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Clinic

 

Pseudonaja sp.

Case reports

Acott  1988: 1 P. textilis bite; identification: morphological; ELISA (wound swab, urine, serum).

Crawford 1980: 1 P. nuchalis bite; identification: morphological.
Fairley 1929: 1 Pseudonaja sp. bite; identification: morphological.
Foxton 1914: 1 Pseudonaja sp. bite; identification: morphological, doubtful.
Harris et al. 1976: 3 bites that were attributed to P. nuchalis or P. affinis (identification doubtful).
Herrmann and Bailey 1979: 2 P. affinis bites; identification: morphological.
Herrmann et al. 1972: 2 P. affinis bites; identification: morphological.
Masci et al. 1990: 4 P. textilis bites; identification: morphological and/or ELISA; haemostasis study.
Morling et al. 1989: 10 Pseudonaja sp. bites; identification: morphological or ELISA: Pseudonaja sp. (7/10), P. affinis (1/10), P. nuchalis (1/10).
Pearn et al. 1981: 1 P. textilis bite; identification: morphological.
Schapel et al. 1971: 1 P. textilis bite; identification: morphological.
Sutherland et al. 1975: 2 Pseudonaja sp. bites; identification: RIA.
Sutherland et al. 1982: 1 Pseudonaja sp. bite; identification: ELISA.
White 1981: 1 Pseudonaja sp. bite; identification: ELISA.
White 1987b: 3 Pseudonaja sp. bites; identification: morphological (Pseudonaja textilis) 1/3; ELISA 2/3.
White 1992: 83 Pseudonaja sp. bites; identification: "positive" 69/83, probable 15/83. Systemic envenoming 24/83.
White and Fasset 1983: 1 Pseudonaja nuchalis bite; identification: morphological.
White and Williams 1989: 1 Pseudonaja textilis bite; identification: morphological.
White et al. 1987: 1 P. modesta bite; identification: morphological; mild systemic envenoming with no neurological or haemostatic signs or symptoms, on gel filtration chromatography the peak that contains active coagulative components for P. textilis venom was missing.

Signs & symptoms

Autopharmacological effects

Nausea, vomiting, abdominal pain, headache, arterial hypotension, loss of consciousness, cerebral seizures (secondary?) (White 1987b and case reports, in particular White and Williams 1989).

40/83 Pseudonaja sp. bites with signs of successful venom injection: nausea 12/40, vomiting 8/40, abdominal pain 7/40, headache 12/40, collapse shortly after the bite 3/40, generalised seizures 2/40 (children) (White 1992).

Haemostatic effects

Bleeding from skin lesions (e.g. injection sites), gingival bleeding, haematemesis, haematuria (White 1987b and case reports); coma (intracranial haemorrhage) (Foxton 1914); bleeding per rectum (Fairley 1929).

40 of 83 Pseudonaja sp. bites with signs of successful venom injection (White 1992): see Laboratory and physical investigations, 1. Haemostasis.

Neurological effects

40/83 Pseudonaja sp. bites with signs of successful venom injection: signs of paralysis 2/40, assisted/controlled ventilation 1/2 (White 1992).

Muscular effects

40/83 Pseudonaja sp. bites with signs of successful venom injection: signs of skeletal muscle damage 0/40 (White 1992).

Renal effects

Renal failure (secondary and possibly primary) (White 1987b and case reports: Acott 1988, White and Fasset 1983).

40/83 Pseudonaja sp. bites with signs of successful venom injection: signs of impairment of renal function 5/40 (White 1992).

Morbidity

Renal failure (White 1987b and case reports: Acott 1988, White and Fasset 1983).

Case fatality rate

Fatality in a pregnant woman (Sutherland et al. 1982). Very little venom was found in the tissue around the site of the bite. Obstruction of the venae cavae was considered to have contributed to her death.

One fatality with intracranial haemorrhage (Foxton 1914).

One fatality with systemic bleeding and cardiovascular failure (Fairley 1929).

40 Pseudonaja sp. bites with signs of successful venom injection: no fatalities.

Laboratory and physical investigations

1. Haemostasis
Type of haemostatic defect

Defibrin(ogen)ation through activation of prothrombin and secondary fibrinolysis (Masci et al. 1990).

Thromboycytopaenia in the context of disseminated intravascular coagulation (Masci et al. 1990), isolated (Acott 1988).

 

Haemostatic parameters


Overview haemostasis
   
A
 
   
B
 
B
 
C
 
 
E
 
F
 
                   
 
H CT (FSP) Tc PT aPTT TT I FSP D II V VIII X XIII PC ATIII PI tPA α2AP
       
 
H
     
 
D
   
 
G
 
G
 
G
             
 

Essential

bed-side

tests

Tests for full clinical assessment Tests for research purposes
H haemorhagic effects
+ definite evidence in
human envenoming
CT full blood clotting test
(FSP)  FSP rapid test
Tc platlets
PT prothrombin time
aPTT partial thromboplastin time
TT thrombin time
I fibrinogen
FSP  fibrinogen split products
D D-dimer
II, V, VII, X, XIII
  clotting factors
PC protein C
ATIII antithrombin III
PI plasminogen
tPA tissue plasmin activator
α2AP α2-antiplasmin
 
In this overview, the deviations from normal
are recorded for those haemostasis para-
meters only, for which good evidence is
documented in the literature.

 

A

CT: incoagulable (Herrmann et al. 1972, Schapel et al. 1971).

