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Sea snakes
 
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Clinic

 

Rhabdophis subminiatus, Rhabdophis tigrinus

Case reports

Rhabdophis subminiatus
Cable et al. 1984, Mather et al. 1978

Rhabdophis tigrinus
Mittleman and Goris 1974, 1978, Kono and Sawai 1975, Minton and Mebs 1978, Mandell et al. 1980, Mori et al. 1983, Akimoto et al. 1991, Nomura et al. 1989, Ogawa and Sawai 1986, Matsuda et al. 1990

Signs & symptoms

(Minton 1990b and case reports)

Autopharmacological effects

Nausea, vomiting (aetiology?).

Local effects

Local pain can occur, but is not always reported.

Local swelling is generally mild and only directly around the site of the bite, but it can extend to adjacent parts of the affected extremity, ecchymosis.

Haemostatic effects

Bleeding from wounds, gingival bleeding, epistaxis, haematuria, gastrointestinal bleeding, melaena, intracranial bleeding (onset of bleeding within a few hours to 10 h after the bite).

Renal effects

Acute kidney failure (secondary to DIC).

Other signs & symptoms

Headache.

Morbidity

Anaemia, kidney failure.

Case fatality rate

1/1 Intracranial bleeding (Ogawa and Sawai 1986); 1/1 kidney failure (Mittleman and Goris 1978).

Laboratory and physical investigations

1. Haemostasis

Type of haemostatic defect:
Rhabdophis tigrinus
DIC due to direct activation of prothrombin (Nahas et al. 1976, Sakai et al. 1983, 1990). Thrombopaenia in the context of the DIC. Slight haemorrhagic effect (Akimoto et al. 1991). Reactive (secondary) hyperfibrinolysis.

 

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

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: increased.
B PT, aPTT: increased.
C

Fibrinogen:
Rhabdophis tigrinus

Minimum <30 mg/100 ml  (Akimoto et al. 1991), 20 mg/100 ml (Nomura et al. 1989), 20 mg/100 ml (Mittleman and Goris 1978), <5 mg/100 ml  (Ogawa and Sawai 1986).
Rhabdophis subminiatus

Minimum no longer detectable. Fibrinogen became detectable again from the 7th day after the bite (Cable et al. 1984).

D

FSP:
Rhabdophis tigrinus

Maximum 3,201 µg/ml (Akimoto et al. 1991).
Rhabdophis subminiatus

Maximum 640 µg/ml (Cable et al. 1984).

E

Platelets:
Rhabdophis tigrinus

Minimum 90,000/mm3 (Ogawa and Sawai 1986).
Rhabdophis subminiatus

Minimum 79,000/mm3, first spontaneous platelet increase on the 7th day after the bite (Cable et al. 1984).

 

2. Haemoglobin

Minimum 9.4 g/100 ml (initial value 12.5 g/100 ml) (Akimoto et al. 1991); 8.5 g/100 ml (initial value 13.0 g/100 ml) (Mandell et al. 1980).

 

3. Haemolysis in the context of DIC

(Cable et al. 1984)

Treatment (symptomatic)

  1. Blood transfusion (11 erythrocyte concentrates) (Cable et al. 1984),
  2. Dialysis.

Treatment (specific)

Anti-Yamakagashi antivenom (Japan Snake Institute) (Kikuchi et al. 1987, Wakamatsu et al. 1986, Kawamura et al. 1986, 1988).

 

Indications for administration of antivenom

Systemic bleeding, confirmation of haemostatic defect with laboratory tests (Akimoto et al. 1991).

 

Dose

10 ml i.v. (Akimoto et al. 1991),
10 ml i.v. (Nomura et al. 1989).

 

Efficacy with regard to haemostatic effects

  • Clinical:
    Systemic bleeding ceases within hours (Akimoto et al. 1991, Nomura et al. 1989).
  • Coagulation defect (laboratory investigations): 
    Tendency for normalization of the haemostatic tests within hours (Akimoto et al. 1991, Nomura et al. 1989).

 

Evaluation and recommendations

Up to 1991, the antivenom had been used in 6 patients. All of them showed clear improvement within hours of administration of the antivenom, even in cases where the antivenom was administered up to 51 h after the bite (Akimoto et al. 1991).