The top end Envenomations - PowerPoint Presentation

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The top end

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Envenomations

Royal

Darwin HospitalRMO education

29.09.2015Laura K.reg

ED

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Northern Territory

Snakes

SpidersStingers

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SNAKES

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Sources

Article Bart

CurrieRDH guidelinePictures from the web and myself

Rural EM skills training syllabus, ACRRMeTG

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Article Bart Currie

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Envenoming

All year but highest incidence during March to May

Highest rate among Top End rural Aboriginal adult males (45.2 per 100.000)59% on foot / ankle, less bites on hands in Aboriginals

Continuing snake activity in evenings / nightsThree cases of overambitious feeding attemptsAverage 2 deaths/

yr in Au, > 70% no first aid or antivenom

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4 Highly venomous snakes

Western brown =

pseudonaja nuchalis = gwardar

Mulga (black snake) = pseudechis

australis = king brownDeath adder = acanthophis

praelongusTaipan =

oxyuranus microlepitodus / scutellatus

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Symptoms 1

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Symptoms 2

Bite swelling, lymphadenitis and non-specific systemic features are most prominent in

Mulga snakeMyotoxicity

is the major feature of Mulga snakeEarly collapse with recovery in > 50% of

syst env. from Wester

Brown snakes (consumptive coagulopathy)Neurotoxicity most important feature of Death Adder, this study in < 50% pts

Mulga and Brown snake have neurotoxins, but neurotoxicity uncommon = ‘brown snake paradox’

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RDH

guI

d.

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Treatment bite

Apply

or reinforce with pressure bandage Eslet S 3A

Immobilize limb with splintFenestrate at bite site, take swab

Have snake identified if possibleTetanus status check +/- ADT

Continuous cardiac monitoringHourly

neuro obsInvestigations



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Investigations

UA

VDK urine (hold if asymptomatic and WBCT < 10min)VDK bite swab (ord.swab

soaked in NS), same procedureBloods: WBCT, FBC, UEC, CK, LDH, Coags, D-dimer, Fibrinogen, serology

tube VDK high

fals pos rate,

esp for brown snake, esp on urine

WBCT = whole blood clotting time (no additive blue container)

VDK = venom detection kit, only on arrival

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Bloods

On arrival

Immediately before administration of antivenom if > 30 min later than bloods taken on arrival30 min after each

antivenom infusion4 hourly until normal results

8 hourly until discharge = 12h after bite when non-envenomed

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Symptoms by snake type

Western brown

Transient early hypotension / collapse with procoagulation.

Neurotox rare, no myotoxMulga

(King Brown = black snake group)Early anticoagulant, marked myotox, occasionally

neurotoxTaipanTransient early hypotension / collapse,

procoagulation, neurotox +/-

myotoxDeath adder Neurotox

only

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Symptoms minor

N, V.

abdo pain, headacheTender regional lymph nodes +/- enlargement

 DO NOT REQUIRE ANTIVENOM

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Symptoms major

Coagulopathy 0-4h after bite

Neurotoxicity 1-6h after bite up to 24h in death adder

Myotoxicity

1-2h after biteCardiac

Also:Thrombotic micro-angiopathy

in ass with coagulopathy

Resulting in kidney damage

 REQUIRE ANTIVENOM

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Coagulopathy 0-4h after bite

WBCT > 10 min

Procoagulant = APPT, PT and D-dimer

Anticoagulant = APPT and PT

 D-dimer =

UA pos

bloodBleeding

Neurotoxicity 1-6h after bite up to 24h: ptosis, then

ophtalmoplegia

, then bulbar

palsy,finally

resp

paralysis

Myotoxicity

1-2h after bite

Dark urine

Pos

dipstick for blood can be true hematuria or

myoglobinuria

or

haemoglobinuria

(

intravsc

haemolysis

)

Cardiac

Early transient hypotension +/- collapse within 30 min

Rarely

arrhytmias

1-12h

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Treatment envenomation

ACDE approach

Continuous cardiac monitoring

Neuro obs

CT brain in every pt with conc. head strike or headacheContact consultant + Bart Currie / Geoff

IsbisterAntivenom

when major symptoms

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Antivenom 1

All groups of poisonous elapids are possible, except tiger snake. Thus

alle snake antivenoms available in RDH:

PolyvalentBrownBlack

TaipanDeath adderSea snake

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Antivenom 2

Administer in

resusIn stable patients commence specific antivenom

(snake identified or pos VDK result, takes 20-30 min)

In unstable patients give 1 vial polyvalent and change to specific when identifiedIn clin. significant bleeding from Brown snake give 2 vials

