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ACEM Fellowship > Toxinology > Flashcards

Toxinology Flashcards

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1
Q

Funnel-web spider envenomation: signs and symptoms

A

Cholinergic - secretions, salivation, bronchorrhoea
+
Adrenergic - HTN, tachycardia, myocardial injury
+
Catecholaminergic carciac toxicity - MI, pulm oedema

+Neuromuscular:
Agitation, fasciculations, paraesthesias (local, distal and perioral)

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2
Q

Funnel-web spider envenomation: management and disposition

A

Antivenom x2 vials
- Signs of severe envenoming
- Move to resus
Pressure bandage
- Within 4 hours
- Remove only once antivenom commenced
Tetanus booster
Seek and support catecholamine-induced myocardial injury w/ inotropes

Observation:
- 4 hours after bite
- 2 hours after removal or pressure bandage
–> DC if well
Envenomation unlikely to develop after 2 hours
- If given antivenom, monitor 12-24 hours until signs and symptoms resolved

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3
Q

Redback spider toxin

A

Alpha-latrotoxin

Acts pre-synaptically to open cation channels (incl. Ca2+) and stimulate release of multiple motor end-plate neurotransmitters

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4
Q

Redback spider envenomation (Latrodectism): clinical features

A

Pain (primary feature)
- Local at bite site (increasing over mins->hours, can last days)
- Radiating to draining lymph nodes
- +non-specific abdo, chest, back

Local autonomic
- Local sweating
- Regional sweating w/ unusual distribution (e.g. bilateral below knees)
- Piloerection, erythema, paraesthesias, muscle spasms

Non-specific
- Malaise, lethargy
- N+V
- Irritability, agitation
- Fever
- Priapism

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5
Q

Redback spider: antivenom trials

A

RAVE 1: No difference between IV vs IM
RAVE 2: No clinical benefit vs analgesia
- Can cause adverse effects (e.g. mild hypersensitivity, serum sickness)

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6
Q

Redback spider envenomation: management

A

Anaglesia
DON’T pressure bandage
Tetanus booster

Discharge once pain well-controlled on oral analgesia (pain can last 5 days)

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7
Q

Snake bite: examination

A
  1. Bite site and regional lymphadenopathy
  2. Neuro: CN deficits + peripheral weakness
  3. Resp muscle weakness: VC/PEFR
  4. VICC: bleeding from gums/cannula site
  5. Myotoxicity: dark urine, muscle tenderness
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8
Q

Snake bite: Bloods

A

FBC and film
EUC
Coags, fibrinogen, D dimer
LDH
CK

Taken at:
Presentation, 1hr post-bandage removal, 6hrs, 12hrs

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9
Q

Snake bite: initial management (general)

A
  1. Pressure bandage + immobilisation (if <4 hrs)
  2. Resuscitation
  3. Bloods
  4. Early administration of antivenom if indicated
  5. FFP for VIC w/ bleeding (avoid if possible)
  6. Haemodialysis for thrombotic microangiopathy w/ renal failure

Antivenom will:
- Reverse anticoagulant coagulopathy + non-specific symptoms
- Prevent further development of other symptoms

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10
Q

Snake bite: when to remove pressure bandage

A

Antivenom given
OR:
- No evidence of envenomation clinically
- No sign of envenomation on bloods
- Monitored resus bed
- Local access to antivenom

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11
Q

Snake bite: discharge criteria

A

No envenomation:
- Bloods normal (at 0, 1hr post-bandage removal, 6hrs, 12hrs)
- No symptoms
- Normal neuro exam

Min 12hrs monitoring for all

Envenomation:
- Resolution of symptoms incl. NM paralysis
- Bloods show:
- No ATM (AKI, TTP, MAHA)
- Normal INR
- CK falling

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12
Q

Venom induced consumption coagulopathy (VICC) biochemistry

A

APTT - high or unrecordable
INR - high: >3 in complete, <3 in partial
D-dimer: high
Fibrinogen - low (partial) or undetectable

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13
Q

Antivenom: criteria and timing

A

Give on clinical features alone if symptoms of envenomation:
- Non-specific headache and vomiting
- Systemically unwell appearance
- Early cardiovascular collapse (hypotension, arrest, unconscious, seizures)
- Ptosis or blurred visison

Ideally given <2 hours
Give up to 12 hrs, no benefit >12

Repeat bloods 6, 12, 24 hours after given

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14
Q

Antivenom: which one when?

