Suspected adder bite

Re: Suspected adder bite

James Laidlaw — Thu, 26 Jul 2012 08:24:19 GMT

If you can smile inwardly at that time, you sir, are a better man than I...

Re: Suspected adder bite

Rajat — Thu, 26 Jul 2012 08:19:44 GMT

Lol so you noticed that! I thought it was hilarious too

It was also the tune playing on the sound system in my first job, coupla months out doing a bitch spay when the ovarian stump slipped and started to bleed- despite the panic I couldn't help smiling inwardly at the bloody irony of the situation..

Re: Suspected adder bite

David Mills — Wed, 25 Jul 2012 13:39:37 GMT

[quote user="Mark Naguib"]

The VPIS retrospective study was mentioned briefly earlier in this thread - here's the bit regarding steroids:

"Oedema occurred in 92 per cent of cases. This initial swelling is not an inflammatory response but due to the cytotoxic effect of the venom and therefore steroids are of limited benefit. In addition to this, in a study on dogs bitten by Vipera palaestinae, the use of steroids was associated with increased mortality (Segev and others 2004). In 53 dogs bitten by V berus in Sweden, treatment with steroids had no clear positive or negative effects. There was a slight trend towards more swelling in dogs given steroids (but that may have been because treating veterinarians gave steroids to dogs with more severe swelling) (Lervik and others 2010). Steroids can also slow and diminish the response to antivenom and increase the risk of infection. Steroids should therefore not be used in animals that have been or are going to be given antivenom."

Veterinary Record 2011;169:607 doi:10.1136/vr.d4695

[/quote]

The Segev paper: "However, due to small number of death cases, a powerful multivariate analysis could not be performed. Thus, confounding by indication in which clinicians administered corticosteroids to dogs that presented combination of clinical signs suggestive of poor condition could not be entirely ruled out." The number of dogs that died was 13 (out of 327). 8 of these had received glucocoticoids. Without multivariant anaylsis this is nothing more than a trend and are we actually going to base our clinical direction on 8 cases?

From the same paper: "However, steroids may slow and diminish antivenom activity (Mann, 1976)". The Mann 1976 is a PhD thesis and there appears to be no follow up - it is a theory which has been conflated in the Vet Record paper into an unsupported recommendation. Further the theroectical increased risk of infection was not seen in the Lervik paper where 22 dogs were treated with glucocorticoids and only 10 with antibiotics. >80% of glucocoricoid tretaed dogs were classed in moderate-severe swelling group cf the non-GT group of 50%.

The glucocorticoid adavntage/disadvantage certainly has not been settled by any of the studies quoted, and the Vet Record is a biased piece on this evidence. All reccomendations are based on retrospective studies which are inherently flawed for treatment assessment given the lack of control.

Re: Suspected adder bite

Bob Russell — Wed, 25 Jul 2012 09:23:23 GMT

We used to give anti-venom i/m but found its effects difficult to identify. If given by slow i/v (diluted) you can almost see the dog improve before your eyes. Until the evidence breaks down treatment given i/v and i/m I will treat it with caution.

I suspect the cases given i/m treatment may not have got much benefit from the anti-venom whether steroids were given or not!

It is always difficult in a situation where venom quantities/quality varies massively, the part of the body varies so much and the details including route of administration of treatment varies.

We have a protocol that seems to work at least as well as any other but I remain open to different opinions.

Re: Suspected adder bite

James Laidlaw — Wed, 25 Jul 2012 08:36:53 GMT

[quote user="Rajat"]

More like Mozart's Carpe diem

http://www.youtube.com/watch?v=CQUFQ_N0JI8

[/quote]

Great start to the day seeing this in the comments under your video link:

this is the song that my secret island base's self destruct system plays during detonation.

Re: Suspected adder bite

karen jones — Tue, 24 Jul 2012 22:32:50 GMT

My dog had an adder bite on medial forearm, had lot of tissue necrosis took 4 months of dressing especially with honey dressings, antibiotic and metacam and buster collars (my house hasn't recovered!!) but is now healed no hair but she is a happy dog sound and enjoying lfe. Adder bites rare in this area . happened on hot August walking in the forestry. I must admit didn't give her steroids as last time she had some it turned her into a ravenous collie which ended with iatrogenic cushings which fortunately only lasted 2 months until the steroid injected into her bicitital tendon wore off. It now says on her records for when I'm away on holiday no steroids unless absolutely necessary. Why do our pets get ill as soon as we leave the UK?

Re: Suspected adder bite

Mark Naguib — Tue, 24 Jul 2012 20:57:11 GMT

Veterinary Record 2011;169:607 doi:10.1136/vr.d4695

Re: Suspected adder bite

Rajat — Tue, 24 Jul 2012 19:55:02 GMT

More like Mozart's Carpe diem

http://www.youtube.com/watch?v=CQUFQ_N0JI8

Re: Suspected adder bite

James Laidlaw — Tue, 24 Jul 2012 18:53:01 GMT

[quote user="Rajat"]And yes DIC is awful, but can be treated successfully sometimes if we keep our eyes and ears open for it in the conditions it occurs in ..[/quote]

What is the sound of DIC? Is that like that Simon and Garfunkel tune?

