Predictors of FabAV use in copperhead envenomation.

CONTEXT: Crotaline snake envenomation is a serious medical condition affecting thousands of Americans each year. Variation in the treatment of Crotaline snakebites exists among physicians in the United States. Management of copperhead snakebites is controversial with some experts advocating minimal intervention, rarely necessitating antivenom use and, even more rarely, surgical intervention. This study assessed the use of Crotaline Polyvalent Immune Fab antivenom (Ovine) (FabAV) and explored factors influencing the decision to prescribe antivenom for copperhead envenomation in patients in Northeastern Oklahoma. METHODS: A retrospective cohort study examining electronic medical records of patients with copperhead snakebites from July 1, 2014 to August 31, 2019. Data collected included: patient demographics, transfer information, snake species, bite site, progression of local tissue effects, additional clinical and lab results, patient comorbidities, and treatment strategy. Associations between patient variables and treatment were evaluated using the chi-square test of independence, median test, and logistic regression analysis. Associations were statistically significant if p < 0.05. DISCUSSION: Of the 130 patients bitten by a copperhead, a majority (75%) received FabAV. Symptoms of copperhead envenomation were mostly limited to the progression of tissue damage. Predictors of treatment with FabAV included progression of venom effects across major joints, younger age, comorbidities, and upper extremity bites. CONCLUSIONS: Patients who have multiple comorbidities, upper extremity bites and progression of venom effects across major joints are more likely to be treated with FabAV. The high usage of FabAV at the study site underscores the need for continued work to optimize the use of antivenom for copperhead envenomations.

Medication Reconciliation Across Care Transitions in the Pediatric Medical Home.

OBJECTIVE: To characterize medication discrepancies for patients with chronic illnesses seen at outside facilities. METHODS: This was a retrospective evaluation of a medication reconciliation across care transitions (MRAT) program developed and piloted for one year in an academic pediatric primary care medical home. The MRAT involved chart review and contacting caregivers upon receiving external specialist notes or hospital discharge summaries. Data obtained from the program were used to determine the frequency and types of medication discrepancies for children with complex and noncomplex chronic conditions. RESULTS: MRATs for 124 encounters were evaluated, 74.0% in response to specialist appointments. Chart review revealed a mean of 3.64 discrepancies per patient, and telephone calls revealed 1.39 additional discrepancies per patient. The number of medication discrepancies from both chart review and telephone calls between complex and noncomplex patients was statistically significant, with a mean of 5.63 vs. 3.77 per patient (p = 0.005). Therapy delays occurred in 16.1% of patients due to insurance rejections, family not starting a new medicine, or confusion about the medication change. Mean time required for reconciliation was 24 minutes. In addition to medication reconciliation, 107 interventions completed during MRATs included patient education, adjusting drug therapy, coordinating care between providers, recommending laboratory monitoring, and facilitating patient appointments. CONCLUSION: Children with chronic illness often experience medication changes and delays in therapy when seen in the hospital or by specialists. Timely identification of these changes improves communication and offers the opportunity to identify and prevent problems with medication therapy.

Use of polyvalent equine anti-viper serum to treat delayed coagulopathy due to suspected Sistrurus miliarius streckeri envenomation in two children.

BACKGROUND: Western Pygmy Rattlesnake (WPR) envenomation reportedly causes refractory and persistent coagulopathy when treated with CroFab® (Crotalidae Polyvalent Immune Fab). We report two cases where polyvalent equine anti-viper serum (AntivipmynTRI®) was used to treat recurrent coagulopathy in children. CASE DETAILS: The first patient was a 16-month-old male who was bitten by a confirmed WPR. The patient received a total of 18 vials of CroFab®. His labs normalized, swelling gradually improved, and the child was discharged to home. On day 5, the child returned to the emergency department with a great deal of inguinal tenderness. Labs were obtained and the child's INR was >13.1, while the fibrinogen was <60 mg/dL and the d-dimer was 11.72 mg/L. A decision was made to administer Antivipmyn TRI®, and the child received a total of 10 vials. Lab values significantly improved: INR 1.2, fibrinogen 93 mg/dL, and d-dimer 4.21 mg/L. The second patient was a 20-month-old male who presented following snake envenomation. The child was administered a total of 22 vials of CroFab® over approximately 70 h following envenomation. Physical exam continued to improve, however, lab results showed an increasing INR 1.98, decreasing platelet count 124 × 103 per µL, fibrinogen <60 mg/dL, and d-dimer >20 ug/mL. A total of 15 vials of Antivipmyn TRI® were administered to this patient. Following this administration, labs and clinical exam both significantly improved. Labs revealed INR 1.16, fibrinogen 110 mg/dL, d-dimer 3.2 mg/L and platelet count 215 × 103/µL. DISCUSSION: CroFab® is still the first-line treatment for children bitten by a WPR, but in some cases patients develop a recurrent coagulopathy. The rapid response demonstrated by Antivipmyn TRI® leads us to conclude that this is a potential therapy for this clinical situation.