Envenomation — Snake, Spider & Marine (ANZ)

Overview & definition

The Australian envenomation — the snake, the spider and the marine — is the distinct, the dangerous, the ANZ (the CICM) emphasis. The Australian snakes are the elapids (the neurotoxic, the coagulopathic, the myotoxic); the funnel-web spider is the life-threatening; the box jellyfish the lethal-in-the-minutes. The pressure-immobilisation bandage, the venom detection kit (the VDK) and the antivenom are the core.[1][1]

The snake envenomation (the ANZ elapids)

The Australian snakes — the brown (the most deaths), the tiger, the taipan, the death adder, the mulga/black, the copperhead, the rough-scaled.[1][1]

The clinical syndromes.[1][2]

• The venom-induced consumption coagulopathy (the VICC) — the brown, the tiger, the taipan, the mulga. The procoagulant venom the activates the prothrombin → the uncontrolled consumption → the INR unmeasurable, the fibrinogen the low, the D-dimer the high, the platelets the normal (the distinguishes from the classical DIC — the platelets the normal). The bleeding risk. The recovery the 6 to 12 h the AFTER the antivenom (the factors the resynthesised).[2]
• The neurotoxicity — the tiger, the taipan, the death adder. The presynaptic (the tiger, the taipan — the irreversible) and the postsynaptic (the death adder — the reversible). The ptosis, the ophthalmoplegia, the limb weakness, the respiratory paralysis.
• The myotoxicity — the tiger, the mulga, the sea snakes. The muscle pain, the CK the rising, the myoglobinuria, the renal.
• The renal failure, the sudden collapse / the cardiac arrest (the brown snake — the thought the massive thrombosis or the presynaptic neurotoxicity).[1]

The epidemiology (the ANZ)

The snakebite in the Australia — the ~3000 the bites the per year, the ~500 the hospitalised, the ~2 the deaths. The brown snake (the Pseudonaja) the responsible for the most the deaths (the ~60%) — the widespread, the aggressive-when-the-cornered, the VICC the profound. The tiger snake (the Notechis) the southern-coastal, the VICC + the myotoxic + the neurotoxic. The taipan (the Oxyuranus) the far-north, the most-the-venomous-the-land-snake, the neurotoxic + the VICC. The death adder (the Acanthophis) the neurotoxic (the postsynaptic — the reversible). The mulga / the king brown (the Pseudechis australis) the myotoxic + the anticoagulant (the NOT the VICC — the INR the normal, the anti-Xa-the-like the low). The rough-scaled (the Tropidechis) the VICC + the myotoxic. The death-rate-the-low-the-modern-era — the antivenom-the-1981-the-funnel-web-the-no-deaths-the-since, the snakebite-the-~2-the-per-the-year.[1][1]

[1]

The neurotoxicity — the presynaptic vs the postsynaptic (the detailed)

The snake-venom the neurotoxins — the two the mechanisms.[1]

• The presynaptic (the phospholipase A2 — the PLA2) — the tiger, the taipan, the rough-scaled, the brown (the sudden-collapse-the-component). The damages the motor the nerve terminal → the initial the massive the acetylcholine release (the fasciculations — the tongue, the perioral) → then the depletion + the structural the destruction of the terminal (the IRREVERSIBLE). The antivenom the BEFORE-the-damage the prevents; the antivenom the AFTER-the-damage the CANNOT the reverse (the days-to-the-weeks the recovery — the new the terminal the sprouting). The clinical: the ptosis (the EARLIEST, the ~90% of the cases), the ophthalmoplegia, the diplopia, the dysphagia, the dysarthria, the limb the weakness, the respiratory the paralysis (the late, the life-the-threatening).
• The postsynaptic (the three-finger the α-neurotoxin) — the death adder. The binds the nicotinic the ACh receptor (the competitive — the curare-the-like) → the block. The REVERSIBLE — the antivenom the displaces the toxin → the effective the EVEN-the-late; the neostigmine the adjunct (the increases-the-the-ACh). The same-the-descending-the-pattern (the ptosis → the ophthalmoplegia → the respiratory).

