Monocled Cobra (Naja kaouthia) Envenomations Requiring Mechanical Ventilation

Greene, Spencer; Osborn, Lesley; Bower, Rachel; Harding, Stephen A.; Takenaka, Katrin

doi:10.1016/j.jemermed.2020.10.014

Cited by 7 publications

(8 citation statements)

References 19 publications

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“…After an official inspection, the adult applicant is permitted to purchase the requested species. There are strict rules that are regularly enforced 3 Antirept (Pasteur Mérieux Lyon-France sérum antivenimeux, polyvalent, purifié: moyen orient -afrique du nord) 4 Polyvalent snake antivenom, National Antivenom and Vaccine Production Centre (NAVPC), Saudi-Arabia 5 CroFab (Crotalide polyvalent immune fab [ovine]), BTG, Pennsylvania, USA 6 Antivipmyn Tri (Instituto Bioclon, Mexico) 7 "Antivenin (suero antiofidico polivalente)", probably BIOL, Paraguay 8 FAV Afrique (Sanofi-Pasteur) 9 ViperTab, unclear which producer 10 SAIMR polyvalent snake antivenom, SA Vaccine Producers (Pty) Ltd. (The South African Institute for Medical Research), South Africa *Two cases are probably: Cobra Antivenin (Naja kaouthia), Queen Saovabha Memorial Institute (Thai Red Cross Society), Thailand…”

Section: Discussionmentioning

confidence: 99%

“…Snakes account for approximately 11% of the imported reptiles, with as many as 9% of those reptiles being venomous [3]. In a recent study, 1.1% of snake envenomation cases reported in the US between 2015 and 2018 concerned non-indigenous venomous snakes [4]. Another study found that one quarter of the snakebites reported in the UK between 2004 and 2010 resulted from non-indigenous snakes, but only 3% were attributed to venomous non-indigenous snakes [5].…”

Section: Introductionmentioning

confidence: 99%

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Exotic venomous snakebites in Switzerland reported to the National Poisons Information Centre over 22 years

et al. 2022

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OBJECTIVE: The private keeping of exotic venomous snakes is legally permitted in Switzerland. The aim of the present study was to characterise the epidemiological and clinical features of bites by exotic venomous snakes over a period of 22 years in Switzerland. METHODS: We included all calls related to exotic snakebites recorded at the Swiss National Poisons Information Centre (Tox Info Suisse) from 1997 to 2018. Exclusion criteria comprised indigenous snakes, non-venomous exotic snakes such boas or pythons, clinical courses incompatible with a snakebite or calls from abroad. Follow-up information was graded according to the Poisoning Severity Score. RESULTS: Within the study period, 1,364 calls related to snakebites were recorded at Tox Info Suisse; 148 (11%) cases were attributed to exotic venomous snakes and fulfilled the study criteria. A total of 112 (98%) of 114 patients with medical follow-up information exhibited sufficient causality between exposure and clinical effects. Only adult patients were affected. The median age was 40 years (range 16–71) and the male gender was predominant (n = 136, 92%). Viperidae were involved in 87 (78%) and Elapidae in 25 (22%) patients. Overall, the main affected body part was the hand (89 patients, 79%). In the majority of the patients the clinical course was mild (46, 41%) or moderate (40, 36%), in a lower proportion asymptomatic (6, 5%) or with severe symptoms (20, 18%). No fatalities were reported in the study period. Severe symptoms were observed after elapid bites in six patients (24%) and after viper bites in 14 patients (16%). Besides local effects, neurological disorders after elapid bites and haematological disorders after viper bites were most frequently reported. Antivenom was administered in 24% (27 patients: 18 Viperidae, 21% and 9 Elapidae, 36%; 5 patients (4%) required multiple doses), overall, with good resolution of symptoms. CONCLUSION: Exotic snakebite is a rare occurrence in Switzerland but has led to medically relevant morbidity, sometimes requiring antivenom treatment. Over half of the envenomed patients required symptomatic or specific treatment. No fatalities or bites in children were reported.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Exotic venomous snakebites in Switzerland reported to the National Poisons Information Centre over 22 years

et al. 2022

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“…As almost all cats and dogs requiring MV due to snake envenomation will have neuromuscular paresis or paralysis, the administration of neuromuscular blocking agents (NMBA) is not necessary ( 16 , 45 , 84 ). Rocuronium use to facilitate intubation in humans with Naja kaouthia envenomation was described in a case series, which more likely reflects species differences in airway management rather than ongoing concern for patient-ventilator dyssynchrony ( 85 ). Another clinical trial evaluating 14 envenomated humans did not use NMBA during MV ( 64 ).…”

Section: Anesthetic Considerationsmentioning

confidence: 99%

“…No standardized anesthesia protocol exists for envenomated humans undergoing MV. A variety of drug protocols have been described, commonly including midazolam and fentanyl ( 63 , 85 ). Additional therapies have been described in humans to improve neuromuscular function.…”

Section: Anesthetic Considerationsmentioning

confidence: 99%

“…Cholinesterase inhibitors (such as neostigmine, edrophonium) have been used in numerous cases of envenomated humans. Their use may reduce the effect of post-synaptic toxins by increasing acetylcholine concentrations but would have no effect on post-synaptic toxins or delayed presentations ( 64 , 85 – 87 ). Two dogs treated with neostigmine in a case series of dogs with neuroparalytic snake envenomation showed no improvement or mild neurological improvement insufficient to change clinical treatment ( 88 ).…”

Section: Anesthetic Considerationsmentioning

confidence: 99%

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Mechanical ventilation in snake envenomation of dogs and cats

Morris¹,

Donaldson²

2023

Front. Vet. Sci.

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Envenomation by snakes in Elapidae and Viperidae families have been associated with respiratory failure in dogs and cats. Mechanical ventilation may be required for hypoventilation due to neuromuscular paralysis or hypoxemia due to pulmonary hemorrhage or aspiration pneumonia. Median incidence of dogs and cats with snake envenomation that require mechanical ventilation is 13% (0.06–40%). Standard treatment of snake envenomation in dogs and cats includes prompt administration of appropriate antivenom and management of envenomation complications such as coagulopathy, rhabdomyolysis and acute kidney injury. When mechanical ventilation is required, overall prognosis is good with appropriate treatment. Standard anesthetic protocols and mechanical ventilator settings are generally appropriate, with lung protective ventilation strategies typically reserved for patients with pulmonary disease. Median survival to discharge for cats and dogs with elapid envenomation is 72% (76–84%) with 33 h (19.5–58 h) median duration of mechanical ventilation and 140 h (84–196 h) median hospitalization. This article reviews indications for mechanical ventilation in cats and dogs with snake envenomation, and discusses ventilator settings, anesthetic and nursing considerations, complications and outcomes specific to this disease.

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