurred respectively in 4 children and 1 adult. One of the children died without obvious signs of envenomation probably resulting from poisoning by plants used by traditional healer. Two other children arrived at the hospital with a severe anemia and died despite transfusion and antivenom. The fourth died from a sepsis. The adult died from a severe hemorrhagic syndrome without receiving antivenom due to out of stock. Local complications (necrosis, abscess, flessum) occurred in 68 patients (10.6%). Surgeries were required in 29 for debridement (23 patients), skin graft (4 patients) and amputation (2 patients). Conclusion: Better management of snakebites and broad use of immunotherapy could explain the good results.
hour after being bitten by a Mohave rattlesnake encountered in Adelanto, California. On arrival he was tachycardic, hypotensive and altered. He had minimal tissue effects at the bite site. However, he had facial and airway angioedema. He began to complain of progressive difficulty breathing, swallowing and had extraocular muscle weakness consistent with neurotoxicity. He also developed generalized myokymia. He then had two episodes of hematemesis. The patient was intubated and airway was noted to be edematous during the procedure. Because the patient was in shock with serious active bleeding, an initial dose of 12 vials of CroFab Ò was initiated. He continued to show signs of hemorrhaging with multiple large bloody bowel movements (approximately 1.5 L), a 8-gram drop in hemoglobin, bloody drainage from foley / gastric tubes and conjunctival hematomas. Initial labs confirmed coagulapathy, INR 3.2, Fibrinogen <50 mg/dl. First platelet count was normal, but severe thrombocytopenia developed shortly thereafter. He was transfused and admitted to the ICU. He ultimately received 6 units of PRBCs, 5 units of FFP and 30 vials of CroFabÒ, which resolved his bleeding and eventually his coagulopathy as well. He developed rhabdomyolysis, which responded to fluid therapy. He was extubated on day 4, and discharged on day 9 with normal labs and was fully intact neurologically by day 11 follow-up. Discussion: Until now, only Mohave rattlesnakes with Venom A (neurotoxic) venom have been reported in Southern California. Venom B (hemorrhagic and tissuedestructive) effects have not been previously described after bites by this species from this region. Other areas, such as Arizona and Texas, may have snakes with A, B or AþB venom/effects. In California, this is a novel find. Conclusion: Hematotoxicity with clinically significant bleeding, together with neurotoxicity and other serious venom effects, can be seen after Mohave rattlesnake envenoming in Southern California. Keywords: Mohave, Mojave, venom 10.1016/j.toxicon.2012.04.240
Keywords: Snakebite, antivenom, Africa 10.1016/j.toxicon.2012.04.239
239. Combined Neurotoxicity and Hematotoxicity with Clinically Significant Bleeding after Mohave Rattlesnake (Crotalus scutulatus) Envenoming in Southern California Sean P. Bush, Eric T. Teacher, Linda Daniel-Underwood, Sarah R. Pearl, Joshua Westeren, Tammy H. Phan, Ellen Reibling Loma Linda University School of Medicine, Department of Emergency Medicine, Loma Linda, CA, USA E-mail address: [email protected] (S.P. Bush).
Methods: Case report. The snake's head was examined by 4 herpetologists with unanimous agreement on speciation. Results: We describe a confirmed Mohave rattlesnake envenomation with angioedema, hemorrhage, neurotoxicity and rhabdomyolysis. A 31-year-old male presented 1
240. Development of a Double Sandwich Flourescent ELISA to Detect Rattlesnake Venom In Biological Samples from Horses with a Clinical Diagnosis of Rattlesnake Bite Lyndi L. Gilliam 1, Amy Giulioli Canida 2, Dianne McFarlane 3, Todd C. Holbrook 1, Mark Payton 4, Charlotte L. Ownby 5 1 Oklahoma State University Center for Veterinary Health Sciences, Department of Veterinary Clinical Sciences, Stillwater, Oklahoma, USA 2 Banfield Animal Hospital, Oklahoma City, Oklahoma, USA 3 Oklahoma State University Center for Veterinary Health Sciences, Department of Physiological Sciences, Stillwater, Oklahoma, USA 4 Oklahoma State University, Department of Statistics, Stillwater, Oklahoma, USA 5 Oklahoma State University, Office of the Vice President for Research and Technology Transfer, Stillwater, Oklahoma, USA E-mail address: [email protected] (L.L. Gilliam).
Background: The mechanism of cardiotoxicity in horses following envenomation by rattlesnakes endemic to North America is unknown.
hospital stay >2days (aOR: 19.5; 95% CI: 2.0 – 192.3) as independent risk factors of high cost of care. Conclusion: Most cases of snake bite occur in young productive farmers and could impact local food production. Delay in presentation associated with unorthodox, harmful practices, could result in prolonged hospital stay and high cost of care.
