Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
Major envenomationMajor envenomation
Hunter Area Toxicology Service
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
PresentationPresentation
56yo male school teacher Major depression for 6 months
– of work for one term– on citalopram 20mg tds
Reflux oesophagitis – laparoscopic fundoplication
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
Christmas Day 1998Christmas Day 1998
Carrying LPG bottle out to barbecue At 0950 stepped on something soft
which moved Looked down to see a “brown” snake
~ 2 feet long Chased snake out of yard to protect the
grandchildren Wife persuaded him to sit down
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
First–aidFirst–aid
Bite seen on dorsum of R second toe Tourniquet applied to forefoot at 1010 Son drove him to nearest hospital At 1030 father complained of chest
tightness and difficulty breathing By 1035 father unconscious in car Arrived at ED at 1037
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
On arrivalOn arrival
1037– Semi–conscious, GCS 6– PR 64, BP 131/77, RR 36 shallow– Bloods taken
1048– Given 1 ampoule brown snake antivenom– Decreased level of consciousness– Decreasing respiration– Monitor showed ST elevation
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
In EmergencyIn Emergency
1052– Intubated with atropine, midazolam,
suxamethonium– IDC inserted– Given 1 ampoule brown snake antivenom– Urine and bite site tested with VDK
1100 – Monitor showed asystole
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
In cardiac arrestIn cardiac arrest
1100– CPR commenced– Adrenaline 1mg x 2– Atropine 600 mcg
1108– Femoral output– Sinus rhythm– PR 123, BP 78/35
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
Post cardiac arrestPost cardiac arrest
1117– PR 142, BP 201/125– Urine and bite site VDK negative– Initial coagulation studies
Blood clotted in coagulation tubes
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
RetrievalRetrieval
1145– Repeat coagulation studies
PT >50 s aPTT > 200 s
– Given 1 bag FFP 1200
– Retrieval team transport to NMMH– Given 2 ampoules brown snake
antivenom en route
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
Coagulation studiesCoagulation studies
Time (h) 0.7 1.7 4.7 7.8 10.7 13.9 22.2
PT (10–13 s) * >50 >180 >60 32 17 13
aPTT (22–35 s) * >200 >120 75 47 34 32
TCT (12–16 s) >60 >60 >60 >60
Fib (2.0–4.0 G/L) 0.0 0.0 1.4 3.2 6.4 1.4
XDP (<0.25 mg/L) >1.6 >1.6 >1.6
PLT (150–400 x 109/L) 14 368 144 125 108
Antivenom † † † † † † † † † †
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
ComplicationsComplications
Chest infection Left ventricular failure/pulmonary
oedema Confusion/delirium/memory deficit
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
Chest infectionChest infection
Eight hours post envenomation– Febrile 38.5° – Purulent material aspirated from
endotracheal tube– Started on
ampicillin metronidazole gentamicin
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
Pulmonary oedemaPulmonary oedema
Days 2–4– Pulmonary oedema requiring CPAP– Placed on
ACE inhibitor diuretic therapy
Day 5– Echocardiogram
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
Muscle enzymesMuscle enzymes
Time (d) 0 1 2 3 4 5
CK (1–185 U/L) 204 827 2866 2120 902 452
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
Muscle enzymesMuscle enzymes
Time (d) 0 1 2 3 4 5
CK (1–185 U/L) 204 827 2866 2120 902 452
Troponin I* 9.3 – 16.7 – 4.9 2.7
*Apparently healthy individuals <0.4 ng/mL Reference range <1.0 ng/mL Diagnostic of AMI 2.0 ng/mL
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
ConfusionConfusion
Extubation was delayed due to a marked confusional state evident even while on the ventilator
Delirium persisted for several days and became a significant management problem
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
SPECT brain scanSPECT brain scan
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
Neuropsychiatric Neuropsychiatric assessmentassessment
Performed at 6 weeks post envenomation
Wechsler Adult Intelligence Scale Revised (Australia)
Wechsler Memory Scale (Form 1) Rey Auditory Verbal Learning Test Rey Complex Figure Trail Making Test A and B
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
ResultsResults
WAIS–R– Verbal IQ – 124– Performance IQ – 99– Full scale IQ – 115
5–digits forward, 4–digits backwards Rey Complex Figure
– Copy – above average– Repeat (3 minutes) – below average
Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital
ResultsResults
Trail making A – 90+ percentile Trail making B – 25 percentile Memory quotient – 132
– Immediate recall very good– Delayed recall (30 min)
Structured information – very good Unstructured information – good Designs – poor