- Email: [email protected]
Introduction: “Advances in the management of snakebite” symposium
TOXICOLOGY
Introduction: “Advances in the Management of Snakebite” Symposium
From the Rocky Mountain Poison and Drug Center, Denver, CO*; and the Department of Emergency Medicine, Baptist Medical Center, Menorah Medical Center, University of Missouri–Kansas City, Kansas City, MO.‡ Reprints not available from the authors. Address for correspondence: Richard C. Dart, MD, PhD, Rocky Mountain Poison and Drug Center, 1010 Yosemite Circle, Denver, CO 80230; 303-739-1100, fax 303-739-1119; E-mail [email protected]. Copyright © 2001 by the American College of Emergency Physicians. 0196-0644/2001/$35.00 + 0 47/1/113580 doi:10.1067/mem.2001.113580
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Richard C. Dart, MD, PhD* Joseph F. Waeckerle, MD‡ Editor in Chief
[Dart RC, Waeckerle JF. Introduction: “Advances in the Management of Snakebite” Symposium. Ann Emerg Med. February 2001;37:166-167.] The lore of snakebite permeates nearly every culture. Few events can so promptly create skin-crawling sensation as the sight of a snake. Snakebite is also medically important, although its medical implications are often underappreciated. Although snakebite is an uncommon event, venomous snakes are indigenous to nearly every state in the United States. The unfortunate habit of collecting and keeping live venomous snakes assures that regions that rarely encounter snakebite have the opportunity to share in an interesting but tricky management. Snake venom poisoning is a remarkably complex disease. Crotaline snake venom contains dozens of components that affect multiple organs. Some components act locally to cause swelling, ecchymosis, and blebs. The long-term sequelae of local injury are disfiguring and disabling. Other venom components cause coagulopathy, and still others may cause diffuse capillary leak, myocardial depression, and even neuromuscular paralysis. Unfortunately, the incidence of snakebite may be destined to increase, as there appears to be no relief from the encroachment of human beings into snake habitat. A new treatment for snakebite has been developed over the past 20 years. Emergency physicians spearheaded the clinical development. As so often occurs during drug development, many important clinical discoveries occurred, in addition to documenting the safety and efficacy of the antivenom. These discoveries were presented at the “Advances in the Management of Snakebite” symposium at the 1999 North American Congress of Clinical Toxicology in La Jolla, CA. Annals is pleased to publish the proceedings of this symposium. The topics include the first published analysis regarding out-of-hospital and interhospital care of the snakebite patient by Patrick E. McKinney, MD. Dr. McKinney is an emergency physician and toxicologist with extensive experience in
ANNALS OF EMERGENCY MEDICINE
37:2 FEBRUARY 2001
SNAKEBITE SYMPOSIUM INTRODUCTION Dart & Waeckerle
the delivery and supervision of medical care in rural areas. Edward L. Hall, MD, addresses the issue of the surgical management of snakebite. This controversial issue has been the topic of many commentaries. For the past 20 years, Dr. Hall has provided snakebite guidance and treatment for a large portion of southern Georgia. Jude McNally, RPh, and Richard C. Dart, MD, PhD, report the primary results of the CroFab trials as well as information not published previously. Finally, Steven A. Seifert, MD, and Leslie V. Boyer, MD, address the phenomenon of recurrence: the return of venom effects after they had been successfully addressed with antivenom. This observation has created new understanding about snakebite and its appropriate treatment. It is uncommon for emergency physicians to inspire new therapeutic drugs. We often alter the use of available drugs, but it seems that we typically are forced to adjust to hand-me-down drugs developed for use in the ICU or outpatient care. Crotaline snakebite is like myocardial ischemia—delay in treatment allows injury to progress. Although much of the injury is ultimately reversible, the patient impact is very large. In short, the emergency department was the appropriate place for the development of this drug and should be the place where snakebite therapy is initiated.