Re: Suspected adder bite

Rajat — Tue, 24 Jul 2012 18:18:54 GMT

Like Hannah and othe rposters, the give away here is the petechiation on the gums, I would have pursued this enthusiastically (not agressively if you insist Evelyn! )

Epecially when the RR went up - I think there is a big assumption in the notes there without further tests (xrays, SPO2, blood gases) that it is consistent with wearing off of pain relief..unless they saw resps normalise with analgesia.

And yes DIC is awful, but can be treated successfully sometimes if we keep our eyes and ears open for it in the conditions it occurs in .. having said this a low platelet count (causing petechiation) is quite a late development in the pathogenesis of DIC and should have rung alarm bells (and at least elicited BMBT, blood smear with manual plateelt counts and so on) to chase this up.

D Mills youre right in this instance PT /APTT not partic useful as the 1' coag system is affected but DIC can affect both due to consumption of factors so worth running if costs allow...afterall not everyone has a TEG lying around in the backroom..! Snake bites can have pro and anti coagulant effects (and pro coag can lead to bleeding due to consumption of factors too)

Given petechiation I would have reached for the anti venom asap and added in FFP if there was signs consistent with DIC (regardless of clotting times) which I suspect there were.

Saying all this, I second the poster who commented the diff vets who saw this and how difficult that can be for comparison and follow up. I would not hold anyone responsible for the dogs death but if what we have heard third hand is true (and I appreciate things may have panned out differently than we can tell from the notes) expect the critical care vets at vets now to be more pro active with managing this case than seems to have been the case.

Sad case and tough for the new grad to deal with - not an easy one for any vet!

Re: Suspected adder bite

Hannah Wynne Richards — Tue, 24 Jul 2012 17:27:16 GMT

I'd probably use something for Gm _ ves and also anaerobes because the tissue swelling would lead to anaerobic conditions

Wynne

Re: Suspected adder bite

Richard Fox — Tue, 24 Jul 2012 17:17:16 GMT

Snakes carry a fair few commensal Gram -ves in their oral cavity but I guess it depends on the inoculum needed to establish and infection however seems unlikely to establish an infection from the journals quoted?

Re: Suspected adder bite

Bob Russell — Tue, 24 Jul 2012 17:05:09 GMT

The justification I use for antibiotics is the degree of tissue trauma can lead to quite dramatic tissue necrosis. An adder strike should be a pretty sterile affair I would have thought.

Steroids and pain relief are the mainstays of my treatment. An adder strike is going to hurt a lot!

Re: Suspected adder bite

Richard Fox — Tue, 24 Jul 2012 16:56:04 GMT

A negative (of an anaerobe or a gram-ve) culture result does not mean infection is or wasn't present? As mentioned prophylaxis would be my aim - if you has any other bite would i.e. cat, dog etc would you not administer antibiotics? Lots of ifs and buts. I expect if you left the majority of adder bites they would prob get better all on their own.

BTW that study was based on information/observations given/sent to the VPIS from cases in the wild so not really gospel (i.e. not really a true prospective scientific study) although useful none the less.

"Antibiotics were used in 56 per cent of cases, although there were no instances of infection reported. In 53 cases of canine adder bites, 19 per cent of dogs received antibiotics but none developed signs of infection (Lervik and others 2010). The routine use of antibiotics in dogs with adder envenomation is not required as infection is not common. A prophylactic broad-spectrum antibiotic could be considered in any dog with widespread necrosis."

Re: Suspected adder bite

Richard Fox — Tue, 24 Jul 2012 16:51:14 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Richard Fox"]as I said above aggressive Ab therapy for a potential gram -ve infection[/quote]

Sorry Richard, not getting at you personally, but why do people talk about "aggressive" therapy? I'd say there were only two kinds of therapy: adequate for the purpose and inadequate for the purpose.

I think "aggressive" is to make the physician feel good: "we're being really aggressive, look at all the stuff we're doing".

[/quote]

Yes fully justified - I don't tend to use it but was following on from the use above - hand smacked

Re: Suspected adder bite

David Mills — Tue, 24 Jul 2012 16:33:25 GMT

No evidence for or against corticosteroids - equivocal on recent studies, although possible non-significant 'trends' either way.

Infection is a more straightforward affair: it is not common at all (0/422 in a recent VPIS retrospective Vet Rec, 2011) meaning likely not indicated: and, I would proffer, fluoroquinolone use is irresponsible in this setting.

Interesting that despite supportive treatment 5% mortality (same study, 422 cases) reported.

Facial oedema in 40%, oedema somewhere in 93%.

Antivenom apparently available through VPIS/VetsNow toxins boxes 24h/day.

