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Major envenomation

Major envenomation. Hunter Area Toxicology Service. Presentation. 56yo male school teacher Major depression for 6 months of work for one term on citalopram 20mg tds Reflux oesophagitis – laparoscopic fundoplication. Christmas Day 1998. Carrying LPG bottle out to barbecue

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Major envenomation

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  1. Major envenomation Hunter Area Toxicology Service

  2. Presentation • 56yo male school teacher • Major depression for 6 months • of work for one term • on citalopram 20mg tds • Reflux oesophagitis – laparoscopic fundoplication

  3. Christmas 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

  4. First–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

  5. On 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

  6. In 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

  7. In cardiac arrest • 1100 • CPR commenced • Adrenaline 1mg x 2 • Atropine 600 mcg • 1108 • Femoral output • Sinus rhythm • PR 123, BP 78/35

  8. Post cardiac arrest • 1117 • PR 142, BP 201/125 • Urine and bite site VDK negative • Initial coagulation studies • Blood clotted in coagulation tubes

  9. Retrieval • 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

  10. Coagulation 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 † † † † † † † † † †

  11. Complications • Chest infection • Left ventricular failure/pulmonary oedema • Confusion/delirium/memory deficit

  12. Chest infection • Eight hours post envenomation • Febrile 38.5° • Purulent material aspirated from endotracheal tube • Started on • ampicillin • metronidazole • gentamicin

  13. Pulmonary oedema • Days 2–4 • Pulmonary oedema requiring CPAP • Placed on • ACE inhibitor • diuretic therapy • Day 5 • Echocardiogram

  14. Muscle enzymes Time (d) 0 1 2 3 4 5 CK (1–185 U/L) 204 827 2866 2120 902 452

  15. Muscle 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

  16. Confusion • 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

  17. SPECT brain scan

  18. Neuropsychiatric assessment • 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

  19. Results • 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

  20. Results • 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

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