1. ACCIDENTS CAUSED BY CROTALUS SNAKES - Symposium - Clinical Toxinology and Envenoming BENEDITO BARRAVIERA Professor Titular de Infectologia da UNESP Pesquisador do CEVAP bbviera@jvat.org.br BENEDITO BARRAVIERA Professor Titular de Infectologia da UNESP Pesquisador do CEVAP bbviera@jvat.org.br

2. Crotalus genus (6 sub-species) Crotalus durissus terrificus, collilineatus, cascavella, ruruima, marajoensis, trigonicus. Crotalus durissus terrificus Caudisona durissa terrifica

3. Crotalus durissus terrificus, collilineatus, cascavella, ruruima, marajoensis, trigonicus. Distribution in Brazil

4. EPIDEMIOLOGY GENUS OF SNAKE Bothrops – 86,16% Crotalus – 8,94% Lachesis – 2,39% Micrurus – 0,63% Others – 1,88% SITE OF THE BITE Legs – 62,75% Arms – 12, 15% Others – 25,1% MONTHS OF OCCURRENCE December to May - summer SEX, AGE AND PROFESSION Male – 76,84% Female – 23,16 Age – 15 to 49 years (64,0%) Rural worker

5. EPIDEMIOLOGY Guia de Vigilância Epidemiológica, Caderno 14, 24p. 2008.

6. CENTER FOR THE STUDY OF VENOMS AND VENOMOUS ANIMALS CEVAP- UNESP Objectives: Promote education, research and extension education in the context of Toxinology (science of toxins from microorganisms, plants and animals).

7. EPIDEMIOLOGY Venomous snakes donated to CEVAP between 2002 and 2009

8. 1-Neurotoxic activity neurotoxic symptoms Crotalic envenoming Clinical aspects Midriasis Local bite Ptosis, Diplopia and blurred vision Crotalus durissus terrificus

9. NEUROTOXICITY

10. Crotalic envenoming Clinical aspects Rhabdomyolysis Increase of CPK, DHL, AST and ALT enzymes Myoglobinuria 2-Systemic rhabdomyolyses skeletal muscle Crotalus durissus terrificus

11. Rhabdomyolysis Crotalus durissus terrificus

12. Crotalic envenoming Clinical aspects Crotalus durissus terrificus Epistaxes 3-Bleeding and Clotting disturbance Gingival bleeding

13. Crotalic envenoming Clinical aspects Tubular necrosis causing renal failure 4-Renal failure Crotalus durissus terrificus

14. Crotalic envenoming Clinical aspects Liver cells with mitochondrial edema Increase of Alanine aminotransferase enzyme Liver necrosis 5-Liver toxicity Liver with edema Crotalus durissus terrificus

15. “Acute envenoming syndrome”

16. SPECIFIC ANTIVENOM CROTALUS TREATMENT -Mild accident - 10 (100 mg) anticrotalic venom ampules by intravenous route without allergic test; -Moderate accident - 20 (200 mg) anticrotalic venom ampules by intravenous route without allergic test; -Severe accident - 30 (300 mg) anticrotalic venom ampules by intravenous route without allergic test.

17. immunoprophylaxis; 7-If renal failure occurs hemodyalisis. 1-Hospitalize the patient for at least 24 hours; 2-Make Clotting Test after 12 hours to evaluate clotting disturbance and indicate, if necessary, more antivenom; 3-Clean and wash the bite region; 4-Hidrate to prevent renal failure with Manitol 20%, four times a day for at least 5 days. 5-Increase pH with Sodium bicarbonate 5%, 50 ml by oral route, four times a day. 5-Give antibiotic prophylaxis – cefuroxime 125 to 250 mg twice a day, for 5 to 7 days; 6-Indicate tetanus immunoprophylaxis; 7-If renal failure occurs hemodyalisis. SUPPORTIVE TREATMENT

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