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Mulga snake (Pseudechis australis) envenoming: a spectrum of myotoxicity, anticoagulant coagulopathy, haemolysis and the role of early antivenom therapy - Australian Snakebite Project (ASP-19).
Clin Toxicol (Phila) 2013; 51(5):417-24CT

Abstract

CONTEXT

Mulga snakes (Pseudechis australis) are venomous snakes with a wide distribution in Australia. Objective. The objective of this study was to describe mulga snake envenoming and the response of envenoming to antivenom therapy.

MATERIALS AND METHODS

Definite mulga bites, based on expert identification or venom-specific enzyme immunoassay, were recruited from the Australian Snakebite Project. Demographics, information about the bite, clinical effects, laboratory investigations and antivenom treatment are recorded for all patients. Blood samples are collected to measure the serum venom concentrations pre- and post-antivenom therapy using enzyme immunoassay.

RESULTS

There were 17 patients with definite mulga snake bites. The median age was 37 years (6-70 years); 16 were male and six were snake handlers. Thirteen patients had systemic envenoming with non-specific systemic symptoms (11), anticoagulant coagulopathy (10), myotoxicity (7) and haemolysis (6). Antivenom was given to ten patients; the median dose was one vial (range, one-three vials). Three patients had systemic hypersensitivity reactions post-antivenom. Antivenom reversed the coagulopathy in all cases. Antivenom appeared to prevent myotoxicity in three patients with high venom concentrations, given antivenom within 2 h of the bite. Median peak venom concentration in 12 envenomed patients with samples was 29 ng/mL (range, 0.6-624 ng/mL). There was a good correlation between venom concentrations and the area under the curve of the creatine kinase for patients receiving antivenom after 2 h. Higher venom concentrations were also associated with coagulopathy and haemolysis. Venom was not detected after antivenom administration except in one patient who had a venom concentration of 8.3 ng/ml after one vial of antivenom, but immediate reversal of the coagulopathy.

DISCUSSION

Mulga snake envenoming is characterised by myotoxicity, anticoagulant coagulopathy and haemolysis, and has a spectrum of toxicity that is venom dose dependant. This study supports a dose of one vial of antivenom, given as soon as a systemic envenoming is identified, rather than waiting for the development of myotoxicity.

Authors+Show Affiliations

School of Medicine Sydney, University of Notre Dame Australia, Darlinghurst, NSW, Australia.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

23586640

Citation

Johnston, C I., et al. "Mulga Snake (Pseudechis Australis) Envenoming: a Spectrum of Myotoxicity, Anticoagulant Coagulopathy, Haemolysis and the Role of Early Antivenom Therapy - Australian Snakebite Project (ASP-19)." Clinical Toxicology (Philadelphia, Pa.), vol. 51, no. 5, 2013, pp. 417-24.
Johnston CI, Brown SG, O'Leary MA, et al. Mulga snake (Pseudechis australis) envenoming: a spectrum of myotoxicity, anticoagulant coagulopathy, haemolysis and the role of early antivenom therapy - Australian Snakebite Project (ASP-19). Clin Toxicol (Phila). 2013;51(5):417-24.
Johnston, C. I., Brown, S. G., O'Leary, M. A., Currie, B. J., Greenberg, R., Taylor, M., ... Isbister, G. K. (2013). Mulga snake (Pseudechis australis) envenoming: a spectrum of myotoxicity, anticoagulant coagulopathy, haemolysis and the role of early antivenom therapy - Australian Snakebite Project (ASP-19). Clinical Toxicology (Philadelphia, Pa.), 51(5), pp. 417-24. doi:10.3109/15563650.2013.787535.
Johnston CI, et al. Mulga Snake (Pseudechis Australis) Envenoming: a Spectrum of Myotoxicity, Anticoagulant Coagulopathy, Haemolysis and the Role of Early Antivenom Therapy - Australian Snakebite Project (ASP-19). Clin Toxicol (Phila). 2013;51(5):417-24. PubMed PMID: 23586640.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Mulga snake (Pseudechis australis) envenoming: a spectrum of myotoxicity, anticoagulant coagulopathy, haemolysis and the role of early antivenom therapy - Australian Snakebite Project (ASP-19). AU - Johnston,C I, AU - Brown,S G A, AU - O'Leary,M A, AU - Currie,B J, AU - Greenberg,R, AU - Taylor,M, AU - Barnes,C, AU - White,J, AU - Isbister,G K, AU - ,, Y1 - 2013/04/15/ PY - 2013/4/17/entrez PY - 2013/4/17/pubmed PY - 2013/7/24/medline SP - 417 EP - 24 JF - Clinical toxicology (Philadelphia, Pa.) JO - Clin Toxicol (Phila) VL - 51 IS - 5 N2 - CONTEXT: Mulga snakes (Pseudechis australis) are venomous snakes with a wide distribution in Australia. Objective. The objective of this study was to describe mulga snake envenoming and the response of envenoming to antivenom therapy. MATERIALS AND METHODS: Definite mulga bites, based on expert identification or venom-specific enzyme immunoassay, were recruited from the Australian Snakebite Project. Demographics, information about the bite, clinical effects, laboratory investigations and antivenom treatment are recorded for all patients. Blood samples are collected to measure the serum venom concentrations pre- and post-antivenom therapy using enzyme immunoassay. RESULTS: There were 17 patients with definite mulga snake bites. The median age was 37 years (6-70 years); 16 were male and six were snake handlers. Thirteen patients had systemic envenoming with non-specific systemic symptoms (11), anticoagulant coagulopathy (10), myotoxicity (7) and haemolysis (6). Antivenom was given to ten patients; the median dose was one vial (range, one-three vials). Three patients had systemic hypersensitivity reactions post-antivenom. Antivenom reversed the coagulopathy in all cases. Antivenom appeared to prevent myotoxicity in three patients with high venom concentrations, given antivenom within 2 h of the bite. Median peak venom concentration in 12 envenomed patients with samples was 29 ng/mL (range, 0.6-624 ng/mL). There was a good correlation between venom concentrations and the area under the curve of the creatine kinase for patients receiving antivenom after 2 h. Higher venom concentrations were also associated with coagulopathy and haemolysis. Venom was not detected after antivenom administration except in one patient who had a venom concentration of 8.3 ng/ml after one vial of antivenom, but immediate reversal of the coagulopathy. DISCUSSION: Mulga snake envenoming is characterised by myotoxicity, anticoagulant coagulopathy and haemolysis, and has a spectrum of toxicity that is venom dose dependant. This study supports a dose of one vial of antivenom, given as soon as a systemic envenoming is identified, rather than waiting for the development of myotoxicity. SN - 1556-9519 UR - https://www.unboundmedicine.com/medline/citation/23586640/Mulga_snake__Pseudechis_australis__envenoming:_a_spectrum_of_myotoxicity_anticoagulant_coagulopathy_haemolysis_and_the_role_of_early_antivenom_therapy___Australian_Snakebite_Project__ASP_19__ L2 - http://www.tandfonline.com/doi/full/10.3109/15563650.2013.787535 DB - PRIME DP - Unbound Medicine ER -