Severe Envenomation Research Articles

A Conceptual Study on Oothu Chikitsa or Blowing Therapy- An Emergency Treatment Procedure

Kerala is exceptional for the practice of Visha chikitsa from time out of mind. Keraleeya visha chikitsa grandhas such as Prayoga sammucchayam and Kriya koumudi point out distinctive treatment procedure for snake envenomation such as Karu prayogam, Vella prayogam, Oothu chikitsa etc. Among this most handy and easy treatment procedure, Oothu chikitsa or blowing therapy which is mentioned for immediate stabilization of the patient from severe cobra envenomation is discussed here. The present study evaluates the role of Ayurveda in emergency management. This procedure, in which three persons are made to blow over vertex and both ears for 150 times by chewing certain drugs such as Viswa, Dusparsa, Maricha and Visha vega in equal quantities are indicated in the initial manifestation of snake bite including altered consciousness. On evaluation, the volatile components of these drugs are found to act on CNS. In this era of emergency medicine, exploration of Ayurvedic emergency treatment procedure is very much important. This emergency treatment procedure can be conceptually applied in the altered consciousness other than snake bite such as altered consciousness arising due to neurological and metabolic causes, diffuse physiological brain dysfunction as seen in certain drug poisoning, alchohol etc. This study aims at application of blowing therapy, indicated in initial manifestation of cobra envenomation and helps the patient to stabilize from a level of altered consciousness in the context of altered consciousness in conditions other than snake bite.

The Deadly Toxin Arsenal of the Tree-Dwelling Australian Funnel-Web Spiders.

Australian funnel-web spiders are amongst the most dangerous venomous animals. Their venoms induce potentially deadly symptoms, including hyper- and hypotension, tachycardia, bradycardia and pulmonary oedema. Human envenomation is more frequent with the ground-dwelling species, including the infamous Sydney funnel-web spider (Atrax robustus); although, only two tree-dwelling species induce more severe envenomation. To unravel the mechanisms that lead to this stark difference in clinical outcomes, we investigated the venom transcriptome and proteome of arboreal Hadronyche cerberea and H. formidabilis. Overall, Hadronyche venoms comprised 44 toxin superfamilies, with 12 being exclusive to tree-dwellers. Surprisingly, the major venom components were neprilysins and uncharacterized peptides, in addition to the well-known ω- and δ-hexatoxins and double-knot peptides. The insecticidal effects of Hadronyche venom on sheep blowflies were more potent than Atrax venom, and the venom of both tree- and ground-dwelling species potently modulated human voltage-gated sodium channels, particularly NaV1.2. Only the venom of tree-dwellers exhibited potent modulation of voltage-gated calcium channels. H. formidabilis appeared to be under less diversifying selection pressure compared to the newly adapted tree-dweller, H. cerberea. Thus, this study contributes to unravelling the fascinating molecular and pharmacological basis for the severe envenomation caused by the Australian tree-dwelling funnel-web spiders.

French Scorpionism (Mainland and Oversea Territories): Narrative Review of Scorpion Species, Scorpion Venom, and Envenoming Management.

Sixty-seven scorpion species have been described in France and its territories, where they have been found to be heterogeneously distributed. Indeed, only one species can be found on Réunion Island, while 38 species exist in French Guiana. The number of stings is also heterogenous, with up to 90 stings per 100,000 inhabitants occurring annually. Scorpion species can frequently be determined through simple visual factors, including species of medical importance (i.e., Buthus, Centruroides and Tityus). Scorpion venom is composed of local enzymes and peptides with a cysteine-stabilized α/β motif (NaTxs, Ktxs, Calcines), which allow for venom diffusion and the prey’s incapacitation, respectively. Harmful scorpion species are limited to Centruroides pococki in the French West Indies, which can induce severe envenoming, and the Tityus obscurus and Tityus silvestris in French Guiana, which can cause fatalities in children and can induce severe envenoming, respectively. Envenomation by one of these scorpions requires hospital monitoring as long as systemic symptoms persist. Typical management includes the use of a lidocaine patch, pain killers, and local antiseptic. In the case of heart failure, the use of dobutamine can improve survival, and pregnant women must consult an obstetrician because of the elevated risk of preterm birth or stillbirth. France does not have scorpion antivenom, as scorpion stings are generally not fatal.

