Antivenom surveillance: An audit of antivenom stock within South Australia.

OBJECTIVES: Antivenoms are important emergency medications to be held within Australia, particularly in regional and remote locations. We audited current antivenom holdings in hospitals and health services across South Australia (SA) and compared to recommendations in the 'Snakebite and Spiderbite Management Guidelines' from the State's Toxinology service. The process also assessed the feasibility of 'real-time' remote stock monitoring. METHODS: Fifty-three sites listed in the guideline were recommended to hold antivenom, though only 49 are currently operational. Interrogation of antivenom stock for 29 sites was possible using electronic reports generated from the State Pharmacy database. The 20 remaining centres had their stock levels confirmed by calling the centres directly. Data obtained were then compared to recommended levels of antivenom holdings in the guideline with discrepancies and associated costs documented. A separate report verification process was used to determine 'real-time' accuracy of the electronic reports. RESULTS: Thirty-seven sites (75%) held more than the recommended number of antivenom vials, totalling 129 vials in excess with an approximate total cost of $110 000. Twelve sites (24%) held inadequate stock to deliver a treatment dose for 19 envenoming events. The report verification revealed variances in the electronic reports. CONCLUSIONS: This audit has demonstrated a significant disparity between recommended and actual antivenom holdings across most sites in SA and has also revealed that 'real-time' remote monitoring of state antivenom holdings is not currently feasible. Correction of stock levels to that recommended may result in financial benefit for State Health while also addressing inequity in regional and remote healthcare provision.

Characteristics of analytically confirmed gamma-hydroxybutyrate (GHB) positive patients in the emergency department: presentation, poly-drug use, disposition and impact on intensive care resource utilisation.

BACKGROUND: Gamma-hydroxybutyrate is a potent central nervous system depressant with a narrow recreational dose window and analytical detection time. We describe data relating to intoxicated patients presenting to emergency departments across metropolitan Adelaide who tested positive for gamma-hydroxybutyrate. This work was part of the Emergency Department Admission Blood Psychoactive Testing study. METHODS: Over a 15-month period, patients presenting to four metropolitan emergency departments with symptoms of drug intoxication were enrolled in the study. The methodology involved the collection of demographic and clinical data and a de-identified blood sample which underwent comprehensive toxicological analysis. Gamma-hydroxybutyrate was determined using an acid-catalysed cyclisation followed by liquid-liquid extraction and gas chromatography-mass spectrometry. Data relating to samples positive for gamma-hydroxybutyrate were examined. RESULTS AND DISCUSSION: A total of 1120 patients were enrolled between March 2019 and May 2020, 309 of whom were positive for gamma-hydroxybutyrate (27.6%). Of these, 256 (83%) were also positive for metamfetamine (methamphetamine). The most common clinical observation in gamma-hydroxybutyrate-positive patients was central nervous system depression (89%). There was a significant relationship between gamma-hydroxybutyrate status and sex; although males outnumbered females in absolute terms, a higher proportion of females (32%) tested positive for gamma-hydroxybutyrate than males (25%, P = 0.0155). Blood gamma-hydroxybutyrate concentrations ranged from 10 to 651 mg/L (0.096-6.2 mmol/L) and increasing gamma-hydroxybutyrate concentration correlated with severe toxicity. The presence of gamma-hydroxybutyrate had a significant impact on the patient discharge destination: the majority (69.2%) of gamma-hydroxybutyrate-positive patients were managed and discharged from the emergency department or their attached short stay wards. A significantly higher proportion of gamma-hydroxybutyrate-positive patients were admitted to the intensive care unit (28.2%) compared with gamma-hydroxybutyrate-negative patients (12.7%, chi-squared = 36.85, P <0 .001). Gamma-hydroxybutyrate positive cases accounted for 45.8% of all study-related intensive care unit admissions. CONCLUSIONS: Gamma-hydroxybutyrate is commonly detected in illicit drug-related emergency department presentations and is detected disproportionately in the patient cohort who require intensive care unit level care.

Toxicoepidemiology of Phosphide Poisoning in the Central Part of Iran.