FEBRUARY 2001
37:2
ANNALS OF EMERGENCY MEDICINE
1 6 7
Introduction: “Advances in the Management of Snakebite” Symposium
From the Rocky Mountain Poison and Drug Center, Denver, CO*; and the Department of Emergency Medicine, Baptist Medical Center, Menorah Medical Center, University of Missouri–Kansas City, Kansas City, MO.‡ Reprints not available from the authors. Address for correspondence: Richard C. Dart, MD, PhD, Rocky Mountain Poison and Drug Center, 1010 Yosemite Circle, Denver, CO 80230; 303-739-1100, fax 303-739-1119; E-mail [email protected]. Copyright © 2001 by the American College of Emergency Physicians. 0196-0644/2001/$35.00 + 0 47/1/113580 doi:10.1067/mem.2001.113580
1 6 6
Richard C. Dart, MD, PhD* Joseph F. Waeckerle, MD‡ Editor in Chief
[Dart RC, Waeckerle JF. Introduction: “Advances in the Management of Snakebite” Symposium. Ann Emerg Med. February 2001;37:166-167.] The lore of snakebite permeates nearly every culture. Few events can so promptly create skin-crawling sensation as the sight of a snake. Snakebite is also medically important, although its medical implications are often underappreciated. Although snakebite is an uncommon event, venomous snakes are indigenous to nearly every state in the United States. The unfortunate habit of collecting and keeping live venomous snakes assures that regions that rarely encounter snakebite have the opportunity to share in an interesting but tricky management. Snake venom poisoning is a remarkably complex disease. Crotaline snake venom contains dozens of components that affect multiple organs. Some components act locally to cause swelling, ecchymosis, and blebs. The long-term sequelae of local injury are disfiguring and disabling. Other venom components cause coagulopathy, and still others may cause diffuse capillary leak, myocardial depression, and even neuromuscular paralysis. Unfortunately, the incidence of snakebite may be destined to increase, as there appears to be no relief from the encroachment of human beings into snake habitat. A new treatment for snakebite has been developed over the past 20 years. Emergency physicians spearheaded the clinical development. As so often occurs during drug development, many important clinical discoveries occurred, in addition to documenting the safety and efficacy of the antivenom. These discoveries were presented at the “Advances in the Management of Snakebite” symposium at the 1999 North American Congress of Clinical Toxicology in La Jolla, CA. Annals is pleased to publish the proceedings of this symposium. The topics include the first published analysis regarding out-of-hospital and interhospital care of the snakebite patient by Patrick E. McKinney, MD. Dr. McKinney is an emergency physician and toxicologist with extensive experience in
ANNALS OF EMERGENCY MEDICINE
37:2 FEBRUARY 2001
SNAKEBITE SYMPOSIUM INTRODUCTION Dart & Waeckerle
the delivery and supervision of medical care in rural areas. Edward L. Hall, MD, addresses the issue of the surgical management of snakebite. This controversial issue has been the topic of many commentaries. For the past 20 years, Dr. Hall has provided snakebite guidance and treatment for a large portion of southern Georgia. Jude McNally, RPh, and Richard C. Dart, MD, PhD, report the primary results of the CroFab trials as well as information not published previously. Finally, Steven A. Seifert, MD, and Leslie V. Boyer, MD, address the phenomenon of recurrence: the return of venom effects after they had been successfully addressed with antivenom. This observation has created new understanding about snakebite and its appropriate treatment. It is uncommon for emergency physicians to inspire new therapeutic drugs. We often alter the use of available drugs, but it seems that we typically are forced to adjust to hand-me-down drugs developed for use in the ICU or outpatient care. Crotaline snakebite is like myocardial ischemia—delay in treatment allows injury to progress. Although much of the injury is ultimately reversible, the patient impact is very large. In short, the emergency department was the appropriate place for the development of this drug and should be the place where snakebite therapy is initiated.
FEBRUARY 2001
37:2
ANNALS OF EMERGENCY MEDICINE
1 6 7