title: Clinical effects and antivenom use for snake bite victims treated at three US hospitals in Afghanistan.
abstract: OBJECTIVE
  Annually, more than 100,000 US and international military and civilian personnel work in Afghanistan within terrain harboring venomous snakes. Current literature insufficiently supports Afghan antivenom treatment and stocking guidelines. We report the clinical course and treatments for snakebite victims presenting to US military hospitals in Afghanistan.
  
  
  METHODS
  All snakebite victims presenting to 3 US military emergency departments between July 2010 and August 2011 in northern and southern Afghanistan were examined via chart review. Case information included patient demographics, snake description, bite details and complications, laboratory results, antivenom use and adverse effects, procedures performed, and hospital course.
  
  
  RESULTS
  Of 17 cases, median patient age was 20 years (interquartile range [IQR], 12-30), 16 were male, and 82% were Afghans. All bites were to an extremity, and median time to care was 2.8 hours (IQR, 2-5.8). On arrival, 8 had tachycardia and none had hypotension or hypoxia. A viper was implicated in 5 cases. Ten cases received at least 1 dose of polyvalent antivenom, most commonly for coagulopathy, without adverse effects. Six received additional antivenom, 6 had an international normalized ratio (INR) > 10, and none developed delayed coagulopathy. Three received blood transfusions. Hospital stay ranged from 1 to 4 days. None required vasopressors, fasciotomy, or other surgery, and none died. All had resolution of marked coagulopathies and improved swelling and pain on discharge.
  
  
  CONCLUSIONS
  We report the largest series of snake envenomations treated by US physicians in Afghanistan. Antivenom was tolerated well with improvement of coagulopathy and symptoms. All patients survived with minimal advanced interventions other than blood transfusion.
authors.affiliation: University of Washington, Seattle, WA; San Antonio Military Medical Center, Fort Sam Houston, TX. Electronic address: jheiner@uw.edu.
authors.forename: Jason D
authors.initials: JD
authors.lastname: Heiner
authors.forename: Vikhyat S
authors.initials: VS
authors.lastname: Bebarta
authors.forename: Shawn M
authors.initials: SM
authors.lastname: Varney
authors.forename: Jason D
authors.initials: JD
authors.lastname: Bothwell
authors.forename: Aaron J
authors.initials: AJ
authors.lastname: Cronin
mesh_terms: D000328:Adult; D000346:Afghanistan; D000368:Aged; D000997:Antivenins / Q000627:therapeutic use*; D002648:Child; D004636:Emergency Service, Hospital; D005260:Female; D006772:Hospitals, Military; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D012909:Snake Bites / Q000503:physiopathology* / Q000628:therapy*; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult
chemical_list: D000997:Antivenins
keywords: Afghanistan; snake antivenom; snake envenomation