SNAKE BITE

Criteria

Signs/Symptoms

Score

No symptom/sign

Dyspnea, minimal chest tightness, mild or vague discomfort, or respirations of 20-25 breaths/min

Moderate respiratory distress (tachypnea, 26-40 breaths/min, accessory muscle use)

Cyanosis, air hunger, extreme tachypnea, or respiratory insufficiency/failure

No symptom/sign

Tachycardia (100-125 beats/min), palpitations, generalized weakness, benign dysrhythmia, or hypertension

Tachycardia (126-175 beats/min) or hypotension with systolic blood pressure < 100 mm Hg

Extreme tachycardia (>175 beats/min) or hypotension with systolic blood pressure < 100 mm Hg, malignant dysrhythmia, or cardiac
arrest

No symptom/sign (swelling or erythema < 2.5 cm of fang mark)

Pain, swelling, or ecchymosis within 5-7.5 cm of bite site

Pain, swelling, or ecchymosis involving less than half of the extremity (7.5 cm from site)

Pain, swelling, or ecchymosis extending beyond affected extremity (>100 cm from site)

No symptom/sign

Pain, tenesmus, or nausea

Vomiting or diarrhea

Repeated vomiting or diarrhea, hematemesis, hematochezia

Pulmonary

Cardiovascular

Local wound

Gastrointestinal

Hematological
No symptom/sign

Coagulation parameters slightly abnormal (PT < 20 seconds, PTT < 50 seconds, platelets 100,000-150,000/L, fibrinogen 100-150
mcg/mL)

Coagulation parameters abnormal (PT < 20-50 seconds, PTT < 50-75 seconds, platelets 50,000-100,000/L, fibrinogen 50-100
mcg/mL)

Coagulation parameters abnormal (PT < 50-100 seconds, PTT < 75-100 seconds, platelets 20,000-50,000/L, fibrinogen < 50
mcg/mL)

Coagulation parameters markedly abnormal, with serious bleeding or threat of spontaneous bleeding (PT or PTT unmeasurable,
platelets < 20,000/L, fibrinogen undetectable), with severe abnormalities in other laboratory values, including venous clotting time

No symptom/sign

Minimal apprehension, headache, weakness, dizziness, chills, or paresthesia

Moderate apprehension, headache, weakness, dizziness, chills, paresthesia, confusion, or fasciculation in area of bite site, ptosis, and
dysphagia

Severe confusion, lethargy, seizure, coma, psychosis, or generalized fasciculation

Extremely severe envenomation leading to death

Central nervous
system

PT = Prothrombin time.

PTT = Partial thromboplastin time.

Patients are eligible for therapy with CroFab if they have moderate or severe envenomation as described or any
degree of envenomation with progression of the envenomation syndrome. Note: As the antivenom dose reflects
venom size, not patient size, the US Food and Drug Administration recommends the same initial and subsequent
doses for pediatric patients. Data show efficacy and safety for patients as young as 14 months.
Table 2. Severity of Envenomation (Open Table in a new window)
Type of
Signs/Symptoms

Minimal

Moderate

Severe

Local

Swelling, erythema, or
ecchymosis confined to bite
site

Progression of swelling, erythema, or

ecchymosis beyond bite site

Rapid swelling, erythema, or ecchymosis involving the

entire body part

Systemic

No systemic signs or
symptoms

Nonlife-threatening signs or symptoms

(nausea/vomiting, mild hypotension, perioral
paresthesias, myokymia)

Markedly severe signs or symptoms (hypotension

[systolic < 80 mm Hg], altered sensorium, tachycardia,
tachypnea, and respiratory distress)

Coagulation

No coagulation abnormalities
or other laboratory
abnormalities

Mild abnormal coagulation profile without

significant bleeding

Abnormal coagulation profile with bleeding (INRa,

aPTTb, fibrinogen, platelet count < 20,000/L

Snakebite Severity
Score

0-3

4-7

8-20

INR = International normalized ratio.

aPTT = Activated partial thromboplastin time.