Delayed Recognition of Severe Systemic Envenomation after Copperhead Bite: A Case Report.

IntroductionWe report a case of severe systemic copperhead, Agkistrodon contortrix, envenomation that resulted in long-term sequelae.Case ReportA 72-year-old man presented to the emergency department after suffering a copperhead snakebite. He developed severe systemic toxicity before local tissue injury developed. Clinicians did not initially recognize his envenomation syndrome and sought alternative explanations for his systemic symptoms before polyvalent immune fab (ovine) antivenom was administered. Although the patient improved, he was discharged with new stage three chronic kidney disease.ConclusionAlthough rare, copperhead envenomation can cause severe systemic toxicity. Envenomation should be promptly treated with antivenom.

Hypocholesterolaemia as a prognostic factor in venomous snakebite: a retrospective study from a single centre in Kerala, India.

Studies have suggested a association between serum cholesterol values and severity of envenoming. The objective of the study was to correlate the serum cholesterol levels with severity of envenoming in victims of snakebite, across snake species in our patient population. Retrospective secondary data analysis of health records of a cohort of snakebite victims treated at Little Flower Hospital, Angamaly, Kerala during June 2006-January 2008 was performed. The cholesterol values were assessed in 205 consecutive patients admitted with snakebite envenoming, within 24 h of admission and 10 h of overnight fasting. Lipid fractions were estimated from fasting serum through the standard CHOD-PAP method on a Hitachi analyzer. The cholesterol level was compared between victims with mild and serious envenoming to assess the proportion among each category with a low cholesterol (defined as ≤150 mg/dl as per institutional criteria). In addition, low cholesterol as a marker of severity was compared with other laboratory parameters suggesting severe envenoming such as low fibrinogen, low platelet count, neutrophilia, elevated creatinine, d-dimer, hepatic transaminases and albuminuria. Of the 146 victims with serious degree of snakebite envenoming 116 (79%) had low cholesterol values ≤150 mg%, while 30 (21%) had values >150 mg%. Of the patients with low cholesterol, 116 (78%) had serious envenoming, while 22% had mild envenoming. By contrast, 30 patients (21%) had values >150 mg%. The risk of moderate-severe envenoming with low cholesterol was 2.7 times (170%) that of victims with normal or high cholesterol on admission. A low cholesterol on admission in victims of snake envenoming suggested a more severe degree of envenoming and likelihood of complications.

Severe neurotoxic envenomation following cobra bite in Northern Nigeria: A report of three cases

Cobra is a common snake throughout Africa and Asia, however, there are few literatures reporting neurotoxic cobra bite from Sub-Saharan Africa (SSA), including Northern Nigeria. Here, we report 3 cases that were bitten by cobra in the savannah region of Nigeria. All the 3 cases presented with features of severe neurotoxic envenomation: generalized hypotonia, ptosis, and features of autonomic dysfunction, which include excessive salivation and sweating. One of the 3 victims progressed to develop respiratory paralysis that resulted in death. The other 2 cases survived after receiving polyvalent anti-snake venom.

Bothrops lanceolatus snake venom impairs mitochondrial respiration and induces DNA release in human heart preparation.

Envenomations by Bothrops snakebites can induce overwhelming systemic inflammation ultimately leading to multiple organ system failure and death. Release of damage-associated molecular pattern molecules (DAMPs), in particular of mitochondrial origin, has been implicated in the pathophysiology of the deregulated innate immune response. To test whether whole Bothrops lanceolatus venom would induce mitochondrial dysfunction and DAMPs release in human heart preparations. Human atrial trabeculae were obtained during cannulation for cardiopulmonary bypass from patients who were undergoing routine coronary artery bypass surgery. Cardiac fibers were incubated with vehicle and whole Bothrops lanceolatus venom for 24hr before high-resolution respirometry, mitochondrial membrane permeability evaluation and quantification of mitochondrial DNA. Compared with vehicle, incubation of human cardiac muscle with whole Bothrops lanceolatus venom for 24hr impaired respiratory control ratio and mitochondrial membrane permeability. Levels of mitochondrial DNA increased in the medium of cardiac cell preparation incubated with venom of Bothrops lanceolatus. Our study suggests that whole venom of Bothrops lanceolatus impairs mitochondrial oxidative phosphorylation capacity and increases mitochondrial membrane permeability. Cardiac mitochondrial dysfunction associated with mitochondrial DAMPs release may alter myocardium function and engage the innate immune response, which may both participate to the cardiotoxicity occurring in patients with severe envenomation.

