Ahmad Khaldun Ismail

Ventricular bigeminy following a cobra envenomation

Context. Envenoming by some species of cobras (Naja species) may include cardiotoxic effects including various dysrhythmias. However, dysrhythmias leading specifically to ventricular bigeminy have not been previously documented. We report a case of cardiotoxicity and the development of ventricular bigeminy following a cobra envenomation. Case details. The patient was a 23-year-old man who presented to an emergency department following an alleged cobra bite. There was transient episode of nausea, vomiting, hypotension and tachycardia. The ECG showed infrequent ventricular ectopics that progressed to ventricular bigeminy and persisted even after the vital signs normalized. Complete resolution and resumption of normal sinus rhythm occurred following an empirical administration of monovalent antivenom against Naja kaouthia venom. The patient was discharged after 24 hours of uneventful observation. Discussion. The patients concomitant local effects, episodic cardiovascular instability and evolution of ventricular bigeminy support the likelihood of a venom-induced disease. Ventricular bigeminy can develop following a cobra envenomation. Thorough clinical evaluation, close serial observation of vital signs and early continuous cardiac monitoring are important in Naja spp. bites.

A prospective study of tracheal intubation in an academic emergency department in Malaysia

BackgroundAirway management is an important part of the management of the critically ill and injured patients in the Emergency Department (ED). Numerous studies from developed countries have demonstrated the competency of emergency doctors in intubation. To date there have been no published data on intubations performed in EDs in Malaysia.MethodsData on intubations from 7 August 2007 till 28 August 2008 were prospectively collected.ResultsThere were 228 intubations included in the study period. Cardiopulmonary arrest was the main indication for intubation (35.5%). The other indications were head injury (18.4%), respiratory failure (15.4%), polytrauma (9.6%) and cerebrovascular accident (7.0%). All of the 228 patients were successfully intubated. Rapid sequence intubation (RSI) was the most frequent method (49.6%) of intubation. A total of 223 (97.8%) intubations were done by ED personnel. In 79.8% of the cases, intubations were successfully performed on the first attempt. Midazolam was the most common induction agent used (97 patients), while suxamethonium was the muscle relaxant of choice (109 patients). There were 34 patients (14.9%) with 38 reported immediate complications. The most common complication was oesophageal intubation.ConclusionEmergency Department UKMMC personnel have a high competency level in intubation with an acceptable complication rate. RSI was the most common method for intubation.

Snakebite and envenomation management in Malaysia

Malaysia is a tropical country and snakes are an essential component of its many ecosystems. A number of medically significant venomous land and marine species have been recorded from Malaysia. Humans are exposed to bites and envenoming from these snakes during their engagement in various activities that bring them into the animal’s natural habitat. Snakebite is an important medical emergency and one of the common causes of hospital admission. There is a clear association between the knowledge and confidence level of healthcare providers managing snakebite with the quality of patient care, the provision of appropriate clinical management, the selection of appropriate antivenom, and the outcome of such treatment. The clinical management of snake bites and envenoming may A.K. Ismail (*) Department of Emergency Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia e-mail: khaldun_ismail@yahoo.com # Springer Science+Business Media Dordrecht 2015 P. Gopalakrishnakone et al. (eds.), Clinical Toxinology in Asia Pacific and Africa, Toxinology, DOI 10.1007/978-94-007-6386-9_54 71 still be suboptimal due to neglect of this issue and negligence at various levels of medical care. The true scale of mortality and morbidity from snakebite remains uncertain as a result of inadequate documentation. To overcome these deficiencies, snake bite envenoming must be recognized as an important notifiable disease. Awareness programs for the public and specially tailored educational programs for healthcare providers should be encouraged and supported. An appropriate clinical management guideline should be established and the inappropriate ones removed. The establishment of an easily accessible qualified clinical expert assistance in managing snakebites and envenomation is also necessary.