Next Secti

General Management Principles

Important considerations when encountering patients with snakebites are described.
Patients with acute presentations still require starting with a rapid assessment of the patient's airway. Obstruction or
respiratory failure requires the acquisition of a definitive airway, which might require rapid sequence intubation (RSI).
Breathing and circulation should also be assessed in the initial state once an airway has been established.
Remove the patient from the snake's territory as soon as stabilization has occurred in order to avoid further harm.
Remove any jewelry or constricting clothing from the patient's affected area. If clothing is not causing any
compression or constriction, it can be left alone until the patient is transferred to a hospital for further care.
In the immediate/acute setting, withhold all alcohol and any drugs that may confound clinical assessment or interfere
with treatment.
Do not manipulate the wound site. It is not recommended to incise the site or perform oral suction.[10]

Further inpatient care

Admission to the hospital is routine for most envenomation cases. A "dry bite" without envenomation can occur in a
significant percentage of cases (50% in coral snake, 25% from pit viper). For dry pit viper bites, observe in the
emergency department for 8-10 hours; however, often this is not feasible. Patients with severe envenomation need
specialized care in the ICU to administer blood products, provide invasive monitoring, and ensure airway protection.
Observe coral snakebites for a minimum of 24 hours.
Perform serial evaluations for further grading and to rule out compartment syndrome. Depending on clinical
scenarios, measure compartment pressures every 30-120 minutes. Fasciotomy can be considered for pressures
greater than 30-40 mm Hg. However, fasciotomy has not been shown to improve outcomes, even when compartment
pressures are elevated, and is not routinely indicated for crotalid snake envenomation.[11, 12]

Depending on the clinical severity of the bite, further blood work may be needed, especially clotting studies, platelet
count, and fibrinogen level. Late coagulopathy has been reported after using FABAV. F(ab)2 immunoglobulin
derivatives under development have a longer half life than CroFab and have been shown to decrease late
coagulopathy after antivenin treatment.[12, 13]

Prehospital Care
As with all medical emergencies, the goal is to support the patient until arrival at the emergency department. The
dictum " primum no nocere " (first, do no harm) has significant meaning here because many poorly substantiated
treatments may cause more harm than good, including making an incision over the bite, mouth suctioning, tourniquet
use, ice packs, or electric shock.
Appropriate field care should adhere to the basic tenants of emergency life support.
Reassure the patient during the implementation of ABCs.
Monitor vital signs and establish at least one large-bore IV and initiate crystalloid infusion. Administer oxygen therapy.
Keep a close watch on the airway at all times in case intubation becomes necessary.
Restrict activity and immobilize the affected area (commonly an extremity); keep walking to a minimum.
Negative-pressure suctioning devices offer some benefit if used within several minutes of envenomation. Again, do
not make an incision in the field.
Immediately transfer to definitive care.
Do not give antivenin in the field.

Emergency Department Care

Physicians who have little experience treating snakebites frequently care for such patients.
Regional centers often have more experience in the care of snakebite victims. Surgical evaluation for an
envenomation victim is paramount.
Definitive treatment includes reviewing the ABCs and evaluating the patient for signs of shock (eg, tachypnea,
tachycardia, dry pale skin, mental status changes, hypotension).
For victims of pit viper (crotaline snake) bites, evenomation grading determines the need for antivenin. Grades are
defined as mild, moderate, or severe. Mild envenomation is characterized by local pain, edema, no signs of systemic
toxicity, and normal laboratory values. Moderate envenomation is characterized by severe local pain; edema larger
than 12 inches surrounding the wound; and systemic toxicity including nausea, vomiting, and alterations in laboratory
values (eg, decreased hematocrit or platelet count). Severe envenomation is characterized by generalized petechiae,
ecchymosis, blood-tinged sputum, hypotension, hypoperfusion, renal dysfunction, changes in prothrombin time and
activated partial thromboplastin time, and other abnormal test results defining consumptive coagulopathy. See Tables
1 and 2 above.
Grading envenomations is a dynamic process. Over several hours, an initially mild syndrome may progress to a
moderate or even severe reaction.