Upper Extremity Crotalid Envenomation: A Review of Incidence and Recent Trends in Management of Snakebites

The goal of this study was to evaluate the recent trends in the management of upper extremity Crotalid envenomation in the state of Georgia, United States. A retrospective review of the Georgia Poison Center database looking at the reported snakebites to the upper extremity between 2015 and 2020 was performed. Patient demographics, timing and location of injury, severity of envenomation, treatment, including use of antivenin and surgical intervention, and reported complications related to the use of antivenin was extracted. A retrospective review of snakebites between 2015 and 2020 showed 2408 snakebite cases with a mean patient age of 37.4 years. Males incurred 62.8% of all bites. The highest incidence was in summer 52.5%, and between the hours of 5 PM to midnight 57.2%. Overall, 1010 (41.9%) of all bites were categorized as venomous snakebites (55.6% copperhead, 20% rattlesnake, 2.4% cottonmouth, and 22% miscellaneous [including 3 Elapid envenomations] or unidentified. The total number of venomous bites to the upper extremity was 575 (56.9%) and 567 patients received antivenin. Envenomation severity was mild in 29%, moderate in 45%, severe in 10%, and undetermined in 16% of cases. Crotalidae polyvalent immune Fab (Ovine) was the main antivenin used, with overall mean initial therapy dose of 6.2 vials and 59% of patients receiving maintenance therapy. Three patients (0.5%) had a severe anaphylactic reaction to antivenin requiring cessation of therapy. Seven patients had acute compartment syndrome of the upper extremity requiring fasciotomy (3 copperhead, 2 rattlesnake, and 2 unidentified). There was no reported mortality during this period. Hand surgeons should be familiar with the management of upper extremity Crotalid envenomation. Antivenin remains the main treatment for symptomatic patients. Crotalid snakebites rarely require operative intervention. Prognostic IV.

Mohave Rattlesnake (Crotalus scutulatus) Identification Revisited.

Crotalus scutulatus (Mohave rattlesnake) is a clinically significant pit viper broadly distributed across much of the arid southwestern United States and mainland Mexico. Identification of C scutulatus is a concern among emergency medical service and emergency department personnel owing to its reputation for severe envenomations and difficulty in visually differentiating between C scutulatus and other species, primarily Crotalus atrox (western diamond-backed rattlesnake). We contrast distinctive characteristics of C scutulatus, C atrox, and 3 other sympatric species: Crotalus molossus, Crotalus ornatus, and Crotalus viridis (western and eastern black-tailed rattlesnakes and prairie rattlesnake, respectively). Greenish coloration eliminates C atrox but does not confirm C scutulatus. Obvious coarse and fine speckling of the dorsal pattern and a pale postocular stripe intersecting the mouth characterize C atrox. Dorsal speckling is insignificant or absent in the other species, whereas the pale postocular stripe passes above the mouth in C scutulatus and C viridis and is absent in C molossus and C ornatus. Tails boldly ringed with alternating black and white or contrasting shades of gray are shared by C atrox and C scutulatus, respectively, but a lack of boldly ringed tails characterizes the other species. The proximal rattle segment is yellow and black, or entirely yellow, in C scutulatus but black in the others. The most reliable visual identifications are based on evaluations of multiple traits, all of which are variable to some extent. Traits such as tail ring width and the size and number of crown scales have frequently been overemphasized in the past.

