6/23/2016 Snakebite Treatment & Management: Severity of Envenomation, General Management Principles, Prehospital Care

SnakebiteTreatment&Management
Author:BrianJDaley,MD,MBA,FACS,FCCP,CNSCChiefEditor:JoeAlcock,MD,MSmore...

Updated:Apr08,2016

SeverityofEnvenomation
Treatmentisbasedontheseverityofenvenomationitisdividedintofieldcareand
hospitalmanagement.SeeTables1and2below.

Table1.SnakebiteSeverityScale(OpenTableinanewwindow)

Criteria Signs/Symptoms Score

Pulmonary
Nosymptom/sign 0
Dyspnea,minimalchesttightness,mildorvague
1
discomfort,orrespirationsof2025breaths/min
Moderaterespiratorydistress(tachypnea,2640
2
breaths/min,accessorymuscleuse)
Cyanosis,airhunger,extremetachypnea,orrespiratory
3
insufficiency/failure
Cardiovascular
Nosymptom/sign 0
Tachycardia(100125beats/min),palpitations,
generalizedweakness,benigndysrhythmia,or 1
hypertension
Tachycardia(126175beats/min)orhypotensionwith
2
systolicbloodpressure<100mmHg
Extremetachycardia(>175beats/min)orhypotensionwith
systolicbloodpressure<100mmHg,malignant 3
dysrhythmia,orcardiacarrest
Nosymptom/sign(swellingorerythema<2.5cmoffang
Localwound 0
mark)
Pain,swelling,orecchymosiswithin57.5cmofbitesite 1
Pain,swelling,orecchymosisinvolvinglessthanhalfof
2
theextremity(7.5cmfromsite)
Pain,swelling,orecchymosisextendingbeyondaffected
3
extremity(>100cmfromsite)
Gastrointestinal
Nosymptom/sign 0
Pain,tenesmus,ornausea 1
Vomitingordiarrhea 2
Repeatedvomitingordiarrhea,hematemesis,
3
hematochezia
Hematological
Nosymptom/sign 0
Coagulationparametersslightlyabnormal(PTa<20
seconds,PTTb<50seconds,platelets100,000150,000/ 1
L,fibrinogen100150mcg/mL)
Coagulationparametersabnormal(PT<2050seconds,
PTT<5075seconds,platelets50,000100,000/L, 2
fibrinogen50100mcg/mL)
Coagulationparametersabnormal(PT<50100seconds,
PTT<75100seconds,platelets20,00050,000/L, 3
fibrinogen<50mcg/mL)
Coagulationparametersmarkedlyabnormal,withserious
bleedingorthreatofspontaneousbleeding(PTorPTT
unmeasurable,platelets<20,000/L,fibrinogen 4
undetectable),withsevereabnormalitiesinother
laboratoryvalues,includingvenousclottingtime
Central
nervous
system
Nosymptom/sign 0
Minimalapprehension,headache,weakness,dizziness,
1
chills,orparesthesia
Moderateapprehension,headache,weakness,dizziness,
chills,paresthesia,confusion,orfasciculationinareaof 2
bitesite,ptosis,anddysphagia
Severeconfusion,lethargy,seizure,coma,psychosis,or
3
generalizedfasciculation
Extremelysevereenvenomationleadingtodeath 4
aPT=Prothrombintime.

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6/23/2016 Snakebite Treatment & Management: Severity of Envenomation, General Management Principles, Prehospital Care

bPTT=Partialthromboplastintime.

PatientsareeligiblefortherapywithCroFabiftheyhavemoderateorsevere
envenomationasdescribedoranydegreeofenvenomationwithprogressionofthe
envenomationsyndrome.Note:Astheantivenomdosereflectsvenomsize,not
patientsize,theUSFoodandDrugAdministrationrecommendsthesameinitialand
subsequentdosesforpediatricpatients.Datashowefficacyandsafetyforpatients
asyoungas14months.

Table2.SeverityofEnvenomation(OpenTableinanewwindow)

Typeof
Minimal Moderate Severe
Signs/Symptoms
Swelling,
Progressionof
erythema,or Rapidswelling,erythema,
swelling,erythema,
Local ecchymosis orecchymosisinvolving
orecchymosis
confinedto theentirebodypart
beyondbitesite
bitesite
Nonlifethreatening
Markedlyseveresignsor
signsorsymptoms
symptoms(hypotension
Nosystemic (nausea/vomiting,
[systolic<80mmHg],
Systemic signsor mildhypotension,
alteredsensorium,
symptoms perioral
tachycardia,tachypnea,
paresthesias,
andrespiratorydistress)
myokymia)
No
coagulation Mildabnormal Abnormalcoagulation
abnormalities coagulationprofile profilewithbleeding(INRa,
Coagulation
orother withoutsignificant aPTTb,fibrinogen,platelet
laboratory bleeding count<20,000/L
abnormalities
Snakebite
03 47 820
SeverityScore
aINR=Internationalnormalizedratio.

baPTT=Activatedpartialthromboplastintime.

