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Greene S, Gilbert M, Wolk B, Campleman S, Ruha AM. Geographic variation in the clinical features of Mohave rattlesnake ( Crotalus scutulatus) envenomations reported to the North American Snakebite Registry. Toxicon X 2024; 21:100171. [PMID: 38047156 PMCID: PMC10689943 DOI: 10.1016/j.toxcx.2023.100171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/04/2023] [Accepted: 10/25/2023] [Indexed: 12/05/2023] Open
Abstract
The geographic variation of Mohave rattlesnake (Crotalus scutulatus) venom is well established. We reviewed all the Mohave rattlesnake bites reported to the Toxicology Investigators Consortium's North American Snakebite Registry between January 1, 2015 and 12/31/2021. Data reviewed for this study included details regarding the snake encounter, patient demographics, signs and symptoms, treatment, and outcomes. Our objective was to describe the epidemiology, clinical manifestations, and management of Mohave rattlesnake envenomations using prospective data from two geographically distinct sites. There were 20 subjects, including eight nonpregnant females. Ages ranged from seven to 75 years, median age 48. Nine of the bites were managed in Arizona and 11 in California. In Arizona, all envenomated patients had local swelling. None had neurological toxicity. In California, swelling was present in nine patients. Neurological effects were observed in five subjects. Four Arizona patients and one California patient had hypotension requiring treatment. Each site had one patient with thrombocytopenia. An Arizona patient who sustained a bite to the face was intubated. Rhabdomyolysis occurred in two California patients. All envenomated patients received antivenom. Mohave rattlesnakes have the potential to cause significant local and/or systemic toxicity. Neurotoxicity was not observed in envenomations from Mohave rattlesnakes that presumably lack Mohave toxin, but hypotension and gastrointestinal signs were more common than in bites from snakes believed to possess Mohave toxin. Neurological toxicity was limited to paresthesias and fasciculations. Significant skeletal or respiratory muscle weakness was not observed in our study population.
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Affiliation(s)
- Spencer Greene
- University of Houston/HCA Kingwood Emergency Medicine Residency Program, Kingwood, TX, USA
| | - Matthew Gilbert
- University of Houston/HCA Kingwood Emergency Medicine Residency Program, Kingwood, TX, USA
| | - Brian Wolk
- Department of Emergency Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | | | - Anne-Michelle Ruha
- Department of Medical Toxicology, Banner University Medical Center – Phoenix, Phoenix, AZ, USA
| | - on behalf of the ToxIC Snakebite Study Group
- University of Houston/HCA Kingwood Emergency Medicine Residency Program, Kingwood, TX, USA
- Department of Emergency Medicine, Loma Linda University School of Medicine, Loma Linda, CA, USA
- American College of Medical Toxicology, Phoenix, AZ, USA
- Department of Medical Toxicology, Banner University Medical Center – Phoenix, Phoenix, AZ, USA
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Pandit K, Rawal A, Maskey HMS, Nepal G. Neurological and neuro-ophthalmological manifestations of snake bite: a systematic review. Ann Med Surg (Lond) 2024; 86:392-400. [PMID: 38222724 PMCID: PMC10783398 DOI: 10.1097/ms9.0000000000001523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/09/2023] [Indexed: 01/16/2024] Open
Abstract
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.
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Affiliation(s)
- Kamal Pandit
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Aastha Rawal
- Department of Pharmacy, Manmohan Memorial Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Himang Man Singh Maskey
- Department of Ophthalmology, Maharjgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj, Kathmandu
| | - Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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Heise CW, Cunningham C, Ruha AM, O'Connor AD. One Bite, Two Patients: Disparate Clinical Courses Following Simultaneous Crotalus oreganus abyssus Envenomation. Wilderness Environ Med 2020; 31:354-357. [PMID: 32826164 DOI: 10.1016/j.wem.2020.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 11/18/2022]
Abstract
A number of crotaline species have been associated with neurotoxic envenomation in North America. One clinical sign that can occur is myokymia: fine, involuntary, wave-like muscle movements occurring at regular intervals. We report an unusual scenario in which a single snakebite resulted in simultaneous envenomation of 2 patients. Both developed myokymia, with 1 having respiratory compromise. One patient also developed a hypersensitivity reaction to antivenom. Envenomation by the Grand Canyon rattlesnake, Crotalus oreganus abyssus, can produce significant neurotoxicity and resultant respiratory compromise. Antivenom may be helpful but can produce hypersensitivity reactions.