For pit viper envenomations, horse-serum antivenin has been available since 1956; a purer antivenin with improved
properties was released in 2000 (see Medication). With the reduced side-effect profile of antigen-binding fragment
antivenom (FabAV) and the improvement in tissue injury with antivenin administration, the threshold for dosing is
lower. One study from the southwest United States demonstrated a reduction in rate of fasciotomy after more liberal
FabAV dosing.[14] In a randomized study of scheduled versus as-needed FabAV dosing in patients whose symptoms
were worsening, the Rocky Mountain Poison and Drug Center demonstrated a reduction in pain and other venom
effects but noted a 20% acute and 23% delayed drug reaction.[15]
Although copperhead bites are generally self-limiting, morbidity was reduced in moderate envenomation 4 hours after
4 vials of FabAV in 88% of cases. The cases that failed to respond were not changed by further FabAV doses.[16]
FabAV is generally considered safe for children, as many of the studies did not discriminate in age. One large study
from Mexico demonstrated no immediate or late allergic reactions to FabAV when administered according to grade of
envenomation.[6]
Although FabAV helps control local tissue effects and hemotoxicity, aggressive antivenom therapy does not usually
ameliorate neurotoxic effects such as myokymia(spontaneous, fine fascicular contractions of muscle without
muscular atrophy or weakness) and major muscle fasciculations. The physician must maintain continuous monitoring
of those patients with myokymia especially of the shoulders, chest, and diaphragm for the development of respiratory
failure and need for mechanical ventilation.[17, 18]
Coral snakes are not pit vipers and their bites should not be treated with FabAV. A previously available Wyeth
antivenin for Micruris fulvius is no longer manufactured. Victims of bites by M fulvius (eastern coral snake) and M
tener (Texas coral snake) should receive general wound care and supportive care, including respiratory support in the
event of respiratory failure. Poison control and toxicologist consultation should be contacted for suspected coral
snake envenomations to obtain the latest location-specific treatment recommendations. See also Coral Snake
Envenomation.

Surgical Care
Surgical assessment focuses on the injury site and concern for the development ofcompartment syndrome.
Fasciotomy is indicated only for those patients with objective evidence of elevated compartment pressure. Liberal
monitoring of compartment pressure is warranted. If this is not available, use the physical hallmark of compartment
hypertension (pain with passive range of motion), along with distal pallor, paresthesia, or pulselessness for the clinical
assessment.
Tissue injury after compartment syndrome is not reversible but is preventable.

Complications
Coagulopathy, including delayed coagulopathy, is a frequent complication of pit viper snakebite. Local wound
complications may include infection and skin loss.
Cardiovascular complications, hematologic complications, and pulmonary collapse may occur. Neurotoxicity with
myokymia of the respiratory muscles may lead to respiratory failure and mechanical ventilation. True compartment
syndrome is a rare complication. Death is rare.
Prolonged neuromuscular blockade may occur from coral snake envenomation.

Antivenin-associated complications include immediate (anaphylaxis, type I) and delayed (serum sickness, type III)
hypersensitivity reactions. Anaphylaxis is an event mediated by immunoglobulin E (IgE), involving degranulation of
mast cells that can result in laryngospasm, vasodilatation, and leaky capillaries. Death is common without
pharmacological intervention. Serum sickness occurs 1-2 weeks after administering antivenin. Precipitation of
antigen-immunoglobulin G (IgG) complexes in the skin, joints, and kidneys is responsible for the arthralgias, urticaria,
and glomerulonephritis (rarely). Usually more than 8 vials of antivenin must be given to produce this syndrome.
Supportive care consists of antihistamines and steroids. Newer studies now report a lower incidence (5.4%) of acute
hypersensitivity reactions with FabAV.[19]