Beneficial effect of fresh frozen plasma in reducing renal complications in Hemiscorpius lepturus scorpion envenomated children with severe hemoglobinuria: an open label randomized clinical trial

Acute kidney injury is a common complication of Hemiscorpius lepturus (HL) scorpion envenomation, via several mechanisms including pigment nephropathy, direct nephrotoxic effects of scorpion venom, hemolytic uremic syndrome (HUS), and acute interstitial nephritis. ADAMTS13 deficiency is highly prevalent in patients with severe HL scorpion envenomation and is effective in the development of HUS. Fresh frozen plasma (FFP), by replacing ADAMTS13, has proven effects on HL scorpion envenomated patients with HUS. This study evaluated the role of FFP in reducing of kidney injuries in complicated cases. In this open label randomized clinical trial, a total of 98 patients with massive hemoglobinuria following HL scorpion envenomation were included in the intervention and control groups (49 patients per group). The intervention group received FFP (10 cc/kg every 12 hours for three days) in addition to the anti-venom and other current therapies. Laboratory findings of renal activity, hemolysis, and urinalysis were evaluated in both groups, and maximum changes were compared. Comparison of maximum changes in laboratory findings between the two groups showed that administration of FFP can significantly reduce the deterioration of Blood Urea Nitrogen (BUN) and Creatinine (Cr) levels in the intervention group (p < 0.001 and p = 0.003, respectively). In comparison with the control group, the incidence of proteinuria was significantly lower (p = 0.012), reduction of platelet count was significantly less (p = 0.044), and increase of lactate dehydrogenase (LDH) and leukocytosis was lower in the intervention group (p = 0.037 and p = 0.007, respectively). The mean length of hospital stay was 5.44 days in the intervention group and 5.933 days in the control group (p = 0.149). According to the present findings, FFP can significantly reduce the development of kidney damage after HL scorpion envenomation and can be safely used against the fatal progression of venom complications in severe cases, along with other common treatments.

Philodryas olfersii: state of the art

Philodryassp. in particular, P. olfersii is an attractive snake emanated by its green color, with a brown stripe along the back, and an inoffensive appearance. Accidents are rare due to the posterior position of the inoculating teeth (opisthoglyphous), but they are not free-effects either local as systemic. Although most studies with this poison date back less than 3 decades, which started with the Duvernoy’s gland secretion and came to transcriptomic analysis, besides the fractioning of the venom to isolate substances responsible for toxic effects, all efforts are converging to the understanding of its pathological mechanisms. We immersed in a scientific platform looking for Philodryas olfersii aiming to establish its “state of the art”. In this work, we hope to sensitize the medical community about the severity of envenomation by P. olfersii can cause, mainly to children, and also the population about the risks of manipulation of this sympathetic snake. Besides, we reinforce that any therapeutic strategy aiming to mitigate the clinical evolution of envenoming is highly desirable.

A case of exotic envenomation by Naja kaouthia in Mexico

In Mexico, an average of 3,893 venomous snakebites is registered annually. Since not all bites are informed, that figure is likely an underestimation. Most bites involve snakes native to Mexico, but reports do not distinguish among the species involved, so the percentage of bites caused by exotic (non-native) snakes is unknown. However, numerous exotic species of venomous snakes are kept in the country, both legally and illegally. Commonly, owners of these snakes do not acquire appropriate antivenoms, leaving themselves vulnerable to severe envenomation. In this article we present the clinical case of a 25-year-old man bitten on the right index finger by a monocled cobra (Naja kaouthia). He developed severe neurotoxicity 15 minutes after the bite and required ventilator support for 16 hours. He recovered after the intravenous administration of eight vials of antivenom specific to N. kaouthia. He had necrosis at the site of the bite, which covered two thirds of the finger but resolved satisfactorily without surgical intervention. Quantitative ELISA assays on seven serum samples confirmed the envenomation and illustrated a secondary rise and fall in systemic venom levels during antivenom treatment.

Predictive Value of Glycemia and Free Fatty Acid Levels upon Admission of Children with Scorpionism in Egypt.

