1. Antivenoms Dr. CC Lau Consultant & Chief of Service A&E Department PYNEH

5. Agkistrodon halys antivenom 6000u/vial (HK$1000) Dosage: 6000u 1.Agkistrodon halys 蝮蛇 Trimersures Monticola Gunther or Mountain pit Viper 山區蝮蛇, 山烙鐵 2. Trimeresurus mucrosquamatus or Chinese Habu, Tortoise Snake, Laotie Tou 烙鐵頭 3. Trimeresurus albolabris: white-lipped green pit viper 青 竹蛇, 白唇竹葉青 (Trimeresurus stejnegeri, Chinese Bamboo Viper) * Green pit viper antivenin (Thailand Red Cross Society)for 0.7mg venom, 3 vials (HK$1000)

7. Agkistrodon acutus antivenom 2000u/vial (HK$1000) Dosage 8000u Agkistrodon acutus, Hundred Pacer 五步蛇

9. Naja Naja antivenom 1000u/vial (HK$1000) Dosage: 2000u Naja Naja 飯鏟頭 眼鏡蛇 * Cobra Antivenin (Thailand Red Cross Society) for 0.8mg venom, 2 vials (HK$1000)

11. Bungarus Multicinctus antivenom 10000u/vial (HK$450) Dosage: 10000u 1.Bungarus Multicinctus 銀腳帶 2.Ophiophages Hannah (Cantor) or King Cobra 過山烏 * King Cobra Antivenin (Thailand Red Cross Society) for 0.8mg venom, 5 vials (HK$900)

13. Tiger Snake antivenom Common tiger snake Notechis scutatus Black tiger snake Notechis ater Rough scaled snake Tropidechis carinatus Common copperhead Austrelaps superbus Highland copperhead Austrelaps ramsayi Pygmy copperhead Austrelaps labialis Broad-headed snake Hoplocephalus bungaroides Pale-headed snake Hoplocephalus bitorquatus Stephen's banded snake Hoplocephalus stephensi Red bellied black snake Pseudechis porphyriacus Spotted black snake Pseudechis guttatus

14. Suction Pressure immobilization Fab antivenom

15. Suction Michael B. Alberts et al. Suction for venomous snakebite: A study of “mock venom” extraction in a human model. Ann Emerg Med. 2004;43:181-186 Conclusion: The Sawyer Extractor pump removed bloody fluid from our stimulated snakebite wounds but removed virtually no mock venom, which suggests that suction is unlikely to be an effective treatment for reducing the total body venom burden after a venomous snakebite.

16. Pressure Immobilization Sean P. Bush, et al. Pressure immobilization delays mortality and increases intracompartmental pressure after artificial intramuscular rattlesnake envenomation in a porcine model. Ann Emerg Med. 2004;44:599- 604 Conclusion: Compared with control animals without treatment, the pressure immobilization group had longer survival, less swelling, and higher intracompartmental pressures after artificial, intramuscular C atrox envenomation in our porcine model.

17. Pressure Immobilization In the 20 pigs studied, application of the pressure immobilization bandage prolonged survival slightly, but increased compartmental pressure greatly. Pressure immobilization should be discouraged for bites that involve venoms that produce substantial local injury, such as the rattlesnake, copperhead, and cottonmouth snakes of the United States.

18. Fab Antivenom Crotalidae Polyvaent Immune Lab (Ovine) (FabAV) From Sheep 5.2 times as potent as Antivenom (Crotalidae) Polyvalent (ACP) Less acute reaction (14% c.f. 23-56%) Less serum sickness (16% c.f. 18-86%) Recurrence of venom effects after therapy >> dosing schedule of loading dose and maintenance doses (smaller molecular weight, larger volume of distribution, efficient binding of venom, enhanced renal clearance, recurrence of symptoms as FabAV level drops)

20. Stonefish Injury Peter Fenner. Emergency Medicine. 2000;12: 295-302 World confirmed death rare and difficult to confirm (5 in poor details) Hot water treatment Parenteral opiods Local nerve block Antivenom for intractable pain or systemic symptoms (some recommend infusion of diluted antivenom for severe cases)

21. Stingray Injury Peter Fenner. Emergency Medicine. 2000;12: 295-302 Immerse wounded area in hot water (43°C) During penetration of the integument of the victim, the barb sheath ruptures, leaving tissue and venom in wound, necrosis and infection >> whole tract should be explored and even excised, if possible to remove remaining foreign material

22. Scorpion Sting Emergency Medicine Clinics of N. America. May 2004 Vol 22 No. 2 Estimated 5000 death / year Dry stings are common Venom –mixture of single chain ploypeptides containing neurotoxins blocking Na / K channels with secondary effects of pronunced Ach and catecholamine release –Hyaluronidase >> spread of toxin

23. Scorpion Sting Emergency Medicine Clinics of N. America. May 2004 Vol 22 No. 2 Sting >> pain and paraesthesia with minimal local redness or oedema Systemic envenomation – usually within 6 hours peak at 12 hours and pain / paraesthesia may last for 2 weeks Initial transient  Ach tone (SLUDGE) Subsequent  Noradrenaline effects >> can be fatal Also CNS, hyperglycaemia, pancreatitis….

24. Scorpion Sting Foex Bernard et al. Scorpion envenomation: does antivenom reduce serum venom concentrations?. Emergency Medicine Journal. 22(3):195-197, March 2005. A short cut review. A clinical bottom line is stated. - in an adult who has been stung by a scorpion, there is very little evidence that giving antivenom will improve clinical outcome.

25. Scorpion Sting Antivenom – University of Arizona (goat serum), not FDA approved May be useful for local pain & paraesthesia Not effective for systemic complications

26. Scorpion Sting Nugent, Jeffrey S. et al.Cross-reactivity between allergens in the venom of the common striped scorpion and the imported fire ant.[Miscellaneous Article]. Journal of Allergy & Clinical Immunology. 114(2):383-386, August 2004. Conclusion: Significant cross-reactivity exists between the venom of C vittatus and IFA WBE. The high sensitization rate to IFA venom in endemic areas may therefore be a risk factor for subsequent immediate reactions to an initial scorpion sting. Patients with immediate hypersensitivity reactions to scorpion stings may potentially benefit from immunotherapy with IFA WBE.