Assuntos
Mordeduras de Serpentes/terapia , Venenos de Víboras/intoxicação , Medicina Selvagem/métodos , Antivenenos/uso terapêutico , Canadá , Venenos de Crotalídeos/intoxicação , Medicina de Emergência/métodos , Medicina de Emergência/normas , Feminino , Humanos , Gravidez , Mordeduras de Serpentes/epidemiologia , Sociedades Médicas , Estados Unidos , Medicina Selvagem/normasRESUMO
We report the first documented death due to a coral snake (Micrurus species) in the United States (U.S.) in over 40 years. The victim failed to seek medical care following the bite of an eastern coral snake (Micrurus fulvius) and succumbed within hours. Post-mortem proof of envenomation was obtained using an ELISA (enzyme-linked immunosorbent assay) developed specifically for this investigation. U.S. coral snakes are briefly reviewed in terms of their venom compositions, their clinical effects, and proper pre-hospital and hospital management. The clinical significance of the impending absence of commercially available antivenom for coral snake bites in the U.S. is highlighted.
Assuntos
Elapidae , Mordeduras de Serpentes/mortalidade , Adulto , Animais , Antivenenos/uso terapêutico , Venenos Elapídicos/toxicidade , Evolução Fatal , Humanos , Masculino , Mordeduras de Serpentes/terapiaRESUMO
Pressure immobilisation (PIM) has been recommended for field management of bites by some venomous snakes. A narrow range of pressures under the encompassing wrap is necessary for PIM to limit venom spread. This study sought to evaluate the effect of focused training on volunteers' ability to apply PIM and to retain such skill over time. Forty volunteers were randomly divided into two groups: Group 1 (N=20; controls) received standard written instructions in PIM application; and Group 2 (N=20) received focused instruction during a 4-h training session (including hands-on practice and real-time feedback regarding pressures achieved). After voicing confidence with the technique, volunteers were tested at 1h, 1 day, 3 days and 3 months post training. One-hour post training, no volunteers in the control group were successful in applying PIM with the correct pressure. Twelve volunteers (60%) in Group 2 achieved target pressures 1h after training. However, there was rapid loss of ability to apply PIM correctly by Group 2, falling to just 25% success at 3 days, with little further deterioration at 3 months. Neither written instructions nor intense training with feedback adequately prepares individuals to apply PIM with correct pressures under the wrap.
Assuntos
Tratamento de Emergência/métodos , Imobilização/métodos , Mordeduras de Serpentes/terapia , Venenos de Serpentes/intoxicação , Adulto , Idoso , Competência Clínica , Tratamento de Emergência/normas , Feminino , Humanos , Perna (Membro) , Masculino , Pessoa de Meia-Idade , PressãoRESUMO
Bites by the mottled rock rattlesnake (Crotalus lepidus lepidus) are rare. There appear to be no reports of bites by this subspecies in the literature. This is a case report of a bite by a captive specimen of this diminutive pit viper, and includes a review of what is known regarding its venom.
Assuntos
Venenos de Crotalídeos/toxicidade , Crotalus , Mordeduras de Serpentes/patologia , Adulto , Animais , Testes Hematológicos , Humanos , Masculino , TexasRESUMO
A team of emergency physicians and nurses from Stanford University responded to the devastating January 2010 earthquake in Haiti. Because of the extreme nature of the situation, combined with limited resources, the team provided not only acute medical and surgical care to critically injured and ill victims, but was required to uniquely expand its scope of practice. Using a narrative format and discussion, it is the purpose of this paper to highlight our experience in Haiti and use these to estimate some of the skills and capabilities that will be useful for physicians who respond to similar future disasters.
Assuntos
Planejamento em Desastres , Serviços Médicos de Emergência , Desastres , Terremotos , Haiti , HumanosRESUMO
The global problem of venomous snakebite continues to attract attention despite it being described as a "neglected" issue. The current focus of the World Health Organization (WHO) remains anti-snake venom quality, although "availability and sustainability" of supply are consistently described as the key issues. Sustainability of antivenom supply has been elusive, with cost and pricing in developing countries being cited as the major reasons. The current WHO approach fails to explore the cost issue, but rather focuses on quality improvements, which may well adversely affect the costs of a product already perceived to be 'unaffordable.' The reference to cost and price indicates a marketing-based perspective may well give more relevant solutions to the snakebite crisis. This paper introduces a marketing model to examine global snakebite and to identify if the current approach is relevant and effective. The "4 Ps" model examines if the correct products are available, whether sufficient information exists concerning estimated market size, whether the assumptions frequently made about the costs of the product are correct and fully understood, if the product is promoted properly, and whether the method by which the product reaches the end user is optimum. The resulting analysis demonstrates that the current approach is characterized by a misunderstanding of the nature of the global snakebite problem. Further, a lack of implementation of key solutions, such as training doctors in developing countries with relevant protocols, has inevitably led to a lack of improvement in the snakebite arena over the last 30 years.
