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Morris CAD, Donaldson RE. Mechanical ventilation in snake envenomation of dogs and cats. Front Vet Sci 2023; 10:1071257. [PMID: 37065246 PMCID: PMC10090310 DOI: 10.3389/fvets.2023.1071257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 03/14/2023] [Indexed: 03/31/2023] Open
Abstract
Envenomation by snakes in Elapidae and Viperidae families have been associated with respiratory failure in dogs and cats. Mechanical ventilation may be required for hypoventilation due to neuromuscular paralysis or hypoxemia due to pulmonary hemorrhage or aspiration pneumonia. Median incidence of dogs and cats with snake envenomation that require mechanical ventilation is 13% (0.06-40%). Standard treatment of snake envenomation in dogs and cats includes prompt administration of appropriate antivenom and management of envenomation complications such as coagulopathy, rhabdomyolysis and acute kidney injury. When mechanical ventilation is required, overall prognosis is good with appropriate treatment. Standard anesthetic protocols and mechanical ventilator settings are generally appropriate, with lung protective ventilation strategies typically reserved for patients with pulmonary disease. Median survival to discharge for cats and dogs with elapid envenomation is 72% (76-84%) with 33 h (19.5-58 h) median duration of mechanical ventilation and 140 h (84-196 h) median hospitalization. This article reviews indications for mechanical ventilation in cats and dogs with snake envenomation, and discusses ventilator settings, anesthetic and nursing considerations, complications and outcomes specific to this disease.
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Affiliation(s)
- Cameron A. D. Morris
- Critical Care Department, Queensland Veterinary Specialists, Brisbane, QLD, Australia
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Cardwell MD, Massey DJ, Smelski G, Wüster W. Mohave Rattlesnake (Crotalus scutulatus) Identification Revisited. Wilderness Environ Med 2022; 33:210-218. [PMID: 35221167 DOI: 10.1016/j.wem.2022.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 01/05/2022] [Accepted: 01/14/2022] [Indexed: 10/19/2022]
Abstract
Crotalus scutulatus (Mohave rattlesnake) is a clinically significant pit viper broadly distributed across much of the arid southwestern United States and mainland Mexico. Identification of C scutulatus is a concern among emergency medical service and emergency department personnel owing to its reputation for severe envenomations and difficulty in visually differentiating between C scutulatus and other species, primarily Crotalus atrox (western diamond-backed rattlesnake). We contrast distinctive characteristics of C scutulatus, C atrox, and 3 other sympatric species: Crotalus molossus, Crotalus ornatus, and Crotalus viridis (western and eastern black-tailed rattlesnakes and prairie rattlesnake, respectively). Greenish coloration eliminates C atrox but does not confirm C scutulatus. Obvious coarse and fine speckling of the dorsal pattern and a pale postocular stripe intersecting the mouth characterize C atrox. Dorsal speckling is insignificant or absent in the other species, whereas the pale postocular stripe passes above the mouth in C scutulatus and C viridis and is absent in C molossus and C ornatus. Tails boldly ringed with alternating black and white or contrasting shades of gray are shared by C atrox and C scutulatus, respectively, but a lack of boldly ringed tails characterizes the other species. The proximal rattle segment is yellow and black, or entirely yellow, in C scutulatus but black in the others. The most reliable visual identifications are based on evaluations of multiple traits, all of which are variable to some extent. Traits such as tail ring width and the size and number of crown scales have frequently been overemphasized in the past.
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Affiliation(s)
- Michael D Cardwell
- Arizona Poison and Drug Information Center, Tucson, Arizona; Biology Department, San Diego State University, San Diego, California.
| | - Daniel J Massey
- Arizona Poison and Drug Information Center, Tucson, Arizona; Banner University Medical Center, Tucson, Arizona
| | | | - Wolfgang Wüster
- Molecular Ecology and Evolution at Bangor, School of Natural Sciences, Bangor University, Bangor, United Kingdom; Chiricahua Desert Museum, Rodeo, New Mexico
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Angioedema and Dual Nurse Flight Crew Cricothyrotomy After Envenomation by a Severed Rattlesnake Head. Air Med J 2020; 39:417-420. [PMID: 33012483 DOI: 10.1016/j.amj.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/05/2020] [Accepted: 06/17/2020] [Indexed: 11/21/2022]
Abstract
Crotalid envenomation may result in airway compromise from angioedema, anaphylaxis, or an anaphylactoid reaction. A 57-year-old man was transported by helicopter to the emergency department (ED) after a bite to his hand from a severed rattlesnake head. He rapidly developed facial and oropharyngeal edema that did not respond to standard treatment. After 2 unsuccessful attempts at intubation, the dual flight nurse team performed a cricothyrotomy. They notified the ED team en route, and antivenom was prepared before arrival. Angioedema was suspected because there was no concomitant urticaria, bronchoconstriction, or persistent hypotension. Edema and ecchymosis of the affected extremity were mild. Severe coagulopathy ensued, which was treated with bolus doses of antivenom and continuous infusion. This case report is significant for several reasons. It is the first detailing a prehospital cricothyrotomy performed by flight crew nurses for life-threatening airway edema caused by snakebite envenomation. In-flight notification enabled the ED staff to prepare and administer antivenom immediately after arrival. Despite the use of antivenom in bolus dosing, crotalid envenomation may be complicated by persistent or recurring coagulopathy, and continuous antivenom infusion may be useful. Finally, it highlights the danger of snakebite envenomation even after the death and decapitation of a snake.