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Affiliation(s)
- Craig William Heise
- Division of Medical Toxicology and Precision Medicine, Department of Medicine, University of Arizona College of Medicine, Phoenix, AZ; Department of Medical Toxicology, Banner - University Medicine Center Phoenix, Phoenix, AZ.
| | | | - Anne-Michelle Ruha
- Division of Medical Toxicology and Precision Medicine, Department of Medicine, University of Arizona College of Medicine, Phoenix, AZ; Department of Medical Toxicology, Banner - University Medicine Center Phoenix, Phoenix, AZ
| | - Ayrn D O'Connor
- Division of Medical Toxicology and Precision Medicine, Department of Medicine, University of Arizona College of Medicine, Phoenix, AZ; Department of Medical Toxicology, Banner - University Medicine Center Phoenix, Phoenix, AZ
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Keyler DE, Saini V, O’Shea M, Gee J, Smith CF, Mackessy SP. Crotalus oreganus concolor: Envenomation Case with Venom Analysis and a Diagnostic Conundrum of Myoneurologic Symptoms. Wilderness Environ Med 2020; 31:220-225. [DOI: 10.1016/j.wem.2019.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 12/01/2019] [Accepted: 12/09/2019] [Indexed: 10/24/2022]
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Kempema J, Watanabe B, Potter A, Williams M. Bites, Stings, and Envenomations. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0140-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Schezaro-Ramos R, Da Silva SL, Pereira BB, Santa Fé Miguel AT, Mendes B, Mogollón NGS, Hyslop S, Carregari VC, Almeida JR. In vitro effects of Crotalus atrox snake venom on chick and mouse neuromuscular preparations. Comp Biochem Physiol C Toxicol Pharmacol 2018; 209:37-45. [PMID: 29604435 DOI: 10.1016/j.cbpc.2018.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 03/06/2018] [Accepted: 03/24/2018] [Indexed: 12/25/2022]
Abstract
The neuromuscular effect of venoms is not a major clinical manifestation shared between rattlesnakes native to the Americas, which showed two different venom phenotypes. Taking into account this dichotomy, nerve muscle preparations from mice and chicks were used to investigate the ability of Crotalus atrox venom to induce in vitro neurotoxicity and myotoxicity. Unlike crotalic venoms of South America, low concentrations of C. atrox venom did not result in significant effects on mouse neuromuscular preparations. The venom was more active on avian nerve-muscle, showing reduction of twitch heights after 120 min of incubation with 10, 30 and 100 μg/mL of venom with diminished responses to agonists and KCl. Histological analysis highlighted that C. atrox was myotoxic in both species of experimental animals; as evidenced by degenerative events, including edematous cells, delta lesions, hypercontracted fibers and muscle necrosis, which can lead to neurotoxic action. These results provide key insights into the myotoxicity and low neurotoxicity of C. atrox in two animal models, corroborating with previous genomic and proteomic findings and would be useful for a deeper understanding of venom evolution in snakes belonging to the genus Crotalus.
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Affiliation(s)
- Raphael Schezaro-Ramos
- Department of Pharmacology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Saulo L Da Silva
- Ikiam - Universidad Regional Amazónica, Km 7 Via Muyuna, Tena, Napo, Ecuador
| | - Beatriz B Pereira
- Department of Pharmacology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Ananda T Santa Fé Miguel
- Department of Pharmacology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Bruno Mendes
- Department of Pharmacology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | | | - Stephen Hyslop
- Department of Pharmacology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Victor C Carregari
- Proteomic and Metabonomic Laboratory, Fondazione Santa Lucia, Rome, Italy
| | - José R Almeida
- Ikiam - Universidad Regional Amazónica, Km 7 Via Muyuna, Tena, Napo, Ecuador.
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Valenta J, Stach Z, Stourac P, Kadanka Z, Michalek P. Neurological symptoms following the Fea's viper (Azemiops feae) bite. Clin Toxicol (Phila) 2015; 53:1150-1. [PMID: 26469140 DOI: 10.3109/15563650.2015.1094703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Jiri Valenta
- a Department of Anaesthesiology and Intensive Care , First Faculty of Medicine, Charles University in Prague and General University Hospital , Prague , Czech Republic
| | - Zdenek Stach
- a Department of Anaesthesiology and Intensive Care , First Faculty of Medicine, Charles University in Prague and General University Hospital , Prague , Czech Republic
| | - Petr Stourac
- b Department of Paediatric Anaesthesiology and Intensive Care Medicine , Faculty of Medicine, Masaryk University and University Hospital , Brno , Czech Republic
| | - Zdenek Kadanka
- c Department of Neurology , Faculty of Medicine, Masaryk University and University Hospital , Brno , Czech Republic
| | - Pavel Michalek
- a Department of Anaesthesiology and Intensive Care , First Faculty of Medicine, Charles University in Prague and General University Hospital , Prague , Czech Republic
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Medrano-Martínez V, Pérez-Sempere A, Moltó-Jordá JM, Fernández-Izquierdo S, Francés-Pont I, Mallada-Frechin J, Piqueras-Rodríguez L. Eyelid myokymia in patients with migraine taking topiramate. Acta Neurol Scand 2015; 132:143-6. [PMID: 25828425 DOI: 10.1111/ane.12395] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Although ocular side effects of topiramate are common, neuroophthalmologic manifestations such as blepharospasm, myokymia and oculogyric crisis are scarcely reported. METHODS We present a serie of 8 patients with migraine who developed eyelid myokymia after treatment with topiramate. We reviewed all patients with migraine treated with topiramate attending the headache outpatient clinic of our hospital from January 2008 to December 2012. RESULTS During the study period, a total of 140 patients with migraine were treated with topiramate in our headache clinic. Eight presented eyelid myokymia after beginning treatment with topiramate (5,7%). Topiramate was stopped and myokymia disappeared in all patients, it was prescribed again and eyelid myokymia reappeared with their previous characteristics in all patients. CONCLUSIONS Eyelid myokymia is an underreported side-effect of topiramate in patients with migraine, of unknown cause, so that in future, further studies are need to examine whether patients with migraine are predisposed or not to this adverse effect.
