Correspondence In reply: The letter from WikEM’s founders1 regarding the importance of wikis raised some valid points. We agree that wikis are valuable social media tools for the dissemination and organization of knowledge. The OpenEM Foundation, in particular, has done an admirable job of developing a useful resource in WikEM and deserves recognition and support for their efforts. However, the strategies in our article2 focused on effectively using online resources and not on specific resources. Wikis have been defined as Web sites that can be openly edited and use crowd-sourcing as a method for improving and revising their content.3 However, for the users consuming content (our article’s target audience), they function as freestanding resources that are similar to others created by individuals or groups. They were not considered a sixth strategy in our article for this reason. However, we do believe WikEM warrants a position of high-quality online resources; there were simply too many great Web sites to list them all in our summary table. The authors would like to thank the OpenEM Foundation for the substantial work that they have done in creating WikEM and encourage the readers of Annals of Emergency Medicine to use and contribute to this resource. Brent Thoma, MD, MA Nikita Joshi, MD Teresa Chan, MD Michelle Lin, MD Emergency Medicine University of Saskatchewan Saskatoon, SK, Canada MedEdLIFE Research Collaborative San Francisco, CA Department of Surgery Division of Emergency Medicine Stanford University Palo Alto, CA Division of Emergency Medicine Department of Medicine McMaster University Hamilton, ON, Canada Department of Emergency Medicine University of California, San Francisco San Francisco, CA N. Seth Trueger, MD, MPH Section of Emergency Medicine University of Chicago Chicago, IL http://dx.doi.org/10.1016/j.annemergmed.2014.12.018
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships Volume 65, no. 4 : April 2015
in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Trueger receives a stipend for his work as the Social Media Editor (Twitter) for Emergency Physicians Monthly. 1. Ostermayer DG, Donaldson RI. The wiki: a key social media tool. Ann Emerg Med. 2015;65:466. 2. Thoma B, Joshi N, Trueger NS, et al. Five strategies to effectively use online resources in emergency medicine. Ann Emerg Med. 2014;64:392-395. 3. Thoma B, Chan TM, Benitez J, et al. Educational scholarship in the digital age: a scoping review and analysis of scholarly products. Winnower. 2014;1:e141827.77297.
The Copperhead Coagulopathy Conundrum To the Editor: We would like to commend Ali et al1 on their research demonstrating the lack of coagulopathy in copperhead envenomation. Their study and review of the literature, which included more than 700 copperhead envenomations, reported only 2 cases of clinically important bleeding. They reported that “it is safe to forgo serial coagulation testing.in the absence of clinically apparent bleeding.” Their review included our previous study of 94 copperhead snakebites without bleeding, but additional clarification is important to safely apply their recommendations.2 We recognize that clinically significant bleeding is an important patient-oriented outcome and that it is rare. However, in both studies hematologic laboratory abnormalities were common, demonstrating the frequency of the hematologic effects caused by copperhead venom. Most of the patients investigated in both studies (159/200) were treated with Crotalidae polyvalent immune Fab (ovine) (CroFab). A patient may have been treated for other venom effects and had his or her initially hematologic venom effect treated as a consequence, which leads to a potential underestimation of the number of patients at risk for progression to clinically significant bleeding. There remains a paucity of quality copperhead-specific data to confidently state that patients who are not treated with antivenom can safely forgo coagulation and platelet count testing. This caveat to their results is important because there remains wide practice variation in the use of antivenom for copperhead envenomation.3 We recommend that, until further data become available, the threshold to test be lower for copperhead envenomation patients who are not treated with antivenom. Additionally, the low number of patients in these studies who had preexisting conditions that predisposed them to bleeding further tempers the conclusions. For example, the threshold to test should likely be lower for patients receiving anticoagulant or antiplatelet medications, those with a predisposition to abnormal bleeding or clotting such as in von Willebrand’s disease, those with antiphospholipid antibodies, or even those receiving dialysis. Last, the authors’ speculation that these results may allow patients to forgo hospital admission may be premature. It assumes that we can determine the peak of the envenomation Annals of Emergency Medicine 467
Correspondence syndrome severity according to the emergency department (ED) evaluation. In our experience, the final severity of the patient’s symptoms is difficult to predict and usually peaks at sometime longer than a typical ED length of stay. Consequently, we continue to follow current recommendations of observation for 12 to 24 hours for even minor envenomation.4 Lack of clinically significant bleeding is unlikely to alter this recommendation because observation for progression of other venom effects remains the standard. If our clinical question is whether all copperhead envenomation patients require laboratory testing, Dr. Ali et al have definitively answered it. However, the important question of who does require testing remains unanswered from the best available evidence to date. C. Scott Evans, DO Division of Emergency Medicine Palo Alto VA Medical Center Palo Alto, CA Charles J. Gerardo, MD, MHS Division of Emergency Medicine Duke University Durham, NC
This presents an opportunity to validate our findings in centers with different rates of antivenom usage. A randomized controlled trial comparing FabAV with placebo in copperhead envenomation is currently under way.3 This trial may resolve this practice variation and might provide more data on the frequency and severity of coagulopathy in copperhead envenomation. We agree that the peak in severity of clinical symptoms often occurs after presentation to the emergency department (ED). We continue to observe our patients with copperhead bites in the ED observation unit or in hospital to guide antivenom treatment, but we do not routinely order hematologic testing in the absence of clinically significant bleeding. We acknowledge that we did not study patients with anticoagulant or antiplatelet medications or patients with preexisting coagulation disorders. We would not extrapolate our data to these patients, who clearly would warrant laboratory testing. Although minor deviations in laboratory measures of coagulation do occasionally occur, clinically significant bleeding rarely, if ever, occurs after copperhead envenomation. We again echo Evans et al4 in concluding that “[r]outine hematologic tests to detect significant bleeding in all patients with copperhead snakebite.are not warranted.”