B

PT, aPTT: slightly increased (Acott 1988), markedly increased (Crawford 1980), not measurably increased (Herrmann and Bailey 1979).
Haemostasis tests in 4 patients 1–2.5 h after the bite (P. textilis): increased (4/4) (Masci et al. 1990).

C

TT: incoagulable (Herrmann and Bailey 1979).
Haemostasis tests in 4 patients 1–2.5 h after the bite (P. textilis): increased (4/4) (Masci et al. 1990).
 

D

Fibrinogen: afibrinogenaemia (Crawford 1980, Herrmann et al. 1972, Schapel et al. 1971); 0 and 0.15 g/l (Herrmann and Bailey 1979).

40 Pseudonaja sp. bites with positive signs of envenoming: coagulation defect (defibrin(ogen)ation) (13/40) (White 1992).
Haemostasis tests in 4 patients 1–2.5 h after the bite (P. textilis): fibrinogen <0.1 g/l (normal 2–4 g/l) (4/4) (Masci et al. 1990).
Haemostasis tests in 10 patients, inclusion criterion fibrinogen <1 g/l on initial investigation: <0.2–0.74 g/l or a titre of 1:3 (Morling et al. 1989).

E

FSP: clearly increased (Crawford 1980, Herrmann et al. 1972); 160 and 1,280 μg/ml (normal <20 μg/ml) (Herrmann and Bailey 1979).

Haemostasis tests in 4 patients 1–2.5 h after the bite (P. textilis): 320–1,280 μg/ml (normal <1 μg/ml) (4/4) (Masci et al. 1990).

Haemostasis tests in 10 patients, inclusion criterion fibrinogen <1 g/l on initial investigation: maximum FSP or XFSP values 160–10,240 mg/l (Morling et al. 1989).

F

D-dimers: haemostasis tests in 4 patients 1–2.5 h after the bite (P. textilis): D-dimers 257–687 μg/ml (normal <0.25 μg/ml) (4/4) (Masci et al. 1990).

G

Clotting factors: VIII: 6.5%, V: 18.5%, II: 28% (Crawford 1980); VIII: 2%, V: 19%, II: 12% (Herrmann et al. 1972).

H

Platelets: markedly decreased (minimum 26,000/mm3) without concurrent significant impairment of coagulability (Acott 1988). Normal with concurrent significant impairment of coagulability (defibrin(ogen)ation) (Crawford 1980, Herrmann et al. 1972); 122,000/mm3 and 136,000/mm3 (normal 150,000–400,000/mm3) (Herrmann and Bailey 1979); marked thrombopaenia with concurrent complete defibrinogenation (Schapel et al. 1971); thrombopaenia (13,000/mm3) with concurrent defibrin(ogen)ation and microangiopathic haemolytic anaemia (White and Fassett 1983).

Haemostasis tests in 4 patients 1–2 h after the bite (P. textilis): platelets 68,000, 70,000, 90,000 and 270,000/mm3 (normal: 200,000–400,000/mm3) (Masci et al. 1990).

Haemostasis tests in 10 patients, inclusion criterion fibrinogen <1 g/l on initial investigation: platelet count on subsequent investigation between 230,000 and 20,000/mm3. Mean platelet count on initial investigation 213,000/mm3, lowest mean platelet count 160,000/mm3, i.e. an average decrease of 25%. If thrombopaenia developed, it appeared within 24 h, independently of antivenom administration (Morling et al. 1989).

Disputed aetiology of the thrombopaenia: in the context of acute renal insufficiency (White 1990); in the context of the haemostatic defect directly induced by the venom (Marshall et al. 1990).


2. Leucocytes

Leucocytosis: 10,600/mm3 (Acott 1988).


3. Haemoglobin

Anaemia (haemolytic), minimum haemoglobin level 9.0 mg/100 ml. Haemolysis (haptoglobin ↓, hyperbilirubinaemia) (Crawford 1980).

 

4. ELISA

See above.

 

5. Renal biopsy

Tubular necrosis, interstitial nephritis (Acott 1988). 

First aid

Efficacy of the compression-immobilisation method: one patient in whom this method was utilised had no symptoms upon hospitalisation 2 h after the bite. Haematological laboratory investigations, including FSP, were within the normal range. No venom was found in serum or urine (sensitivity: 0.5 ng/ml). 5 minutes after removal of the bandage the patient experienced severe headache and nausea, as well as pallor, perspiration and tachycardia, pain and tension of the facial and pharyngeal musculature, dyspnoea. 15 minutes after removal of the bandage the level of venom in serum was 1.5 ng/ml, 30 min after that 4 ng/ml. After 45 min venom was no longer detectable in serum; however, the venom level in urine was 5 ng/ml. FSPs increased steadily from 1 h after removal of the bandage to a maximum of 1,280 μg/ml (normal: <10 μg/ml). Thrombin time rose to a maximum of 60 s (normal: 12–18 s) within a period of 50 min, the prothrombin time rose to 50 s (normal: 12–15 s) within 3 h (Pearn et al. 1981).

Treatment (symptomatic)

Dialysis (White 1987b and case reports: Acott 1988, White and Fasset 1983).

Treatment (specific)

Antivenoms
Brown snake antivenom, CSL, Parkville, Australia.

Efficacy

With regard to the haemostatic effect: reversal of the coagulation defect coinciding with antivenom administration (Crawford 1980, Herrmann and Bailey 1979, White 1987b).

In those patients who became thrombopaenic, the thrombopaenia appeared within 24 hours of the bite, independently of antivenom administration (Morling et al. 1989).