Summary of the randomised comparative trials of treatment for VICC, including antivenom and heparin with details of study size, design, and outcomes.

<p>* Varied based on the clinical assessment of the severity on admission;</p>†<p>May differ from the author's conclusion, see text. Abbreviations: AV – antivenom; WBCT20 – 20-minute whole blood clotting test (or 12-, 15-, or 30-minute); WBC time – whole blood clotting time; IVIG – intravenous immunoglobulin; PT – prothrombin time;</p><p>Summary of the randomised comparative trials of treatment for VICC, including antivenom and heparin with details of study size, design, and outcomes.</p

Summary of snakes known to cause venom-induced consumption coagulopathy, the procoagulant toxin, and the factor deficiencies that have been reported (with permission from WikiToxin).

<p>aPTT – activated partial thromboplastin time, CT – clotting time, VCT – venous clotting time, FDP – fibrinogen degradation products, PLA₂ – phospholipase A₂, PT – prothrombin time, TLE – thrombin like enzymes, WBCT – whole blood clotting time, WBCT20 – 20 minutes whole blood clotting time, FII – factor II, FV – factor V, FX – factor X, FDP – fibrinogen degradation products; PTA – prothrombin activator; SVMP – snake venom metalloproteinase; NR – not reported;</p><p>* A SVMP has been isolated from <i>D. typus</i> venom but its function (? PTA, FX activator, TLE) is unclear and only fibrinogen has been measured in patients.</p><p>Summary of snakes known to cause venom-induced consumption coagulopathy, the procoagulant toxin, and the factor deficiencies that have been reported (with permission from WikiToxin).</p

Summary of the non-randomised studies if VICC comparing two groups.

†<p>May differ to the author's conclusion, see text. Abbreviations: AV – antivenom; WBCT20 – 20 minute whole blood clotting test (or 12, 15 or 30 minute); PT – prothrombin time; aPTT – activated partial thromboplastin time; INR – international normalised ratio; IM – intramuscular; IV - intravenous.</p><p>Summary of the non-randomised studies if VICC comparing two groups.</p

Consort diagram showing all patient recruitments, exclusions and outcomes in each of the arms of the study. *

<p>Exclusion criteria were age <14 years, pregnancy, clinician excluded, premedication given, prior administration of antivenom, were missed or did not consent to the study.</p

The time of onset of the reaction after antivenom comparing the rapid and slow infusion groups.

<p>(The whiskers are the minimum and maximum, the box the interquartile range, and the median line across the box).</p

Comparison of patients with and without antivenom reactions, subdividing into severe and mild/moderate reactions. Proportions are reported with 95% confidence intervals.

1<p>Venom concentration for Russell’s viper patients only.</p

Demographic features, snake type and clinical effects for patients randomised to the rapid infusion arm and the slow infusion arm.

<p>Demographic features, snake type and clinical effects for patients randomised to the rapid infusion arm and the slow infusion arm.</p

Secondary outcomes for patients randomised to the rapid infusion arm and the slow infusion arm.

<p>Secondary outcomes for patients randomised to the rapid infusion arm and the slow infusion arm.</p

2-Methyl-4-chlorophenoxyacetic acid (MCPA) and bromoxynil herbicide ingestion

<p><b>Context:</b> Ingestion of bromoxynil and 2-methyl-4-chlorophenoxyacetic acid (MCPA) in combination is associated with high mortality. Toxicity is characterised by hyperthermia and metabolic acidosis. Dialysis is a proposed treatment, but little data exist regarding its effectiveness.</p> <p><b>Case details:</b> Case 1: A 50-year-old female presented 18 h post-ingestion of 200  mL of bromoxynil(200 g/L) and MCPA(200 g/L). She was agitated, tachycardic and tachypnoeic. She was intubated and continuous venovenous haemodiafiltration (CVVHDF) was commenced. She deteriorated, becoming hypotensive, hyperthermic (39.5 °C) and hypercapnic (80 mmHg). She was cooled, paralysed, received CVVHDF for 2d and was extubated on day 4 making a full recovery. Case 2: A 60-year-old male presented 6 h post-ingestion of an unknown amount of bromoxynil (200 g/L) and MCPA (200 g/L). On arrival, he was tachycardic and tachypneic (pCO₂ 25 mmHg). At 8h post-ingestion he became hyperthermic, hypercapnic and acidotic (pH 7.15), and was intubated, paralysed, cooled and received CVVHDF for 36 h. He was extubated after 42 h and made a full recovery. Bromoxynil and MCPA serum and effluent concentrations were measured. Peak MCPA serum concentrations were 161 µg/ml and 259 µg/ml and peak bromoxynil concentrations were 119 µg/ml and 155 µg/ml in case 1 and 2, respectively. The estimated clearance of both herbicides by CVVHDF was low (<10 mL/min).</p> <p><b>Conclusion:</b> CVVHDF did not result in significant clearance of either herbicide but may have assisted with hyperthermia control. Both patients survived with vigorous cooling, paralysis and ventilatory support.</p

Summary plots of the mean times to respiratory arrest and mean venom-induced decline of respiration frequency for a range of Ptx venom doses.

<p>Both measures exhibited an approximately linear relationship with venom dose for the range shown (n = 6, 6, 11 & 3 for 0.4, 0.6, 1.0 & 1.5 mg/kg respectively).</p