Letter to the Director
Snakebite management in a pediatric patient: More doubts than certainties
Manejo de una mordedura de ofidio en un paciente pediátrico: más dudas que certezas
E. Sanjuan, L. Álvarez-Baena, D. Callejo, A. Romera
Corresponding author
Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario Gregorio Marañón, Madrid, Spain
Read
Not available
Timeswas read the article
Total PDF
Total HTML
Share statistics
array:24 [ "pii" => "S234119292100069X" "issn" => "23411929" "doi" => "10.1016/j.redare.2021.04.001" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1197" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2020" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2021;68:304-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935620301894" "issn" => "00349356" "doi" => "10.1016/j.redar.2020.07.005" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1197" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "cor" "cita" => "Rev Esp Anestesiol Reanim. 2021;68:304-5" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta al Director</span>" "titulo" => "Manejo de una mordedura de ofidio en un paciente pediátrico: más dudas que certezas" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "304" "paginaFinal" => "305" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Snakebite management in a pediatric patient: More doubts than certainties" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Sanjuan, L. Álvarez-Baena, D. Callejo, A. Romera" "autores" => array:4 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Sanjuan" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Álvarez-Baena" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Callejo" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Romera" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S234119292100069X" "doi" => "10.1016/j.redare.2021.04.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234119292100069X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935620301894?idApp=UINPBA00004N" "url" => "/00349356/0000006800000005/v3_202110060547/S0034935620301894/v3_202110060547/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192921000792" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.06.017" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1187" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2021;68:306-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Image of the month</span>" "titulo" => "Difficult airway by hematoma of the thongue in a patient on anticoagulant therapy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "306" "paginaFinal" => "307" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vía aérea difícil por hematoma lingual en paciente anticoagulado" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 908 "Ancho" => 2917 "Tamanyo" => 221335 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nasopharyngeal image (A and C) and cervical (B and C) CT scan showing thickening of the tongue causing a “mass effect” due to oedema and haematoma (arrowhead) that almost completely obliterates the lumen of the oropharynx. (A) Narrowing of the oropharynx, showing a thin filiform lumen of approximately 3–4 mm (arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. España Fuente" "autores" => array:1 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "España Fuente" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935620301808" "doi" => "10.1016/j.redar.2020.06.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935620301808?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921000792?idApp=UINPBA00004N" "url" => "/23411929/0000006800000005/v1_202106150624/S2341192921000792/v1_202106150624/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192921000706" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.06.016" "estado" => "S300" "fechaPublicacion" => "2021-05-01" "aid" => "1215" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2021;68:301-3" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Tranexamic acid use in severely injured patients, is it always appropriate?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "301" "paginaFinal" => "303" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ácido tranexámico en el paciente politraumatizado grave, ¿está siempre indicado?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Duque, L. Gonzalez-Zarco, R. Martínez, S. Gago, J.A. Varela" "autores" => array:5 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Duque" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Gonzalez-Zarco" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Martínez" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Gago" ] 4 => array:2 [ "nombre" => "J.A." "apellidos" => "Varela" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935620302073" "doi" => "10.1016/j.redar.2020.06.019" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935620302073?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921000706?idApp=UINPBA00004N" "url" => "/23411929/0000006800000005/v1_202106150624/S2341192921000706/v1_202106150624/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Director</span>" "titulo" => "Snakebite management in a pediatric patient: More doubts than certainties" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "304" "paginaFinal" => "305" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "E. Sanjuan, L. Álvarez-Baena, D. Callejo, A. Romera" "autores" => array:4 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Sanjuan" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Álvarez-Baena" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Callejo" ] 3 => array:4 [ "nombre" => "A." "apellidos" => "Romera" "email" => array:1 [ 0 => "andreilla111@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo de una mordedura de ofidio en un paciente pediátrico: más dudas que certezas" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Snake bites are rare in our setting,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> a factor that complicates decision-making difficult and delays the start of treatment, particularly in paediatric patients.