1. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Major envenomation Hunter Area Toxicology Service

2. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Presentation  56yo male school teacher  Major depression for 6 months –of work for one term –on citalopram 20mg tds  Reflux oesophagitis – laparoscopic fundoplication

3. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Christmas Day 1998  Carrying LPG bottle out to barbecue  At 0950 stepped on something soft which moved  Looked down to see a “brown” snake ~ 2 feet long  Chased snake out of yard to protect the grandchildren  Wife persuaded him to sit down

4. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital First–aid  Bite seen on dorsum of R second toe  Tourniquet applied to forefoot at 1010  Son drove him to nearest hospital  At 1030 father complained of chest tightness and difficulty breathing  By 1035 father unconscious in car  Arrived at ED at 1037

5. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital On arrival  1037 –Semi–conscious, GCS 6 –PR 64, BP 131/77, RR 36 shallow –Bloods taken  1048 –Given 1 ampoule brown snake antivenom –Decreased level of consciousness –Decreasing respiration –Monitor showed ST elevation

6. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital In Emergency  1052 –Intubated with atropine, midazolam, suxamethonium –IDC inserted –Given 1 ampoule brown snake antivenom –Urine and bite site tested with VDK  1100 –Monitor showed asystole

7. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital In cardiac arrest  1100 –CPR commenced –Adrenaline 1mg x 2 –Atropine 600 mcg  1108 –Femoral output –Sinus rhythm –PR 123, BP 78/35

8. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Post cardiac arrest  1117 –PR 142, BP 201/125 –Urine and bite site VDK negative –Initial coagulation studies l Blood clotted in coagulation tubes

9. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Retrieval  1145 –Repeat coagulation studies l PT >50 s l aPTT > 200 s –Given 1 bag FFP  1200 –Retrieval team transport to NMMH –Given 2 ampoules brown snake antivenom en route

10. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Coagulation studies Time (h)0.71.74.77.810.713.922.2 PT (10–13 s) *>50>180>60321713 aPTT (22–35 s) *>200>12075473432 TCT (12–16 s) >60>60>60>60 Fib (2.0–4.0 G/L) 0.00.01.43.26.41.4 XDP ( 1.6>1.6>1.6 PLT (150–400 x 10 9 /L) 14368144125108 Antivenom † † † † † † † † † †

11. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Complications  Chest infection  Left ventricular failure/pulmonary oedema  Confusion/delirium/memory deficit

12. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Chest infection  Eight hours post envenomation –Febrile 38.5° –Purulent material aspirated from endotracheal tube –Started on l ampicillin l metronidazole l gentamicin

13. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Pulmonary oedema  Days 2–4 –Pulmonary oedema requiring CPAP –Placed on l ACE inhibitor l diuretic therapy  Day 5 –Echocardiogram

14. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Muscle enzymes Time (d)012345 CK (1–185 U/L) 20482728662120902452

15. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Muscle enzymes Time (d)012345 CK (1–185 U/L) 20482728662120902452 Troponin I*9.3–16.7–4.92.7 *Apparently healthy individuals<0.4 ng/mL Reference range<1.0 ng/mL Diagnostic of AMI  2.0 ng/mL

16. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Confusion  Extubation was delayed due to a marked confusional state evident even while on the ventilator  Delirium persisted for several days and became a significant management problem

17. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital SPECT brain scan

18. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Neuropsychiatric assessment  Performed at 6 weeks post envenomation  Wechsler Adult Intelligence Scale Revised (Australia)  Wechsler Memory Scale (Form 1)  Rey Auditory Verbal Learning Test  Rey Complex Figure  Trail Making Test A and B

19. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Results  WAIS–R –Verbal IQ – 124 –Performance IQ – 99 –Full scale IQ – 115  5–digits forward, 4–digits backwards  Rey Complex Figure –Copy – above average –Repeat (3 minutes) – below average

20. Clinical Toxicology & Pharmacology, Newcastle Mater Misericordiae Hospital Results  Trail making A – 90+ percentile  Trail making B – 25 percentile  Memory quotient – 132 –Immediate recall very good –Delayed recall (30 min) l Structured information – very good l Unstructured information – good l Designs – poor