Princess Alexandra Hospital Emergency Department. Clinical Module. Clinical features of envenoming: Major toxin syndromes 1 :

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1 Princess Alexandra Hospital Emergency Department Clinical Module Toxicology Review Officer: Toxicology registrar Version no: 1 Approval date: February 2017 Review date: February 2019 Approving Officer Dr Colin Page Key Words: 1 Introduction While most snakebites do not result in envenoming, the potential for life threatening injury warrants all patients to receive high priority assessment and management even if they initially appear well. Clinical features of envenoming: Local: pain, swelling, bruising, lymphadenopathy Systemic: nausea, vomiting, abdominal pain, diarrhoea, diaphoresis & headache Major toxin syndromes 1 : Venom-induced consumptive coagulopathy o Complete if INR > 3.0, abnormal aptt and very high D dimer o Partial if INR < 3 and low but detectable fibrinogen level ( <1.5g/L) Neurotoxicity o Descending flaccid paralysis involving ocular muscles first, followed by bulbar, respiratory muscles and limb paralysis Myotoxicity o CK > 1000 with Myalgia or muscle tenderness Anticoagulant coagulopathy o aptt is moderately abnormal Thrombotic microangiopathy o Fragmented RBC on film with MAHA, thrombocytopenia and elevated creatinine Version No 1; Last reviewed February 2017 Page 1 of 6

2 2 Assessment Important features on history History of bite Time of bite First aid measures applied Early symptoms; eg collapse Known species if snake in captivity Relevant comorbidities; eg coagulopathies, renal impairment Relevant medications; eg anticoagulants, Important feature on examination Bite site: fang marks, bruising, local necrosis Regional lymphadenopathy Neurological examination; ptosis, ophthalmoplegia, bulbar weakness, limb weakness, respiratory muscle weakness Haematological examination; bleeding from bite site or cannula site, oral cavity or occult sites Investigations On arrival: FBC, EUC, CK, coags including fibrinogen & D dimer. Remember to document snakebite on the request form to assist processing in the lab. Version No 1; Last Reviewed February 2017 Page 2 of 6

3 VDK from bite site specimen can be sent if there are features of envenomation. Bite site swabs can be taken on admission and kept for later testing if envenomation develops. Bloods (CK, coags) should be repeated 1 hour post pressure bandage removal and at 6 and 12 hours post bite. 3 Management First aid Measures Application of a broad (15cm), elasticised pressure bandage to the entire affected limb with immobilisation is recommended for all patients with suspected snakebite. The pressure applied should be similar to that used for a sprained ankle. The application of a pressure bandage after 4 hours post bite is unlikely to be effective. The bandage can be removed once there is no clinical evidence of envenoming following the return of the initial blood results. Version No 1; Last Reviewed February 2017 Page 3 of 6

4 4 Disposition Patients with no evidence of envenoming: See Appendix Follow the Clinical Pathway This group should be observed for 12 hours with repeat testing (neurological examination, coags, CK one hour following the removal of the pressure bandage and at 6 and 12 hours following the bite. This group should be admitted to the Short Stay Unit under TOXE and the toxicology registrar should be notified Discharge should occur in daylight hours Ensure adequate tetanus prophylaxis Patients with evidence of envenoming: This group should receive an appropriate antivenom in a timely manner There is no role for redosing of antivenom Discuss this group with the toxicologist on call This group requires admission under the toxicology unit for observation and adjunctive therapy as required Full set of bloods (FBC, EUC, CK, coags, D dimer) should be repeated 6, 12, 18 and 24 hours post bite. This patient group should be recruited to the Australian Project (ASP) 5 Additional Information VDK from urine specimen can be used in envenomed patient if the bite site specimen is unavailable. False positive VDK results for brown snake are not uncommon and the result needs to be interpreted in the context of the clinical findings of the patient. One vial of the appropriate venom is sufficient to treat envenomed patients. There is no role for redosing of antivenom. Antivenom needs to be given in a resuscitation area with capacity to treat anaphylaxis should it occur. Premedication is not recommended. Acute systemic hypersensitivity occurs in 23% of patients, and is severe (hypotension) in 7% 2 See table below. Serum sickness occurs in 29% 2 See table below of patients given antivenom and is characterised by flu like symptoms and rash which develops 4 to 14 days after antivenom administration. It is treated with prednisolone 25mg for 5 days. Version No 1; Last Reviewed February 2017 Page 4 of 6

5 Antivenom is diluted 1:10 with saline and administered over minutes, dilution can be 1:5 in the paediatric population for larger volumes of antivenom. 3 The role of treating VICC with factor replacement is controversial. While studies have shown providing FFP does restore clotting function more rapidly this hasn t resulted in meaningful outcomes for the patient. It appears reasonable to administer FFP (rather than any other factor replacement, given these patients are deficient in factors I, V and VIII) to patients with life threatening bleeding secondary to VICC. 6 Reference 1. Isbister GK, Brown S, Page C et al. in Australia: a practical approach to diagnosis and treatment. MJA 2013; 199(11): Ryan N, Kearney RT, Brown S and Isbister GK. Incidence of serum sickness after the administration of Australian snake antivenom (ASP-22). Clin Toxicol 2016; 54(1): etg Toxicology and Wilderness 2016 ed. chapter. Version No 1; Last Reviewed February 2017 Page 5 of 6

6 7 Appendix Version No 1; Last Reviewed February 2017 Page 6 of 6

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