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Greene SC, Folt J, Wyatt K, Brandehoff NP. Epidemiology of fatal snakebites in the United States 1989-2018. Am J Emerg Med 2020; 45:309-316. [PMID: 33046301 DOI: 10.1016/j.ajem.2020.08.083] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND There are 5000-10,000 snake envenomations annually in the United States. Fortunately, few are fatal. In this study we review the epidemiology of fatal snakebites. METHODS Native snakebite cases from the American Association of Poison Control Centers (AAPCC) National Poison Data System from 1989 to 2018 were reviewed. Additional cases that were not reported to the AAPCC were identified by reviewing Wikipedia and by searching PubMed and online news outlets using various combinations of relevant keywords. RESULTS We identified 101 fatal bites from native snakes. Rattlesnakes accounted for 74 (90.2%) of the 82 deaths for which the species was known or which occurred where rattlesnakes are the only native crotalids. There were five fatalities attributed to copperheads, two due to cottonmouths, and one caused by an eastern coral snake. Males were disproportionately affected. The median age for victims was 40 years old. In cases for which data were available, many of the snake interactions were intentional, e.g. religious services, animal husbandry, and attempting to kill the snake. CONCLUSIONS Death following envenomation from a native U.S. snake is unlikely, particularly if medical attention is sought promptly. Rattlesnake envenomations are more likely to be fatal than bites from other species. Intentionally engaging with a venomous snake raises the risk of incurring a fatal bite, as does concurrent alcohol or drug use. Age less than 12 years old does not appear to be a risk factor for a fatal outcome, while elderly patients may have a slightly increased risk of death.
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Affiliation(s)
- Spencer C Greene
- Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, 3525 Southern Blvd, Dayton, OH 45429, United States of America; Bayou City Medical Toxicology & Emergency Medicine Consultants, 6711 Stella Link Rd. #313, Houston, TX 77005, United States of America.
| | - Jason Folt
- Department of Emergency Medicine, Henry Ford Health System, 2799 West Grand Boulevard, CFP-258, Detroit, MI 48202, United States of America
| | - Kimberly Wyatt
- Department of Biological Sciences, University of Cincinnati, 614 Rieveschl Hall, Cincinnati, OH 45221-0006, United States of America
| | - Nicklaus P Brandehoff
- Rocky Mountain Poison and Drug Center, 1391 Speer Blvd #600, Denver, CO 80204, United States of America; Department of Emergency Medicine, University of Colorado School of Medicine, 12401 East 17th Avenue, Aurora, CO 80045, United States of America
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Yeh YT, Chen MH, Chang JCY, Fan JS, Yen DHT, Chen YC. Protobothrops mucrosquamatus Bites to the Head: Clinical Spectrum from Case Series. Am J Trop Med Hyg 2018; 99:753-755. [PMID: 29943718 PMCID: PMC6169154 DOI: 10.4269/ajtmh.18-0220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/02/2018] [Indexed: 11/07/2022] Open
Abstract
Protobothrops mucrosquamatus (Trimeresurus mucrosquamatus) is a medically important species of pit viper with a wide geographic distribution in Southeast Asia. Bites by P. mucrosquamatus mostly involve the extremities. Little is known about the toxic effects of P. mucrosquamatus envenoming to the head because of the infrequency of such occurrence. To better delineate the clinical manifestations of envenoming to the head, we report three patients who suffered from P. mucrosquamatus bites to the head and were treated successfully. All three patients developed progressive soft tissue swelling extending from head to neck, with two patients expanding further onto the anterior chest wall. Mild thrombocytopenia was noted in two patients. One patient had transient acute renal impairment and airway obstruction, necessitating emergent intubation. All three patients received high doses of species-specific antivenom with recovery within 1 week. No adverse reactions to antivenom were observed.
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Affiliation(s)
- Ying-Tse Yeh
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Julia Chia-Yu Chang
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ju-Sing Fan
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - David Hung-Tsang Yen
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yen-Chia Chen
- Emergency Department, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- National Defense Medical Center, Taipei, Taiwan
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Idicula W, Varman R, Nguyen D. Acute airway obstruction management in scorpion envenomation to submandibular region: A case report. OTOLARYNGOLOGY CASE REPORTS 2018. [DOI: 10.1016/j.xocr.2018.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract
Rattlesnake envenomation causes a spectrum of symptoms and signs, many of which closely resemble an anaphylactic reaction. Development of airway compromise after a snake bite to an extremity is unusual, but has been previously reported. The majority of such reports detail a history of probable sensitization from previous contact with snakes or snake venom. Few reports exist without such previous contact; no reports are of pediatric cases. Here we present a 14-year-old boy with no history of prior snake exposure who presents with an anaphylactoid reaction after a rattlesnake bite.
