Suicide attempt by the intravenous injection of rattlesnake venom.Abstract: A 14-year-old male milked the venom from a rattlesnake and injected it with a syringe into his right antecubital vein in a suicide attempt. He immediately developed severe pain and vomiting, then hypotension, swollen lips and tongue, and coma. The injection site did not have the considerable tissue damage seen with severe rattlesnake envenomation envenomation /en·ven·om·a·tion/ (en-ven?o-ma´shun) poisoning by venom.
The injection of a poisonous material by sting, spine, bite, or other similar means. . Critical hematological hematological, hematologic
pertaining to or emanating from blood cells.
total and differential white cell counts, hematocrit estimation, erythrocyte count. abnormalities, gastrointestinal bleeding, and hematuria hematuria
Blood in the urine. It usually indicates injury or disease of the kidney or another structure of the urinary system or possibly, in males, the reproductive system. It may result from infection, inflammation, tumours, kidney stones, or other disorders. developed over 24 hours. He received crotalidae polyvalent polyvalent /poly·va·lent/ (-va´lent) multivalent.
1. Acting against or interacting with more than one kind of antigen, antibody, toxin, or microorganism.
2. immune fab (ovine ovine
pertaining to, characteristic of, or derived from sheep.
ovine atopic dermatitis
symmetrical erythema, alopecia, lichenification, excoriation on woolless areas; sporadic cases, recur each summer. ) antivenom antivenom Antivenin Toxicology A vehicle that contains an antibody or other substance that binds specifically to a toxin, deactivating it and was discharged after 5 days without sequela sequela /se·que·la/ (se-kwel´ah) pl. seque´lae [L.] a morbid condition following or occurring as a consequence of another condition or event.
n. pl. . This patient's clinical findings were similar to those seen in patients bitten by rattlesnakes with rare intravenous envenomation.
Key Words: snake, injection, IV, venom, suicide
A 14-year-old male was seen vomiting on the side of the road and emergency medical services (EMS) were dispatched. On EMS arrival, the patient stated he had "injected snake into myself" in an apparent suicide attempt. He had killed one of his stepfather's rattlesnakes and removed its head. Based on his description and location, it was probably a western diamondback rattlesnake, Crotalus atrox. He then milked the venom, drew up an unknown amount into a syringe, and injected it into his right antecubital vein. The patient states he had immediate severe pain and began vomiting. Past medical history included attention deficit hyperactivity disorder attention deficit hyperactivity disorder (ADHD), formerly called hyperkinesis or minimal brain dysfunction, a chronic, neurologically based syndrome characterized by any or all of three types of behavior: hyperactivity, distractibility, and impulsivity. , oppositional-defiant disorder, and illicit drug use. His parents suspected IV drug use but the patient denied it. He had two recent suicide attempts with a benzodiazepine benzodiazepine (bĕn'zōdīăz`əpēn'), any of a class of drugs prescribed for their tranquilizing, antianxiety, sedative, and muscle-relaxing effects. Benzodiazepines are also prescribed for epilepsy and alcohol withdrawal. overdose and laceration laceration /lac·er·a·tion/ (las?er-a´shun)
1. the act of tearing.
2. a torn, ragged, mangled wound.
1. A jagged wound or cut.
2. of his right wrist. He was currently taking no medications.
The patient was transported to a local hospital emergency department. At arrival, he was confused and agitated, had severe swelling of the lips and tongue, and had marked cyanosis cyanosis (sī'ənō`sĭs), bluish coloration of the skin, mucous membranes, and nailbeds, resulting from a lack of oxygenated hemoglobin in the blood. of his hands and feet. His initial blood pressure could not be determined but he did have palpable femoral pulses. He received endotracheal intubation and a normal saline IV bolus. Dopamine 2.5 [micro]g/kg/min was initiated and was increased to 5 [micro]g/kg/min after 10 minutes. Following this, blood pressure was 138/85 mmHg and pulse was 118 beats/min. Physical examination showed an adolescent male who weighed about 70 kg. His skin was cool and diaphoretic diaphoretic /di·a·pho·ret·ic/ (-fo-ret´ik)
1. pertaining to, characterized by, or promoting sweating.
2. an agent that promotes sweating.
adj. . He had normal breath sounds and no abnormal heart sounds. His abdomen was soft and nontender. His right arm bad no swelling or blisters but he did have an area of ecchymosis ECCHYMOSIS, med. jur. Blackness. It is an extravasation of blood by rupture of capillary vessels, and hence it follows contusion; but it may exist, as in cases of scurvy, and other morbid conditions, without the latter. Ryan's Med. Jur. 172. with several pinpoint petechiae Petechiae
Tiny purple or red spots on the skin associated with endocarditis, resulting from hemorrhages under the skin's surface.