Non-front-fanged colubroid ("colubrid") snakebites: three cases of local envenoming by the mangrove or ringed cat-eyed snake (Boiga dendrophila; Colubridae, Colubrinae), the Western beaked snake (Rhamphiophis oxyrhynchus; Lamprophiidae, Psammophinae) and the rain forest cat-eyed snake (Leptodeira frenata; Dipsadidae)

Abstract Context. Non-front-fanged colubroid snakes (NFFC; formerly and artificially taxonomically assembled as “colubrids”) comprise the majority of extant ophidian species. Although the medical risks of bites by a handful of species have been documented, the majority of these snakes have oral products (Duvernoys secretions, or venoms) with unknown biomedical properties/unverified functions and their potential for causing harm in humans is unknown. Case details. Described are three cases of local envenoming from NFFC bites inflicted respectively by the mangrove or ringed cat-eyed snake (Boiga dendrophila, Colubridae), the Western beaked snake (Rhamphiophis oxyrhynchus, Lamprophiidae) and the rain forest cat-eyed snake (Leptodeira frenata, Dipsadidae). The effects ranged from mild pain, edema and erythema to severe pain, progressive edema, and blistering with slowly resolving arthralgia; there were no systemic effects. Discussion. Although these three taxa occasionally inflict bites with mild to moderate local effects, there is no current evidence of systemic involvement. Two of these cases were reported to one of the authors for medical evaluation, and although verified, thus constitute reliably reported cases, but low-quality evidence. Type-1 local hypersensitivity may contribute to some cases, but most local effects observed or reported in these three cases were consistent with the effects of venom/oral product components.

The role of an emergency department short-stay ward in the management of dengue fever: A case-control study in a university hospital

Objective Dengue fever is endemic in Malaysia and poses a significant problem to the national health system. Because of its nonspecific clinical features, it creates clinical and administrative uncertainties. We evaluated the role of an emergency department short-stay ward (EDSSW) in the management of dengue fever in the Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Methods A retrospective study was carried out on suspected dengue patients who were admitted to UKMMC EDSSW, between January and March 2010. Data were retrieved from the EDSSW Monthly Census Book and patients’ medical records. Patients were categorized as follows: group 1, which included patients who received treatment in the EDSSW only, and group 2, which included patients who received initial treatment in EDSSW and were subsequently admitted to the inpatient (IP) wards. Results A total of 147 patients’ records were available. The total length of stay was 32.2 h in group 1 and 100.5 h in group 2. For group 2 patients, a median of 21.8 h was spent in EDSSW and 78.8 h was spent in IP. All patients in group 1 and group 2 were discharged well. The total EDSSW stay was 4309 patient-hours; IP stay totalled 5137 patient-hours. The use of the EDSSW reduced the IP burden in managing dengue by 45.6%. Conclusion EDSSW limit the number and burden of dengue patients requiring formal IP admissions while acting as a ‘safety net’ for inappropriate discharges and unnecessary admissions.

The use of warning lights and siren by the ambulance crew in the Universiti Kebangsaan Malaysia Medical Centre.

Warning lights and siren (L&S) use is a privilege and their major function is to alert other road users to the approaching ambulance. There have been concerns that L&S were being utilized regardless of the severity of a patient’s condition. Its indiscriminate use has contributed to ambulance crashes [1–4]. Ambulance crashes have become a major public concern in Malaysia, with 288 accidents involving ambulances from 2006 to 2010 [5]. Depending on the organization involved, providers of differing qualifications, training and experiences run various ambulance services in the country. In Universiti Kebangsaan Malaysia Medical Centre (UKMMC), the paramedic is responsible for assessing the patients’ condition. However, it is not certain whether the decision to initiate L&S is appropriate. The purpose of this study is to assess the utilization of warning L&S and the factors that may influence their use.

Cross reactivity and lethality neutralization of venoms of Indonesian Trimeresurus complex species by Thai Green Pit Viper Antivenom

