Successful treatment of neurotoxic king cobra envenomation in Myrtle Beach, South Carolina.

The growing trend toward the collection of exotic snakes by private collectors increases the likelihood that emergency physicians will face the challenge of treating an exotic envenomation. We report a case involving a professional reptile handler who sustained an extremity bite from a king cobra (Ophiophagus hannah ). Rapid, progressive neurotoxicity developed as manifested clinically by bulbar and respiratory paralysis requiring endotracheal intubation and mechanical support. After infusion of Thai Red Cross Society monospecific king cobra antivenin, all neurologic sequelae rapidly resolved within 7 hours after the bite. In treating an exotic envenomation, the emergency physician should contact personnel at the regional poison control center or local zoo. Both are prepared to assist the physician by facilitating the timely acquisition of exotic antivenins and by arranging consultation with experts experienced in the management and treatment of exotic envenomations.

Neostigmine for the treatment of neurotoxicity following envenomation by the Asiatic cobra.

Envenomation by the monocellate cobra (Naja kaouthia) is usually manifested clinically as neurotoxicity and local tissue necrosis. Treatment often requires administration of large quantities of antivenin, resulting in a high incidence of serum reactions. In cases where antivenin administration may be delayed for several hours or administration is contraindicated, the use of the anticholinesterase drug neostigmine may temporarily reverse the potentially lethal neurological effects of the venom. Detailed in this report is the case of immediate and dramatic reversal of envenomation symptoms following the administration of the anticholinesterase neostigmine methyl sulfate.

Snake venom poisoning in the United States: a review of therapeutic practice.

Snake venom poisoning constitutes a medical emergency. It is a complex type of poisoning that not only affects the local bite site but may involve multiple organ systems as well. In the United States, poisonous snakes account for approximately 8,000 bites annually, resulting in about 9 to 15 fatalities. The majority of deaths occur in children, the elderly, and untreated or mistreated individuals. Pit vipers account for almost all bites. Diagnosis and treatment are based on clinical signs and symptoms of envenomation along with identification of the snake. First aid treatment should focus on transporting the victim to the nearest medical facility as soon as possible. Previously advocated first aid measures such as tourniquet, incision and suction, cryotherapy, and electric shock should be avoided. The mainstay of treatment for envenomation is the prompt administration of sufficient quantities of the appropriate antivenin.

Venomous snakebites. Current concepts in diagnosis, treatment, and management.

It is essential that all emergency physicians become familiar with the recognition and treatment of venomous snakebites. Techniques such as the use of tourniquets and incision and suction should no longer be performed routinely. The mainstay of treatment for poisonous bites is the intravenous administration of the appropriate antivenin to neutralize the effects of the venom.

The utility of preoperative electrocardiograms in the ambulatory surgical patient.

To determine the utility of preoperative screening electrocardiograms (ECGs) among ambulatory surgery patients, we reviewed the charts of 751 consecutive adult patients who underwent ambulatory surgery. Data were collected on demographic characteristics, coexisting medical problems, American Society of Anesthesiologists physical status score, preoperative ECG results, adverse intraoperative cardiovascular events, and postoperative cardiovascular complications. In our study population of relatively healthy outpatients, preoperative ECGs were abnormal in 42.7% of patients. Age, increased physical status score, and male gender were associated with a greater incidence of abnormal preoperative ECGs. There were 12 adverse cardiovascular perioperative events among the 751 patients (1.6%), and the preoperative ECG may have been clinically useful in six of these 12 patients. Neither preoperative ECGs nor results of preoperative screening questionnaires were predictive of adverse cardiovascular perioperative events. These findings question the utility of preoperative ECGs in the ambulatory surgery setting, especially among younger, relatively healthy patients.

Unanticipated admission to the hospital following ambulatory surgery.

We conducted a case-control study to identify clinical and demographic risk factors for admission to the hospital following ambulatory surgery. Of 9616 adult patients who underwent ambulatory surgery at a university-affiliated hospital between 1984 and 1986, one hundred were admitted. The most common reasons for admission were pain (18), excessive bleeding (18), and intractable vomiting (17). The mean age (+/- SD) of patients who were admitted was 37 +/- 13 years, and 96% had American Society of Anesthesiologists' physical status scores of 1 or 2. Factors that were independently associated with an increased likelihood of admission were general anesthesia (odds ratio, 5.2), postoperative emesis (odds ratio, 3.0), lower abdominal and urologic surgery (odds ratio, 2.9), time in the operating room greater than 1 hour (odds ratio, 2.7), and age (odds ratio, 2.6). Our results indicate that the likelihood of unanticipated admission is related more to the type of anesthesia and surgical procedure rather than to the patient's clinical characteristics.