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The Australian Snakebite Project, 2005–2015 (ASP-20)

Christopher I Johnston, Nicole M Ryan, Colin B Page, Nicholas A Buckley, Simon GA Brown, Margaret A O'Leary and Geoffrey K Isbister
Med J Aust 2017; 207 (3): 119-125. || doi: 10.5694/mja17.00094

Abstract

Objective: To describe the epidemiology, treatment and adverse events after snakebite in Australia.

Design: Prospective, multicentre study of data on patients with snakebites recruited to the Australian Snakebite Project (2005–2015) and data from the National Coronial Information System.

Setting, participants: Patients presenting to Australian hospitals with suspected or confirmed snakebites from July 2005 to June 2015 and consenting to participation.

Main outcome measures: Demographic data, circumstances of bites, clinical effects of envenoming, results of laboratory investigations and snake venom detection kit (SVDK) testing, antivenom treatment and adverse reactions, time to discharge, deaths.

Results: 1548 patients with suspected snakebites were enrolled, including 835 envenomed patients (median, 87 per year), for 718 of which the snake type was definitively established, most frequently brown snakes (41%), tiger snakes (17%) and red-bellied black snakes (16%). Clinical effects included venom-induced consumption coagulopathy (73%), myotoxicity (17%), and acute kidney injury (12%); severe complications included cardiac arrest (25 cases; 2.9%) and major haemorrhage (13 cases; 1.6%). There were 23 deaths (median, two per year), attributed to brown (17), tiger (four) and unknown (two) snakes; ten followed out-of-hospital cardiac arrests and six followed intracranial haemorrhages. Of 597 SVDK test results for envenomed patients with confirmed snake type, 29 (4.9%) were incorrect; 133 of 364 SVDK test results for non-envenomed patients (36%) were false positives. 755 patients received antivenom, including 49 non-envenomed patients; 178 (24%), including ten non-envenomed patients, had systemic hypersensitivity reactions, of which 45 (6%) were severe (hypotension, hypoxaemia). Median total antivenom dose declined from four vials to one, but median time to first antivenom was unchanged (4.3 hours; IQR, 2.7–6.3 hours).

Conclusions: Snake envenoming is uncommon in Australia, but is often severe. SVDKs were unreliable for determining snake type. The median antivenom dose has declined without harming patients. Improved early diagnostic strategies are needed to reduce the frequently long delays before antivenom administration.

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  • Christopher I Johnston1,2
  • Nicole M Ryan2
  • Colin B Page3
  • Nicholas A Buckley4
  • Simon GA Brown5,6
  • Margaret A O'Leary2
  • Geoffrey K Isbister2,3

  • 1 NSW Poisons Information Centre, Sydney Children's Hospitals Network, Sydney, NSW
  • 2 University of Newcastle, Newcastle, NSW
  • 3 Calvary Mater Newcastle, Newcastle, NSW
  • 4 University of Sydney, Sydney, NSW
  • 5 University of Western Australia, Perth, WA
  • 6 Centre for Clinical Research in Emergency Medicine (CCREM), Harry Perkins Institute of Medical Research, Perth, WA

Correspondence: geoff.isbister@gmail.com

Acknowledgements: 

Geoffrey Isbister is supported by a National Health and Medical Research Council (NHMRC) Senior Research Fellowship (1061041). Nicole Ryan is supported by an NHMRC Early Career Fellowship. Colin Page is funded by a Queensland Emergency Medicine Research Foundation Fellowship. The study described in this article is funded by an NHMRC Centre for Research Excellence Grant (1110343). We acknowledge the help of numerous critical care nurses and medical staff who assisted in recruiting patients to the study, and the local investigators at hospitals around Australia.

Competing interests:

Christopher Johnston is employed by Boehringer Ingelheim; this research was independent of his employment by Boehringer Ingelheim.