[1]

The VICC — the pathophysiology (the detailed)

The venom-induced the consumption the coagulopathy — the procoagulant the toxin (the "the snake-the-prothrombin-the-activator") the directly the converts the prothrombin → the thrombin (the NOT the via-the-Xa — the direct).[2] The uncontrolled the consumption of the fibrinogen + the factors V, VIII, X, the II (the prothrombin), the protein C. The platelets the SPARED (the NOT the consumed — the distinguishes from the classical the DIC). The D-dimer the very-the-high (the massive the fibrin the degradation). The APTT the unmeasurable. The INR the unmeasurable. The recovery — the AFTER the antivenom the stops the further the consumption; the hepatic the resynthesis of the factors — the 6 to 12 h the for the fibrinogen, the 12 to 24 h the for the II / the X. The NOT-the-FFP-the-early — the venom the still-the-circulating the consumes the transfused the factors (the fuels-the-the-further-the-consumption). The FFP the reserved the for the active the bleeding the AFTER the antivenom. The vWF + the factor VIII the also the consumed; the vWF the recovers the slower (the 1 to 2 the days) — the role in the late the bleeding-the-risk (the primary the haemostasis the impaired).[2][1]

[1] [1]

The first aid — the pressure-immobilisation. The firm bandage (the from the bite the up the limb, the splint, the immobilise) — the delays the lymphatic spread of the elapid venom. The NOT for the viper/crotalid (the tissue necrosis the worsens) — but the Australian snakes are the elapids, so the bandage IS the correct. The NOT the wash, the NOT the cut, the NOT the suck, the NOT the tourniquet.[1][1]

The venom detection kit (the VDK). The bite-site swab + the urine → the genus identification → the monovalent antivenom (the cheaper, the specific). The polyvalent if the VDK the unavailable or the uninterpretable (the more-expensive).[1]

The antivenom. The IV (the slowly, the observed for the reaction). The premedication the debated (the adrenaline reduces the reaction; the risk the hypertensive / the intracranial haemorrhage — the esp. the elderly). The dose the depends the genus and the severity (the brown — the 1 vial; the tiger — the 1 to 2; the death adder — the 1 to 2; the taipan — the 1 to multiple).[3][1]

The observation. The 12 to 24 h with the serial the coagulation (the INR, the fibrinogen, the D-dimer), the CK, the U&E, the platelets. The snakebite without the envenomation — the observe; the serial bloods; the discharge if the negative at the 12 h.[1]

The antivenom — the dosing + the ASV (the detailed)

The Australian the snake the antivenom (the ASV — the equine the F(ab')2 the fragments — the CSL Bio) — the monovalent the vials (the brown, the tiger, the taipan, the death adder, the black, the sea snake) the OR the polyvalent (the all-the-five — the more-the-expensive, the higher-the-reaction-rate). The dose — the based the genus + the severity (the ASP the data — the MOST the envenomations the controlled with the 1 to 2 the vials; the pre-2010 the high-the-dose-the-practice the no-the-longer the recommended).[2][3][1]

[1]

The premedication. The adrenaline-the-premedication the reduces the acute-the-reaction-the-rate (the Isbister-the-trial). The risk — the hypertensive / the intracranial-the-haemorrhage — the esp. the elderly-the-the-CVD. The SELECTIVE-the-the-high-the-risk-the-only (the asthma, the prior-the-reaction, the elderly-with-the-CVD). The NOT-the-routine-the-ANZ-the-standard (the antihistamine / the steroid-the-no-the-prevent-the-IgE).[3][1]

The serum-the-sickness. The 4 to 14 days the post-the-antivenom — the fever, the rash, the arthralgia, the lymphadenopathy. The Type-III-the-immune-complex. The common (the ~30% with the polyvalent, the ~5 to 10% the monovalent). The self-limiting — the oral the prednisolone (the 30 mg, the weaning) the for the severe.[3]

[1] [1] [1]

The sudden-the-collapse (the brown snake)

