Correspondence

Snakebite: use of antivenom in a pregnant woman

To the Editor,

We read the article “Human cytokine response to Texas crotaline envenomation before and after antivenom administra- tion” written by Crocker et al [1] with great interest. They found that crotaline venom produces a broad cytokine response in human bite victims with several identified markers that might lead to improved therapies and better prognostic indicators. We hope that this may provide new diagnostic tools to identify unknown snakebites. In the emergency department in Taiwan, the biggest challenge for the physician is dealing with a patient bitten by an unknown venomous snake. We had one patient, a 21-year-old woman, who was bitten by an unknown animal in her kitchen and was transferred to our emergency department 8 hours later with high suspicion of snakebite because a cobra was found and killed near her house the day before, after a massive flood. However, there were also other venous snakes in the area around her home. Unfortunately, she was 24 months pregnant, which delayed the administration of antivenins because of the uncertainty of the species. Two small bites over the second and third toes with Skin necrosis were found, with progressive swelling from foot to lower leg. However, she did not have any neurotoxic symptoms. The wounds were photographed, and the pictures were e-mailed to snakebite experts for a second opinion with her Blood drawn for protein chip test. Six doses of antivenin of Naja naja atra were given slowly 10 hours after the bite. She was admitted for further observation. Her laboratory data were obtained repeatedly the following day without the finding of any hematuria or coagulopathy, which further excluded hematoxic symptoms, although no neurotoxic symptoms were found either. Unfortunately, progressive swelling with local tissue necrosis with bulla formation was found; and another 6 doses of antivenin of N naja atra were given in the second day. She received debridement of her necrosis tissue destruction from the toes to the upper ankle. She survived

biomarkers can tell us which species of snake the bite is from and provide more information about the doses we should give, the risk of adverse effect of antivenin may be reduced and error of administration may be prevented. Therefore, we echo the notion that this study and further studies focused on the biomarkers should provide such required answers.

Hsing-Lin Lin MD, MS Tsung-Ying Lin MD Wei-Che Lee MD, MS

Division of Trauma, Department of Surgery Kaohsiung Medical university hospital

Kaohsiung Medical University, Kaohsiung 807, Taiwan

Department of Emergency Medicine Kaohsiung Medical University Hospital

Kaohsiung Medical University, Kaohsiung 807, Taiwan E-mail address: [email protected]

doi:10.1016/j.ajem.2010.11.008

References

1. Crocker P, Zad O, Milling T, Maxson T, King B, Whorton E. Human cytokine response to Texas crotaline envenomation before and after Antivenom administration. Am J Emerg Med 2010;28(8):871-9.
2. Spiller HA, Bosse GM, Ryan ML. Use of antivenom for snakebites reported to United States poison centers. Am J Emerg Med 2010;28(7): 780-5.
3. Larreche S, Mion G, Mayet A, Verret C, Puidupin M, Benois A, et al. Antivenin remains effective against African Viperidae bites despite a delayed treatment. Am J Emerg Med; DOI:10.1016/j.ajem.2009.08.022.

Development of a computational method to automatically acquire ED crowding data^?,??

To the Editor,

The problem of emergency department (ED) crowding continues to plague health care systems around the world [1].

and delivered a healthy baby 4 months later.

In the United States, a new antivenin is reported to have reduced potential for adverse reactions [2]; and further study on the delayed treatment of antivenin has also been performed [3]. However, diagnosis of unknown snakebites is still a challenge for clinical physicians. Therefore, if the increasing

^? Presented at the Fifth Mediterranean Emergency Medicine Congress in Valencia, Spain, on September 14 to 17, 2009, and at the SAEM Midwest Regional Meeting at the University of Michigan in Ann Arbor, MI, on September 21, 2009.

^?? The Emergency Medicine Foundation provided support through an

Emergency Medicine Basic Research Skills workshop grant for a related study.

0735-6757/$ - see front matter (C) 2011