ABSTRACT Arboreal pit vipers of the Trimeresurus complex group are medically important species in Indonesia (west of Wallaces line), but there is no specific antivenom produced in the country for treating related envenomation. Instead, the exiting trivalent Indonesian antivenom, Biosave® Serum Anti Bisa Ular (SABU, indicated for envenoming by Malayan pit viper, Javan spitting cobra and banded krait) is often misused to treat Trimeresus envenoming resulting in poor therapeutic outcome. Here, we investigated the cross‐reactivity and neutralization capability of Thai Green Pit Viper Antivenom (GPVAV) against the venoms of four Indonesian Trimeresurus species. Consistently, the venoms of Trimeresurus (Trimeresurus) insularis, Trimeresurus (Trimeresurus) purpureomaculatus, Trimeresurus (Parias) hageni and Trimeresurus (Craspedocephalus) puniceus of Indonesia showed stronger immunoreactivity on ELISA to GPVAV than to Biosave®. The findings correlated with in vivo neutralization results, whereby GPVAV was far more effective than Biosave® in cross‐neutralizing the lethality of the venoms by a potency of at least 13 to 80 times higher. The efficacy of GPVAV is partly attributable to its cross‐neutralization of the procoagulant effect of the venoms, thereby mitigating the progression of venom‐induced consumptive coagulopathy. The paraspecific effectiveness of GPVAV against Trimeresurus species envenoming in Indonesia await further clinical investigation. Graphical abstract Figure. No Caption available. HighlightsPit viper envenoming by Trimeresurus sp. is serious in Indonesia.Thai Green Pit viper Antivenom (GPVAV) was tested for cross‐neutralization.GPVAV showed strong immunoreactivity toward Indonesian Trimeresurus venoms.Lethality and procoagulant effects were effectively cross‐neutralized.

A bite by the Twin-Barred Tree Snake, Chrysopelea pelias (Linnaeus, 1758).

Introduction. The Twin-Barred Tree Snake, Chrysopelea pelias, is a colubrine that, like other members of the genus Chrysopelea, is able to glide in the arboreal strata. Little is known about the effects of its bite. This report is the first clinically documented bite by this relatively uncommon rear-fanged species. Case report. The patient was a 19-year-old female who arrived at the Emergency Department (ED) of an urban teaching hospital 6 h after being bitten by a snake that was later provisionally identified as a C. pelias. Noted on presentation were bite marks on the right middle toe with minimal inflammation and tenderness. There was slight numbness over the dorsum of the right foot and discomforting sensation radiating up the thigh that persisted for several days. There was mild pyrexia, but no evidence of any systemic effects. The full blood count did show neutrophil leucocytosis, and transient hemoglobinuria was noted in an initial urine analysis. Discussion . The properties of Duvernoys secretion of C. pelias remain uncharacterized. In this case, the clinical course featured only the local effects noted above. However, the significant local pain reported by the patient suggests that bites by C. pelias are not necessarily trivial and do require full evaluation and observation in a medical facility. Discussed also is the importance of the establishment of a national registry for animal bites and stings in Malaysia. Conclusion. Such a facility could expedite safe and appropriate management of envenomed patients.

The Poisoned Patient

Acute exposure to toxic or poisonous substances can be intentional or accidental. The onset of the toxic effect depends on the degree of absorption of the toxicant. The management of acute exposure to toxicants is generally supportive. Knowledge of the pharmacokinetics and pharmacodynamics of the offending agent is important. The use of pharmacological agents in treating poisoning is to manipulate the pharmacokinetic or pharmacodynamic profiles of the toxicant. These pharmacological agents will minimize the absorption and/or enhance the elimination of the toxicant from the body. Specific antidotes are used to alter the effects of certain known toxicants through neutralization and pharmacological antagonism. Having the ability to identify the effect of specific classes of substances on the body (toxidromes) will facilitate the selection of an appropriate management strategy to optimize the outcome.

Locked-in Syndrome Following a King Cobra (Ophiophagus hannah) Envenomation

The incidence of envenoming from king cobra, Ophiophagus hannah in human is relatively rare. Its venom acts on the postsynaptic region of the neuromuscular junction causing descending flaccid paralysis. Locked-in syndrome is a clinical state of inability to provide motor response in a conscious patient. Many reported cases of locked-in syndrome following neurotoxic snake-bite mimics brain death. We report a case of a middle aged man who presented with progressive neurological deficit following a king cobra bite over his right arm. He had local and systemic neurotoxic envenoming. His condition deteriorated, and was intubated and ventilated in the emergency department. He received a total of 33 vials of the Ophiophagus hannah monospecific antivenom and subsequently recovered well with no neurological deficit. Retrospectively, he was able to recall the events and while he was lying paralysed and intubated under minimal sedation in the intensive care unit. He described it as a terrifying and painful experience. This case highlights the rare presentation of locked-in syndrome following a systemic envenoming from a king cobra bite. It is important to differentiate neurotoxic snake envenoming lock-in syndrome from brain dead. Patients are unable to respond to physical pain and require adequate analgesia. A patient suffering this highly distressing experience may require psychological support.