GeneralManagementPrinciples
Importantconsiderationswhenencounteringpatientswithsnakebitesaredescribed.

Patientswithacutepresentationsstillrequirestartingwitharapidassessmentofthe
patient'sairway.Obstructionorrespiratoryfailurerequirestheacquisitionofa
definitiveairway,whichmightrequirerapidsequenceintubation(RSI).Breathingand
circulationshouldalsobeassessedintheinitialstateonceanairwayhasbeen
established.

Removethepatientfromthesnake'sterritoryassoonasstabilizationhasoccurred
inordertoavoidfurtherharm.

Removeanyjewelryorconstrictingclothingfromthepatient'saffectedarea.If
clothingisnotcausinganycompressionorconstriction,itcanbeleftaloneuntilthe
patientistransferredtoahospitalforfurthercare.

Intheimmediate/acutesetting,withholdallalcoholandanydrugsthatmayconfound
clinicalassessmentorinterferewithtreatment.

Donotmanipulatethewoundsite.Itisnotrecommendedtoincisethesiteor
performoralsuction.[10]

Furtherinpatientcare

Admissiontothehospitalisroutineformostenvenomationcases.A"drybite"
withoutenvenomationcanoccurinasignificantpercentageofcases(50%incoral
snake,25%frompitviper).Fordrypitviperbites,observeintheemergency
departmentfor810hourshowever,oftenthisisnotfeasible.Patientswithsevere
envenomationneedspecializedcareintheICUtoadministerbloodproducts,
provideinvasivemonitoring,andensureairwayprotection.Observecoralsnakebites
foraminimumof24hours.

Performserialevaluationsforfurthergradingandtoruleoutcompartment
syndrome.Dependingonclinicalscenarios,measurecompartmentpressuresevery
30120minutes.Fasciotomycanbeconsideredforpressuresgreaterthan3040
mmHg.However,fasciotomyhasnotbeenshowntoimproveoutcomes,evenwhen
compartmentpressuresareelevated,andisnotroutinelyindicatedforcrotalidsnake
envenomation.[11,12]

Dependingontheclinicalseverityofthebite,furtherbloodworkmaybeneeded,
especiallyclottingstudies,plateletcount,andfibrinogenlevel.Latecoagulopathy
hasbeenreportedafterusingFABAV.F(ab)2immunoglobulinderivativesunder
developmenthavealongerhalflifethanCroFabandhavebeenshowntodecrease

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latecoagulopathyafterantivenintreatment.[12,13]

PrehospitalCare
Aswithallmedicalemergencies,thegoalistosupportthepatientuntilarrivalatthe
emergencydepartment.Thedictum"primumnonocere"(first,donoharm)has
significantmeaningherebecausemanypoorlysubstantiatedtreatmentsmaycause
moreharmthangood,includingmakinganincisionoverthebite,mouthsuctioning,
tourniquetuse,icepacks,orelectricshock.

Appropriatefieldcareshouldadheretothebasictenantsofemergencylifesupport.

ReassurethepatientduringtheimplementationofABCs.

MonitorvitalsignsandestablishatleastonelargeboreIVandinitiatecrystalloid
infusion.Administeroxygentherapy.Keepaclosewatchontheairwayatalltimesin
caseintubationbecomesnecessary.

Restrictactivityandimmobilizetheaffectedarea(commonlyanextremity)keep
walkingtoaminimum.

Negativepressuresuctioningdevicesoffersomebenefitifusedwithinseveral
minutesofenvenomation.Again,donotmakeanincisioninthefield.

Immediatelytransfertodefinitivecare.

Donotgiveantivenininthefield.

EmergencyDepartmentCare
Physicianswhohavelittleexperiencetreatingsnakebitesfrequentlycareforsuch
patients.

Regionalcentersoftenhavemoreexperienceinthecareofsnakebitevictims.
Surgicalevaluationforanenvenomationvictimisparamount.

DefinitivetreatmentincludesreviewingtheABCsandevaluatingthepatientforsigns
ofshock(eg,tachypnea,tachycardia,drypaleskin,mentalstatuschanges,
hypotension).

