Shock, respiratory failure, and coagulopathy after an intravenous copperhead envenomation

Zad, Omid; Cooper, Hassie; Crocker, Patrick; Milling, Truman J.

doi:10.1016/j.ajem.2008.08.013

Cited by 7 publications

(9 citation statements)

References 20 publications

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confidence: 99%

“…While administration of antivenom has been recommended to prevent local and circulatory morbidity [3,8], there is debate concerning the need to serially assess patient coagulation status [9,10] or even administer antivenom at all [11]. Nevertheless, significant morbidity and occasional mortality occurs after envenomation by Agkistrodon species [5,6,12].Cottonmouth and copperhead snakes in North America generally possess venom that is fibrinogenolytic [13][14][15][16][17][18]. Intact venom or purified metalloproteinases typically cleave the A (a)-chain and the B(b)-chain of fibrinogen, resulting in hypofibrinogenaemia state and decreased coagulation [13][14][15][16][17][18].…”

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confidence: 99%

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Effect of Iron and Carbon Monoxide on Fibrinogenase‐like Degradation of Plasmatic Coagulation by Venoms of Six Agkistrodon Species

Nielsen

Redford

Boyle

2015

Basic Clin Pharma Tox

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Annually, thousands suffer poisonous snakebite, often from defibrinogenating species. It has been demonstrated that iron and carbon monoxide change the ultrastructure of plasma thrombi and improve coagulation kinetics. Thus, this investigation sought to determine whether pre-treatment of plasma with iron and carbon monoxide could attenuate venom-mediated catalysis of fibrinogen obtained from Agkistrodon species with fibrinogenase activity. Human plasma was pre-treated with ferric chloride (0-10 lM) and carbon monoxide-releasing molecule-2 (CORM-2, 0-100 lM) prior to exposure to 0.5-11 lg/ml of six different Agkistrodon species' venom. The amount of venom used for experimentation needed to decrease coagulation function of one or more kinetic parameters by at least 50% of normal values for (e.g. half the normal speed of clot formation). Coagulation kinetics were determined with thrombelastography. All six snake venoms degraded plasmatic coagulation kinetics to a significant extent, especially prolonging the onset to clot formation and diminishing the speed of clot growth. Pre-treatment of plasma with iron and carbon monoxide attenuated these venom-mediated coagulation kinetic changes in a species-specific manner, with some venom effects markedly abrogated while others were only mildly decreased. Further in vitro investigation of other pit viper venoms that possess fibrinogenolytic activity is indicated to identify species amenable to or resistant to iron and carbon monoxide-mediated attenuation of venom-mediated catalysis of fibrinogen. Lastly, future pre-clinical investigation with animal models (e.g. rabbit ear-bleed model) is planned to determine whether iron and carbon monoxide can be used therapeutically after envenomation.Thousands of individuals experience venomous snakebites annually in the United States [1][2][3][4], with cottonmouth and copperhead snakes (Agkistrodon species) second only to rattlesnakes (Crotalus species) as the most identified responsible vipers [2]. Snakebites by Agkistrodon species result in a spectrum of degrees of local and systemic injury [5,6], including hypofibrinogenaemia and coagulopathy [7]. Of interest, there is heterogeneity in therapeutic approach to envenomation by Agkistrodon species in the literature. While administration of antivenom has been recommended to prevent local and circulatory morbidity [3,8], there is debate concerning the need to serially assess patient coagulation status [9,10] or even administer antivenom at all [11]. Nevertheless, significant morbidity and occasional mortality occurs after envenomation by Agkistrodon species [5,6,12].Cottonmouth and copperhead snakes in North America generally possess venom that is fibrinogenolytic [13][14][15][16][17][18]. Intact venom or purified metalloproteinases typically cleave the A (a)-chain and the B(b)-chain of fibrinogen, resulting in hypofibrinogenaemia state and decreased coagulation [13][14][15][16][17][18]. While antivenom can bind and inactivate these enzymes, another approach to maintain circula...