Objective: Aluminum phosphide (ALP) and zinc phosphide (ZnP) are toxic agrochemical pesticides, which are commonly used as an agent of self-harm in developing countries. Because of high toxicity of phosphides, we evaluated toxico-epidemiology ALP and ZnP poisoning in with respect to outcome. Methods: We performed a cross-sectional study with retrospective chart review including the records for patients admitted due to phosphide poisoning (ALP, ZnP) in a poisoning referral center in Khorshid Hospital, affiliated with Isfahan University of Medial Sciences, Isfahan, Iran. Demographic characteristics, clinical manifestations, outcome (survived or death), and length of hospital stay for the patients were recorded in a data collecting form. Binary backward stepwise logistic regression was used for outcome prediction. Findings: Sixty patients were evaluated in the study. The mean age of patients was 27.61. Thirty-nine patients were men. 96.7% of the patients ingested it intentionally. Most of the patients on admission were conscious (66.7%). Abnormality of EKG was noted in 8.3%. The mortality in ALP and ZnP poisoning was 39.2% and 22.2%, respectively. Serum bicarbonate and base excess in the venous blood gas analysis, systolic blood pressure, and serum sodium level were significantly different between patients with ALP and ZnP poisoning on admission time (P < 0.05). On admission, systolic blood pressure was an important predictive factor for mortality (odds ratio 4.87; 95% confidence interval: 1.5-15.45; P = 0.007). Conclusion: The rate of mortality in phosphide poisoning is high. Knowing predictive factors for mortality help physicians for selecting patients in intensive care unit admission and aggressive treatment.

The efficacy of hemodialysis on paraquat poisoning mortality: A systematic review and meta-analysis.

Background: Paraquat (PQ) poisoning is a serious public health concern, especially in developing countries, due to its easy access and lack of awareness of potential harms. No effective treatment has been reported yet. Conventional hemodialysis (HD) is still used in many centers for excreting PQ or reducing acute kidney injury, but there is no consensus on its efficacy. Therefore, we aimed to review the HD efficacy in PQ poisoning mortality. Materials and Methods: We searched Web of Science, PubMed, Excerpta Medical Database, Google Scholar, Scopus, Cochrane, Web of Knowledge, Pro-Quest, ScienceDirect, Springer, Clinical Key, Scientific Information Database, Magiran, and Iran-doc, in publications before January 1, 2020. We compared patients who underwent HD (Group 1) with those who did not (Group 2). The outcome was considered mortality/survival. The data were analyzed by Comprehensive Meta-analysis Software. Results: This systematic review and meta-analysis included five studies with a combined total of 203 patients. The patients in the Group 1 had higher mortality than Group 2 (odds ratio, 2.84; 95% confidence interval: 1.22-6.64; P = 0.02). There was no evidence of publication bias (P value for Egger's test = 0.833). Conclusion: Although HD did not affect the survival of patients, other variables such as the amount of ingested PQ, poisoning severity, the time between PQ ingestion and the start of HD, duration, and times of HD sessions may influence the results regarding mortality.

Substance use in the emergency department: Screening for risky drug use, using the ASSIST-Lite.

INTRODUCTION: Substance use is a common contributing factor to emergency department (ED) presentations. While screening, brief intervention, and referral to treatment for alcohol and tobacco is common in ED settings, it is not routinely conducted for illicit substances. This study aimed to deploy the ASSIST-Lite to screen for risky use of alcohol and other drugs in the ED, to identify differences in risk based on between demographic characteristics. METHOD: All ED attenders, aged 18 years or older, deemed well enough to participate were approached. Recruitment occurred at the Royal Adelaide Hospital ED between May and June 2017. Participants were asked to self-complete the ASSIST-Lite in the ED waiting room. Overall, 632 people were approached, of which 479 (75.8%) agreed to participate. RESULTS: Alcohol (72.2%), tobacco (27.1%) and cannabis (15.2%) were most commonly reported. Eighty-nine participants reported moderate- or high-risk use of two substances, and a further 49 individuals reported moderate- or high-risk use of three or more substances. Across most substances, age, gender and employment status was associated with risky substance use, with higher likelihood of risk reported by males, unemployed and younger participants. Unemployment was also significantly associated with increased risk severity for both moderate and high-risk illicit use. DISCUSSIONS AND CONCLUSIONS: The rate of risky illicit and polysubstance use found here highlight the need more focused research in ED settings. The findings also provide support for more routine screening, and early intervention approaches; and suggest the need for active referral pathways through an alcohol and other drug consultation liaison service.