  • 1. Sutherland SK, Tibballs J. Australian animal toxins: the creatures, their toxins and care of the poisoned patient. 2nd edition. Melbourne: Oxford University Press, 2001.
  • 2. Sutherland SK. Deaths from snake bite in Australia, 1981–1991. Med J Aust 1992; 157: 740-746.
  • 3. Sutherland SK, Leonard RL. Snakebite deaths in Australia 1992–1994 and a management update. Med J Aust 1995; 163: 616-618.
  • 4. Winkel KD, Mirtschin P, Pearn J. Twentieth century toxinology and antivenom development in Australia. Toxicon 2006; 48: 738-754.
  • 5. White J. A clinician’s guide to Australian venomous bites and stings: incorporating the updated CSL antivenom handbook. Melbourne: CSL, 2012.
  • 6. Munro JG, Pearn JH. Snake bite in children: a five year population study from South-East Queensland. Aust Paediatr J 1978; 14: 248-253.
  • 7. Jamieson R, Pearn J. An epidemiological and clinical study of snake-bites in childhood. Med J Aust 1989; 150: 698-702.
  • 8. Jelinek GA, Breheny FX. Ten years of snake bites at Fremantle Hospital. Med J Aust 1990; 153: 658-661.
  • 9. Mead HJ, Jelinek GA. Suspected snakebite in children: a study of 156 patients over 10 years. Med J Aust 1996; 164: 467-470. <MJA full text>
  • 10. 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.
  • 11. Fisher MM, Bowey CJ. Urban envenomation. Med J Aust 1989; 150: 695-698.
  • 12. Barrett R, Little M. Five years of snake envenoming in far north Queensland. Emerg Med (Fremantle) 2003; 15: 500-510.
  • 13. Currie BJ. Snakebite in tropical Australia: a prospective study in the “Top End” of the Northern Territory. Med J Aust 2004; 181: 693-697. <MJA full text>
  • 14. Yeung JM, Little M, Murray LM, et al. Antivenom dosing in 35 patients with severe brown snake (Pseudonaja) envenoming in Western Australia over 10 years. Med J Aust 2004; 181: 703-705. <MJA full text>
  • 15. de Silva HA, Ryan NM, de Silva HJ. Adverse reactions to snake antivenom, and their prevention and treatment. Br J Clin Pharmacol 2016; 81: 446-452.
  • 16. Currie BJ. Treatment of snakebite in Australia: the current evidence base and questions requiring collaborative multicentre prospective studies. Toxicon 2006; 48: 941-956.
  • 17. Kulawickrama S, O’Leary MA, Hodgson WC, et al. Development of a sensitive enzyme immunoassay for measuring taipan venom in serum. Toxicon 2010; 55: 1510-1518.
  • 18. Johnston CI, Ryan NM, O’Leary MA, et al. Australian taipan (Oxyuranus spp.) envenoming: clinical effects and potential benefits of early antivenom therapy — Australian Snakebite Project (ASP-25). Clin Toxicol (Phila) 2017; 55: 115-122.
  • 19. Ireland G, Brown SG, Buckley NA, et al. Changes in serial laboratory test results in snakebite patients: when can we safely exclude envenoming? Med J Aust 2010; 193: 285-290. <MJA full text>
  • 20. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report — Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006; 117: 391-397.
  • 21. Brown SG. Clinical features and severity grading of anaphylaxis. J Allergy Clin Immunol 2004; 114: 371-376.
  • 22. Bugeja L, Ibrahim JE, Ferrah N, et al. The utility of medico-legal databases for public health research: a systematic review of peer-reviewed publications using the National Coronial Information System. Health Res Policy Syst 2016; 14: 28.
  • 23. Johnston CI, O’Leary MA, Brown SG, et al. Death adder envenoming causes neurotoxicity not reversed by antivenom — Australian Snakebite Project (ASP-16). PLoS Negl Trop Dis 2012; 6: e1841.
  • 24. Isbister GK, O’Leary MA, Elliott M, Brown SG. Tiger snake (Notechis spp) envenoming: Australian Snakebite Project (ASP-13). Med J Aust 2012; 197: 173-177. <MJA full text>
  • 25. Johnston CI, Brown SG, O’Leary MA, et al. Mulga snake (Pseudechis australis) envenoming: a spectrum of myotoxicity, anticoagulant coagulopathy, haemolysis and the role of early antivenom therapy — Australian Snakebite Project (ASP-19). Clin Toxicol (Phila) 2013; 51: 417-424.
  • 26. Churchman A, O’Leary MA, Buckley NA, et al. 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: 696-700. <MJA full text>
  • 27. Allen GE, Brown SG, Buckley NA, et al. Clinical effects and antivenom dosing in brown snake (Pseudonaja spp.) envenoming — Australian snakebite project (ASP-14). PLoS One 2012; 7: e53188.
  • 28. Nimorakiotakis VB, Winkel KD. Prospective assessment of the false positive rate of the Australian snake venom detection kit in healthy human samples. Toxicon 2016; 111: 143-146.
  • 29. Isbister GK, Brown SG, Page CB, et al. Snakebite in Australia: a practical approach to diagnosis and treatment. Med J Aust 2013; 199: 763-768. <MJA full text>
  • 30. Maduwage K, O’Leary MA, Isbister GK. Diagnosis of snake envenomation using a simple phospholipase A2 assay. Sci Rep 2014; 4: 4827.

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