Mentioned in: Endocarditis, Hantavirus Infections, Hemorrhagic Fevers, Idiopathic Thrombocytopenic Purpura
surrounding the puncture site. Initial laboratory results showed an elevation in white blood cell count white blood cell count,
n a diagnostic clinical laboratory test to determine the number and types of leukocytes present in a measured sample of blood. Overall the normal number of leukocytes ranges from 5000 to 10,000/mm3. (19,300/mm) and hemoconcentration (hemoglobin was 21.7 g/dL and hematocrit was 62.8). Platelets were low (52,000/mm). PT was 98.3 seconds and INR was 8.9. Arterial blood gases showed a pH of 7.38, PC[O.sub.2] 25 mm Hg, P[O.sub.2] of 566 mm Hg, and a bicarbonate of 14.3 mmol/L. Urinalysis revealed pinktinged urine with a specific gravity of 1.015 and 10 to 20 red blood cells Red blood cells
Cells that carry hemoglobin (the molecule that transports oxygen) and help remove wastes from tissues throughout the body.
Mentioned in: Bone Marrow Transplantation
red blood cells per high powered field. Four vials of crotalidae polyvalent immune fab (ovine) antivenom were administered over one hour.
Three hours after the venom injection, he had received 7 L of fluid and he had a blood pressure of 111/51mm Hg and a pulse of 78 beats/min. Physical examination was remarkable for epistaxis, minimally reactive pupils, coffee-ground emesis, and he was incontinent with melena melena /me·le·na/ (me-le´nah) the passage of dark stools stained with altered blood.
n. . Chest x-ray and computed tomography of the head were normal. Creatine kinase was normal and cardiac enzymes were negative. Fibrinogen level was decreased at 118 mg/dL, fibrin split products Fibrin Split Products Definition
Fibrin split products (FSP) are fragments of protein released from a dissolving clot. The fibrin split products test is one of several tests done to evaluate a person with blood clotting problems (coagulation), were elevated at greater than 40 [micro]g/mL, and D-dimer was normal.
Due to the active gastrointestinal bleeding, 2 U of fresh frozen plasma fresh frozen plasma
n. Abbr. FFP
Blood plasma frozen within 6 hours of collection.
fresh frozen plasma and 6 U of platelets were administered. During the first 24 hours, the patient received a total of 18 vials of crotalidae polyvalent immune fab (ovine). He was kept sedated and paralyzed using lorazepam lorazepam /lor·a·ze·pam/ (lor-az´e-pam) a benzodiazepine used as an antianxiety agent, sedative-hypnotic, preanesthetic medication, and anticonvulsant.
n. , morphine, and vecuronium. His coagulation panel, platelets, and fibrinogen level all returned within normal range by his 48th hour of admission. The local minimal reaction in the right antecubital fossa showed no signs of necrosis and resolved after several days. Sedation was slowly weaned off and the patient extubated himself on the third day. After psychiatric consultation, he was transferred five days after admission to a psychiatric facility. No additional complications were noted.
Patients with suicidal ideation have intentionally injected many unusual substances intravenously (IV) including insecticide, (1) bleach, (2) mercury, (3) lamp oil, (4) cyanide and arsenic. (5) The self-injection of snake venom with a syringe by suicidal patients is uncommon but not unique. Two separate case reports described adult men who died after injecting venom from African snakes into SC tissue. (6-7) The only previously published report of IV self-injection of rattlesnake venom presented an adult man who injected venom milked from an eastern diamondback rattlesnake (Crotalus adamanteus). (8) He rapidly lost consciousness and then developed hematemesis hematemesis /he·ma·tem·e·sis/ (he?mah-tem´e-sis) the vomiting of blood.
The vomiting of blood. , gross hematuria, melena, and bleeding from the injection site. He also had severe hematological abnormalities which resolved after 15 vials of antivenin antivenin /an·ti·ven·in/ (-ven´in) a material used in treatment of poisoning by animal venom.
black widow spider antivenin a. . (crotalidae) polyvalent (equine origin), and he survived.