The brown-snake-the-the-bite-the-occasionally-the-the-sudden-the-cardiac-the-collapse (the minutes-the-post-the-bite) — the thought-the-mechanisms: (1) the massive the VICC + the hypertensive-the-surge → the intracranial-the-haemorrhage; (2) the presynaptic-the-neurotoxin-the-respiratory-the-arrest; (3) the direct-the-cardiotoxicity. The bystander-the-CPR-the-life-saving. The early-the-IV-the-access, the antivenom-the-1-vial-the-ASAP, the avoid-the-hypertensive-the-spike (the judicious-the-adrenaline-the-anaphylaxis).[1]

The snakebite-the-without-the-envenomation

The ~50% of the snakebites-the-NO-the-systemic-the-envenomation (the "the dry-the-bite" — the no-the-venom-the-injected OR the insufficient). The observe-the-the-12-to-24 h with the serial the coagulation (the INR, the fibrinogen, the D-dimer), the CK, the U&E, the platelets. The first-the-bloods-the-normal-the-NOT-the-discharge (the VICC-the-onset-the-1-to-2-h, the neurotoxicity-the-1-to-3-h). The repeat-the-at-12-h — the negative-the-discharge. The VDK-the-NOT-the-confirm-the-envenomation (the detects-the-venom-the-only-the-identifies-the-genus — the positive-the-without-the-syndrome-the-NOT-the-treat).[1]

The spider envenomation

• The funnel-web (the Sydney — the Atrax, the Hadronyche) — the robustoxin → the presynaptic the massive neurotransmitter release → the hypertension, the tachycardia, the pulmonary oedema, the neuromuscular, the death. The life-threatening. The antivenom (the funnel-web) — the lifesaving. The first aid the pressure-immobilisation (like the snake).[3][1]
• The redback (the Latrodectus) — the latrotoxin → the neurotransmitter release → the severe local pain, the sweating, the piloerection, the muscle spasm, the hypertension, the malaise. The rarely the life-threatening. The antivenom (the redback) for the severe; the symptomatic. The NOT the pressure-immobilisation (the latrotoxin the stays the local; the bandage the worsens the pain).[3][1]

The funnel-web (the detailed)

The funnel-web (the Sydney — the Atrax robustus; the Northern-tree — the Hadronyche formidabilis; the Southern, the Blue-Mountains, the Port-Macquarie — the all-the-Hadronyche) — the robustoxin (the Atrax) / the versutoxin (the Hadronyche) — the 42-the-amino-acid-the-peptide → the massive-the-release-the-acetylcholine / the adrenaline / the GABA at the nerve the terminals → the the-sympathetic-the-overdrive (the hypertension, the tachycardia, the vasoconstriction), the the-parasympathetic (the salivation, the lacrimation, the miosis, the sweating), the the-neuromuscular (the fasciculations, the weakness), the the-pulmonary-oedema (the non-the-cardiogenic), the death (the historically the ~the-hours). The male-the-spider-the-more-the-venomous (the wandering, the mating-the-season).[3][1]

The clinical — the bite-the-pain, the perioral-the-tingling, the tongue-the-fasciculations, the nausea, the vomiting, the profuse-the-sweating, the salivation, the lacrimation, the piloerection, the hypertension, the tachycardia, the pulmonary-the-oedema, the confusion, the coma. The onset the 10 to 60 the min. The children-the-higher-the-risk (the smaller-the-body-the-mass).[3][1]

The management — the pressure-the-immobilisation (the lifesaving — the delays-the-venom-the-lymphatic-the-spread), the antivenom (the funnel-web) — the 2 vials the initial, the repeat the 15 min the until-the-controlled, the IV-the-infusion. The supportive — the airway, the ventilation, the atropine (the muscarinic-the-excess), the benzodiazepine (the agitation), the BP-the-control. The since-the-1981-the-antivenom-the-no-the-deaths.[3][1]

The redback (the detailed)