Scorpion envenomation is a life-threatening emergency and causes serious health problems in tropical and subtropical regions. The aim of this study was to correlate the serum levels of biochemical parameters at admission in children with scorpion envenomation with subsequent morbidity and mortality. It was a prospective, observational, and descriptive study conducted for scorpion-envenomed children who presented to emergency and intensive care units between April 2019 and September 2019. Demographic, clinical, and laboratory findings of patients were recorded and tabulated. Routine investigations were done for all patients in addition to blood levels of lactate, free fatty acids (FFA), and insulin. All patients were compared according to outcome as survivors and nonsurvivors and according to glucose level as normoglycemic and hyperglycemic groups. There were 62 scorpion sting cases; their mean age was 8.6 ± 3.2 years. Patients aged more than 6 years (74.2%), and males (66.1%) were more affected than others. As regards severity, 25.8% were suffering organ dysfunction, 40.3% suffered systemic manifestations without organ dysfunction, and (33.9%) with only local manifestations. Serum glucose and FFA were significantly higher in nonsurvivors compared with survivors. Shock, convulsion, coma, heart failure, and pulmonary edema were significantly more common in hyperglycemic than normoglycemic group. Hyperglycemia, and raised FFA were associated with severe scorpion envenomation. Raised FFA was well correlated with presence of heart failure, leucocytosis, and hyperglycemia. Adding serum glucose and FFA to monitoring parameters of scorpionism severity can help the prediction of high-risk patients.

Rhabdophis tigrinus (Yamakagashi) Bites in Japan Over the Last 50 Years: A Retrospective Survey.

Introduction: Rhabdophis snakes, which include 27 species, are rear-fanged venomous snakes that are widely distributed from India to East Asia and Russia. Severe envenomation by R. tigrinus (Yamakagashi snake) in Japan and R. subminiatus in Southeast Asia has been reported. The epidemiology of R. tigrinus bites, such as geographical features, the incidence, and changes in the number of bites over time have not been comprehensively examined. Hence, we intended to clarify the epidemiological features of R. tigrinus bites through a careful review of scientific data over the last 50 years in Japan.Methods: Patient records of R. tigrinus bites between 1971 and 2020 at the Japan Snake Institute were examined retrospectively. The following were ascertained: patient characteristics, clinical symptoms, laboratory data, treatment-related factors, and hospital mortality. These variables were compared in the antivenom and the without-antivenom groups.Results: Over the 50-year study period, 43 R. tigrinus bites, including five fatal cases, were encountered. Severe cases of R. tigrinus bites have been treated with antivenom since 1985; however, fatalities occurred in 2006 and 2020. R. tigrinus bite cases have been well-distributed in the western part of Japan since 2000. The mortality rate in the antivenom group was significantly lower in the patient group that was not administered the antivenom (0 vs. 23.8%, p = 0.048).Conclusion: This study clarified the epidemiology of R. tigrinus bites in Japan over a 50-year period. Almost all severe cases of R. tigrinus bites have been treated with the antivenom in the current situation, and fatalities occurred in cases not treated with the antivenom. It is important to diagnose R. tigrinus bites in the early phase of the clinical course. The antivenom, the definitive treatment for R. tigrinus bites, is an unapproved drug. Hence, approval needs to be obtained for the drug.

Mapping of the venomous stingrays of the Potamotrygon genus in the Tietê River, São Paulo Sstate, Brazil.

Freshwater stingrays are fish that have adapted to the rivers and lakes in South America. The expansion of the Potamotrygonidae family in the Paraná River began after the damming of the Sete Quedas Falls, reaching the mouth of the Paranapanema and Tietê rivers approximately 20 years ago via the locks of the hydroelectric power plants. They are not aggressive animals; however, they have one to four stingers on their tails covered by a venom-producing epithelium and can cause severe envenomation in fishermen and bathers if stepped on or manipulated. We conducted a descriptive, retrospective, and prospective study by monitoring the fishing of the Potamotrygon genus in the lower Tietê River, mapping the location of the rays as a fishery product of professional fishermen and/or recording images of the fish caught. Sixteen stingrays of the Potamotrygon genus were mapped by monitoring fishermen's fish products in the extensive area between the municipalities of Pereira Barreto and Buritama, São Paulo state. The lower Tietê River is fully colonized by freshwater stingrays and this expansion likely continues upstream, reaching various sub-basins of the river. The advancement of these venomous fish in areas where they did not exist previously requires education programs and interaction with the community to avoid serious injuries in bathers and fishermen and the unreasonable extermination of the animals.

