Snakebite Envenoming Challenge

aka Toxicology Conundrum 026

So you sailed through the toxidrome challenge did you? How are you with elapids? Let’s see how you fare on the ‘Australian Snakebite Envenoming Challenge’…

How this works

For each of the six types of venomous Australian snake see if you can describe the classic findings for each of the clinical questions listed below – click on the link to show/hide the answer. And if you’re ready to manage a snakebite victim, try Toxicology Conundrum 005.


Questions

Q1. What is the genus for each type of snake?

Brown snake
  • Pseudonaja
Tiger snake
  • Notechis
Death adder
  • Acanthophis
Black snake
  • Pseudochis
Taipan
  • Oxyuranus
Sea snake
  • Hydrophilidae

Q2. What is the geographic distribution for each type of snake?

Brown snake
  • Throughout Australia except Tasmania
Tiger snake
  • Southern Australia (Tasmania, south of the Moore River and Point Malcolm in WA, the Eyre Peninsula and Kangaroo Island in SA, Victoria) and up the East Coast (as far as Cooktown in North Queensland)
Death adder
  • Throughout Australia except the far south: Tasmania, Victoria and southern WA (south of Mundaring and Esperance)
Black snake
  • Most of Australia except the far south (Tasmania and the southern coast from south of the Perth Hills and Kalgoorlie in WA, across to the Eyre Peninsula in SA)
Taipan
  • Northern Australia (the Top End of the NT, north of Koolan Island in WA, and within a few hundred kilometers of the coast in Queensland) and Central Australia
Sea snake
  • Throughout coastal Australia except the west coast of Tasmania and the southern coast from Sydney to Esperance

Q3. Is coagulopathy a feature? What type?

Brown snake
  • Venom-induced consumptive coagulopathy (VICC) is always present with significant envenoming
Tiger snake
  • Venom-induced consumptive coagulopathy (VICC) is always present with significant envenoming, may resolve spontaneously in 12-24h
Death adder
  • Coagulaopathy does not occur
Black snake
  • a mild anticoagulant effect may be present (raised INR and APTT, with normal fibrinogen)
Taipan
  • Venom-induced consumptive coagulopathy (VICC) is always present with significant envenoming
Sea snake
  • coagulaopathy does not occur

Q4. Is (irreversible) presynaptic neurotoxicity a feature of envenoming?

Brown snake
  • rare (unless you’re a dog or cat!)
Tiger snake
  • slow onset over hours (up to 12-24h)
Death adder
  • absent
Black snake
  • absent
Taipan
  • may be rapid in onset
Sea snake
  • may be rapid in onset

Q5. Is (reversible) postsynaptic neurotoxicity a feature of envenoming?

Brown snake
  • absent
Tiger snake
  • absent
Death adder
  • slow onset over hours (up to 12-24h)
Black snake
  • absent
Taipan
  • absent
Sea snake
  • absent

Q6. Is rhabdomyolysis a feature of envenoming?

Brown snake
  • absent
Tiger snake
  • slow onset over hours, may be severe causing renal failure
Death adder
  • absent
Black snake
  • slow onset over hours, may be severe causing renal failure
Taipan
  • may develop over minutes to hours
Sea snake
  • may develop over minutes to hours

Q7. Is renal failure a feature of envenoming?

Brown snake
  • uncommon: possible direct nephrotoxicity or MAHA
Tiger snake
  • uncommon: possible direct nephrotoxicity or MAHA, also secondary to rhabdomyolysis
Death adder
  • absent
Black snake
  • secondary to rhabdomyolysis
Taipan
  • uncommon: possible direct nephrotoxicity or MAHA, also secondary to rhabdomyolysis
Sea snake
  • secondary to rhabdomyolysis

Q8. What other features of envenoming may be present?

Brown snake
  • microangiopathic hemolytic anemia (MAHA) and thrombocytopenia
Tiger snake
  • microangiopathic hemolytic anemia (MAHA) and thrombocytopenia
Death adder
  • local bite site pain often present
Black snake
  • bite site pain may be significant; envenoming often associated with nausea, vomitng, abdominal pain and headache
Taipan
  • microangiopathic hemolytic anemia (MAHA) and thrombocytopenia
Sea snake
  • nil

LITFL Toxicology Challenges


CLINICAL CASES

Toxicology Conundrum

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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