The redback (the Latrodectus hasselti) — the α-latrotoxin — the 130-kDa-the-protein → the massive-the-calcium-the-influx → the uncontrolled-the-exocytosis of the neurotransmitters (the acetylcholine, the noradrenaline) → the synaptic-the-depletion. The clinical — the bite (the often-the-painless-the-initially), the ~5 to 60 min the local-the-pain (the severe, the radiating), the sweating, the piloerection, the erythema, the muscle-the-spasm (the local → the generalised), the hypertension, the tachycardia, the headache, the nausea, the malaise. The "the-latrodetism" — the persistent-the-severe-the-syndrome (the days-to-the-weeks). The rarely-the-life-the-threatening (the no-the-deaths-the-since-the-1956-the-antivenom).[3]

The management — the symptomatic-the-initially (the ice-the-pack, the simple-the-analgesia, the benzodiazepine-the-spasm), the antivenom (the redback) — the 2 vials the IM (the OR-the-IV) the for-the-severe / the refractory. The NOT-the-pressure-the-immobilisation (the latrotoxin-the-local-the-action; the bandage-the-worsens-the-pain).[3][1]

The mouse-spider (the Missulena)

The mouse-the-spider (the Missulena) — the venom-the-similar-to-the-funnel-web (the robustoxin-the-like) → the same-the-syndrome (the rarely-the-severe). The management-the-the-funnel-web-the-protocol-the-IF-the-severe (the pressure-the-immobilisation, the funnel-web-the-antivenom). The mostly-the-mild-the-pain-the-local-the-only.[1]

The marine envenomation

• The box jellyfish (the Chironex fleckeri) — the cardiotoxic nematocysts → the excruciating pain, the dermal necrosis, the cardiovascular collapse, the death in the minutes. The vinegar (the inactivates the undischarged nematocysts — the NOT the fresh water, the NOT the rub), the antivenom, the CPR, the magnesium.[3][1]
• The blue-ringed octopus (the tetrodotoxin) — the flaccid paralysis (the respiratory), the patient the conscious (the reassuring) — the no the antivenom — the supportive ventilation (the hours to the days, the full recovery).[1]
• The stonefish — the severe pain (the local) — the antivenom. The stingray — the barbed trauma (the cardiac — the Steve Irwin).[1]

The Irukandji (the Carukia barnesi)

The Irukandji — the small-the-jellyfish (the north-the-Queensland, the tropical), the nematocysts → the the-delayed-the-catecholamine-the-surge (the 20 to 40 min the post-the-sting) — the "the Irukandji-the-syndrome": the severe the back / the chest the pain (the excruciating), the hypertension (the severe — the intracranial-the-haemorrhage-the-risk), the tachycardia, the sweating, the vomiting, the restlessness, the impending-the-doom, the euphoria-the-paradoxical. The cardiac — the troponin-the-rise (the coronary-the-vasospasm), the cardiogenic-the-shock, the pulmonary-the-oedema. The management — the analgesia (the opioid — the fentanyl / the morphine — the LARGE-the-doses-the-common), the magnesium (the analgesic-the-sparing, the anti-the-catecholamine — the 10 mmol the IV the infusion), the BP-the-control (the GTN — the severe-the-hypertension), the antivenom-the-NOT-the-available. The supportive-the-ICU-the-for-the-severe-the-hypertension / the cardiogenic-the-shock.[1]

The bluebottle / the Physalia (the marine)

The bluebottle (the Physalia physalis) — the local-the-pain, the dermal-the-wheal — the NOT-the-life-the-threatening. The management — the hot-the-water (the 45 °C the for the 20 min — the denatures-the-the-toxin), the analgesia. The NOT-the-vinegar-the-bluebottle (the controversial — the vinegar-the-may-the-discharge-the-further-the-some-the-species).[1]

The cone snail / the stingray (the marine)

The cone-the-snail (the Conus) — the conotoxins → the flaccid-the-paralysis (the respiratory), the no-the-antivenom — the supportive-the-ventilation. The stingray — the barbed-the-trauma (the penetrating — the cardiac-the-injury-the-Steve-Irwin-2006) — the trauma-the-management-the-primary (the tetanus, the imaging, the surgical-the-exploration, the infection-the-the-Vibrio).[1]