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We report the case of a child bitten by a viper who developed compartment syndrome that required 2 fasciotomies. As anaesthesiologists and paediatric critical care specialists, we ask ourselves whether the administration of antivenom would have improved management.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 5-year-old boy weighing 20 kg, with no clinical history, who was bitten by a snake in the thenar space. He was transferred to 2 hospitals before arriving at the Gregorio Marañón General University Hospital in Madrid, where he was admitted 12 h after being bitten. The diagnosis of viper bite, probably from a <span class="elsevierStyleItalic">Vipera latastei</span> or “snub-nosed viper”, was performed correctly in both hospitals, based on the morphology of the bite, the geographic location, and the description provided by the patient. Both hospitals decided to take a conservative approach and transfer the patient to a tertiary hospital. When he finally arrived in our paediatric critical care unit, the patient was in good general condition with haemodynamic and respiratory stability. The affected hand, in addition to the bite mark, was swollen, hot and flushed. The parents reported that these symptoms had increased gradually and spread upwards. The only laboratory abnormality found was leucocytosis of 17,000 μl. The National Institute of Toxicology and Forensic Sciences was contacted by telephone and, following their protocol, antivenom was not administered. The patient was examined by the trauma unit and underwent fasciotomy in the wrist within 1 h of admission, and a second intervention 48 later, both to treat compartment syndrome. The patient was treated with amoxicillin-clavulanate and intravenous corticosteroids. In the first 24 h, mild phlebitis was observed in the forearm, which progressed to the axilla. The pitting oedema reached as far as his wrist. Aside from the initial leucocytosis, which normalized within 8 h of admission, his laboratory parameters (urine sediment, blood count, biochemistry, coagulation, acute phase markers and muscle damage) were normal. He remained stable during his hospital stay and was discharged home 11 days later.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Snake bites in Spain are rare, but potentially serious.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although the patient was treated by a multidisciplinary team, none of the specialists involved—anaesthesiologists, traumatologists and experts in infectious diseases—had experience in snake bites. A comprehensive review of the international literature showed that this pathology can be confusing, given the many different classifications of patient severity and different therapeutic criteria.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In terms of the clinical classification, some authors use the Audebert classification or a slightly modified version,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> which divides patients into 4 grades and considers extensive oedema and moderate general symptoms (grade III) to be the determining factors for severity. In our patient, oedema only reached as far as the wrist (although the phlebitis progressed along the arm over the first days) and the leucocytosis lasted only a few hours; both factors suggested mild envenoming.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Children and elderly patients are more likely to develop severe envenoming.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The site of the bite in our patient is the most frequently described in Spain.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Although most envenomations are superficial to the fascia and rarely progress to compartment syndrome, bites in the hand are the exception to this rule,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and this has prompted some authors to claim that the anatomical site can be a determining factor in the development of compartment syndrome. Management is similar for all snake species in Spain, so knowing the specific type of viperis is not essential for treatment.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The most important diagnostic studies are electrocardiography, since toxins can have a direct cardiotoxic effect and cause arrhythmias—particularly supraventricular tachycardia and heart block, and renal function tests for the presence of choluria due to myoglobinuria or haematuria, proteinuria, oliguria or progression to kidney failure.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In terms of therapy, the affected limb should be immobilized and elevated, but never compressed, and cryotherapy (applied indirectly) and bed rest should be considered. Tourniquets, cutting or sucking the wound are not recommended, and cauterizing the bite area, amputation or applying electric current should be avoided, as should the administration of stimulating drugs or drinks that increase cardiac output and facilitate the spread of venom. Anti-tetanus prophylaxis should be administered if needed, analgesics (not salicylates) should be started. The use of antivenom serum should be considered, with or without intravenous mannitol at 1−2 g/kg/weight.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There are no randomized clinical trials comparing the benefit of antivenom and the effectiveness of fasciotomy in humans. Although fasciotomy has hitherto been prioritized, more recent studies recommend administering antivenom as first-line treatment, as it is effective and well-tolerated, prevents progression, improves inflammation, and reduces hospital stay.