The Emerging Drugs Network of Australia: A toxicosurveillance system of illicit and emerging drugs in the emergency department.

OBJECTIVE: The unprecedented rise in synthetic drugs, many containing unknown toxic agents, has made timely analytical diagnosis more difficult, and has reduced the confidence of clinicians providing ED management to this population of patients. This has also impacted the quality of evidence informing harm reduction responses. The Emerging Drugs Network of Australia (EDNA) brings together emergency physicians, toxicologists and forensic laboratories to establish a standardised ED toxicosurveillance system in Australia. METHODS: Blood analysis of intoxicated patients will be conducted by forensic laboratories to enable precise identification of the substances causing acute toxicity. This will be linked with clinical data collected at the time of ED presentation to enable analysis of the clinical effects and outcomes associated with different illicit and emerging drugs. Toxicological and clinical data collected across sentinel sites will align with a nationally endorsed minimum dataset. RESULTS: EDNA's collaborative network will establish a national system of surveillance and reporting of illicit and emerging drugs causing acute toxicity. Standardisation of data collection recorded in a national clinical registry will provide more robust data on epidemiology and associated harms. This will facilitate the translation of clinical and toxicological evidence into timely, appropriate harm reduction and policy. CONCLUSION: Our work represents a collaborative response to calls for more sophisticated data on emerging drug trends in Australia. EDNA will improve coordination between clinicians and analytical services by way of its standardised approach to surveillance and reporting.

Characteristics and significance of "green snake" bites in Myanmar, especially by the pit vipers Trimeresurus albolabris and Trimeresurus erythrurus.

Snakebite is an important problem in Myanmar. Regionally, bites by Eastern Russell's vipers, Daboia siamensis (Viperidae, Viperinae), and monocled cobras, Naja kaouthia are considered medically important, but those categorised as "green snake" bites are not. However, these may include bites by green pit vipers, Trimeresurus spp. (Viperidae, Crotalinae) for which no antivenom is available in Myanmar. Elsewhere in Southeast Asia, these snakes are reported to cause local and systemic envenoming. As part of the Myanmar Snakebite Project, prospective case data were collected over 3 years from five hospitals in the Mandalay region. These included 3803 snakebite cases reported from Mandalay region. Of these, 355 were listed as bites by a witnessed green-coloured snake. In 22 cases, the snakes responsible were retained and preserved, then expertly identified; 21 were medically important white-lipped pit vipers (Trimeresurus albolabris), and one as an Asian vine snake, Ahaetulla prasina (Colubridae, Ahaetuliinae) which is not of medical importance. Among confirmed Trimeresurus albolabris bites, 15/21 developed swelling of the bitten limb, and 3/21 coagulopathy, defined as a positive 20-min whole blood clotting test (20WBCT). None developed necrosis, blistering, thrombocytopenia or acute kidney injury (AKI). Of the remaining 333 patients bitten by green snakes that were not specifically identified, 241 (72%) developed swelling of the bitten limb, and 62 (19%) coagulopathy. AKI occurred in 21/333 patients, but only one required dialysis. At least 10/21 of the cases with AKI in this study were more likely to represent bites from Trimeresurus spp. than D. siamensis because the snake responsible was brought into the hospital, examined and described by the treating physician as "green-coloured". This study describes a previously unpublished case of AKI from envenoming by T. erythrurus in Yangon, and reviews cases of AKI following bites by this species and T. albolabris in Myanmar. This confirms that, at least on rare occasions, Trimeresurus spp. envenoming can cause AKI. This has important implications for snakebite management in Myanmar as the finding of local swelling, coagulopathy and AKI is generally considered pathognomonic of D. siamensis envenoming. Further collection of confirmed Trimeresurus spp. bites is required in Myanmar in order better to define the syndrome of envenoming and to assess the possible need for antivenom against Trimeresurus spp. in this country.

Delivering harm reduction to the community and frontline medical practitioners through the South Australian Drug Early Warning System (SADEWS).