A

Most unidentified bites:
- 1x vial tiger snake monovalent
- 1x vial brown snake monovalent
Will cover: red-bellied black
Won’t cover: taipan, death adder

Tiger monovalent alone if:
- Definite red-bellied black
- In Tasmania
- Expert identification
- DW clinical tox or poisons

Polyvalent antivenom if:
- Significant doubt about snake type
- Likelihood of mulga, death adder or taipan
- Far northern Aus w/ VICC

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15
Q

Antivenom: monovalent vs polyvalent adverse effect rate (+polyvalent components)

A

Anaphylaxis or anaphylactoid reactions:
- Monovalent 1%
- Polyvalent 5%

Polyvalent:
- brown, tiger, black, death adder, taipan

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16
Q

Snake bite: signs and symptoms indicative of envenomation

A

Non-specific:
- N+V, headache, avbdo pain, diarrhoea, sweating
Significant local bite site effects
Early CV collapse (hypotension etc.)
Neurotoxicity:
- Ptsosis, blurred vision
- Descending flaccid paralysis
Myotoxicity
Coagulopathy
AKI

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17
Q

Brown snake envenomation: location and features

A

Mainland Aus

  1. Early CVS collapse
  2. VICC
  3. Thrombotic microangiopathy
  4. AKI

No myotox/neurotox

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18
Q

Tiger snake envenomation: location and features

A

Southern Aus incl. WA and Tas

EVERYTHING EXCEPT ANTICOAG
1. CV collapse
2. VICC
3. Myotox
4. Neurotox
5. Thrombotic microangiopathy
6. AKI

Same as taipan

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19
Q

Taipan envenomation: location and features

Study These Flashcards
A

Northern Aus, mainly FNQ

EVERYTHING EXCEPT ANTICOAG
1. CV collapse
2. VICC
3. Myotox
4. Neurotox
5. Thrombotic microangiopathy
6. AKI

Same as tiger

20
Q

Red-bellied black snake envenomation: location and features

Study These Flashcards
A

Eastern Aus

BAM
1. Bite site pain
2. Anticoagulant coagulopathy
3. Myotoxicity

Same as mulga

21
Q

Mulga snake envenomation: location and features

Study These Flashcards
A

Mainland Aus but not eastern seaboard (opposite to RBB)

BAM
1. Bite site pain
2. Anticoagulant coagulopathy
3. Myotoxicity

Same as RBB

22
Q

Death adder toxicity: location and features

Study These Flashcards
A

Mainland Aus but not Vic

  1. Neurotoxicity - post-synaptic
  2. Local pain
23
Q

Venom detection kit?

Study These Flashcards
A

NOT used to determine envenomation
Can be used to guide choice antivenom
May have false positives
Not recommended to use - better assessment based on location, clinical syndrome

