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Clinical effects of red-bellied black snake (Pseudechis porphyriacus) envenoming and correlation with venom concentrations: Australian Snakebite Project (ASP-11)

Med J Aust 2010; 193 (11): 696-700.

Summary

Objective: To describe the clinical features and laboratory findings in patients with definite red-bellied black snake (RBBS; Pseudechis porphyriacus) bites, including correlation with results of venom assays.

Design, patients and setting: Prospective cohort study of patients with definite RBBS bites, recruited to the Australian Snakebite Project from January 2002 to June 2010.

Main outcome measures: Clinical and laboratory features of envenoming; peak venom concentrations and antivenom treatment.

Results: There were 81 definite RBBS bites; systemic envenoming occurred in 57 patients (70%) and local envenoming alone occurred in one patient. Systemic envenoming was characterised by local envenoming in 55 patients (96%), systemic symptoms in 54 patients (95%), anticoagulant coagulopathy with a raised activated partial thromboplastin time (aPTT) in 35 patients (61%) and myotoxicity in seven patients (12%). One patient required non-invasive ventilation for severe myotoxicity that resulted in muscle weakness. Three patients developed local ulceration. There were no deaths. Twenty-two envenomed patients (39%) received tiger snake or black snake antivenom, and administration within 6 hours of the bite was associated with normalisation of the aPTT. Eight patients (36%) had immediate hypersensitivity reactions to antivenom, including one case of anaphylaxis. The median peak venom concentration in 37 systemically envenomed patients with serum available was 19 ng/mL (interquartile range, 12–50 ng/mL; range, 3–360 ng/mL), which did not correlate with clinical severity. In 17 patients who received antivenom and had venom concentration measured, no venom was detected in serum after the first antivenom dose, including nine who were given one vial of tiger snake antivenom.

Conclusion: RBBS envenoming caused local effects, systemic symptoms, anticoagulant coagulopathy and, uncommonly, myotoxicity. One vial of tiger snake or black snake antivenom appears to be sufficient to remove venom and neutralise reversible effects, but hypersensitivity reactions occurred in over a third of patients.

  • Andrew Churchman1
  • Margaret A O’Leary2
  • Nicholas A Buckley3
  • Colin B Page1,2
  • Alan Tankel4
  • Chris Gavaghan5
  • Anna Holdgate6,7
  • Simon G A Brown8,9
  • Geoffrey K Isbister10,2

  • 1 Emergency Department, Princess Alexandra Hospital, Brisbane, QLD.
  • 2 Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, NSW.
  • 3 Medical Professorial Unit, Prince of Wales Hospital Medical School, University of New South Wales, Sydney, NSW.
  • 4 Emergency Department, Coffs Harbour Base Hospital, Coffs Harbour, NSW.
  • 5 Emergency Department, Lismore Base Hospital, Lismore, NSW.
  • 6 Emergency Department, Liverpool Hospital, Sydney, NSW.
  • 7 Department of Anaesthetics, Emergency Medicine and Intensive Care, University of New South Wales, Sydney, NSW.
  • 8 Centre for Clinical Research in Emergency Medicine, Western Australian Institute for Medical Research, Perth, WA.
  • 9 Emergency Medicine, Royal Perth Hospital, University of Western Australia, Perth, WA.
  • 10 Discipline of Clinical Pharmacology, University of Newcastle, Newcastle, NSW.

Correspondence: geoff.isbister@gmail.com

Acknowledgements: 

We thank the ASP clinical investigators who recruited patients to the study — Richard Whitaker and Lambros Halkidis (Cairns Base Hospital), David Spain and Graham Ireland (Gold Coast Hospital), Mark Miller (John Hunter Hospital), Andis Graudins (Prince of Wales Hospital), Naren Gunja (Westmead Hospital) — and the ASP laboratory investigators. We also acknowledge the many referrals from the poison information centres and clinical toxicologists, and thank the many other nurses, doctors and laboratory staff who helped recruit patients and collect samples.

Competing interests:

None identified.

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