1. The top end

2. Envenomations Royal Darwin Hospital RMO education 14.06.2016 Laura K. reg ED

3. Northern Territory  Snakes  Spiders  Stingers

4. SNAKES

5. Sources  Article Bart Currie  RDH guideline  Pictures from the web and myself  Rural EM skills training syllabus, ACRRM  eTG

6. Envenoming  All year but highest incidence during March to May  Highest rate among Top End rural Aboriginal adult males (45.2 per 100.000)  59% on foot / ankle, less bites on hands in Aboriginals  Continuing snake activity in evenings / nights  Three cases of overambitious feeding attempts  Average 2 deaths/yr in Au, > 70% no first aid or antivenom

7. 4 Highly venomous snakes  Western brown = pseudonaja nuchalis = gwardar  Mulga (black snake) = pseudechis australis = king brown  Death adder = acanthophis praelongus  Taipan = oxyuranus microlepitodus / scutellatus

9. Symptoms 1

10. Symptoms 2  Bite swelling, lymphadenitis and non-specific systemic features are most prominent in Mulga snake  Myotoxicity is the major feature of Mulga snake  Early collapse with recovery in > 50% of syst env. from Western Brown snakes (consumptive coagulopathy)  Neurotoxicity most important feature of Death Adder, this study in < 50% pts  Mulga and Brown snake have neurotoxins, but neurotoxicity uncommon = ‘brown snake paradox’

11. RDH g u I d.

12. Treatment bite  Apply or reinforce with pressure bandage Eslet S 3A  Immobilize limb with splint  Fenestrate at bite site, take swab  Have snake identified if possible  Tetanus status check +/- ADT  Continuous cardiac monitoring  Hourly neuro obs  Investigations 

13. Investigations  UA  VDK urine (hold if asymptomatic and WBCT < 10min)  VDK bite swab (ord.swab soaked in NS), same procedure  Bloods: WBCT, FBC, UEC, CK, LDH, Coags, D-dimer, Fibrinogen, serology tube  VDK high fals pos rate, esp for brown snake, esp on urine WBCT = whole blood clotting time (no additive blue container) VDK = venom detection kit, only on arrival

14. Bloods  On arrival  Immediately before administration of antivenom if > 30 min later than bloods taken on arrival  30 min after each antivenom infusion  4 hourly until normal results  8 hourly until discharge = 12h after bite when non- envenomed

15. Symptoms minor  N, V. abdo pain, headache  Tender regional lymph nodes +/- enlargement  DO NOT REQUIRE ANTIVENOM

16. Symptoms major  Coagulopathy 0-4h after bite  Neurotoxicity 1-6h after bite up to 24h in death adder  Myotoxicity 1-2h after bite  Cardiac  Also:  Thrombotic micro-angiopathy in ass with coagulopathy  Resulting in kidney damage  REQUIRE ANTIVENOM

17.  Coagulopathy 0-4h after bite  WBCT > 10 min  Procoagulant = APPT, PT and D-dimer   Anticoagulant = APPT and PT  D-dimer =  UA pos blood  Bleeding  Neurotoxicity 1-6h after bite up to 24h: ptosis, then ophtalmoplegia, then bulbar palsy,finally resp paralysis  Myotoxicity 1-2h after bite  Dark urine  Pos dipstick for blood can be true hematuria or myoglobinuria or haemoglobinuria (intravsc haemolysis)  Cardiac  Early transient hypotension +/- collapse within 30 min  Rarely arhytmias 1-12h

18. Treatment envenomation ACDE approach Continuous cardiac monitoring Neuro obs CT brain in every pt with conc. head strike or headache Contact consultant + Bart Currie / Geoff Isbister Antivenom when major symptoms 

19. Antivenom 1  All groups of poisonous elapids are possible, except tiger snake. Thus alle snake antivenoms available in RDH:  Polyvalent  Brown  Black  Taipan  Death adder  Sea snake

20. Antivenom 2  Administer in resus  In stable patients commence specific antivenom (snake identified or pos VDK result, takes 20-30 min)  In unstable patients give 1 vial polyvalent and change to specific when identified  Dilute antivenom 1:10 with NS, infuse over 30 min

21. Antivenom 3  In anaphylaxis (25%) (5% severe) stop infusion, Tx normally  Same amount for children  Remove PBI towards the end of the antivenom infusion  Admit unless snake identified as non-venomous by reptile specialist  D/c pts bitten in Darwin urban area at 12h if asymptomatic and bloods normal, all others 24h (Death adder)

22. Sea snake  Treat bite as land snake bite  CSL sea snake antivenom, 1 vial

23. SPIDERS

24. Sources  http://arnhemlandpestcontrol.com.au/spiders/spiders.h tm http://arnhemlandpestcontrol.com.au/spiders/spiders.h tm  Common spiders in the Darwin area, Chin, july 2014  Rural EM skills training syllabus, ACRRM

25. Red back

26. Mechanism  Venom depletes neurotransmitters at  Neuromuscular junction -> patchy paralysis  Adrenergic nerve ending -> autonomic dysfunction  Can cause serious illness / death.  No fatalities since antivenom 1956, but painful.