Australia does not have a formal drug early warning system. A coordinated program of fixed or event-based drug-checking is expensive and provides harm reduction information to atargeted user group. The South Australian Drug Early Warning System (SADEWS) is an informal inter-agency collaboration which rapidly and confidentially exchanges contemporary,evidence-based information about drug seizures, usage trends and clinical outcomes associated with drug use in South Australia. Information is sourced from policing, forensic analysis,waste-water analysis, medical research, clinical data and directly from people using drugs. SADEWS exchanges information relating to new drug emergences and clusters of adverseoutcomes following drug use, amongst members via secure digital platforms. The diverse but complimentary expertise of members allows a comprehensive assessment of changes tothe baseline risk associated with drug use and, where a potential community harm is identified, enables the timely delivery of warnings through formal mechanisms existing withinmember agencies. It is expected that these warnings contribute to significantly reduced medical consequences associated with community drug use through decreased drug overdosefatalities and hospital presentations rates, contributing to reduced healthcare costs. Importantly, this drug early warning system is politically risk-free, is achieved simply and without external funding or significant administrative overheads.

Establishing the protocols for the South Australian Emergency Department Admission Blood Psychoactive Testing (EDABPT) programme for drug surveillance.

OBJECTIVE: ED presentations because of illicit use of psychotropic drugs and pharmaceuticals result in significant medical harm and resource consumption. Patient assessment is complicated by the regular emergence of new psychoactive substances, difficulties associated with their identification and a lack of information about their effects. Here we report the protocol for the Emergency Department Admission Blood Psychoactive Testing (EDABPT) programme, an observational study utilising clinical data capture and definitive drug identification to assess the medical impact and patterns of illicit drug use in the community, and their geographic and temporal fluctuations. The study provides data to an early warning system targeting an improved public health response to emerging drugs of concern. METHODS: Enrolment of adult patients presenting with suspected illicit drug use occurs at four major EDs in a single urban setting. Clinical and demographic data are collected by treating clinicians. Blood samples are collected at presentation and frozen on site prior to transport to a specialised forensic facility for comprehensive toxicological screening. RESULTS: Results are fed back to clinicians and disseminated more broadly via an existing local early warning system. Targeted warnings and public health releases are instigated where heightened risk or harm is identified. CONCLUSION: The study pairs city-wide patient enrolment with analytically confirmed toxicology results to allow broad sampling and identification of illicit drugs causing medical harm. It provides a mechanism for the identification of new agents as they emerge in the community, delivers a relevant and reliable source of information for public health agencies and clinicians and supplements existing local early warning mechanisms.

Inadequate knowledge about snakebite envenoming symptoms and application of harmful first aid methods in the community in high snakebite incidence areas of Myanmar.

INTRODUCTION: Every year millions of people in developing countries suffer from snakebite, causing a large number of deaths and long term complications. Prevention and appropriate first aid could reduce the incidence and improve the health outcomes for those who suffer bites. However, many communities where snakebite is a major issue suffer from a lack of information about prevention and first aid measures that a family or community member could take to prevent severe envenoming, complications and poor outcomes. Myanmar suffers from a high burden of snakebites with a large number of deaths. As part of a health services and community development program, a community survey was conducted to identify communities' knowledge about snakebite and their sequelae, and knowledge and practice about first aid and health services use. METHOD: 4,276 rural residents of Kyaukse and Madaya townships in the Mandalay region were recruited by cluster sampling, involving random selection of 144 villages and random sampling of 30 households from each village. One adult member of each household was interviewed using a structured questionnaire. RESULTS: The incidence of snakebite was 116/100,000 people. Respondents reported 15 different types of snakes in the area, with Russell's Viper, Cobra and Green snakes as the most common. 88% of the people informed that working in the fields and forests was when most of the bites occur. A majority knew about snakebite prevention methods such as wearing long boots. However, only a few people knew about the specific symptoms caused by snakebites. Only 39% knew about the correct methods of first aid. More than 60% mentioned tourniquet as a first aid method, though this may cause significant complications such as ischaemia of the limb. 88% said that they would take a snakebite victim to a government hospital, and 58% mentioned availability of antivenom as the reason for doing this. At the same time, the majority mentioned that traditional methods existed for first aid and treatment and 25% mentioned at least one harmful traditional method as an effective measure that they might use. CONCLUSION: The community is aware of snakebites as a major public health issue and know how to prevent them. However, the high incidence of snakebites point to lack of application of preventive methods. The community recognise the need for treatment with antivenom. However, inadequate knowledge about appropriate first aid methods, and a reliance on using tourniquets require a targeted education program. Existing knowledge in communities, albeit insufficient, provides a good starting point for mass media educational campaigns.