Rattlesnakes inject venom through hollow fangs usually into the skin and SC tissue of their victims. (9) This causes the severe local reaction of swelling, pain, ecchymosis, and blisters near the bite site. Rarely, a fang penetrates a superficial vein causing both SC and IV envenomation. (10) Reports of at least 5 patients with suspected IV envenomation by rattlesnakes have been published. (10-12) All these patients developed severe systemic symptoms with only minor or moderate local reactions to the bites. Although all were treated with antivenin (crotalidae) polyvalent (equine origin), two died. (11-12) The others were discharged within a few days. Reports of IV envenomation usually note immediate (within a few minutes) findings of vomiting, swelling of lips and face, coma, and hypotension. Over the next few hours, these patients develop bleeding from several sites, increased PTT, decreased platelet count, generalized fasciculations, and fecal incontinence.
Our patient had minimal local findings around the injection site, but had severe systemic effects. This suggests that the patient did indeed inject the venom IV rather than SC or IM. In addition, our patient had immediate vomiting, swelling of the lips, decreased sensorium sensorium /sen·so·ri·um/ (sen-sor´e-um)
1. a sensory nerve center.
2. the state of an individual as regards consciousness or mental awareness.
n. pl. , and hypotension. He developed gastrointestinal bleeding, gross hematuria, fecal incontinence, and severe hematological abnormalities. However, our patient was unique in that he was an adolescent, the venom was probably from a western diamondback rattlesnake, and he was treated with crotalidae polyvalent immune fab (ovine) antivenom. This antivenom has only been commercially available in the USA since 2000.
Pit viper (including rattlesnake) bites with IV injection of venom probably occur more often than is reported. The physician should be aware that an IV envenomation of rattlesnake venom may not have the severe local reactions seen with the typical SC and IM envenomations. (9) Unfortunately, antivenom treatment is frequently determined by the amount of local reaction only. However, patients who develop the life-threatening symptoms of lip and tongue swelling, hypotension, and coma within a few minutes require antivenom regardless of the local reaction. (9) In addition, the hypotension usually responds to large amounts of IV saline solution. These patients usually undergo endotracheal intubation due to the initial facial and tongue swelling and coma. This swelling is also typically treated with steroids and antihistamines, but the effectiveness of this treatment in these patients is unknown.
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4. Houben MH, Drent M, Jacobs JA, et al. Multiple organ dysfunction syndrome Multiple organ dysfunction syndrome MODS, previously known as multiple organ failure (MOF), is altered organ function in an acutely ill patient requiring medical intervention to perform homeostasis. (MODS) after an intravenous injection of lamp oil (liquid paraffin). Intensive Care Med 1998;24:87-88.
5. DiNapoli J, Hall AH. Drake R, et al. Cyanide and arsenic poisoning by intravenous injection. Ann Emerg Med 1989;18:308-311.
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7. Yadlowski JM, Tu AT, Garriott JC, et al. Suicide by snake venom injection. J Forensic Sciences 1980;25:760-764.
8. Weston MW. Lovelorn and snakebit snake·bit also snake·bit·ten
Experiencing a period of misfortune or inability to succeed. . Hospital Practice 1986;21:140-143.
9. Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med 2002;347:347-356.
10. Davidson TM. Intravenous rattlesnake envenomation. West J Med 1988;148:45-47.
11. Banner W, Russell F, Barton B, et al. Fatal rattlesnake bite in a child (abstract). Vet Hum Toxicol 1984;26:400.
12. Curry SC, Kraner JC, Kunkel DB, et al. Noninvasive vascular studies in management of rattlesnake envenomations to extremities. Ann Emerg Med 1985;14:1081-1084.</p> <pre> Happiness is spiritual, born of truth and love. It is unselfish; therefore it cannot exist alone, but requires all mankind to share it. --Mary Baker Eddy </pre> <p>David L. Morgan, MD, Hollie W. Blair, RPH, and Ryan P. Ramsey, MD
From the Central Texas Poison Center, and the Department of Emergency Medicine, Texas A & M University Health Sciences Center, Temple, TX.
Reprint requests to: David L. Morgan, MD, Department of Emergency Medicine, Scott and White Memorial Hospital, 2401 South 31st Street, Temple, TX 76508. Email: DLMorgan@swmail.sw.org
Accepted December 2, 2005.
RELATED ARTICLE: Key Points
* Suicidal patients may inject unusual substances intravenously.
* Clinical findings of self-inflicted rattlesnake venom injected intravenously appear similar to those of the rare intravenous (IV) envenomation from a rattlesnake bite.
* IV envenomation of rattlesnake venom causes immediate vomiting, coma, hypotension, and swelling of the face, followed by severe hematological abnormalities and bleeding.
* Antivenom administration should focus on the systemic findings, not on the local reaction.