Charles J. Gerardo

Duke University Health System

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João Ricardo Nickenig Vissoci

Duke Institute for Health Innovation

Eric J. Lavonas

Denver Health Medical Center

Scott M. Silvers

Mayo Clinic in Florida

Steven A. Godwin

Florida College

Sharon E. Mace

Cleveland Clinic

Susan B. Promes

Pennsylvania State University

Bernard Lo

Ottawa Hospital Research Institute

Richard D. Shih

Florida Atlantic University

Deborah B. Diercks

The University of Texas Southwestern Medical Center

Christian Tomaszewski

UC San Diego Health System

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Duke University

146

Duke Medical Center

Duke University Hospital

Duke Institute for Health Innovation

Fundação de Medicina Tropical

Universidade do Estado do Amazonas

Escola Superior de Ciências da Saúde

American College of Emergency Physicians

University of Colorado Denver

University of North Carolina at Chapel Hill

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Incidence of hypersensitivity reactions following copperhead snakebites treated with Fab AV or placebo

Toxicology Letters (2016)

Michael E. Mullins Charles J. Gerardo Eric J. Lavonas

10.1016/j.toxlet.2016.07.594

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The BRAVO Clinical Study Protocol: Oral Varespladib for Inhibition of Secretory Phospholipase A2 in the Treatment of Snakebite Envenoming

Toxins (2022)

Rebecca W. Carter Charles J. Gerardo Stephen P. Samuel Surendra Kumar Suneetha D. Kotehal

Snakebite is an urgent, unmet global medical need causing significant morbidity and mortality worldwide. Varespladib is a potent inhibitor of venom secretory phospholipase A

10.3390/toxins15010022

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Citations (28)

Oral Varespladib for the Treatment of Snakebite Envenoming in India and the United States (BRAVO): A Phase 2 Randomised Clinical Trial

Charles J. Gerardo Rebecca W. Carter Surendra Kumar Farshad M. Shirazi Suneetha D. Kotehal

Download This Paper Open PDF in Browser Add Paper to My Library Share: Permalink Using these links will ensure access to this page indefinitely Copy URL Copy DOI

10.2139/ssrn.4774402

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In reply:

Annals of Emergency Medicine (2017)

Charles J. Gerardo Eric J. Lavonas

Antivenom

10.1016/j.annemergmed.2017.08.003

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Antivenom Treatment Is Associated with Fewer Patients using Opioids after Copperhead Envenomation

Western Journal of Emergency Medicine (2019)

Caroline E. Freiermuth Eric J. Lavonas Victoria E. Anderson Kurt Kleinschmidt Kapil Sharma

Introduction: Copperhead envenomation causes local tissue destruction, leading people to seek treatment for the pain and swelling. First-line treatment for the pain is opioid medications. There is rising concern that an initial opioid prescription from the emergency department (ED) can lead to long-term addiction. This analysis sought to determine whether use of Fab antivenom (FabAV) for copperhead envenomation affected opioid use.Methods: We performed a secondary analysis using data from a randomized clinical trial designed to determine the effect of FabAV on limb injury recovery following mild to moderate copperhead envenomation. Opioid use was a defined secondary outcome in the parent trial. Patients were contacted after discharge, and data were obtained regarding medications used for pain and the patients’ functional status. This analysis describes the proportion of patients in each treatment group reporting opioid use at each time point. It also assesses the interaction between functional status and use of opioids.Results: We enrolled 74 patients in the parent trial (45 received FabAV, 29 placebo), of whom 72 were included in this secondary analysis. Thirty-five reported use of any opioids after hospital discharge. A smaller proportion of patients treated with FabAV reported opioid use: 40.9% vs 60.7% of those in the placebo group. The proportion of patients using opioids remained smaller in the FabAV group at each follow-up time point. Controlling for confounders and interactions between variables, the model estimated that the odds ratio of using opioids after hospital discharge among those who received placebo was 5.67 times that of those who received FabAV. Patients who reported higher baseline pain, those with moderate as opposed to mild envenomation, and females were more likely to report opioid use at follow-up. Patients with ongoing limitations to functional status had an increased probability of opioid use, with a stronger association over time. Opioid use corresponded with the trial’s predefined criteria for full recovery, with only two patients reporting opioid use in the 24 hours prior to achieving full limb recovery and no patients in either group reporting opioid use after full limb recovery.Conclusion: In this study population, the proportion of patients using opioids for pain related to envenomation was smaller in the FabAV treatment group at all follow-up time points.