Assuntos
Antivenenos/economia , Antivenenos/uso terapêutico , Saúde Pública , Mordeduras de Serpentes/epidemiologia , Venenos de Serpentes , Animais , Análise Custo-Benefício , Custos e Análise de Custo , Países em Desenvolvimento , Humanos , Qualidade da Assistência à Saúde , Mordeduras de Serpentes/tratamento farmacológico , Venenos de Serpentes/antagonistas & inibidores , Venenos de Serpentes/imunologia , Venenos de Serpentes/intoxicação , Organização Mundial da SaúdeRESUMO
The crown-of-thorns starfish (Acanthaster planci) inhabits coral reefs, largely throughout the Indo-Pacific region. Its dorsal surface is covered with stout thorn-like spines. When handled or stepped on by humans, the spines can puncture the skin, causing an immediate painful reaction, followed by inflammation and possible infection. Initial pain and swelling may last for days. Effects of envenomation on the liver have been demonstrated previously in animal models, but hepatic toxicity has not previously been described in humans. We describe elevated liver enzymes in a 19-year-old female associated with A planci spine puncture wounds. To our knowledge, this is the first documented report of transaminitis in a human after A planci envenomation.
Assuntos
Mordeduras e Picadas/complicações , Doença Hepática Induzida por Substâncias e Drogas , Pé/patologia , Corpos Estranhos/complicações , Testes de Função Hepática , Fígado/enzimologia , Estrelas-do-Mar , Animais , Feminino , Pé/cirurgia , Humanos , Hepatopatias/enzimologia , Hepatopatias/patologia , Peçonhas/toxicidade , Adulto JovemRESUMO
Snakebites continue to be a major medical concern in India. However, there is very little hard evidence of a numerical nature to enable us to understand which species are responsible for mortality and morbidity. For many decades, the concept of the "Big 4" Snakes of Medical Importance has reflected the view that 4 species are responsible for Indian snakebite mortality--the Indian cobra (Naja naja), the common krait (Bungarus caeruleus), the Russell's viper (Daboia russelii) and the saw-scaled viper (Echis carinatus). However, a recent discovery that another species, the hump-nosed pit viper (Hypnale hypnale), is capable of causing lethal envenomation, and that this problem was being concealed by systematic misidentification of this species as the saw-scaled viper, has necessitated a review of the concept of the "Big 4." The concept of the "Big 4" snakes is reviewed to demonstrate its failure to include all currently known snakes of medical significance in India, and its negative effects related to clinical management of snakebite. The emergence of the hump-nosed pit viper (Hypnale hypnale) as a snake of medical significance has rendered the "Big 4" obsolete in terms of completeness. The concept of the "Big 4" is restricting sound epidemiological work and the development of effective snake antivenoms. It should be replaced by the model introduced in the 1980s by the World Health Organization, which has not received adequate circulation and implementation.
Assuntos
Antivenenos/uso terapêutico , Mordeduras de Serpentes/complicações , Serpentes/classificação , Venenos de Víboras/efeitos adversos , Animais , Bungarotoxinas , Bungarus , Venenos de Crotalídeos , Venenos Elapídicos , Elapidae , Humanos , Índia , Daboia , Especificidade da Espécie , ViperidaeRESUMO
Venomous snakebite continues to exact a tremendous toll in human suffering and mortality in India. Contributing to this problem is the fact that all of the current Indian snake antivenom manufacturers include a great deal of misinformation in the package inserts and guidelines that accompany their products. Examples include erroneous recommendations regarding first aid, misleading information regarding the signs and symptoms to be anticipated after Indian snakebite, and misleading and ambiguous recommendations as to initial dosing and repeat dosing of antivenom. In addition, the significant problem of acute adverse reactions to Indian antivenoms is compounded by a lack of appropriate recommendations regarding prevention, diagnosis, and management of such reactions. It is the intent of this article to point out problems with the current Indian antivenom product guidelines and to encourage these manufacturers to produce new literature to accompany their products based on the best available evidence.