Dilute antivenom 1:10 with NS, infuse over 30 min

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Antivenom 3

In anaphylaxis

(25%) (5% severe) stop infusion, Tx normally

(PM: Adrenaline im

safer)Same amount for childrenRemove PBI towards the end of the

antivenom infusionAdmit unless snake identified as non-venomous by reptile specialistD/c

pts bitten in Darwin urban area at 12h if asymptomatic and bloods normal, all others 24h (Death adder)

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Sea snake

Treat bite as land snake bite

CSL sea snake antivenom, 1 vial

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SPIDERS

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Sources

http

://arnhemlandpestcontrol.com.au/spiders/spiders.htm

Common spiders in the Darwin area, Chin, july

2014Rural EM skills training syllabus, ACRRM

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Red back

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Mechanism

Venom depletes neurotransmitters at

Neuromuscular junction -> patchy paralysisAdrenergic nerve ending -> autonomic dysfunction

Can cause serious illness / death.

No fatalities since antivenom 1956, but painful.

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Symptoms

Immediate pain

and local swelling, sweating20 min: swelling lymph nodes,

abdo pain, tachycardia,

60 min: headache, N and V, fever, insomnia, restlessnessOccasionally: severe hypertension, paralysis, convulsions, skin rashes, tongue swelling, jaw rigidity, migratory arthralgia

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Treatment

Monitoring and

neuro obsDo

not apply pressure bandage, increases painApply iceMorphine

Benzodiazepine for muscle spasms or extreme anxietyAntivenom for syst

symptoms or severe pain: 2 vials / 500 IE im (adults and kids) and monitor for 4 h after administration. Can be given days / weeks after bite.

Tetanus status check +/- ADT

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Northern mouse

No fatalities but painful bite, can cause headache and N, treat with funnel-web

antivenom

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Huntsman

Local symptoms, sometimes inflammation, headache, V and irreg. pulse

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Orb

Occasional N and dizziness

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Wolf

Local symptoms, less commonly ulceration, sometimes with N and V

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STINGERS

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Sources

RDH guideline

Resus.com.auPictures from the webRural EM skills training syllabus,

ACRRMCARPA standard treatment manualeTG

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Box jellyfish

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Box Jellyfish

= Chironex

fleckeriAbout 40 ED visits RDH every wet season = october

-mayBell 20 cm, up to fifteen tentacles on each corner, up to 3 mtrs long, up to 5000 nematocysts on each tentacle

Venom:NeurotoxinsCardiotoxins

Dermatonecrotic toxins

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Symptoms

Intense pain and tentacle marks

Irrational behaviourArrhythmias In severe envenomation systemic effects WITH CARDIORESPIRATORY ARREST within

minutesFatalities rare. Last 11 deaths in children

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Appearance

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Investigations

ECG – ventricular

ectopy or arrhytmias?

Cardiac monitoringSticky tape test to send to Bart Currie, identifying species

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Tx

non-systemic

ABCDEVinegar to inactivate undischarged

nematocystsRemove tentaclesApply iceAnalgesia - Morphine

Antivenom 1 ampule if pain not controlled iv or im

No pressure bandage, increases painTreat as burn. Tetanus status check +/- ADT

d/c home with advise, RDH guideline

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Tx

if systemic

Resuscitation and supportive therapyIncl 2 iv lines and high flow O2Antivenom

1 ampule 1: 10 diluted in NS, in 5 min iv, up to 3 ampulesOr 3 ampules im

at different sitesRepeat if no response, up to 6 ampules

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Tx (imp) cardiac arrest

Resuscitation

6 ampules antivenom20

mmol = 2 ampules MgSO4 ivContinue CPR until all 6 ampules given

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Irukandji

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Irukandji

= Carukia

Barnesi25

cms across, 1 tentacle from each cornerUsually

october to april

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Symptoms

Severe lower back, chest and

abdo painOn and off muscle crampsV, restlessness, anxiety, sweating,

piloerectionTachycardia, hypertension, heart failure, pulmonary edema

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Tx

R

DH

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Blue ringed octopus

Can penetrate wetsuit. Enough venom to kill 26 adults

Saliva potent fast acting paralytic neurotoxin Small painless bitePerioral

paraesthesia, then N/V and rapid onset flaccid paralysis in 5-30 minIn severe cases respiratory and cardiac arrest

Irrigate wound, suction, PBI, supportive careTetanus status check +/- ADT

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Stonefish

Pain

, swelling, weakness limb. Tx 40-

45 degrees waterLocal Lignocaine, opioids, nerve

blockAntivenom 1 vialNo pressure bandage

Tetanus status check +/- ADT

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Catfish

Same as stonefish

No antivenomX-ray, piece of barb often breaks off into wound

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Stingray

Stingray barb injury:

Pain, bleeding wound, then pale / bluish-white wound

Significant local trauma, damage to underlying structures (heart / lung if chest wall puncture)

Rarely systemic symptomsPain

relieve same as other fishXray. May need surgery to remove pieces

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Don’t let

it be