Mark Little

Thrombotic microangiopathy from Australian brown snake (Pseudonaja) envenoming

Background: Australian brown snake (genus Pseudonaja) envenoming causes a venom‐induced consumptive coagulopathy (VICC). A proportion of cases go on to develop thrombotic microangiopathy characterized by thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and acute renal failure (ARF).

A risk assessment based approach to the management of acute poisoning

Early assessment and management of poisoning constitutes a core emergency medicine competency. Medical and psychiatric emergencies coexist; the acute poisoning is a dynamic medical illness that represents an acute exacerbation of a chronic underlying psychosocial disorder. The emergency physician must use an approach that ensures early decisions address potentially time critical interventions, while allowing management to be tailored to the individual patient’s needs in that particular medical setting. This article outlines a rationale approach to the management of the poisoned patient that emphasises the importance of early risk assessment. Ideally, this approach should be used in the setting of a health system designed to optimise the medical and psychosocial care of the poisoned patient.

The use of pressure immobilization bandages in the first aid management of cubozoan envenomings

This study is aimed to evaluate whether the application of pressure results in additional release of venom from naturally discharged, vinegar soaked nematocysts of the box jellyfish Chironex fleckeri. The results show that large quantities of venom are expressed with the application of pressures similar to that applied by compression immobilization bandages. The volume of venom expressed by this pressure was similar to the quantity expressed upon initial natural discharge of the nematocysts. The current recommended practice of applying PIB to cubozoan stings might worsen the envenomation. As the existing data now show that PIB may be detrimental to victims envenomed by cubozoans, we suggest that the current practice of the use of PIB in cubozoan envenomings be discarded until there is direct experimental evidence to support its use.

Intracerebral hemorrhage and death after envenoming by the jellyfish Carukia barnesi

Introduction. Irukandji syndrome is because of envenoming by a number of small jellyfish. It results in a delayed onset of generalized pain, sweating hypertension, and tachycardia. There is no antivenom. Case report. A 44-year-old healthy male was stung while swimming in NE Australia. He rapidly developed Irukandji syndrome. He had a rapid deterioration in conscious level because of an intracerebral hemorrhage. He developed left ventricular failure with an elevated troponin (34 mcg/L, N < 0.4) requiring inotropic support. He progressed to brain death and died on day 13 poststing. Nematocysts recovered from the patient skin were consistent with a large Carukia barnesi. Discussion. This is the first case of a death because of Irukandji syndrome where the jellyfish Carukia barnesi has been demonstrated to the causative creature.

First aid for jellyfish stings: do we really know what we are doing?

Jellyfish stings remains a common envenoming, and yet confusion appears to exist in the community as to the correct first aid. Current guidelines from the Australian Resuscitation Council still recommends ice for most jellyfish stiings, although there appears to belittle evidence to support this. There is more evidence supporting the use of hot water. More research is required to simplify first aid for jellyfish stings.

Randomised trial of magnesium in the treatment of Irukandji syndrome

Irukandji syndrome is a distressing condition characterised by pain, hypertension and tachycardia. Some develop cardiac failure and there have been two reported deaths. Magnesium sulphate has become the standard of care despite minimal evidence. The aim of this study was to investigate if magnesium would reduce analgesic requirement and length of stay for patients with Irukandji syndrome.

'Lessons learned': a comparative case study analysis of an emergency department response to two burns disasters

The Royal Perth Hospital (RPH; Perth, Australia) has been the receiving facility for burns patients in two separate disasters. In 2002, RPH received 28 severely injured burns patients after the Bali bombing, and in 2009 RPH received 23 significantly burnt patients as a result of an explosion on board a foreign vessel in the remote Ashmore Reef Islands (840 km west of Darwin). The aim of this paper is to identify the interventions developed following the Bali bombing in 2002 and review their effectiveness of their implementation in the subsequent burns disaster.

The evacuation of Cairns hospitals due to Severe Tropical Cyclone Yasi

On February 2, 2011, Tropical Cyclone Yasi, the largest cyclone to cross the Australian coast and a system the size of Hurricane Katrina, threatened the city of Cairns. As a result, the Cairns Base Hospital (CBH) and Cairns Private Hospital (CPH) were both evacuated, the hospitals were closed, and an alternate emergency medical center was established in a sports stadium 15 km from the Cairns central business district. This article describes the events around the evacuation of 356 patients, staff, and relatives to Brisbane (approximately 1,700 km away by road), closure of the hospitals, and the provision of a temporary emergency medical center for 28 hours during the height of the cyclone. Our experience highlights the need for adequate and exercised hospital evacuation plans; the need for clear command and control with identified decision-makers; early decision-making on when to evacuate; having good communication systems with redundancy; ensuring that patients are adequately identified and tracked and have their medications and notes; ensuring adequate staff, medications, and oxygen for holding patients; and planning in detail the alternate medical facility safety and its role, function, and equipment.

Coagulopathy from tiger snake envenoming and its treatment

[Extract] Sir, We would like to make some comments on two articles recently published on tiger snake bite and the resultant coagulopathy that occurs with envenoming. Both articles discuss important issues relating to the coagulopathy associated with Australasian elapid envenoming. They correctly make the distinction between snake venominduced activation of the coagulation cascade (VIACC) and disseminated intravascular coagulation (DIC). VIACC is often loosely referred to as defibrination, but is more accurately termed fibrinogen depletion. The article on eastern tiger snake envenoming provides important new information by reporting serial measurements of prothrombin cleavage fragments which has not been previously investigated. It demonstrates that the presence of F1 + 2 levels are possibly highly sensitive tests for envenoming.

Analytically confirmed recreational use of Phenibut (β-phenyl-γ-aminobutyric acid) bought over the internet

The internet can be used for the sale of many drugs substances including anxiolytics and sedatives not regulated by government authorities. We describe a case of analytically confirmed severe phenibut toxicity necessitating intensive care unit (ICU) admission and management. The phenibut was purchased readily over the internet.