The bee / the wasp / the anaphylaxis (the insect-the-envenomation)

The hymenoptera (the bee — the Apis mellifera; the wasp / the yellow-the-jacket — the Vespula; the European-the-wasp — the Vespula germanica; the paper-the-wasp — the Polistes; the ant — the Myrmecia / the jack-the-jumper / the bull-the-ant) — the venom (the melittin / the phospholipase A2 / the hyaluronidase / the apamin / the mastoparan) → the two-the-syndromes:[1]

• (1) The local (the normal-the-reaction) — the pain, the swelling, the erythema (the cm-the-scale). The management — the cold-the-ice, the antihistamine, the simple-the-analgesia.
• (2) The systemic-the-anaphylaxis (the IgE-the-mediated — the prior-the-sensitisation — the minutes-the-post-the-sting) — the urticaria, the angioedema, the bronchospasm, the hypotension, the abdominal-the-cramping, the collapse, the death. The leading-the-cause-the-of-death-the-from-the-insect-the-stings (the Australia — the ~3-to-5-the-deaths-the-per-the-year; the bee-the-most). The risk-factors — the atopy, the prior-the-reaction (the ~50%-the-recurrence-the-per-sting), the mastocytosis, the beta-the-blocker / the ACE-the-inhibitor-the-medication.[1]
• (3) The toxic-the-reaction (the NOT-the-IgE — the multiple-the-stings, the >50) — the vomiting, the diarrhoea, the headache, the fever, the myalgia, the rhabdomyolysis, the haemolysis, the AKI, the hepatic-the-injury, the MI, the stroke — the dose-dependent-the-toxicity. The management-the-supportive (the IV-the-fluid-the-rhabdo-the-prevention, the analgesia, the monitoring-the-CK / the troponin / the LFTs / the U&E). The ICU-the-for-the-organ-the-failure.[1]

The anaphylaxis-the-management — the IM-the-adrenaline (the 0.5 mg the adult — the 0.3 mg the >12-the-years — the anterolateral-the-thigh, the repeat the 5 min the PRN — the no-the-maximum, the titrate-to-the-response), the airway-the-oxygen-the-fluid-the-reclined (the legs-the-elevated), the H1 + H2 (the promethazine + the ranitidine), the steroid (the hydrocortisone 200 mg — the biphasic-the-prevention-2-day-the-course), the bronchodilator (the salbutamol-the-neb), the glucagon (the beta-the-blocker-the-patient — the 1 to 5 mg the IV — the bypass-the-the-beta-the-receptor), the observation the 6 h (the biphasic-the-risk the 5 to 20%), the epinephrine-the-autoinjector (the EpiPen) the on-the-discharge, the action-the-plan, the allergy-the-referral-the-immunotherapy (the 95%-the-effective).[1]

[1] [1]

Prognosis

The snakebite is the survivable with the antivenom; the mortality driven by the bleeding (the VICC), the paralysis (the respiratory), the renal, the sudden collapse. The funnel-web is the survivable with the antivenom (the lifesanved). The box jellyfish is the lethal-in-the-minutes without the immediate CPR; the blue-ringed octopus the survivable with the ventilation.[1][3][1]

[1] [1]

The ClinicalPearls (the high-yield-the-exam)

[1] [1] [1] [1] [1] [1] [1] [1] [1] [1] [1] [1] [1] [1] [1] [1] [1] [1] [1]

The management algorithm (the overall)

[1]

Red flags

[1] [1] [1] [1] [1] [1]

References

1. [1]Cummings GE, Hardy CL. Snake bite in Australia: first aid and envenomation management Accid Emerg Nurs, 2003.PMID 12633629
2. [2]Isbister GK, et al. Novel Treatment Strategy for Patients with Venom-Induced Consumptive Coagulopathy from a Pit Viper Bite Toxins (Basel), 2020.PMID 32380672
3. [3]Isbister GK, et al. Antivenom efficacy or effectiveness: the Australian experience Toxicology, 2010.PMID 19782716