Antivenom

10.5811/westjem.2019.3.42693

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The Copperhead Coagulopathy Conundrum

Annals of Emergency Medicine (2015)

C. Scott Evans Charles J. Gerardo

Consumptive Coagulopathy

Thrombelastography

10.1016/j.annemergmed.2014.12.026

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Validation of a Culturally Relevant Snakebite Envenomation Clinical Practice Guideline in Brazil

Toxins (2022)

Gisele dos Santos Rocha Altair Seabra de Farias João Arthur Alcântara Vinícius Azevedo Machado Felipe Murta

Snakebite envenoming (SBE) is a neglected tropical disease with significant global morbidity and mortality. Even when antivenom is available in low-resource areas, health workers do not receive adequate training to manage SBEs. This study aims to develop and validate a clinical practice guideline (CPG) for SBE management across Brazil. A panel of expert judges with academic and/or technical expertise in SBE management performed content validation. The content validity index (CVI) score was 90% for CPG objectives, 89% for structure and presentation and 92% for relevance and classified the CPG as valid. A semantic validation was performed by analyzing focus group discussions with doctors and nurses from three municipalities of the Brazilian Amazon, after a 5-day meeting during which the CPG was presented. Two central themes emerged: knowledge acquired during the meeting and recommendations for improving the CPG. Based on these results, the CPG was revised into a final version. This study presents the successful development and validation process of a CPG for SBE management, which is targeted to a specific low-resource, high-burden setting. This development and validation process can be adapted to other settings and/or other neglected tropical diseases.

Guideline

Antivenom

Presentation (obstetrics)

10.3390/toxins14060376

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346 A Comparative Analysis of Machine Learning Models in Predicting Emergency Department Patient Volumes in a University Hospital

Annals of Emergency Medicine (2024)

Jason Theiling Lauren Siewny João Vítor Perez de Souza João Ricardo Nickenig Vissoci Charles J. Gerardo

10.1016/j.annemergmed.2024.08.346

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American College of Emergency Physicians' Risk Management Outline and Resources

Catherine A. Marco Thomas E. Syzek Charles J. Gerardo Jennifer Casaletto Lynn P. Roppolo

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Does This Patient Have a Severe Snake Envenomation?

JAMA Surgery (2019)

Charles J. Gerardo João Ricardo Nickenig Vissoci C. Scott Evans David L. Simel Eric J. Lavonas

Venomous snakebite severity ranges from an asymptomatic dry bite to severe envenomation and death. The clinical evaluation aids in prognosis and is essential to determine the risks and potential benefits of antivenom treatment.To identify historical features, clinical examination findings, basic laboratory testing, and clinical grading scales that will risk-stratify patients with pit viper snake envenomation for severe systemic envenomation, severe tissue injury, and/or severe hematologic venom effects.We conducted a structured search of PubMed (1966-October 3, 2017) and Embase database (1980-October 3, 2017) to identify English-language studies that evaluated clinical features predictive of severe envenomation.We included studies that evaluated the test performance of at least 1 clinical finding with an acceptable reference standard of severe envenomation for venomous snakes of the Western Hemisphere. Only studies involving the most common subfamily, Crotalinae (pit vipers), were evaluated. Seventeen studies with data were available for abstraction.The clinical features assessed and severity outcome measures were extracted from each original study. We assessed severity in 3 categories: systemic toxicity, tissue injury, and hematologic effects. Differences were resolved by author consensus.The pooled prevalence of severe systemic envenomation was 14% (95% CI, 9%-21%). The pooled prevalence of severe tissue injury and severe hematologic venom effects were 14% (95% CI, 12%-16%) and 18% (95% CI, 8%-27%), respectively. Factors increasing the likelihood of severe systemic envenomation included the time from bite to care of 6 or more hours (likelihood ratio [LR], 3.4 [95% CI, 1.1-6.4]), a patient younger than 12 years (LRs, 3.2 [95% CI, 1.5-7.1] and 2.9 [95% CI, 1.3-6.2]), large snake size (LR, 3.1 [95% CI, 1.5-5.7]), and ptosis (LRs, 1.4 [95% CI, 1.0-2.1] and 3.8 [95% CI, 1.8-8.3]). Envenomation by the genus Agkistrodon (copperhead and cottonmouth), as opposed to rattlesnakes, decreased the likelihood of severe systemic envenomation (LR, 0.28 [95% CI, 0.10-0.78]). Initial hypofibrinogenemia (LR, 5.1 [95% CI, 1.7-15.0]) and thrombocytopenia (LR, 3.7 [95% CI, 1.9-7.3]) increased the likelihood of severe hematologic venom effects. Other clinical features from history, physical examination, or normal laboratory values were not discriminative.Clinical features can identify patients at increased risk of severe systemic envenomation and severe hematologic venom effects, but there are few features that are associated with severe tissue injury or can confidently exclude severe envenomation. Physicians should monitor patients closely and be wary of progression from nonsevere to a severe envenomation and have a low threshold to escalate therapy as needed.

Antivenom

10.1001/jamasurg.2018.5069

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Citations (46)