A comprehensive approach to managing a neglected, neglected tropical disease; The Myanmar Snakebite Project (MSP).

Snakebite is predominantly an occupational disease affecting poor rural farmers in tropical regions and was recently added to the World Health Organisation list of Neglected Tropical Diseases (NTD). We document an overview of methodologies developed and deployed in the Myanmar Snakebite Project, a foreign aid project largely funded by the Australian Government, with the core aim to "improve outcomes for snakebite patients". A multidisciplinary team of experts was assembled that worked in a collaborative manner with colleagues in Myanmar, first to identify problems related to managing snakebite and then develop interventions aimed to improve selected problem areas. A broad approach was adopted, covering antivenom production, antivenom distribution and health system management of snakebite. Problems identified in antivenom production included poor snake husbandry resulting in poor survival of captive specimens, lack of geographical diversity; poor horse husbandry, resulting in high mortality, inadequate stock acquisition protocols and data collection, and inappropriate immunisation and bleeding techniques; and inadequate production capacity for freeze dried antivenoms and quality control systems. These problems were addressed in various ways, resulting in some substantial improvements. Antivenom distribution is being reorganised to achieve better availability and utilisation of stock. Health system management of snakebite was assessed across all levels within the area selected for the study, in Mandalay region. A comprehensive community survey indicated that hospital statistics substantially underestimated the snakebite burden, and that access to care by local villagers was delayed by transport and cost issues compounded by lack of antivenom at the most peripheral level of the health service. A health system survey confirmed under-resourcing at the local village level. Prospective case data collection initiated at tertiary hospitals indicated the extent of the snakebite burden on health resources. Interventions initiated or planned include training of health staff, development of a core of senior trainers who can "train the trainers" nationwide in a sustainable way, development and deployment of management guidelines and algorithms for snakebite and a distribution of solar powered fridges to remote health facilities to allow storage of antivenom and prompt treatment of snakebite cases before transfer to major hospitals, thereby reducing the "bite to needle" time.

Twelve month prospective study of snakebite in a major teaching hospital in Mandalay, Myanmar; Myanmar Snakebite Project (MSP).

The Myanmar Snakebite Project is an Australian government (Department of Foreign Affairs and Trade) supported foreign aid project in collaboration with the Myanmar government with the aim of improving outcomes for snakebite patients in Myanmar. As part of the project a case record database was established to document prospective cases of snakebite presenting to Mandalay General Hospital, in Upper Myanmar. The study period was 12 months (1-2-2016 to 31-1-2017). Snake identity was based on a mixture of identified dead snakes brought with patients, doctor's clinical opinion and patient identification. 965 patients were enrolled during the 12 month period, of whom 948 were included for analysis. The male: female ratio was 1.58:1. Most cases involved bites to the lower limbs (82.5%) and adults involved in farm work, confirming snakebite as an occupational disease in this community. Motorised transport was by far the most common form of transport to health care and most patients sought care from the health system (87.7%), not traditional healers (11.5%) as their first point of contact. The officially promoted application of a pressure pad, bandage and immobilisation as first aid for snakebite was almost never used, while most patients used some form of tourniquet (92.0%). 85.4% of cases where a snake ID was listed were bitten by Russell's vipers. Russell's viper bites were responsible for all fatalities (9.8% of cases) and all cases of Acute Kidney Injury (AKI). For all cases, clinical features included local swelling (76.5%), local pain (62.6%), AKI (59.8%), incoagulable blood (57.9%), regional lymphadenopathy (39.8%), nausea/vomiting (40.4%), thrombocytopenia (53.6%), abdominal pain (28.8%), shock (11.8%), secondary infection (8.6%), panhypopituitarism (2.1%). AKI required renal replacement therapy (RRT) in 23.9% of cases, all ascribed to Russell's viper bite. Green pit viper bites were the next most common cause of bites (7.6%) and were associated with incoagulable blood (29%) and occasionally shock (5%) and local necrosis (3%), and in one case AKI not requiring RRT. In contrast to Russell's viper bites, green pit viper bite was most likely to occur in the home (49%). Some green pit viper patients were treated with Russell's viper antivenom (15%), presumably because they had incoagulable blood, although this antivenom is not effective against green pit viper envenoming. For the entire patient group, antivenom was given in 80.5% of cases. The most common indications were presence of coagulopathy/non-clotting blood (59.8%), local swelling (47.4%), oliguria/anuria (19.8%), heavy proteinuria (19.4%). A febrile reaction to antivenom was reported in 47.9% of cases, while anaphylaxis, occurred in 7.9% of cases.