Forvictimsofpitviper(crotalinesnake)bites,evenomationgradingdeterminesthe
needforantivenin.Gradesaredefinedasmild,moderate,orsevere.Mild
envenomationischaracterizedbylocalpain,edema,nosignsofsystemictoxicity,
andnormallaboratoryvalues.Moderateenvenomationischaracterizedbysevere
localpainedemalargerthan12inchessurroundingthewoundandsystemic
toxicityincludingnausea,vomiting,andalterationsinlaboratoryvalues(eg,
decreasedhematocritorplateletcount).Severeenvenomationischaracterizedby
generalizedpetechiae,ecchymosis,bloodtingedsputum,hypotension,
hypoperfusion,renaldysfunction,changesinprothrombintimeandactivatedpartial
thromboplastintime,andotherabnormaltestresultsdefiningconsumptive
coagulopathy.SeeTables1and2above.

Gradingenvenomationsisadynamicprocess.Overseveralhours,aninitiallymild
syndromemayprogresstoamoderateorevenseverereaction.

Forpitviperenvenomations,horseserumantiveninhasbeenavailablesince1956
apurerantiveninwithimprovedpropertieswasreleasedin2000(seeMedication).
Withthereducedsideeffectprofileofantigenbindingfragmentantivenom(FabAV)
andtheimprovementintissueinjurywithantiveninadministration,thethresholdfor
dosingislower.OnestudyfromthesouthwestUnitedStatesdemonstrateda
reductioninrateoffasciotomyaftermoreliberalFabAVdosing.[14]Inarandomized
studyofscheduledversusasneededFabAVdosinginpatientswhosesymptoms
wereworsening,theRockyMountainPoisonandDrugCenterdemonstrateda
reductioninpainandothervenomeffectsbutnoteda20%acuteand23%delayed
drugreaction.[15]

Althoughcopperheadbitesaregenerallyselflimiting,morbiditywasreducedin
moderateenvenomation4hoursafter4vialsofFabAVin88%ofcases.Thecases
thatfailedtorespondwerenotchangedbyfurtherFabAVdoses.[16]

FabAVisgenerallyconsideredsafeforchildren,asmanyofthestudiesdidnot
discriminateinage.OnelargestudyfromMexicodemonstratednoimmediateorlate
allergicreactionstoFabAVwhenadministeredaccordingtogradeofenvenomation.
[6]

AlthoughFabAVhelpscontrollocaltissueeffectsandhemotoxicity,aggressive
antivenomtherapydoesnotusuallyameliorateneurotoxiceffectssuchasmyokymia
(spontaneous,finefascicularcontractionsofmusclewithoutmuscularatrophyor
weakness)andmajormusclefasciculations.Thephysicianmustmaintain
continuousmonitoringofthosepatientswithmyokymiaespeciallyoftheshoulders,
chest,anddiaphragmforthedevelopmentofrespiratoryfailureandneedfor
mechanicalventilation.[17,18]

CoralsnakesarenotpitvipersandtheirbitesshouldnotbetreatedwithFabAV.A
previouslyavailableWyethantiveninforMicrurisfulviusisnolongermanufactured.
VictimsofbitesbyMfulvius(easterncoralsnake)andMtener(Texascoralsnake)
shouldreceivegeneralwoundcareandsupportivecare,includingrespiratory
supportintheeventofrespiratoryfailure.Poisoncontrolandtoxicologist
consultationshouldbecontactedforsuspectedcoralsnakeenvenomationstoobtain
thelatestlocationspecifictreatmentrecommendations.SeealsoCoralSnake
Envenomation.

SurgicalCare
Surgicalassessmentfocusesontheinjurysiteandconcernforthedevelopmentof

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compartmentsyndrome.Fasciotomyisindicatedonlyforthosepatientswith
objectiveevidenceofelevatedcompartmentpressure.Liberalmonitoringof
compartmentpressureiswarranted.Ifthisisnotavailable,usethephysicalhallmark
ofcompartmenthypertension(painwithpassiverangeofmotion),alongwithdistal
pallor,paresthesia,orpulselessnessfortheclinicalassessment.

Tissueinjuryaftercompartmentsyndromeisnotreversiblebutispreventable.

Consultations
Contactingthepoisoncontrolcenterisimportant.Consultationwithasurgeonoften
iswarrantedinbitemanagement.Generalandtraumasurgeonsoftenhave
experiencewithenvenomation,resuscitation,complications,andwoundcare.They
canleadtheinpatienttreatment.

Complications
Coagulopathy,includingdelayedcoagulopathy,isafrequentcomplicationofpitviper
snakebite.Localwoundcomplicationsmayincludeinfectionandskinloss.