A comparison between adult and paediatric snakebites and their outcomes in North Eastern South Africa

BackgroundSnakebites are common among rural communities. The aim of this study was to ascertain the differences between paediatric and adult snakebite patients regarding severity, management and outcome. MethodsThis study included a total of 878 patients admitted to Ngwelezana Hospital, with a snakebite or snakebite-related complication, from September 1, 2008 to December 31, 2014. This included 274 paediatric patients (13 years and younger) and 604 adults. ResultsThere was a male predominance (56%) in the paediatric group and a female predominance (51%) amongst adults. The duration between the time of the bite and presentation to the hospital was significantly longer in children. The vast majority of children and adults presented with cytotoxic envenomation. Laboratory parameters were worse amongst children in the cytotoxic group. 53 children (19%) and 44 adults (7%) required antivenom administration. Of those who received antivenom, 25% suffered adverse reactions in the paediatric group and 20% in the adult group. 56 Children (20%) underwent one or more procedures on their affected limbs compared to 26 adults (4%). ConclusionThe paediatric population carries a higher risk for serious morbidity and should be treated at a facility with the necessary resources. Children require antivenom more often due to severe envenomation. Delayed presentation carries significant morbidity.

Integrating snake distribution, abundance and expert‐derived behavioural traits predicts snakebite risk

Abstract Despite important implications for human health, distribution, abundance and behaviour of most medically relevant snakes remain poorly understood. Such data deficiencies hamper efforts to characterise the causal pathways of snakebite envenoming and to prioritise management options in the areas at greatest risk. We estimated the spatial patterns of abundance of seven medically relevant snake species from Sri Lanka, a snakebite hotspot, and combined them with indices of species' relative abundance, aggressiveness and envenoming severity obtained from an expert opinion survey, to test whether these fundamental ecological traits could explain spatial patterns of snakebite and envenoming incidence. The spatial intensity of snake occurrence records in relation to independent environmental factors (fundamental niches and land cover) was analysed with point process models. Then, with the estimated patterns of abundance, we tested which species' abundances added together, with and without weightings for aggressiveness, envenoming severity and relative abundance, best correlate with per capita geographic incidence patterns of snakebite and envenoming. We found that weighting abundance patterns by species' traits increased correlation with incidence. The best performing combination had three species weighted by aggressiveness and abundance, with a correlation of r = 0.47 (p &lt; 0.01) with snakebite incidence. An envenoming severity and relative abundance‐weighted combination of two species was the most strongly associated with envenoming incidence (r = 0.46, p = 0). Synthesis and applications. We show that snakebite risk is explained by abundance, aggressiveness and envenoming severity of the snake species most frequently involved in envenoming cases. Incorporating causality via ecological information of key snake species is critical for snakebite risk mapping, helping to tailor preventive measures for dominant snake species and deploying the necessary antivenom therapies.

Clinical features and prognosis of severe scorpion envenomation in children.

Scorpionism is endemic and represents a real public health problem in Morocco. The most dangerous arthropod in the central area is Androctonus mauretanicus (Am) scorpion. Its venom can be lethal, especially for children. This study aimed to determine a clinico-epidemiological profile of severe scorpion envenomation among children and identify risk factors for mortality. This retrospective cohort study included 606 children admitted for severe scorpion envenomation (SSE) from January 2010 to July 2015 in the Pediatric Intensive Care Unit (PICU) of Mohammed VI Teaching Hospital. The mean age of envenomed children was 6.3 ± 4.2 years. Seventy-four percent of them came from rural settings. Envenomation occurred mostly during the summer months and 78.4% of stings were nocturnal. The time between the sting and evaluation was greater than 2 h in 83% of cases. Bivariate analysis indicated that from 1 to 24 months of age (P = 0.001), hyperthermia (P = 0.022), episodes of diarrhea (P < 0.001), tachycardia (P < 0.001), abdominal distention (P < 0.001), skin marbling (P < 0.001), signs of respiratory distress (P < 0.001), irritability (P < 0.001), generalized seizures (P = 0.053), and Glasgow Coma Score (GCS) of 3 to 9 (P < 0.001) were significantly correlated with mortality. On multivariate analysis, diarrhea (P = 0.007), skin marbling (P = 0.006), and respiratory distress (P = 0.002), and GCS 3-9 (P = 0.007) were found to be independent risk factors for mortality in our patient population. Children are at high risk of developing serious complications, even death, from severe scorpion envenomation. Here we identified multiple factors that appear to increase the mortality risk in children after scorpion envenomation, including previously described central nervous system alterations.

