Clinical Toxicology ISSN: 1556-3650 (Print) 1556-9519 (Online) Journal homepage: http://www.tandfonline.com/loi/ictx20 Epidemiology and clinical outcomes of snakebite in the elderly: a ToxIC database study Meghan B. Spyres, Anne-Michelle Ruha, Kurt Kleinschmidt, Rais Vohra, Eric Smith & Angela Padilla-Jones To cite this article: Meghan B. Spyres, Anne-Michelle Ruha, Kurt Kleinschmidt, Rais Vohra, Eric Smith & Angela Padilla-Jones (2018) Epidemiology and clinical outcomes of snakebite in the elderly: a ToxIC database study, Clinical Toxicology, 56:2, 108-112, DOI: 10.1080/15563650.2017.1342829 To link to this article: https://doi.org/10.1080/15563650.2017.1342829 Published online: 13 Jul 2017. Submit your article to this journal Article views: 120 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ictx20 CLINICAL TOXICOLOGY, 2018 VOL. 56, NO. 2, 108–112 https://doi.org/10.1080/15563650.2017.1342829 CLINICAL RESEARCH Epidemiology and clinical outcomes of snakebite in the elderly: a ToxIC Ã database study Meghan B. Spyresa, Anne-Michelle Ruhab, Kurt Kleinschmidtc, Rais Vohrad, Eric Smithc and Angela Padilla-Jonesb aDepartment of Emergency Medicine, Division of Medical Toxicology, University of Southern California, Los Angeles, CA, USA; bDepartment of Medical Toxicology, Banner-University Medical Center Phoenix, Phoenix, AZ, USA; cDepartment of Emergency Medicine, Univesity of Texas Southwestern Medical Center, Dallas, TX, USA; dDepartment of Emergency Medicine, UCSF Fresno Medical Center, Fresno, CA, USA ABSTRACT ARTICLE HISTORY Introduction: Epidemiologic studies of snakebites in the United States report typical victims to be Received 23 February 2017 young men. Little is known regarding other demographics including children and the elderly. The Revised 29 April 2017 objective of this study was to describe the epidemiology and clinical manifestations of snake bite in Accepted 9 June 2017 elderly patients reported to the ToxIC (Toxicology Investigators Consortium) North American Snakebite Published online 14 July Registry (NASBR) 2017 Methods: This was a multicenter analysis of a prospectively collected cohort of patients with snakebite KEYWORDS reported to the ToxIC NASBR between 1 January 2013 and 31 December 2015. Inclusion criterion was Snakebite; elderly; age >65. Variables collected included patient demographics, medical comorbidities, medications, date rattlesnake; ToxIC; risk the case was reported to the registry, location of exposure, bite location, snake species, clinical mani- factor festations, outcomes, and management. Results: Of the 450 cases reported, 30 (6.7%) occurred in elderly patients, with an average age of 74 years. Rattlesnake envenomations were common (93.3%). The majority of patients were men (66.7%) and reported at least one medical comorbidity (83.3%). Most patients were on cardiac medica- tions (60%) and use of antiplatelet or anticoagulant medications was common (33%). Hemotoxicity occurred in 30% of patients on initial presentation and 11.5% of patients on initial follow-up. No clinic- ally significant early or late bleeding was observed. Conclusions: Elderly patients with North American snake envenomation are likely to have co-morbid- ities and to take medications that may increase their risk for hemotoxicity, however risk of bleeding or other complications was not increased in this group. Introduction population compared to that of a younger cohort. Specifically, the elderly commonly suffer from cardiovascular Approximately 10,000 snake bites are treated in US disease and are frequently prescribed antiplatelet or anti- Emergency Departments (EDs) each year resulting in signifi- coagulant medications [4]. As such, this population may be cant morbidity and rare mortality [1]. Although epidemiologic at increased risk of cardiovascular or hematologic complica- studies have shown typical snake bite victims to be young tions after a crotalid envenomation. To date, there is no lit- men [1–3], little is known regarding outcomes of demo- erature focusing on the geriatric population after snake graphic groups at potential higher risk, such as the elderly or envenomation. This study aims to describe the epidemiology, pediatric populations. clinical manifestations, and complications of US snake bites Most snakebites in the US are due to native snakes, pre- in the elderly using data reported to the Toxicology dominantly the crotalids of the Viperidae family (rattlesnakes, Investigators Consortium (ToxIC) North American Snakebite cottonmouth, and copperheads). Coral snakes of the Elapidae Registry (NASBR). family are responsible for a much smaller subset of native envenomations in the United States. The rare elapid Methods envenomation classically results in neurologic toxicity. Crotalid envenomations, conversely, are characterized by This was a multicenter cohort study of prospectively col- hematologic toxicity including thrombocytopenia and hypofi- lected data from the ToxIC NASBR. Data reported to the brinogenemia, as well as direct tissue toxicity. Anaphylaxis ToxIC NASBR between 1 January 2013 and 31 December and shock can also occur. 