Development of an ELISA assay to determine neutralising capacity of horse serum following immunisation with Daboia siamensis venom in Myanmar.

Snakebite envenoming is a serious problem in Myanmar. The great majority of snakebite in this country is due to Russell's Viper (Daboia siamensis). For many years, the Burma Pharmaceutical Industry has produced a monovalent antivenom to Russell's Viper in horses. At present, the only way of determining the level of antibody against D. siamensis venom in hyperimmune horse serum is to perform venom neutralisation tests in mice. In this study, we describe the development of an in vitro ELISA assay to estimate neutralising capacity of horse serum. We found a strong correlation between the ELISA assay and the venom neutralisation test in mice (r = 0.982). The assay is robust and has sufficient sensitivity (92%) and specificity (96%) to replace the venom neutralisation test in mice during the immunisation phase in horses.

Snakebite incidence in two townships in Mandalay Division, Myanmar.

INTRODUCTION: The global incidence of snakebite is estimated at more than 2.5 million cases annually, with greater than 100,000 deaths. Historically, Myanmar has one of the highest incidences of venomous snakebites. In order to improve the health outcomes of snakebite patients in Myanmar, access to accurate snakebite incidence data is crucial. The last population-based study in Myanmar was conducted more than a decade ago. In 2014, the Ministry of Health and Sports data from health facilities indicated an incidence of about 29.5 bites/ 100,000 population/year (a total of 15,079 bites). Since data from health facilities lack information about those who do not seek health care from government health services, a new population-based survey was conducted in 2 rural areas of Mandalay region. The survey data were compared to those obtained from healthcare services. METHOD: 4,276 rural respondents in Kyaukse and Madaya townships in Mandalay Division were recruited using cluster sampling that involved random selection of 150 villages and random sampling of 30 households from each village. One adult member of each household was interviewed using a structured questionnaire. RESULTS: One respondent from each of 4,276 households represented 19,877 residents from 144 villages. 24 people in these households had suffered snakebite during the last one year giving an annual incidence of 116/100,000. During the last ten years, 252 people suffered snakebites. 44.1% of the victims were women. 14% of the villages reported 4 or more bites during the last ten years, whereas 27% villages reported no snakebites. 92.4% of the victims recovered fully, 5.4% died, and 2% suffered long term health issues. One victim was reported to have died from causes unrelated to the snakebite. While there was no statistically significant difference between outcomes for children and adults, 4 of 38 of those under 18 years of age died compared to 7 of 133 adults between 19 to 40 years of age. CONCLUSION: This incidence reported by the community members points to substantially more snakebites than the number of snakebite patients attending health facilities. This higher incidence points to the need for a nation-wide population-based survey, community education about gaining access to care where antivenom is available, and to the potential need for a larger supply of antivenom and expansion of medical care in rural areas.

Why snakebite patients in Myanmar seek traditional healers despite availability of biomedical care at hospitals? Community perspectives on reasons.

BACKGROUND: Snakebite is a major public health problem in many developing countries. Farmers are particularly exposed to snakes, and due to their rural location often experience delays in accessing formal healthcare. The reasons to use traditional healers may include difficulties in accessing formal healthcare, certain beliefs about snakes and snake venom, tradition, and trust in the capacity of traditional healers. Traditional healing, however, may have serious consequences in terms of delays or added complications. There is little in-depth current information about the reasons for its continued use for snakebite. As part of a health services development project to improve health outcomes for snakebite patients, community attitudes to the use of traditional healers were explored in the Mandalay region of Myanmar. METHODOLOGY & FINDINGS: With the objective of learning from local communities, information was generated in three communities using participatory appraisal methods with the communities, and focus group discussions with the local healthcare staff. Many snakebite victims in these communities use traditional healing. Reasons include transport difficulties, low cost for traditional healing, inadequacy of anti-snake venom in the formal healthcare sector, and traditional beliefs, as traditional healing practices are rooted in many cultural and traditional factors. The communities reported that even if access to medical care were improved, traditional healing would continue to be used. CONCLUSION: These findings point to the need for working with traditional healers for prevention, appropriate first aid and timely access to effective treatment for snakebite.