24
Q

Snake envenomation: thrombotic microangiopathy biochemistry

Study These Flashcards
A

Fragmented RBCs on film
Thrombocytopaenia
Cr >120
Raised LDH

25
Snake antivenom anaphylaxis
Some immediate hypersensitivity in 25% patients - urticaria, rash Severe anaphylaxis in 2-3% - Hypotension most common Mx: - Temporarily cease antivenom - IM adrenaline if severe - IVF, bronchodilators - No role for pre-medication w/ adrenaline
26
Antivenom serum sickness: symptoms, timing and management
Fever, rash, arthralgia, myalgia, non-specific 4-14 days after administration 25-50mg PO pred for 7 days
27
Antivenom administration practicalities
Dilute 1:10 in NaCl 0.9% Give IV over 15 mins Only in resus bay w/ access to adrenaline Only repeat dose after d/w tox Warn about delayed serum sickness (4-14 days post)
28
Water animal wound management
1. Remove stinger/spine 2. Wash/irrigate well - If marine, warm water (45degC) for up to 90 mins 3. Imaging - XR/US for FB 4. Consider delayed closure or surgical washout and debridemenet 5. Consider ABx covering marine infections - Doxy 6. Tetanus booster 7. Follow-up within 48 hours
29
Blue bottle management
Wash sting site with sea water (not fresh) Remove tentacles Immerse in hot water (45 degC) for 20 mins - Alt. hot shower NOT cold and NOT vinegar
30
Box jellyfish sting: clinical features
Local - Immediate severe pain - Delayed erythematous wheal - Superficial necrosis (severe) Systemic - CV collapse (hypotension, arrest, LOC, seizures) - Muscular paralysis - Death in 20-30 mins
31
Box jellyfish sting: management
Remove tentacles Vinegar + ice pack Analgesia If CVS collapse: - CPR - Box jellyfish antivenom (1 vial, 1:10 NaCl, over 15 mins) - MgSO4 10mmol IV
32
Irukandji sting: clinical features
Local: - Minor, can't see sting site Systemic (20-30 mins post): - Severe generalised pain - back, abdo, chest, MSK - Tachy + HTN - Anxiety, agitation - N+V
33
Irukandji sting: managment
Vinegar Analgesia ECG + trop (cardiotoxic) Manage HTN - GTN, aim SBP <160 mmHg Seek and treat CVS complications: - APO - ACS - Takotsubo ?MgSO4 10mmol IV NO ANTIVENOM
34
Stone fish sting: clinical features and management
Features: - Pain++ at site - Hypotension + CV collapse - Paralysis Mx: - Hot water immersion - 45 deg, 90 mins - Analgesia - Wound care - DON'T pressure bandage - Stonefish antivenom if systemic symptoms
35
Stingray sting
Penetrating trauma + Tissue necrosis from venom Mx: Resus if thorax/abdo trauma Hot water immersion (45degC for 90mins) Analgesia Wound care: - Irrigation - Consider surgical exploration/debridement - Tetanus booster - Consider ABx for marine wounds (cipro 500mg BD) - Review wound in 24-48 hours
36
Blue ring octopus sting: clinical features
Tetrodotoxin = Na channel blockade 1. PAINLESS bite 2. Local numbness + tingling 3. Descending flaccid paralysis - CNs -> ptosis, diplopia, dysphagia - Flaccid paralysis incl. resp muscles 4. Cardiorespiratory collapse
37
Blue ring octopus sting: management
Pressure bandage + immobilisation Resuscitation Intubate + ventilate - Until resp paralysis resolves, usually 2-5 days NO antivenom
38
Puffer fish or toad fish (ingestion)
Tetrodotoxin = Na channel blockade 1. Facial numbness, descending paralysis 2. GI upset 3. Arrhythmias/CVS collapse As per blue ring No antivenom - supportive I+V for 2-5 days Atropine if bradycardic
39
Box jellyfish vs blue-ring octopus
Box jelly: mainly CVS collapse, can have paralysis Blue-ring octopus/puffer: mainly paralysis, can have CVS collapse
40
Sea snake envenomation
1. Myolysis - rhabdo, spasms 2. N+V, malaise 3. Neurotox - ptosis, ophthalmoplegia, weakness NO coagulopathy Manage as per land snakes: - Pressure bandage + immobilisation - Resus - Sea snake antivenom 1x vial If sea snake antivenom not available, use 1-3 vials TIGER snake monovalent (2-4 vials = 1 vial sea snake venom)
41
Sea urchin envenomation
Features: Intense pain Pigment may be visible in surrounding tissue Systemic: - N+V - Paraesthesias, numbness - Muscle paralysis - Resp distress - Hepatitis (uncommon) Mx: Hot water immersion Remove spines - Removal or buried spines not recommended, will resorb with time XR for FB Tetanus Prophylactic ABx for deep injuries (cipro/doxy)
42
Cone snail toxin
Conotoxins Potent neurotoxic peptides Immediate pain --> progressive paralysis, perioral tingling --> resp failure/death Mx: Pressure immobilisation Analgesia Resus Tetanus NO antivenom
43
Platypus sting
Immediate, severe, disabling pain Hyperaesthesia Mx Analgesia+++ Local anaesthetic infiltration or block Wound care Tetanus prophylaxis ?ABx, uncertain
44
Tick bite complications
1. Persistent local reactions (persistent arthropod reaction) 2. Systemic allergies (early anaphylaxis vs late e.g. mammalian meat allergy) 3. Neurotoxic effects/paralysis 4. Transmission of rickettsial and Coxiella infections
45
Tick removal
Kill: - Freeze with ether-containing spray - Dab with permethrin Remove: - Fine blunt forceps - Pull from as close to skin as possible - Pull in a perpendicular direction, do not twist
46
Tick bite paralysis
Requires tick to be attached for 4-5 days + takes days to manifest 1. Ataxia 2. Ascending paralysis - legs --> uper limbs, trunk, neck 3. CN involvement 4. Resp muscle paralysis May look like GBS but w/ more CN involvement Mx - supportive Mild: observation + serial neuro exams for 48 hours after tick removal Severe: intubation and mechanical ventilation for resp failure NO antivenom

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