2015 were reviewed. The number and severity of medical comorbidities, as well The ToxIC Registry was established in 2010 by the as use of prescription medications is higher in the elderly American College of Medical Toxicology (ACMT) as a novel, CONTACT Meghan B. Spyres [email protected] Department of Emergency Medicine, Division of Medical Toxicology, University of Southern California, 1200 N State St. Rm 1011, Los Angeles, CA 90033, USA Ã This research was presented in abstract form at ACMT 2015. ß 2017 Informa UK Limited, trading as Taylor & Francis Group CLINICAL TOXICOLOGY 109 prospective toxico-survelliance and research tool. It records Types of snakes all cases cared for at the bedside by medical toxicologists at There were 28 native rattlesnake snake bites reported and each of more than 50 sites across the United States that actively contribute cases to the registry. The Registry allows two envenomations in which the type of snake was not for pooling of detailed, de-identified clinical information from reported. Rattlesnakes were not consistently identified by across all Registry centers. species. Two Western Diamondbacks, one Timber, one The Registry is Health Insurance Portability and Southern Pacific, one Great Basin, and one Arizona Black Accountability Act (HIPAA) compliant and no patient identi- rattlesnake were reported, the remainder were not identified. fiers are available on the database. Participation in the There were no non-native envenomations. One envenom- Registry is done in accordance with local institutional and ation occurred after exposure to a captive rattlesnake. Western Internal Review Board (IRB) policies and procedures. ’ ACMT s ToxIC NASBR Sub-Registry is a database that gath- Demographics and medical history ers de-identified, detailed, prospective information regarding snake bite, clinical manifestations of envenomation, and Twenty patients (66.7%) were men and 10 (33.3%) were response to treatment for patients who receive bedside care women. The median age was 73 years (IQR: 70–78). One (3.3%) from medical toxicologists across the United States. Criteria patient was over age 89. One occupational bite occurred in a of age was a mandatory field in the Registry database. The venomous animal educator. Acute alcohol intoxication was Sub-Registry was established in 2013. reported in two cases. The majority of patients were on cardiac Inclusion criterion was age >65 years. Data collected medications. Use of antiplatelet or anticoagulant medications included patient demographics, medical comorbidities, was common (33.3%), with eight (26.7%) reporting antiplatelet medications, date the case was reported to the registry, and two (6.7%) reporting anticoagulant medication use. See location of exposure, bite location, snake species, clinical Table 2 for prescription medication details. manifestations, outcomes, and management. Method of Medical comorbidities were present in 25 (83.3%) cases. identification of snake was not specified. Hemotoxicity was Eighteen (60%) had two or more conditions, nine (30%) had defined as thrombocytopenia (platelet (PLT) <120 K/mm3) three or more conditions, and six (20%) had four or more or coagulopathy (fibrinogen (Fib) <170 mg/dL). Severe conditions. Cardiovascular comorbidities, defined as hyper- hemotoxicity was defined as severe thrombocytopenia tension, hyperlipidemia, coronary artery disease, atrial fibrilla- 3 (PLT <50 K/mm ) or severe coagulopathy (Fib <80 mg/dL). tion, valvular disease, and history of CABG, were present in Prothrombin time (PT) was analyzed separately to avoid 21 patients (70%). The most common comorbidity was hyper- confounding with use of anticoagulant medications. Data tension (60%), followed by hyperlipidemia (27%), coronary for late bleeding events (defined as bleeding after the ini- artery disease (17%), cancer (17%), atrial fibrillation (13%), tial hospitalization) were obtained from direct patient con- and benign prostatic hypertrophy (10%) (see Table 3). tact or telephone interview. Descriptive statistics were used. Envenomation details Results Seventeen (56.7%) upper extremity envenomations occurred, and the finger was the single most common site of envenom- Cases ation. Thirteen (43.3%) lower extremity envenomations Between 1 January 2013 and 31 December 2015, 450