27. Symptoms  Immediate pain and local swelling, sweating  20 min: swelling lymph nodes, abdo pain, tachycardia,  60 min: headache, N and V, fever, insomnia, restlessness  Occasionally: severe hypertension, paralysis, convulsions, skin rashes, tongue swelling, jaw rigidity, migratory arthralgia

28. Treatment  Monitoring and neuro obs  Do not apply pressure bandage, increases pain  Apply ice  Morphine  Benzodiazepine for muscle spasms or extreme anxiety  Antivenom for syst symptoms or severe pain: 2 vials / 500 IE im (adults and kids) and monitor for 4 h after administration. Can be given days / weeks after bite.  Tetanus status check +/- ADT

29. Northern mouse No fatalities but painful bite, can cause headache and N, treat with funnel-web antivenom

30. Huntsman Local symptoms, sometimes inflammation, headache, V and irreg. pulse

31. Orb Occasional N and dizziness

32. Wolf Local symptoms, less commonly ulceration, sometimes with N and V

33. STINGERS

34. Sources  RDH guideline  Resus.com.au  Pictures from the web  Rural EM skills training syllabus, ACRRM  CARPA standard treatment manual  eTG

35. Box jellyfish

36. Box Jellyfish  = Chironex fleckeri  About 40 ED visits RDH every wet season = october- may  Bell 20 cm, up to fifteen tentacles on each corner, up to 3 mtrs long, up to 5000 nematocysts on each tentacle  Venom:  Neurotoxins  Cardiotoxins  Dermatonecrotic toxins

37. Symptoms  Intense pain and tentacle marks  Irrational behaviour  Arrhythmias  In severe envenomation systemic effects WITH CARDIORESPIRATORY ARREST within minutes  Fatalities rare. Last 11 deaths in children

38. Appearance

39. Investigations  ECG – ventricular ectopy or arrhytmias?  Cardiac monitoring  Sticky tape test to send to Bart Currie, identifying species

40. Tx non-systemic  ABCDE  Vinegar to inactivate undischarged nematocysts  Remove tentacles  Apply ice  Analgesia - Morphine  Antivenom 1 ampule if pain not controlled iv or im  No pressure bandage, increases pain  Treat as burn. Tetanus status check +/- ADT  d/c home with advise, RDH guideline

41. Tx if systemic  Resuscitation and supportive therapy  Incl 2 iv lines and high flow O2  Antivenom 1 ampule 1: 10 diluted in NS, in 5 min iv, up to 3 ampules  Or 3 ampules im at different sites  Repeat if no response, up to 6 ampules

42. Tx (imp) cardiac arrest  Resuscitation  6 ampules antivenom  20 mmol = 2 ampules MgSO4 iv  Continue CPR until all 6 ampules given

43. Irukandji

44.  = Carukia Barnesi  25 cms across, 1 tentacle from each corner  Usually october to april

45. Symptoms  Severe lower back, chest and abdo pain  On and off muscle cramps  V, restlessness, anxiety, sweating, piloerection  Tachycardia, hypertension, heart failure, pulmonary edema

46. Tx R D H

47. Blue ringed octopus  Can penetrate wetsuit. Enough venom to kill 26 adults  Saliva potent fast acting paralytic neurotoxin  Small painless bite  Perioral paraesthesia, then N/V and rapid onset flaccid paralysis in 5-30 min  In severe cases respiratory and cardiac arrest  Irrigate wound, suction, PBI, supportive care  Tetanus status check +/- ADT

48. Stonefish  Pain, swelling, weakness limb.  Tx 40-45 degrees water  Local Lignocaine, opioids, nerve block  Antivenom 1 vial  No pressure bandage  Tetanus status check +/- ADT

49. Catfish  Same as stonefish  No antivenom  X-ray, piece of barb often breaks off into wound

50. Stingray  Stingray barb injury:  Pain, bleeding wound, then pale / bluish-white wound  Significant local trauma, damage to underlying structures (heart / lung if chest wall puncture)  Rarely systemic symptoms  Pain relieve same as other fish  Xray. May need surgery to remove pieces

51. Don’t let it be