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Bush SP, Lepak MR. Reply: severe anaphylactic reaction following crotalidae polyvalent immune fab (ovine) administration for copperhead snakebite. Ann Pharmacother 2015; 49:497-8. [PMID: 25762656 DOI: 10.1177/1060028015571164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Recurrent coagulopathy after rattlesnake bite requiring continuous intravenous dosing of antivenom. Case Rep Emerg Med 2015; 2015:719302. [PMID: 25664187 PMCID: PMC4309308 DOI: 10.1155/2015/719302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 12/20/2014] [Indexed: 11/26/2022] Open
Abstract
Context. Snakebite envenomation is common and may result in systemic coagulopathy. Antivenom can correct resulting laboratory abnormalities; however, despite antivenom use, coagulopathy may recur, persist, or result in death after a latency period. Case Details. A 50-year-old previously healthy man presented to the emergency department after a rattlesnake bite to his right upper extremity. His presentation was complicated by significant glossal and oropharyngeal edema requiring emergent cricothyrotomy. His clinical course rapidly improved with the administration of snake antivenom (FabAV); the oropharyngeal and upper extremity edema resolved within several days. However, over the subsequent two weeks, he continued to have refractory coagulopathy requiring multiple units of antivenom. The coagulopathy finally resolved after starting a continuous antivenom infusion. Discussion. Envenomation may result in latent venom release from soft tissue depots that can last for two weeks. This case report illustrates the importance of close hemodynamic and laboratory monitoring after snakebites and describes the administration of continuous antivenom infusion, instead of multidose bolus, to neutralize latent venom release and correct residual coagulopathy.
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Lefkowitz RY, Taylor J, Balfe D. Reality bites: a case of severe rattlesnake envenomation. J Intensive Care Med 2012; 28:314-9. [PMID: 22588374 DOI: 10.1177/0885066612446415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rattlesnake venoms can cause a wide range of adverse human health effects. However, with the availability of modern antivenin, toxicity can generally be minimized and controlled. We present a rare case of rattlesnake envenomation resulting in severe systemic effects and syndrome relapse. Management considerations and patient course are described in the context of the current literature.
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Affiliation(s)
- Rafael Y Lefkowitz
- Department Fellow of Internal Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA
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Janes DN, Bush SP, Kolluru GR. Large Snake Size Suggests Increased Snakebite Severity in Patients Bitten by Rattlesnakes in Southern California. Wilderness Environ Med 2010; 21:120-6. [DOI: 10.1016/j.wem.2010.01.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Richardson WH, Goto CS, Gutglass DJ, Williams SR, Clark RF. Rattlesnake envenomation with neurotoxicity refractory to treatment with crotaline Fab antivenom. Clin Toxicol (Phila) 2008; 45:472-5. [PMID: 17503249 DOI: 10.1080/15563650701338187] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Neurotoxicity following rattlesnake envenomation is reported with certain crotaline species. In some instances, crotaline Fab antivenom therapy that effectively halts progression of local tissue edema and hemotoxicity fails to reverse neurologic venom effects. CASE SERIES A 50-year-old man presented following a rattlesnake envenomation to the left ring finger. He had swelling and pain in the affected hand and complained of dyspnea and dysphonia. Significant fasciculations were seen in the face, tongue, neck, trunk, and arms. The patient received crotaline Fab antivenom but continued to develop worsening respiratory distress. His respiratory insufficiency requiring ventilatory support appeared related to respiratory muscle incoordination as extremity motor function remained intact. Initial control of local edema progression and hematologic parameters was achieved with antivenom, but diffuse fasciculations involving the entire body worsened despite aggressive antivenom treatment. In another case, a 9-year-old boy was envenomated by a rattlesnake on the left thenar eminence. He presented with pain and swelling up to the forearm and fasciculations of the tongue, face, and upper extremities. The progression of edema was halted at the mid-bicep level and hematologic parameters normalized with crotaline Fab antivenom. However, fasciculations continued for two days despite antivenom treatment. CONCLUSION We describe two cases of neurotoxicity following rattlesnake envenomation in which treatment with crotaline Fab antivenom adequately obtained initial control of local swelling and hematologic effects, but neurotoxic venom effects remained refractory to antivenom therapy. This phenomenon is anecdotally recognized following certain crotaline species envenomations.
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Affiliation(s)
- William H Richardson
- Palmetto Health Richland, Palmetto Poison Center, South Carolina College of Pharmacy-University of South Carolina, Columbia, South Carolina 29208, USA.
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