Assuntos
Antivenenos/uso terapêutico , Rotulagem de Medicamentos/normas , Primeiros Socorros/normas , Mordeduras de Serpentes/tratamento farmacológico , Venenos de Serpentes/antagonistas & inibidores , Animais , Guias como Assunto , Humanos , Índia , Mordeduras de Serpentes/diagnóstico , SerpentesRESUMO
Fatalities following rattlesnake bite are rare in the United States, usually occur some hours following the bite, and are generally secondary to direct venom effects. We report a patient with acute syncope and subsequent massive aspiration resulting in airway obstruction and rapid death following a probable Northern Pacific rattlesnake (Crotalus oreganus oreganus) bite.
Assuntos
Crotalus , Mordeduras de Serpentes/diagnóstico , Animais , Morte Súbita Cardíaca , Diagnóstico Diferencial , Tratamento de Emergência , Humanos , Masculino , Pessoa de Meia-Idade , Aspiração Respiratória/etiologia , Mordeduras de Serpentes/complicações , Mordeduras de Serpentes/patologia , Síncope/etiologiaRESUMO
The prevention and management of venomous snakebite in the world's mountains present unique challenges. This paper presents a series of practical, clinically sound recommendations for management of venomous snakebite in a mountain environment. The authors performed an extensive review of current literature using search engines and manual searches. They then fused the abundant knowledge of snakebite with the realities of remote first aid and mountain rescue to develop recommendations. A summary is provided of the world's most troublesome mountain snakes and the mechanisms of toxicity from their bites. Preventive measures are described. Expected symptoms and signs are reviewed in lay and medical terms. A review of currently recommended first-aid measures and advanced medical management for physicians, paramedics, and other clinicians is included. Venomous snakebites in mountainous environments present unique challenges for management. This paper offers practical recommendations for managing such cases and summarizes the approach to first aid and advanced management in 2 algorithms.
Assuntos
Antivenenos/uso terapêutico , Serviços Médicos de Emergência/normas , Primeiros Socorros/normas , Mordeduras de Serpentes/prevenção & controle , Venenos de Serpentes , Animais , Árvores de Decisões , Serviços Médicos de Emergência/estatística & dados numéricos , Primeiros Socorros/estatística & dados numéricos , Montanhismo , SerpentesRESUMO
OBJECTIVES: In India, venomous snakebite remains an enigma. Although ineffective first aid treatments that are centuries old continue to be used by people bitten by snakes, important factual information, such as the importance and uniqueness of bites by the northern saw-scaled viper (Echis sochureki), has been largely lost and forgotten. In this paper, we report the first systematically gathered data on the clinical course of envenoming by E sochureki in Rajasthan, India. Clinical information is reported on 12 victims bitten by definitively identified E sochureki, and 2 clinical cases are described in greater detail to illustrate the severity of envenoming by this snake. METHODS: A data collection form was developed and used to prospectively gather clinical information regarding patients who were bitten by E sochureki and who brought the dead snake with them to hospital. All snakes were definitively identified by an experienced herpetologist. Information on symptoms and signs, management (both first aid and hospital), and outcomes was collected. RESULTS: All 12 victims had evidence of systemic envenoming, including abnormal 20-minute whole blood clotting tests (with systemic bleeding in 7). All received polyvalent antivenom made, in part, with Echis carinatus venom from southern India. Antivenom was relatively ineffective in restoring coagulation to these patients. All patients survived, although 1 patient suffered an intracranial bleed with residual hemiparesis. CONCLUSIONS: Echis sochureki causes severe bites in Rajasthan. Work needs to be done to alter the first aid practices used for snakebites in this area, to encourage more rapid presentation to hospital, and to develop antivenom that is more effective against E sochureki.
