Antivenom Therapy for Crotaline Snakebites: Has the Poison Control Center Provided Effective Guidelines?

Abstract

Crotaline snakebites (Protobothrops mucrosquamatus and Trimeresurus stejnegeri) are a common medical emergency in Taiwan that can be effectively treated by a bivalent F(ab)2 antivenom. We investigated the differences in the clinical outcomes of patients who received different therapeutic regimens of antivenom in a medical center where clinical toxicologists followed the poison control center (PCC) guidelines (medical group) and surgeons did not (surgical group). The medical records of inpatients with crotaline snakebites between 1991 and 2005 were reviewed and information on demographics, treatments, adverse effects of antivenom, and complications was abstracted and analyzed. A total of 179 patients (90 medical, 89 surgical) were eligible for study. There was no significant intergroup difference in baseline characteristics except that the dose of antivenom and the probability of antibiotic use were both higher in the surgical group (5.9 +/- 4.2 vials vs. 2.7 +/- 1.6 vials; 93% vs. 60%). Multiple logistic regression adjusting for age, gender, calendar year of envenomation, severity of envenomation, and antibiotic use did not disclose evidence of any difference in various clinical outcomes between medical and surgical patients. The lower dose of antivenom recommended by the PCC may be as effective and safe as the higher dose used in the surgical group for the treatment of crotaline snakebites.

An investigation of snakebite antivenom usage in Taiwan

“…Although some authors suggested that treatment with FH antivenom is administration of 1 vial every 2 hours until clinical stabilization and a maximum administration of 4 vials in the FH group snakebites patients. 6 As for tissue necrosis, compartment syndrome due to limb swelling, the TPCC guideline clearly stated surgical treatment is not allowed unless deep tissue necrosis or compartment syndrome developed. Lacking these important recommendations may make doctors who treat snakebite patients on their free evaluation of severity but not on the basis of evidence medicine.…”

“…13e16 One singlecenter study found that although patients who were treated by surgeons had been administered a higher FH antivenom dosage (5.9 AE 4.2 vials) than those who were treated by emergency medicine physicians (2.7 AE 1.6 vials), in accordance with the TPCC guideline both groups of patients experienced similar outcomes. 6 Thus, the TPCC guidelines for treatment with FH antivenom may need little revision by adding severity grading systems to guide the antivenom dosage.…”

“…Only one report conducted by a TPCC-affiliated hospital has concluded that the TPCC guidelines for treating venomous snakebites are useful. 6 Moreover, even this one report raised concerns regarding antivenom dosage discrepancies among different groups of doctors within the same hospital in their use of the same type of antivenom. An additional research difficulty is that snakebite data in Taiwan are limited, 1 with most derived from single-hospital-based case series that also reported discrepancies in antivenom dosage.…”

Wound infections secondary to snakebite in central Taiwan

“…There are six main kinds of venomous snakes in Taiwan, including Naja atra (cobra), Bungarus multicinctus, Trimeresurus mucrosquamatus, Trimeresurus stejnegeri, Deinagkistrodon acutus, and Daboia russelii siamensis (1). Antivenom administration is the standard therapy for snakebite.…”

Bungarus multicinctus multicinctus Snakebite in Taiwan

“…54 In Taiwan, only 0.7-3% of patients receiving bivalent T. stejnegeri and P. mucrosquamatus antivenom were reported to have a skin allergy. 55,56 Moreover, anaphylaxis was only reported in this study despite the fact that nearly 1,000 cases received antivenom in Taiwan each year. 1 Because of the overall low incidence of allergic reactions after antivenom administration, routine premedication with epinephrine or antihistamines and corticosteroids is not recommended in Taiwan.…”