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Affiliation(s)
- V. Medrano-Martínez
- Department of Neurology; Hospital General Universitario Virgen De La Salud; Elda Spain
| | - A. Pérez-Sempere
- Department of Neurology; Hospital General Universitario De Alicante; Alicante Spain
| | | | | | - I. Francés-Pont
- Department of Neurology; Hospital General Universitario Virgen De La Salud; Elda Spain
| | - J. Mallada-Frechin
- Department of Neurology; Hospital General Universitario Virgen De La Salud; Elda Spain
| | - L. Piqueras-Rodríguez
- Department of Neurology; Hospital General Universitario Virgen De La Salud; Elda Spain
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Bosak AR, Ruha AM, Graeme KA. A case of neurotoxicity following envenomation by the Sidewinder rattlesnake, Crotalus cerastes. J Med Toxicol 2015; 10:229-31. [PMID: 24414250 DOI: 10.1007/s13181-013-0373-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION North American rattlesnake envenomations typically result in local tissue injury and hematologic derangements. Neurotoxicity is uncommon but when present often manifests as fasciculations and paresthesias. Neurotoxicity following Sidewinder (Crotalus cerastes) envenomation has not been previously reported. CASE REPORT A 56-year-old man bitten on the right foot developed painful paresthesias, weakness and fasciculations of the right lower extremity, and involuntary muscle contractions of the anterior thigh. Local tissue effects and hemotoxicity never developed. The patient was discharged 5 days after the bite with resolution of fasciculations but continued to have right-sided weakness. The snake was identified as a Sidewinder, C. cerastes, by the patient and two independent herpetologists. CONCLUSION This is the first reported case of a Sidewinder rattlesnake envenomation resulting in neurotoxicity.
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Affiliation(s)
- Adam R Bosak
- Department of Medical Toxicology, Banner Good Samaritan Medical Center, 925 East McDowell Road, Phoenix, Arizona, USA,
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Bedside management considerations in the treatment of pit viper envenomation. J Emerg Nurs 2014; 40:537-45. [PMID: 24698390 DOI: 10.1016/j.jen.2014.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 11/25/2013] [Accepted: 01/01/2014] [Indexed: 01/21/2023]
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Abstract
Snakebite is classified by the WHO as a neglected tropical disease. Envenoming is a significant public health problem in tropical and subtropical regions. Neurotoxicity is a key feature of some envenomings, and there are many unanswered questions regarding this manifestation. Acute neuromuscular weakness with respiratory involvement is the most clinically important neurotoxic effect. Data is limited on the many other acute neurotoxic manifestations, and especially delayed neurotoxicity. Symptom evolution and recovery, patterns of weakness, respiratory involvement, and response to antivenom and acetyl cholinesterase inhibitors are variable, and seem to depend on the snake species, type of neurotoxicity, and geographical variations. Recent data have challenged the traditional concepts of neurotoxicity in snake envenoming, and highlight the rich diversity of snake neurotoxins. A uniform system of classification of the pattern of neuromuscular weakness and models for predicting type of toxicity and development of respiratory weakness are still lacking, and would greatly aid clinical decision making and future research. This review attempts to update the reader on the current state of knowledge regarding this important issue.
