Evidence of efficacy for Antivenom in managing snake bites in India

Date: Wed, Jun 22, 2011 at 1:13 PM
Subject: Evidence on Anti-Snake-Venom

To: EVIDENCE-BASED-HEALTH@jiscmail.ac.uk


This could be naive and i would be glad to benefit from the advise of esteemed others who could guide me to a systematic review on the 'topic':
There is still something unsettling about the use of Anti-Snake-Venom which has historically never been subjected to placebo controlled trials(neither has been penicillin but it is no longer as much used as anti-snake venom).

Is it possible that it may not have much role at all (other than harm) from whatever historical evidence available? Most of the successes of snake bite management appears to be due to supportive management like dialysis and ventilation. People have brought down the dose of ASV by 50 to 70% in controlled trials and the effect appears same. http://www.ncbi.nlm.nih.gov/pubmed/10778516, http://www.ncbi.nlm.nih.gov/pubmed/15909856, http://www.ncbi.nlm.nih.gov/pubmed/15633711, http://emj.bmj.com/content/22/6/397.abstract

The above are trials based in India. Is it possible that the low dose anti-venom can be gradually in subsequent trials brought down to zero? Would be good to learn if anyone has looked into other similar trials elsewhere. Again apologize for any 'naivete' in this ( perhaps not well though out) query.

Conversational learning: Acute subdural hematoma

Email via MedLink Neurology: Sat, Dec 14, 2013 at 7:51 PM

87 male who had a fall and CT of the brain showed a right curvilinear acute SDH about 2 mm in width. Is there is any data about the risks of expansion that would require surgical intervention. He has been on ASA 81 mg. Also he had a femur fracture that needed surgical correction. Repeat CT in 4 hours and 8 hours later showed no changes.



Email via Medlink from Neurosurgeon,  Berkeley, California: Sat, Dec 14, 2013 at 11:56 PM



I think that it could be carefully watched. If any neurological signs develop, or if the hematoma enlarges, I would consider intervention. Avoid anticoagulants.



Email to Medlink from caregiver7careseeker on Sun, Dec 15, 2013 at 2:03 PM:



We reviewed some of the literature around this (non systematically)
for a similar patient (who continues to live with a non surgically
managed subdural hematoma 2 years since he first became acutely
symptomatic with it). Online patient record after 'informed
de-identification' available here: http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=265



The link below is a non systematic review with experience based
guidelines that recommend conservative management for those without
overt focal deficits: https://ssl-w03dnn0374.websiteseguro.com/sbn-neurocirurgia/site/download/artigos/article.pdf


For more Chronic instances, UK surgeons employ conservative management
in less than one-quarter of such cases and 55% of these surgeons
prescribe steroids to those managed conservatively. http://www.ncbi.nlm.nih.gov/pubmed/18686063

Learning points from yesterday's renal biopsy

Some good radiologists and nephrologists appear to have faced problems
in the past during renal biopsy and they write,

 "Occasionally, after conventional ultrasound localization of the
kidney, the operating physician finds it difficult to determine
whether the biopsy needle has been positioned correctly, that is, with
the tip of the needle at or near the capsular surface of the kidney.

    In this circumstance, I have frequently seen attempts made to try
to visualize the relationship of the inserted needle tip to the
capsular surface for the kidney by positioning the transducer on the
patient's flank, lateral to the inserted biopsy needle,  and surveying
the ultrasound image to direct the final proper positioning of the
needle.

    It is my experience that this above described maneuver is rarely,
if ever, helpful.    The procedure seems logical and appropriate, and
I have no idea why the maneuver seems almost uniformly
non-productive." More here:
http://www.kidneybiopsy.com/technique/location.html

They suggest an innovative technique where a plastic needle guide is
attached to the transducer. See here
http://www.kidneybiopsy.com/technique/location_1.html

Here's a review on USG guided renal biopsy and further learning points
that i wish i had read up since i began doing these biopsies 14 years
back (albeit infrequently). :-)

Our needle gauge choice was wrong yesterday and that was responsible
for the small amount of tissue we obtained. We should go with 16G if
not 14 G. More here:http://www.ajronline.org/doi/pdf/10.2214/AJR.10.4427,
http://www.nature.com/ki/journal/v66/n4/full/4494783a.html,http://www.intechopen.com/download/get/type/pdfs/id/34940