Cardiovascularcomplications,hematologiccomplications,andpulmonarycollapse
mayoccur.Neurotoxicitywithmyokymiaoftherespiratorymusclesmayleadto
respiratoryfailureandmechanicalventilation.Truecompartmentsyndromeisarare
complication.Deathisrare.

Prolongedneuromuscularblockademayoccurfromcoralsnakeenvenomation.

Antiveninassociatedcomplicationsincludeimmediate(anaphylaxis,typeI)and
delayed(serumsickness,typeIII)hypersensitivityreactions.Anaphylaxisisanevent
mediatedbyimmunoglobulinE(IgE),involvingdegranulationofmastcellsthatcan
resultinlaryngospasm,vasodilatation,andleakycapillaries.Deathiscommon
withoutpharmacologicalintervention.Serumsicknessoccurs12weeksafter
administeringantivenin.PrecipitationofantigenimmunoglobulinG(IgG)complexes
intheskin,joints,andkidneysisresponsibleforthearthralgias,urticaria,and
glomerulonephritis(rarely).Usuallymorethan8vialsofantiveninmustbegivento
producethissyndrome.Supportivecareconsistsofantihistaminesandsteroids.
Newerstudiesnowreportalowerincidence(5.4%)ofacutehypersensitivity
reactionswithFabAV.[19]

Prevention
Wearprotectiveclothingandneverhandlesnakes.

Medication

ContributorInformationandDisclosures
Author
BrianJDaley,MD,MBA,FACS,FCCP,CNSCProfessorandProgramDirector,DepartmentofSurgery,Chief,
DivisionofTraumaandCriticalCare,UniversityofTennesseeHealthScienceCenterCollegeofMedicine

BrianJDaley,MD,MBA,FACS,FCCP,CNSCisamemberofthefollowingmedicalsocieties:American
AssociationfortheSurgeryofTrauma,EasternAssociationfortheSurgeryofTrauma,SouthernSurgical
Association,AmericanCollegeofChestPhysicians,AmericanCollegeofSurgeons,AmericanMedical
Association,AssociationforAcademicSurgery,AssociationforSurgicalEducation,ShockSociety,Societyof
CriticalCareMedicine,SoutheasternSurgicalCongress,TennesseeMedicalAssociation

Disclosure:Nothingtodisclose.

Coauthor(s)
SnehaBhat,MDResidentPhysician,DepartmentofSurgery,UniversityofTennesseeHealthScienceCenter
CollegeofMedicine

Disclosure:Nothingtodisclose.

SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference

Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.

DanielROuellette,MD,FCCPAssociateProfessorofMedicine,WayneStateUniversitySchoolofMedicine
ChairoftheClinicalCompetencyCommittee,PulmonaryandCriticalCareFellowshipProgram,SeniorStaffand
AttendingPhysician,DivisionofPulmonaryandCriticalCareMedicine,HenryFordHealthSystemChair,
GuidelineOversightCommittee,AmericanCollegeofChestPhysicians

DanielROuellette,MD,FCCPisamemberofthefollowingmedicalsocieties:AmericanCollegeofChest
Physicians,SocietyofCriticalCareMedicine,AmericanThoracicSociety

Disclosure:Nothingtodisclose.

ChiefEditor
JoeAlcock,MD,MSAssociateProfessor,DepartmentofEmergencyMedicine,UniversityofNewMexicoHealth
SciencesCenter

JoeAlcock,MD,MSisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine

Disclosure:Nothingtodisclose.

AdditionalContributors
LisaKirkland,MD,FACP,FCCM,MSHAAssistantProfessor,DepartmentofInternalMedicine,Divisionof
HospitalMedicine,MayoClinicViceChair,DepartmentofCriticalCare,ANWIntensivists,AbbottNorthwestern
Hospital

LisaKirkland,MD,FACP,FCCM,MSHAisamemberofthefollowingmedicalsocieties:AmericanCollegeof

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6/23/2016 Snakebite Treatment & Management: Severity of Envenomation, General Management Principles, Prehospital Care
Physicians,SocietyofHospitalMedicine,SocietyofCriticalCareMedicine

Disclosure:Nothingtodisclose.

ChandlerLong,MDResidentPhysician,DepartmentofSurgery,UniversityofTennesseeMedicalCenter
Knoxville

Disclosure:Nothingtodisclose.

AMariahAlexander,MDResidentPhysician,DepartmentofSurgery,UniversityofTennesseeGraduateSchool
ofMedicine,Knoxville

AMariahAlexander,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,Society
ofAmericanGastrointestinalandEndoscopicSurgeons

Disclosure:Nothingtodisclose.

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