Fig. 1. A. Haematoma from bite on the buttocks; B. Leg swelling; C. Cellulitis and gangrene; D. Bleeding diathesis. Keywords: Access, cost of care, Echis ocellatus, envenomation, Nigeria 10.1016/j.toxicon.2012.04.237
predominance (83% male victims). Upper extremity bites were more common (32/41 upper vs 10/42 lower extremity). One victim sustained bilateral bites to the hands. Thirty-five patients (85%) were admitted, with an average length of stay 2.12 days. The longest hospitalization was 15 days. There were no fatalities. The average time from bite to ED presentation was 164 minutes. Bites occurred during every month except November, with the majority occurring during spring and summer months and peaking in June (12/42 cases). Most bites occurred in the hours between noon and 8 pm. The amount of antivenom given ranged from 2 to 35 vials (average, 9 vials). Interfacility transfers were common in our study population: thirteen (32%) patients were transferred into our emergency department for a higher level of care, and 3 (7%) were transferred out (two because of insurance requirements, and one for higher level of Pediatric ICU care). There were no surgical interventions in our study group. Intoxication did not appear to play a major role in this population as only 3 patients (7%) were found to be acutely intoxicated: one with cannabis and amphetamines, 1 with alcohol, and 1 with opioids. Conclusions: In Central California, Crotaline envenomations occurred mainly in adult males. Dry bites, or bites not requiring antivenom administration, were uncommon, comprising only 10% of bites in this study population. Contrary to popular and clinical beliefs, substance abuse and/or alcohol intoxication did not appear to play a role in the majority of patients. Care providers and snakebite specialists should also be aware that snakebite patients are often transferred between facilities, a finding that may be useful in informing future first aid protocols and research. We hope these findings add concrete data and help correct some common misconceptions about snakebites in Central California. Keywords: Snakebites, epidemiology, interhospital transfers 10.1016/j.toxicon.2012.04.238
237. Snakebite Survivors Club: Ten-year, retrospective review of Crotaline envenomations in Central California
238. Incidence and Management of Snakebite in Northern Central African Republic
Susanne Spano 1, Fernando Macias 1, Brandy Snowden 1, Rais Vohra 1, 2
Séverine Gras 1, Gaëtan Plantefève 2, Jean-Philippe Chippaux 3
1
UCSF-Fresno Medical Center, Fresno, CA, USA California Poison Control System, Fresno-Madera Division, Madera, CA USA E-mail address: [email protected] (R. Vohra). 2
Objective: We investigated clinical patterns of Crotaline envenomation presenting to a tertiary-care academic hospital in Central California over a 10-year period. Methods: An IRB-approved, retrospective chart review was conducted on all patients diagnosed with snakebite from December 2000 to December 2010. Data abstracted: demographics, anatomic location of bite, comorbid conditions and intoxicants, length of stay, antivenom dose, laboratory results, and complications or procedures. Results: There were 46 snakebite cases admitted over the study period. Five were “dry bites;” the remaining cases (41/46) received antivenom. There was a male
217
1 Département d'Anesthésie - Réanimation, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France 2 Réanimation Polyvalente, CH Victor Dupouy, Argenteuil, France 3 UMR 216 “Mère et enfant face aux infections tropicales”, Institut de Recherche pour le Développement and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Pharmacie, Cotonou, Bénin E-mail address: [email protected] (J.-P. Chippaux).
Background: Snakebite represents a serious public health problem in sub-Saharan Africa. Methods: A retrospective study was conducted in Paoua hospital (northern CAR) for 27 months to assess the incidence and severity of snakebites. A team of Médecins Sans Frontières (MSF) is working in this hospital the resources of which are better than the average of sub-Saharan facilities. Results: 842 people were registered for snakebite of which 825 were included in the study. The seasonal
218
Abstracts Toxins 2012 / Toxicon 60 (2012) 95–248
distribution shows a slight increase during rainy season. Only 11 snakes were identified. The sex ratio was 1.56 (503 M/322 F) and the median age [IQ:25;75] was 17 [10;27.5] years. A third of the patients (174/523) reached the hospital within 6 hours after the bite, while 46.5% (243/523) arrived 12 hours after or more. Feet were involved in 70.7% of cases and hands in 24.6%. Immunotherapy was administered to 644 patients (78.1%) who received 1.9 0.06 [IC:95%] vials. Antivenom was renewed twice or more for 131 patients (20.3), owing to edema progression (40%), persistent bleeding (30%), abnormal coagulation test (30%) or persistence of neurological disorders (0.2%). Three patients did not benefit from immunotherapy due to lack of antivenom. The average stay was 4.03 0.28 days. Seven patients (0.8%) showed clinical signs consistent with envenoming by elapid. Viper-like envenomation was observed in 640 patients (77.6%). Edema was present in 681 of 812 patients for whom the data was specified (83.9%). Edema involving two joints was observed in 399 patients (49.1%) and edema reaching or exceeding the limb's root was present in 114 (14%). A clinical sign of hemorrhage (blisters, persistent local bleeding, epistaxis, gingival bleeding, hemoptysis, hematemesis) was reported in 145 patients (17.6%). Five deaths (0.6%) occurred respectively in 4 children and 1 adult. One of the children died without obvious signs of envenomation probably resulting from poisoning by plants used by traditional healer. Two other children arrived at the hospital with a severe anemia and died despite transfusion and antivenom. The fourth died from a sepsis. The adult died from a severe hemorrhagic syndrome without receiving antivenom due to out of stock. Local complications (necrosis, abscess, flessum) occurred in 68 patients (10.6%). Surgeries were required in 29 for debridement (23 patients), skin graft (4 patients) and amputation (2 patients). Conclusion: Better management of snakebites and broad use of immunotherapy could explain the good results.