ENVENIMATIONS VIPERINES

Rational:The viper envenomations are a real public health problem in Morocco more deaths are reported each year. It is a medical-surgical emergency which can be daunting and life-threatening, as well as the patients functional prognosis. Patients and Methods or Material and Methods:We present 24 cases of serious viper envenomation, on a retrospective study extended over a period of 9 years from 2010 to 2019, and through a literature review we clarify the following aspects: epidemiological, pathophysiological, clinical and therapeutic. Inclusion criteria: The presence of traces of hooks with at least one locoregional and / or general sign of envenomation. The actual presence of the snake in question and / or its description by a witness or the victim. Results:This is a retrospective study that interested 12 men and 13 women, mean age 41 years. The bites were due to vipers, the species was known cerastescerastes type in two cases, MacroviperaMauritanica in one case. 13 patients had a consumptive coagulopathy table with two cases of ischemic stroke, one case of hypovolemic shock and 4 cases of hemorrhagic shock, ten patients had compartment syndrome treated by emergency fasciotomy discharge.11 patients received anti venom serum with clinical improvement and reduction of complications. Discussion:The poison of vipers is a chemical proteinaceous with two essential components: the toxins and enzymes. These proteins are responsible for the observed symptoms. The severity of envenomation is related to the plasma concentration of the venom. The definition of early clinical and biological criteria of gravity has envenomation better assess and clarify the therapeutic indications. Processing viper envenomation considerably simplified over the past decade. The medical care is based on a symptomatic therapy component associated with a specific serum therapy. On early treatment with these specific immunoglobulins from the onset of signs of grades II or III envenomation reduces morbidity, sequelae and the total cost of care. Conclusion:Improving the prognosis of envenomation involves information education and good care that can only be achieved through close collaboration between.

The Usefulness of Platelet Distribution Width and Platelet Distribution Width to Lymphocyte Ratio in Predicting Severity and Outcomes in Patients with Snakebite.

Tissue damage, inflammatory response, and hematologic abnormalities may occur in snakebite envenomation. This study aimed to evaluate the predictive ability of platelet distribution width (PDW) and platelet distribution width to lymphocyte ratio (PDWLR) in the severity and outcome of envenomation in patients with snakebites in the emergency department (ED). All adult patients admitted to the ED after a snakebite were retrospectively evaluated. Patients were classified according to the severity of envenomation. The relationship between the PDW and PDWLR and envenomation severity and patient outcomes was analyzed. Multivariate logistic regression analysis was performed to determine the predictors of severe envenomation. Results were presented as 95% CIs with odds ratios. Statistical significance was accepted at P<0.05. Envenomation was classified as none/minimal in 42 patients and moderate/severe in 29. PDW and PDWLR were significantly higher in the moderate/severe group (P=0.016 and P<0.001, respectively). Cut-off values of 16.5 for PDW and 6.15 for PDWLR were related to more severe envenomation (area under the curve 0.67, 95% CI 0.55-0.78 and area under the curve 0.85, 95% CI: 0.74-0.92, respectively). Blood product replacement, thrombocytopenia, hematologic abnormality, advanced local findings, compartment syndrome/fasciotomy, antivenom dosing, and moderate/severe envenomation were associated with PDWLR >6.15 (P<0.05). In multivariate analysis, PDWLR (odds ratio 1.19 [95% CI 1-1.4]; P=0.04) was an independent predictor of severe envenomation. Higher PDW and PDWLR were associated with severe envenomation in patients with snakebites in the ED. PDWLR may be used as a predictor of severe envenomation and adverse outcomes.