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Early (within 6 h of the bite), rather than late administration of the antivenom serum is more effective, probably because the venom has had less time to act. However, late administration, though less effective, is also useful (even after 24 h).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Likewise, some authors recommend early administration of antivenom in pregnant women and in patients that already show signs of compartment syndrome.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Our diagnosis of compartment syndrome was made on the basis of clinical criteria, without directly measuring compartment pressure. Some authors recommend performing this measurement to determine whether the oedema is intracompartmental or extracompartmental, and to apply the appropriate treatment in each case,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> since snake venom itself causes muscle necrosis and can mimic compartment syndrome.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Furthermore, fasciotomy resolves compartment syndrome, but not muscle necrosis.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Although the administration of antivenom is not without risk—pruritus, urticaria, angioedema, nausea, hypotension or anaphylactic shock—most experts agree that adverse effects are rare.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Some authors advise premedicating with antihistamines and corticosteroids and/or performing a hypersensitivity test. The rate of administration should be reduced or suspended altogether if adverse effects appear, although this is highly unlikely given the low antigenicity of these sera.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The prophylactic use of antibiotics has not been shown to be useful.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Corticosteroids are only indicated in the exceptional case of an allergic reaction to the poison or in the event of a very rare adverse reaction after administration of the serum.</p><p id="par0060" class="elsevierStylePara elsevierViewall">We believe that this was a borderline patient as far as antivenom serum is concerned. Factors advising against administration were the time elapsed since the bite and the extent of the lesion; factors in favour were the age of the patient, the location of the bite and the need for fasciotomy. Given our limited experience and the diversity of criteria found in the literature, we cannot establish an unequivocal guideline for action.</p><p id="par0065" class="elsevierStylePara elsevierViewall">We recommend always contacting the National Institute of Toxicology and taking their opinion and protocol into account, albeit it bearing in mind that they can be too conservative in some cases.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they have not received funding for this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sanjuan E, Álvarez-Baena L, Callejo D, Romera A. Manejo de una mordedura de ofidio en un paciente pediátrico: más dudas que certezas. Rev Esp Anestesiol Reanim. 2021;68:304–305.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Envenenamiento por mordedura de serpiente en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Martín-Sierra" 1 => "S. Nogué-Xarau" 2 => "M.A. Pinillos" 3 => "J.M. Rey" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Emergencias." "fecha" => "2018" "volumen" => "30" "paginaInicial" => "126" "paginaFinal" => "132" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "<span class="elsevierStyleItalic">Vipera berus</span> bite in a child, with severe local symptoms and hypotension" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B. Moser" 1 => "G. Roeggla" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1580/07-WEME-LE-157.1" "Revista" => array:6 [ "tituloSerie" => "Wilderness Environ Med." "fecha" => "2009" "volumen" => "20" "paginaInicial" => "100" "paginaFinal" => "101" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19364163" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tratamiento de la mordedura por víbora en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Estefanía" 1 => "D. Alonso" 2 => "P. García" 3 => "A. López" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.semerg.2014.08.005" "Revista" => array:6 [ "tituloSerie" => "Semergen." "fecha" => "2016" "volumen" => "42" "paginaInicial" => "320" "paginaFinal" => "326" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25440968" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Síndrome compartimental en extremidad superior tras mordedura de ofidio en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "B.D. Grijelmo Sada" 1 => "M.E. Estefanía Díez" 2 => "D. Alonso Peña" 3 => "M.E. Ruiz Alonso" 4 => "M.J. Rivera Vegas" 5 => "M.P. García Cano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Iberam Cir Mano." "fecha" => "2017" "volumen" => "45" "paginaInicial" => "50" "paginaFinal" => "56" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antivenom for European Vipera species envenoming" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T. Lamb" 1 => "L. de Haro" 2 => "D. Lonati" 3 => "M. Brvar" 4 => "M. Eddleston" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Toxicol." "fecha" => "2017" "volumen" => "55" "paginaInicial" => "557" "paginaFinal" => "568" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006800000005/v1_202106150624/S234119292100069X/v1_202106150624/en/main.assets" "Apartado" => array:4 [ "identificador" => "66474" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006800000005/v1_202106150624/S234119292100069X/v1_202106150624/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234119292100069X?idApp=UINPBA00004N" ]
