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Suspected snakebite in children: a study of 156 patients over 10 years

Helen J Mead and George A Jelinek
Med J Aust 1996; 164 (8): 467.
Published online: 15 April 1996

Suspected snakebite in children: a study of 156 patients over 10 years

Helen J Mead and George A Jelinek


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Abstract - Introduction - Methods - Results - Discusssion - References - Authors' details

- - ©MJA1997


 

Abstract

Objective: To describe the epidemiology and clinical features of children presenting to an emergency department with suspected snakebite.
Design: A retrospective study of patient records.
Setting: An emergency department of a children's teaching hospital (Princess Margaret Hospital) in Perth, Western Australia.
Participants: All children attending the emergency department from 1984 to 1993 with suspected snakebite.
Main outcome measure: Clinical and laboratory evidence of envenomation.
Results: Over the decade studied, 156 children (mean age, six years and eight months) presented with suspected snakebite; over two-thirds (68%) were boys. In at least 31% of cases, no appropriate first aid had been applied. Only 14 children were envenomed according to clinical and laboratory criteria: 10 of these had coagulopathy; one of the 10 also had rhabdomyolysis. A Venom Detection Kit was used in 117 children. The test gave a positive result in 21 children (13%). Antivenom was given to 18 children, 14 of whom were definitely envenomed. Four of the envenomed children returned a negative result of Venom Detection Kit testing at all sites tested, and in five patients not clinically envenomed the urine specimen tested positive with the Venom Detection Kit (presumably a false positive result or subclinical envenomation). Of the 156 children, 130 were admitted to hospital, and 26 were discharged directly from the emergency department. All children recovered completely.
Conclusions: (i) Many children did not receive appropriate first aid for snakebite; (ii) Most children with suspected snakebite presenting to the emergency department were not envenomed; (iii) Envenomation was best diagnosed by clinical features and laboratory investigations, with the Venom Detection Kit being used to determine the appropriate antivenom; (iv) Discharging children directly from the emergency department is not recommended.

MJA 1996; 164: 467  

Introduction

Three major Australian studies of snakebite in children have been published.1-3 Two were from south-east Queensland1,2 and the third from Victoria.3 No similar studies have been reported from Western Australia, but one has been published on patterns of envenomation in 193 adults admitted to Perth teaching hospitals.4 There are also no published data on children presenting to Australian emergency departments with snakebite.

Our aim was to describe the presenting features, treatment and outcome in children with suspected snakebite attending an emergency department. We also examined aspects of the use of the Venom Detection Kit, which was widely used as an adjunct in the diagnosis and management of these children.  

Methods

We studied the records of all children presenting to Perth's Princess Margaret Hospital for Children with suspected or definite snakebite between 1 January 1984 and 31 December 1993. If parents or other carers had a reasonable suspicion that a child may have been bitten by a snake, this was classified as "suspected snakebite", and in "definite snakebite" a reliable history was available of a snake striking the child (whether or not envenomation occurred), or there was clinical and/or laboratory evidence of envenomation in circumstances consistent with snakebite.

To ensure all records were found, multiple data sources were accessed, including hospital morbidity coding for inpatient admissions; intensive care unit records; and emergency department records. Data extracted from the records were entered onto a Microsoft Access 2.0 database to assist with analysis.5

To facilitate a comparison with the study in adults from Perth hospitals,4 data on patients' snakebite history and envenomation status were extracted and patients were grouped in the categories listed in the Perth study4 and shown in Box 1.

Systemic envenomation was deemed present if there was clinical (vomiting, abdominal pain, or neurotoxic effects -- ptosis, convulsions, or difficulty with breathing or swallowing) or laboratory evidence (coagulopathy, haemolysis, rhabdomyolysis or renal failure).


 

Results

Over the 10 years, 160 children presented to the Emergency Department at Princess Margaret Hospital with suspected snakebite. Patient records were available for 156 children. The snake was brought in with the patient for identification on 16 occasions (on one occasion the snake was still alive!). Thirty-one children were admitted to the Intensive Care Unit, 87 to a general ward, 12 to the Emergency Department observation ward and 26 were discharged directly from the Emergency Department.

Age and sex distribution
The mean age of the children was six years and eight months (range, 15 months to 14 years 4 months), and over two-thirds (68%) were boys. Athough there was an even age distribution among children who were envenomed, there were 46 (29%) toddlers (less than three years) among the children presenting.