Assuntos
Antivenenos/uso terapêutico , Mordeduras de Serpentes/tratamento farmacológico , Mordeduras de Serpentes/epidemiologia , Venenos de Víboras/efeitos adversos , Viperidae , Adulto , Animais , Feminino , Humanos , Índia , Masculino , Estudos Prospectivos , Índice de Gravidade de Doença , Mordeduras de Serpentes/patologiaRESUMO
OBJECTIVE: To determine whether volunteers (with or without prior medical training) can correctly apply pressure immobilization (PI) in a simulated snakebite scenario after receiving standard instructions describing the technique. METHODS: Twenty emergency medicine physicians (residents and attendings) and 20 lay volunteers without prior formal medical training were given standard printed instructions describing the application of PI for field management of snakebite. They were then supplied with appropriate materials and asked to apply the technique five separate times (twice to another individual [one upper and one lower extremity] and three times to themselves [nondominant upper extremity, dominant upper extremity, and one lower extremity]). Successful application was defined a priori by four criteria previously published in the literature: wrap begins at the bite site, entire extremity is wrapped, splint or sling is applied, and pressures under the dressing are between 40 and 70 mm Hg in upper-extremity application and between 55 and 70 mm Hg in lower-extremity use. Pressures were determined using a specially designed skin interface pressure-measuring device placed at the simulated bite site. RESULTS: The technique was correctly applied as judged by the preset criteria in only 13 out of 100 applications by emergency medicine physicians and in only 5 out of 100 applications by lay people. There was no significant difference in success rates between physicians and lay volunteers. Likewise, there was no significant difference in success based on which extremity was being wrapped. More detailed analysis revealed that the major contributor to failure was inability to achieve recommended target pressures. CONCLUSIONS: Volunteers in a simulated snakebite scenario have difficulty applying PI correctly, as defined in the literature. The major source of failure is an inability to achieve recommended pressure levels under the dressing. New methods of instructing people in the proper use of PI or new technologies to guide or automate application are needed if this technique is to be used consistently in an effective manner for field management of bites by venomous snakes not known to cause significant local wound necrosis.
Assuntos
Competência Clínica , Tratamento de Emergência/métodos , Imobilização/métodos , Mordeduras de Serpentes/terapia , Animais , Braço , Humanos , Perna (Membro) , Médicos , Pressão , VoluntáriosRESUMO
OBJECTIVE: To develop a model that compares 2 different routes of antivenom administration (standard intravenous [IV] administration vs regional administration below a tourniquet) to assess their ability to limit muscle necrosis in a rabbit model of rattlesnake venom poisoning. METHODS: New Zealand white rabbits were randomly assigned to 4 groups. All animals underwent general anesthesia and were then injected intramuscularly (IM) with a sublethal dose of western diamond-back rattlesnake (Crotalus atrox) venom in the right thigh and a similar volume of normal saline (NS) control in the left thigh. Thirty minutes later, standard treatment group animals (n = 4) received 1 vial of reconstituted Antivenin (Crotalidae) Polyvalent (ACP) and 10 mL of NS through an ear vein. Experimental treatment group animals (n = 4) had their lower extremities exsanguinated and isolated by arterial tourniquets. One vial of ACP was then given through a distal IV in the envenomed extremity, and 10 mL of NS was given through an IV in the sham extremity. Tourniquets were removed 30 minutes later. Positive control group animals (n = 2) similarly had their lower extremities exsanguinated and isolated by tourniquets. They then received 10 mL of NS through distal IVs in each lower extremity. Tourniquets were again removed after 30 minutes. Negative control group animals (n = 2) received 2 doses of NS only (10 mL each) through an ear vein. Serum creatinine phosphokinase (CPK) levels were drawn at baseline and 48 hours following venom injection. At 48 hours, the animals were injected with technetium pyrophosphate. Two hours later, they were euthanized, and the lower extremities were scanned to determine levels of radionucleotide uptake in envenomed muscles compared to contralateral sham-injected muscles. The anterior thigh muscle groups were then removed, fixed, stained, sectioned, and analyzed in a blinded fashion by a veterinary pathologist for muscle necrosis grading. RESULTS: There was no evidence of statistically significant differences in changes in serum CPK levels (from baseline to 48 hours), technetium pyrophosphate uptake ratios (right leg/left leg), or muscle necrosis indices in any 2-group analysis. CONCLUSIONS: Results of this pilot study do not suggest any beneficial effect of ACP, in the dose and routes used, in limiting local muscle necrosis following IM rattlesnake venom poisoning in the rabbit model.