Neurotoxicity with persistent unilateral ophthalmoplegia from envenoming by a wild inland taipan (Oxyuranus microlepidotus, Elapidae) in remote outback South Australia.

INTRODUCTION: A case of life threatening envenoming by a wild specimen of the inland taipan, Oxyuranus microlepidotus, is described. There have been 11 previously well-documented envenomings by O. microlepidotus, but only 2 were inflicted by wild snakes. Envenomed patients have presented predominantly with defibrinating coagulopathy and neurotoxicity. CASE REPORT: The victim was seeking to observe members of an isolated population of this species and was envenomed while attempting to photograph an approximately 1.5 m specimen. He reported feeling "drowsiness" and blurred vision that progressed to ptosis; he later developed dysphagia and dysarthria. The patient was treated with 1 vial of polyvalent antivenom, which was later followed with an additional two vials of taipan monovalent. He was intubated during retrieval, and recovered after 3 days of intensive care. He had a right ophthalmoplegia that persisted for approximately 1 week post-envenoming. Despite a positive 20-min whole blood clotting test, defibrination coagulopathy was absent, and there was no myotoxicity, or acute kidney injury. DISCUSSION: Physicians presented with a patient envenomed by O. microlepidotus should remain cognizant of the possible variability of medically important venom toxins in some populations of this species. Some patients seriously envenomed by this species may develop persistent cranial nerve palsies. When clinically indicated, prompt provision of adequate antivenom is the cornerstone of managing O. microlepidotus envenoming. Rapid application of pressure-bandage immobilization and efficient retrieval of victims envenomed in remote locales, preferably by medically well-equipped aircraft, probably improves the likelihood of a positive outcome.

The Australian mulga snake (Pseudechis australis: Elapidae): report of a large case series of bites and review of current knowledge.

BACKGROUND: The mulga snake (Pseudechis australis) is the largest terrestrial venomous snake in Australia. It is capable of inflicting severe and occasionally fatal envenoming, but there have been few studies of P. australis bites. OBJECTIVES: To highlight and reinforce the main features of P. australis envenoming and to provide a clearer picture of the epidemiology of bites from this species. METHODS: Selected case records kept by the Toxinology Dept. (Women's and Children's Hospital, Adelaide, Australia) were reviewed retrospectively to determine definite P. australis bites. INCLUSION CRITERIA: definite cases where the snake was identified by a competent person and/or lab specimens (bite site/urine) tested positive for "black snake" using CSL snake venom detection kit in a locality within the known range of P. australis, but without sympatry with other Pseudechis spp. EXCLUSION CRITERIA: where the snake could not be clearly identified under criteria above. Epidemiological and clinical information was recorded and analysed for the definite cases. RESULTS: A total of 27 cases were identified as definite P. australis bites; there were no fatalities. The median age was 35.5 years (IQR 51-23) and 80% of bites occurred in males. More bites occurred in the warmer months (Dec-March) and in those handling/interfering with snakes. Seven people were bitten whilst asleep at night. 21/27 patients developed systemic envenoming (based on signs, symptoms and laboratory results) and 17 cases received antivenom. Local bite site pain (18) and swelling (17) were common as were non-specific generalised symptoms such as nausea, vomiting and headache. Myotoxicity (11) and anticoagulant coagulopathy (10) occurred frequently; haemolysis was seen in fewer cases (3). Two patients developed local tissue injury around the bite site requiring further treatment. CONCLUSIONS: This study confirms previous reports about P. australis bites with respect to high rates of envenoming, commonly associated with pain and swelling and systemic effects of rhabdomyolysis and anticoagulant coagulopathy. Systemic envenoming, even severe cases, responds well to antivenom therapy. Compared to other Australian snakes, a high proportion of bites occur in people asleep at night. Medically significant local tissue injury around the bite site may occur and may be associated with inappropriate first-aid, particularly the vascular occlusive type.