Location
Most snakebites occurred in the victims' garden (59 cases; 38%) or surrounding suburban bushland (51 cases; 33%). Eight (5%) occurred in a house or outbuilding and 26 (17%) children were bitten in open country. The location of the remaining 12 (7%) was not specified.

Seasonal distribution
Most children presented in the summer months, with very few presentations during winter; only three of the 14 children who were envenomed were bitten outside the months of October to April.

Bite site
Most children were bitten on a limb (lower limb: 103 cases, 66%; upper limb: 43 cases, 28%). There was one bite to the torso and one to the head, with the site not recorded in eight cases. Puncture marks were noted in 81 cases (52%).

First aid
It was often difficult to determine from the patient records whether first aid had been applied. However, in 39 cases it was clearly documented that no first aid was used, and inappropriate first aid (such as washing the site or use of an arterial tourniquet) was recorded in 10 cases (i.e., at least 49 children [31%] did not have effective first aid). The pressure- immobilisation first aid technique was used in 75 children (48%), although in some it was noted that the bandage had been applied only loosely or the limb was not fully immobilised. There was no record of whether first aid was applied in 32 children (21%). In some cases first aid measures were inappropriately left in place for a prolonged period after reaching hospital.

Envenomation
Fourteen children had systemic envenomation and 17 possible systemic envenomation according to the criteria used in this study (Box 1). The details of the clinical features, management and outcome of the 14 envenomed children are summarised in Box 2. In two children with possible envenomation, laboratory coagulation tests gave values just outside the normal range; both had an uneventful course and were not given antivenom. Four other child ren classified with possible envenomation received antivenom early for non-specific symptoms, without confirmatory laboratory evidence of envenomation.

Venom detection
Of the 117 cases in which the Venom Detection Kit was used, a positive result was obtained in 21 children (12 from wound swabs, 10 from urine, and four from blood). In nine of these child ren with no evidence of systemic envenomation, venom was detected in urine in five, and in skin swabs in the other four. In a child with borderline coagulopathy, the Venom Detection Kit gave a positive result in blood, but a negative one in urine. Another child treated for possible envenomation tested positive for venom at the "bite site", but tests of urine and blood gave a negative result with the Venom Detection Kit (Case D under "Use of antivenom").

The venom type detected by the Venom Detection Kit in envenomed patients is shown in Box 2.

Use of antivenom
Antivenom was given to 18 children (polyvalent in eight cases, brown snake in seven and tiger snake in five; two patients received more than one type of antivenom). Four children who were given antivenom may not have been envenomed.

Case A: An eight-year-old boy with a witnessed bite received antivenom for regional lymphaden o pathy and headache. No venom was detected at the bite site, nor in blood or urine.

Case B: A 10-year-old girl (no snake was seen) had a negative result of a Venom Detection Kit test of a bite site, and urine and coagulation studies showed no abnormality, but she was given antivenom because of symptoms of tiredness and non-specific weakness.

Case C: A nine-month-old girl who was crying and vomiting and noted to have a mark on her arm was given polyvalent antivenom before transfer to Princess Margaret Hospital. No venom detection tests were undertaken. Her symptoms of fever and intermittent vomiting were subsequently thought to be due to a viral illness.

Case D: A six-year-old girl had tiger snake venom detected at a possible bite site (but no venom detected in blood or urine). She was given tiger snake antivenom for symptoms of headache, fever, abdominal pain and nausea. A groin abscess was noted the next day, which may possibly have been the cause of her illness.

Other supportive treatment
Three children were administered fresh frozen plasma. No child required artificial ventilation.

Outcome
All children were discharged well from hospital; no permanent morbidity was recorded.  

Discusssion

As in the previous epidemiological studies of snakebite in children in Australia,1-3 most of the children who presented to hospital with suspected snakebite were not envenomed (Box 3). In our study the over-representation of toddlers in the children presenting, despite an even age distribution of children with envenomation, probably reflected heightened parental concern and the difficulty obtaining a history from this age group.


Patterns of envenomation and treatment for snakebite in Perth children were similar to those reported previously in adults.4 The sex distribution of victims, the seasonal pattern of envenomation and the site of bites were also similar.