http://dx.doi.org/10.1016/j.annemergmed.2014.12.026
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Gerardo reports receiving research funding from BTG International Inc.
Michael E. Mullins, MD Anah J. Ali, MD Division of Emergency Medicine Washington University School of Medicine St. Louis, MO http://dx.doi.org/10.1016/j.annemergmed.2014.12.027
1. Ali AJ, Horowitz DA, Mullins ME. Lack of coagulopathy after copperhead snakebites. Ann Emerg Med. 2015;65:404-409. 2. Evans CS, Drake WG, Diskina M, et al. Hematologic abnormalities and bleeding in copperhead snakebite [abstract]. Wild Environ Med. 2014;25:116. 3. Ward KN, Wortley AG, Quakenbush EB, et al. Variability in antivenom treatment in snake envenomations between two major tertiary care emergency departments [abstract]. Ann Emerg Med. 2014;64:S141. 4. Lavonas EJ, Ruha AM, Banner W, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med. 2011;11:2.
In reply: We appreciate the comments and insights from Drs. Evans and Gerardo. We acknowledge, as we did in our original article,1 that a majority of patients received Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV), which conceivably could mask or suppress a trend toward coagulopathy. We believe that the wide variation in antivenom use within North Carolina reflects practice variation across the region where copperheads are endemic.2
468 Annals of Emergency Medicine
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Mullins is the site principal investigator for an industry-funded trial of CroFab for copperhead snakebites and has received paid travel to 2 investigator meetings in Atlanta, GA.
1. Ali AJ, Horowitz DA, Mullins ME. Lack of coagulopathy after copperhead snakebites. Ann Emerg Med. 2015;65:404-409. 2. Ward KN, Wortley AG, Quakenbush EB, et al. Variability in antivenom treatment in snake envenomations between two major tertiary care emergency departments [abstract]. Ann Emerg Med. 2014;64:S141. 3. National Institutes of Health. A randomized, double-blind, placebocontrolled study comparing CroFab versus placebo with rescue treatment for copperhead snake envenomation (Copperhead RCT). Available at: http://clinicaltrials.gov/show/NCT01864200. Accessed December 7, 2014. 4. Evans CS, Drake WB, Diskina M, et al. Hematologic abnormalities and bleeding in copperhead snakebite [abstract]. Wild Environ Med. 2014;25:116.
Volume 65, no. 4 : April 2015
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships Volume 65, no. 4 : April 2015
in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Trueger receives a stipend for his work as the Social Media Editor (Twitter) for Emergency Physicians Monthly. 1. Ostermayer DG, Donaldson RI. The wiki: a key social media tool. Ann Emerg Med. 2015;65:466. 2. Thoma B, Joshi N, Trueger NS, et al. Five strategies to effectively use online resources in emergency medicine. Ann Emerg Med. 2014;64:392-395. 3. Thoma B, Chan TM, Benitez J, et al. Educational scholarship in the digital age: a scoping review and analysis of scholarly products. Winnower. 2014;1:e141827.77297.