hour after being bitten by a Mohave rattlesnake encountered in Adelanto, California. On arrival he was tachycardic, hypotensive and altered. He had minimal tissue effects at the bite site. However, he had facial and airway angioedema. He began to complain of progressive difficulty breathing, swallowing and had extraocular muscle weakness consistent with neurotoxicity. He also developed generalized myokymia. He then had two episodes of hematemesis. The patient was intubated and airway was noted to be edematous during the procedure. Because the patient was in shock with serious active bleeding, an initial dose of 12 vials of CroFab Ò was initiated. He continued to show signs of hemorrhaging with multiple large bloody bowel movements (approximately 1.5 L), a 8-gram drop in hemoglobin, bloody drainage from foley / gastric tubes and conjunctival hematomas. Initial labs confirmed coagulapathy, INR 3.2, Fibrinogen <50 mg/dl. First platelet count was normal, but severe thrombocytopenia developed shortly thereafter. He was transfused and admitted to the ICU. He ultimately received 6 units of PRBCs, 5 units of FFP and 30 vials of CroFabÒ, which resolved his bleeding and eventually his coagulopathy as well. He developed rhabdomyolysis, which responded to fluid therapy. He was extubated on day 4, and discharged on day 9 with normal labs and was fully intact neurologically by day 11 follow-up. Discussion: Until now, only Mohave rattlesnakes with Venom A (neurotoxic) venom have been reported in Southern California. Venom B (hemorrhagic and tissuedestructive) effects have not been previously described after bites by this species from this region. Other areas, such as Arizona and Texas, may have snakes with A, B or AþB venom/effects. In California, this is a novel find. Conclusion: Hematotoxicity with clinically significant bleeding, together with neurotoxicity and other serious venom effects, can be seen after Mohave rattlesnake envenoming in Southern California. Keywords: Mohave, Mojave, venom 10.1016/j.toxicon.2012.04.240
Keywords: Snakebite, antivenom, Africa 10.1016/j.toxicon.2012.04.239
239. Combined Neurotoxicity and Hematotoxicity with Clinically Significant Bleeding after Mohave Rattlesnake (Crotalus scutulatus) Envenoming in Southern California Sean P. Bush, Eric T. Teacher, Linda Daniel-Underwood, Sarah R. Pearl, Joshua Westeren, Tammy H. Phan, Ellen Reibling Loma Linda University School of Medicine, Department of Emergency Medicine, Loma Linda, CA, USA E-mail address: [email protected] (S.P. Bush).
Methods: Case report. The snake's head was examined by 4 herpetologists with unanimous agreement on speciation. Results: We describe a confirmed Mohave rattlesnake envenomation with angioedema, hemorrhage, neurotoxicity and rhabdomyolysis. A 31-year-old male presented 1
240. Development of a Double Sandwich Flourescent ELISA to Detect Rattlesnake Venom In Biological Samples from Horses with a Clinical Diagnosis of Rattlesnake Bite Lyndi L. Gilliam 1, Amy Giulioli Canida 2, Dianne McFarlane 3, Todd C. Holbrook 1, Mark Payton 4, Charlotte L. Ownby 5 1 Oklahoma State University Center for Veterinary Health Sciences, Department of Veterinary Clinical Sciences, Stillwater, Oklahoma, USA 2 Banfield Animal Hospital, Oklahoma City, Oklahoma, USA 3 Oklahoma State University Center for Veterinary Health Sciences, Department of Physiological Sciences, Stillwater, Oklahoma, USA 4 Oklahoma State University, Department of Statistics, Stillwater, Oklahoma, USA 5 Oklahoma State University, Office of the Vice President for Research and Technology Transfer, Stillwater, Oklahoma, USA E-mail address: [email protected] (L.L. Gilliam).
Background: The mechanism of cardiotoxicity in horses following envenomation by rattlesnakes endemic to North America is unknown.