The venoms of the two snake genera responsible for most bites in Perth, Pseudonaja (brown snake) and Notechis (tiger snake), have powerful procoagulants, and coagulopathy was present in most (71%) of the envenomed patients. Among Perth snakes, only the tiger snake produces myolysis, and only one patient in this series had rhabdomyo lysis. Despite local differences in fauna, these findings are very similar to those in children with snakebite in Victoria.3

Despite continuing confirmation of the great efficacy of the pressure-immobilisation first aid technique in delaying venom spread,6,7 it is disturbing that this method is still not being used widely. In many cases it is also being applied incorrectly. More public education on first aid in snakebite is needed.

The role of the Venom Detection Kit in patients with suspected snakebite attending emergency departments is discussed in Box 4.

Although it appeared that no child came to harm after discharge from the Emergency Department, this practice is fraught with danger, as a case from 1973 illustrates. A two-year-old girl with restlessness and dry retching presented to hospital with an unclear history; the possibility of snakebite was raised by the parents. The examining medical officer concluded that she had been bitten by an insect, no investigations were ordered and she was discharged. The next morning she was found dead in bed, and it was later confirmed that tiger snake envenomation had been the cause of death. The Coroner found that there had been a lack of care on the part of the hospital, contributing to her death.10

In most children presenting to an emergency department there is no way of determining absolutely whether a venomous snakebite has occurred. There are special difficulties in obtaining a reliable history from young children and it may be tempting to use a negative result of a Venom Detection Kit to facilitate early discharge. Indeed, a number of children in this study were discharged from the Emergency Department without laboratory investigations, apart from use of the Venom Detection Kit. However, all children in whom snakebite is suspected, whether a snake was seen or not, should be admitted to hospital for observation and investigation (including coagulation profiles). In a number of cases of envenomation in our series, no snake bite was observed, and in two cases no snake was seen. Discharging children with suspected snakebite directly from emergency departments without a period of observation is not recommended.  

References

  1. Munro JGC, Pearn JH. Snake bite in children. A five year population study from South-East Queensland. Aust Paediatr J 1978; 14: 248-253.
  2. Jamieson R, Pearn J. An epidemiological and clinical study of snake-bites in childhood. Med J Aust 1989; 150: 698-702.
  3. Tibballs J. Diagnosis and treatment of confirmed and suspected snake bite. Implications from an analysis of 46 paediatric cases. Med J Aust 1992; 156: 270-274.
  4. Jelinek GA, Hamilton T, Hirsch RL. Admissions for suspected snake bite to the Perth adult teaching hospitals, 1979 to 1988. Med J Aust 1991; 155: 761-764.
  5. Microsoft Access [database]. Version 2.0. Redmond, WA: Microsoft Corporation, 1989-1994.
  6. Howarth DM, Southee AE, Whyte IM. Lymphatic flow rates and first-aid in simulated peripheral snake or spider envenomation. Med J Aust 1994; 161: 695-700.
  7. Sutherland SK. The pressure immobilisation technique. Med J Aust 1994; 161: 700-701.
  8. CSL Diagnostics. Snake venom detection kit. Product information leaflet. Melbourne: CSL Diagnostics, 1992.
  9. Wentworth B, Moisidis A, Jones S. Performance of the new snake venom detection kit at high and low concentrations [abstract]. Proceedings of the 22nd Annual Scientific Meeting of the Australasian Society of Immunology; 1992 Dec 2-4; Auckland. Parkville: Australasian Society of Immunology, 1992.
  10. Snake and lack of care killed girl. The West Australian 1973 19 Jun: 3 (col. 3, 4 and 5).

(Received 6 Jul, accepted 20 Dec 1995)
 


Authors' details

Department of Emergency Medicine, Fremantle Hospital, Fremantle, WA.
Helen J Mead, FRACP, FACEM, Staff Specialist; formerly, Senior Registrar, Intensive Care Unit, Princess Margaret Hospital for Children, Perth, WA;
George A Jelinek, MD, FACEM, Assistant Director and Staff Specialist.

No reprints will be available. Correspondence: Dr George A Jelinek, Department of Emergency Medicine, Fremantle Hospital, PO Box 480, Fremantle, WA 6160.

©MJA 1997

<URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Received 21 September 2018, accepted 21 September 2018

  • Helen J Mead
  • George A Jelinek


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