The Copperhead Coagulopathy Conundrum To the Editor: We would like to commend Ali et al1 on their research demonstrating the lack of coagulopathy in copperhead envenomation. Their study and review of the literature, which included more than 700 copperhead envenomations, reported only 2 cases of clinically important bleeding. They reported that “it is safe to forgo serial coagulation testing.in the absence of clinically apparent bleeding.” Their review included our previous study of 94 copperhead snakebites without bleeding, but additional clarification is important to safely apply their recommendations.2 We recognize that clinically significant bleeding is an important patient-oriented outcome and that it is rare. However, in both studies hematologic laboratory abnormalities were common, demonstrating the frequency of the hematologic effects caused by copperhead venom. Most of the patients investigated in both studies (159/200) were treated with Crotalidae polyvalent immune Fab (ovine) (CroFab). A patient may have been treated for other venom effects and had his or her initially hematologic venom effect treated as a consequence, which leads to a potential underestimation of the number of patients at risk for progression to clinically significant bleeding. There remains a paucity of quality copperhead-specific data to confidently state that patients who are not treated with antivenom can safely forgo coagulation and platelet count testing. This caveat to their results is important because there remains wide practice variation in the use of antivenom for copperhead envenomation.3 We recommend that, until further data become available, the threshold to test be lower for copperhead envenomation patients who are not treated with antivenom. Additionally, the low number of patients in these studies who had preexisting conditions that predisposed them to bleeding further tempers the conclusions. For example, the threshold to test should likely be lower for patients receiving anticoagulant or antiplatelet medications, those with a predisposition to abnormal bleeding or clotting such as in von Willebrand’s disease, those with antiphospholipid antibodies, or even those receiving dialysis. Last, the authors’ speculation that these results may allow patients to forgo hospital admission may be premature. It assumes that we can determine the peak of the envenomation Annals of Emergency Medicine 467
Correspondence syndrome severity according to the emergency department (ED) evaluation. In our experience, the final severity of the patient’s symptoms is difficult to predict and usually peaks at sometime longer than a typical ED length of stay. Consequently, we continue to follow current recommendations of observation for 12 to 24 hours for even minor envenomation.4 Lack of clinically significant bleeding is unlikely to alter this recommendation because observation for progression of other venom effects remains the standard. If our clinical question is whether all copperhead envenomation patients require laboratory testing, Dr. Ali et al have definitively answered it. However, the important question of who does require testing remains unanswered from the best available evidence to date. C. Scott Evans, DO Division of Emergency Medicine Palo Alto VA Medical Center Palo Alto, CA Charles J. Gerardo, MD, MHS Division of Emergency Medicine Duke University Durham, NC
This presents an opportunity to validate our findings in centers with different rates of antivenom usage. A randomized controlled trial comparing FabAV with placebo in copperhead envenomation is currently under way.3 This trial may resolve this practice variation and might provide more data on the frequency and severity of coagulopathy in copperhead envenomation. We agree that the peak in severity of clinical symptoms often occurs after presentation to the emergency department (ED). We continue to observe our patients with copperhead bites in the ED observation unit or in hospital to guide antivenom treatment, but we do not routinely order hematologic testing in the absence of clinically significant bleeding. We acknowledge that we did not study patients with anticoagulant or antiplatelet medications or patients with preexisting coagulation disorders. We would not extrapolate our data to these patients, who clearly would warrant laboratory testing. Although minor deviations in laboratory measures of coagulation do occasionally occur, clinically significant bleeding rarely, if ever, occurs after copperhead envenomation. We again echo Evans et al4 in concluding that “[r]outine hematologic tests to detect significant bleeding in all patients with copperhead snakebite.are not warranted.”
http://dx.doi.org/10.1016/j.annemergmed.2014.12.026
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Gerardo reports receiving research funding from BTG International Inc.
Michael E. Mullins, MD Anah J. Ali, MD Division of Emergency Medicine Washington University School of Medicine St. Louis, MO http://dx.doi.org/10.1016/j.annemergmed.2014.12.027
1. Ali AJ, Horowitz DA, Mullins ME. Lack of coagulopathy after copperhead snakebites. Ann Emerg Med. 2015;65:404-409. 2. Evans CS, Drake WG, Diskina M, et al. Hematologic abnormalities and bleeding in copperhead snakebite [abstract]. Wild Environ Med. 2014;25:116. 3. Ward KN, Wortley AG, Quakenbush EB, et al. Variability in antivenom treatment in snake envenomations between two major tertiary care emergency departments [abstract]. Ann Emerg Med. 2014;64:S141. 4. Lavonas EJ, Ruha AM, Banner W, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med. 2011;11:2.
In reply: We appreciate the comments and insights from Drs. Evans and Gerardo. We acknowledge, as we did in our original article,1 that a majority of patients received Crotalidae polyvalent immune Fab (ovine) (CroFab; FabAV), which conceivably could mask or suppress a trend toward coagulopathy. We believe that the wide variation in antivenom use within North Carolina reflects practice variation across the region where copperheads are endemic.2
468 Annals of Emergency Medicine
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Mullins is the site principal investigator for an industry-funded trial of CroFab for copperhead snakebites and has received paid travel to 2 investigator meetings in Atlanta, GA.
1. Ali AJ, Horowitz DA, Mullins ME. Lack of coagulopathy after copperhead snakebites. Ann Emerg Med. 2015;65:404-409. 2. Ward KN, Wortley AG, Quakenbush EB, et al. Variability in antivenom treatment in snake envenomations between two major tertiary care emergency departments [abstract]. Ann Emerg Med. 2014;64:S141. 3. National Institutes of Health. A randomized, double-blind, placebocontrolled study comparing CroFab versus placebo with rescue treatment for copperhead snake envenomation (Copperhead RCT). Available at: http://clinicaltrials.gov/show/NCT01864200. Accessed December 7, 2014. 4. Evans CS, Drake WB, Diskina M, et al. Hematologic abnormalities and bleeding in copperhead snakebite [abstract]. Wild Environ Med. 2014;25:116.
Volume 65, no. 4 : April 2015