Re: Suspected adder bite

Sandra Milburn — Tue, 24 Jul 2012 15:46:03 GMT

Cases like this are hard to deal with, especially when the 'blame game' starts! Saw a suspected adder bite recently as well, that had had a work up at another vets for muscular swelling on the thigh (including NSAIDs, x-rays, ABs etc). Eventually all settled down, but then presented shortly after with nose bleed (yes, 12 hour duration!) and white mm (despite low PCV VERY bright. It was lucky, was an ESS). Massively elevated clotting times, but responded brilliantly to Vitamin K alone (phew).

Its never easy when your dealing with 'suspected' cases of anything really.

Re: Suspected adder bite

Evelyn Barbour-Hill — Tue, 24 Jul 2012 15:26:37 GMT

[quote user="Richard Fox"]as I said above aggressive Ab therapy for a potential gram -ve infection[/quote]

Sorry Richard, not getting at you personally, but why do people talk about "aggressive" therapy? I'd say there were only two kinds of therapy: adequate for the purpose and inadequate for the purpose.

I think "aggressive" is to make the physician feel good: "we're being really aggressive, look at all the stuff we're doing".

Re: Suspected adder bite

Richard Fox — Tue, 24 Jul 2012 15:13:59 GMT

[quote user="Mark Rowland"]

Well Ive not seen any studies showing beneficial effect of steroids as first line treatment for snake envenomations, I would love for someone to link me to one?

[/quote]

I agree which is why I looked it all up when my neighbour told me and showed the dogs axillary lesion to me and I reported back suggesting what she should do - as I said above aggressive Ab therapy for a potential gram -ve infection and some NSAIDS (not trying to make the OP feel bad)?

However you have to treat as you see fit - you suspect it was an adder bite but no one really know so you do the best you can on presentation. Who knows if the lesion became infected and progressed etc - sounds like it to me and if it was resistant then the lesion could have been cultured if it was not progressing well - sounds like it did but then relapsed?

Re: Suspected adder bite

Bob Russell — Tue, 24 Jul 2012 15:09:56 GMT

Swellings head and neck area and the potential for anaphylaxis if you use anti-venom later seem good enough reason for corticosteroid use. Our protocol was based on recommendations from VPIS!

I have had one death in 20+ years despite living in the adder capitol of the UK.

Pain relief is generally opiates. I have to admit I generally use co-amoxyclav but will rethink the choice!

Re: Suspected adder bite

Mark Rowland — Tue, 24 Jul 2012 15:07:06 GMT

Well Ive not seen any studies showing beneficial effect of steroids as first line treatment for snake envenomations, I would love for someone to link me to one?

Re: Suspected adder bite

Mark Hedberg — Tue, 24 Jul 2012 15:06:42 GMT

[quote user="Julian Earl"]

[quote user="Mark Hedberg"]

Snakebites are fiddly things. You're always watching the patient like a hawk, because until you really know what kind of snake it was, you're always wondering what the next presenting symptom is going to be.

[/quote]

There's only adder bites that count in the UK - not many escaped cobras or pit vipers I imagine! Anyway, I would have given steroids early in large doses, plus fluids, plus antibiotics. Whether early steroids would have made a difference, who knows, but the only deaths I've seen have been from facial strikes? I give steroids , wait a few hours, and repeat if the swelling/bruising is worsening. I seem to recall that some poisons booklet states corticosteroids are C/I but I humbly beg to differ! We always admit them as well.[/quote]

I know, it's just that when I worked in the Middle East, any snakebite was treated as a crisis. (I had a doberman lose most of the skin on his back leg about three years ago - unbelievable how tolerant and kind that dog was!)

(Actually I'm still quite impressed he survived!)

Still, old habits are hard to break and I'd rather overtreat a snakebite than not. (Bit embarrassing, my first snakebite case in the UK - I treated it like a four alarm emergency, admitted it and treated it with antihistamines, AB's, the full monty - then one of my new colleagues politely explained that the common adder wasn't particularly poisonous!)

The owner didn't complain or anything - the dog recovered brilliantly and the O was quite touched at my concern for her dog's welfare!

Re: Suspected adder bite

Andrew Kent — Tue, 24 Jul 2012 15:03:32 GMT

I guess that using a separate out of hours provider has not helped this dog as it has been seen by 4 different people who can't really assess response to therapy as they have never seen the dog before and has had to travel between practices for management!

Re: Suspected adder bite

Julian Earl — Tue, 24 Jul 2012 14:59:14 GMT

[quote user="Mark Hedberg"]

[/quote]

Re: Suspected adder bite

Hannah Wynne Richards — Tue, 24 Jul 2012 14:57:29 GMT

I would have included antibiotics-but that may be a result of my age-we did use them prophylactically a lot more when I first qualified Like with early use of corticosteroids in snake bites it's more opinions than facts I'm sorry for everyone, veterinary surgeons/owners/most of all dog

Wynne

PS The weather has just improved and venom is worst in early summer-and despite the calender-this is where we're at now