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Affiliation(s)
- Udaya K. Ranawaka
- Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
- * E-mail:
| | - David G. Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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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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Schaeffer TH, Khatri V, Reifler LM, Lavonas EJ. Incidence of immediate hypersensitivity reaction and serum sickness following administration of Crotalidae polyvalent immune Fab antivenom: a meta-analysis. Acad Emerg Med 2012; 19:121-31. [PMID: 22320362 DOI: 10.1111/j.1553-2712.2011.01276.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Crotalidae polyvalent immune Fab (ovine) (FabAV) is commonly used in the treatment of symptomatic North American crotaline snake envenomation. When approved by the U.S. Food and Drug Administration in 2000, the incidences of immediate hypersensitivity reactions and serum sickness were reported as 0.14 and 0.18, respectively. The objective of this meta-analysis was to evaluate the incidence of immediate hypersensitivity reactions and serum sickness reported in studies of patients treated with FabAV therapy after North American crotaline envenomation. METHODS The authors searched PubMed, Ovid MEDLINE, and EMBASE from January 1, 1997, to September 20, 2010, for English-language medical literature and cross-referenced bibliographies of reviewed articles. The published abstracts of the major toxicology conferences were also searched. All prospective and retrospective cohort studies with patients receiving FabAV therapy for North American crotaline envenomations were eligible for data abstraction. Two content experts reviewed full-text articles and extracted relevant study design and outcome data. Proportions of immediate hypersensitivity and serum sickness for each study were analyzed in a random-effects model to produce an overall estimate of immediate hypersensitivity and serum sickness incidence associated with FabAV administration. RESULTS The literature search revealed 11 unique studies of patients who received FabAV that contained information on immediate hypersensitivity reactions and serum sickness. The meta-analysis produced a combined estimate of the incidence of immediate hypersensitivity of 0.08 (95% confidence interval [CI] = 0.05 to 0.11) and a combined estimate of the incidence of serum sickness of 0.13 (95% CI = 0.07 to 0.21). CONCLUSIONS In this systematic literature review and meta-analysis, the combined estimates of the incidence of immediate hypersensitivity reactions and serum sickness from FabAV in the treatment of symptomatic North American crotaline envenomations appear to be lower than previously reported, at 0.08 and 0.13, respectively.
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Affiliation(s)
- Tammi H Schaeffer
- Rocky Mountain Poison & Drug Center, Denver Health and Hospital Authority, Denver, CO, USA.
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Hack JB, Orogbemi B, Deguzman JM, Brewer KL, Meggs WJ, O'Rourke D. A localizing circumferential compression device delayed death after artificial eastern diamondback rattlesnake envenomation to the torso of an animal model in a pilot study. J Med Toxicol 2010; 6:207-11. [PMID: 20349164 DOI: 10.1007/s13181-010-0050-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Nearly all prior studies to delay onset of systemic toxicity and death after snake bite use a model of distal extremity envenomation. In the first of a series of planned studies using snake venoms with different toxicity profiles, the application of a novel device in a new model of torso envenomation in the setting of Eastern Coral Snake (Micrurus fulvius) venom (a potent neurotoxin) envenomation showed promise by delaying systemic intoxication. In this pilot study, we investigated this novel localizing circumferential compression (LoCC) device's ability to delay onset of life threatening systemic toxicity after Eastern Diamondback Rattlesnake (Crotalus adamanteus) envenomation, a potent hemotoxic and myotoxic venom. With university approval, four juvenile female pigs (22-25 kg) were anesthetized, sedated, and intubated but not paralyzed to allow for spontaneous respirations. Each animal was injected subcutaneously with 50 mg of C. adamanteus venom in identical preselected areas of the trunk. After 1 min, two treatment animals had the LoCC device applied; two control animals had no intervention. Vital signs were recorded every 10 min for the first 2 h and every 30 min thereafter. Endpoints included cardiovascular collapse (fatal arrhythmia, loss of mean arterial pressure, or pulse) or respiratory arrest (<3 breaths/min, saturation < 80%) or survival to 7 h. The pigs in the treatment group reached an endpoint at an average time of 355 (+/-65) min compared with control 32 (+/-3.5) min (p < 0.04). In this pilot study, the LoCC device significantly delayed onset of systemic symptoms and death after torso envenomation with Eastern Diamondback Rattlesnake venom in this model.
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Affiliation(s)
- Jason B Hack
- Department of Emergency Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
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Vanhaesebrouck AE, Bhatti SF, Bavegems V, Gielen IM, Van Soens I, Vercauteren G, Polis I, Van Ham LM. Inspiratory stridor secondary to palatolingual myokymia in a Maltese dog. J Small Anim Pract 2010; 51:173-5. [DOI: 10.1111/j.1748-5827.2009.00865.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Crotaline snakebites occur frequently in children, often resulting in significant morbidity. Crotalidae Polyvalent Immune Fab antivenom (FabAV) became available for clinical use in the US in 2000 and is currently the standard of care for the treatment of crotaline envenomation. The pediatric emergency care provider should be familiar with FabAV because its judicious use in affected children can greatly decrease morbidity caused by crotaline snakebites. This article will review the use of FabAV for the treatment of pediatric crotaline envenomation.
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