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confidence: 99%

mentioning

confidence: 99%

Effect of Iron and Carbon Monoxide on Fibrinogenase‐like Degradation of Plasmatic Coagulation by Venoms of Six Agkistrodon Species

Nielsen

Redford

Boyle

2015

Basic Clin Pharma Tox

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“…There were close to another 2000 calls in which the type of snake was not identified 2. Severe manifestations of crotaline envenomation include coagulopathy, hypotension, shock and death; however, these are rare complications in copperhead envenomations 3,4,5…”

Section: Introductionmentioning

confidence: 76%

Antivenom Treatment Is Associated with Fewer Patients using Opioids after Copperhead Envenomation

Freiermuth

Anderson

Kleinschmidt

et al. 2019

WestJEM

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Introduction Copperhead envenomation causes local tissue destruction, leading people to seek treatment for the pain and swelling. First-line treatment for the pain is opioid medications. There is rising concern that an initial opioid prescription from the emergency department (ED) can lead to long-term addiction. This analysis sought to determine whether use of Fab antivenom (FabAV) for copperhead envenomation affected opioid use. Methods We performed a secondary analysis using data from a randomized clinical trial designed to determine the effect of FabAV on limb injury recovery following mild to moderate copperhead envenomation. Opioid use was a defined secondary outcome in the parent trial. Patients were contacted after discharge, and data were obtained regarding medications used for pain and the patients’ functional status. This analysis describes the proportion of patients in each treatment group reporting opioid use at each time point. It also assesses the interaction between functional status and use of opioids. Results We enrolled 74 patients in the parent trial (45 received FabAV, 29 placebo), of whom 72 were included in this secondary analysis. Thirty-five reported use of any opioids after hospital discharge. A smaller proportion of patients treated with FabAV reported opioid use: 40.9% vs 60.7% of those in the placebo group. The proportion of patients using opioids remained smaller in the FabAV group at each follow-up time point. Controlling for confounders and interactions between variables, the model estimated that the odds ratio of using opioids after hospital discharge among those who received placebo was 5.67 times that of those who received FabAV. Patients who reported higher baseline pain, those with moderate as opposed to mild envenomation, and females were more likely to report opioid use at follow-up. Patients with ongoing limitations to functional status had an increased probability of opioid use, with a stronger association over time. Opioid use corresponded with the trial’s predefined criteria for full recovery, with only two patients reporting opioid use in the 24 hours prior to achieving full limb recovery and no patients in either group reporting opioid use after full limb recovery. Conclusion In this study population, the proportion of patients using opioids for pain related to envenomation was smaller in the FabAV treatment group at all follow-up time points.

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“…4 This approach neglects the rare, severe systemic envenomation syndromes that have been described in the literature, resulting in shock requiring antivenom therapy. 12 Time from envenomation to treatment greater than six hours increases the likelihood of severe systemic toxicity in other pit viper envenomations. 5 In copperhead snakebite specifically, later treatment results in longer times to recovery.…”

Section: Discussionmentioning

confidence: 99%

Delayed Recognition of Severe Systemic Envenomation after Copperhead Bite: A Case Report

Kelly

Gerardo

2022

Clinical Practice and Cases in Emergency Medicine

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Introduction: We report a case of severe systemic copperhead, Agkistrodon contortrix, envenomation that resulted in long-term sequelae. Case Report: A 72-year-old man presented to the emergency department after suffering a copperhead snakebite. He developed severe systemic toxicity before local tissue injury developed. Clinicians did not initially recognize his envenomation syndrome and sought alternative explanations for his systemic symptoms before polyvalent immune fab (ovine) antivenom was administered. Although the patient improved, he was discharged with new stage three chronic kidney disease. Conclusion: Although rare, copperhead envenomation can cause severe systemic toxicity. Envenomation should be promptly treated with antivenom.

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Shock, respiratory failure, and coagulopathy after an intravenous copperhead envenomation

Cited by 7 publications

References 20 publications

Effect of Iron and Carbon Monoxide on Fibrinogenase‐like Degradation of Plasmatic Coagulation by Venoms of Six Agkistrodon Species

Effect of Iron and Carbon Monoxide on Fibrinogenase‐like Degradation of Plasmatic Coagulation by Venoms of Six Agkistrodon Species

Antivenom Treatment Is Associated with Fewer Patients using Opioids after Copperhead Envenomation

Delayed Recognition of Severe Systemic Envenomation after Copperhead Bite: A Case Report

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