eMedicine Specialties > Emergency Medicine > Environmental

Snake Envenomation Overview: Follow-up

Author: Brian James Daley, MD, MBA, FACS, Associate Program Director, Professor, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee School of Medicine
Contributor Information and Disclosures

Updated: Aug 20, 2009

Follow-up

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 is indicated for pressures greater than 30-40 mm Hg.
  • Depending on the clinical severity of the bite, further blood work may be needed, especially clotting studies, platelet count, and fibrinogen level.

Further Outpatient Care

Limit outpatient care to local wound care.

Deterrence/Prevention

Wear protective clothing and never handle snakes.

Complications

  • Compartment syndrome is the most 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.
  • 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.9

Prognosis

Full recovery is the rule, though local complications from envenomation may occur. Death occurs in less than 1 bite in 5000.

Patient Education

  • For excellent patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education article Snakebite.
  • A new web site (Australian Venom Research Unit) based at the University of Melbourne in Australia comprehensively outlines the species, first aid, and treatment of all venomous creatures indigenous to the region. The web site is easily navigated and sectionally divided for the practitioner, interested epidemiologists, snake fanciers, and children of Australia and the Asia/Pacific region.

Miscellaneous

Medicolegal Pitfalls

  • Overnight observation in the hospital allows staff to quickly diagnose delayed signs and symptoms.
  • Envenomation determination is time-independent.
  • Determining the genus of the snake may be difficult.
    • Because most snakebites happen with known or visualized snakes, at least their physical characteristics can be determined.
    • Knowledge of indigenous snakes, from either local experts or zoological experts, can be helpful.
 


More on Snake Envenomation Overview

Overview: Snake Envenomation Overview
Differential Diagnoses & Workup: Snake Envenomation Overview
Treatment & Medication: Snake Envenomation Overview
Follow-up: Snake Envenomation Overview
Multimedia: Snake Envenomation Overview
References
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References

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Further Reading

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Keywords

snakebite, snake bite treatment, snake envenomation, poisonous snakes, Crotalidae, Elapidae, pit vipers, rattlesnakes, copperheads, coral snakes, Crotalus, Sistrurus, Agkistrodon, Micrurus fulvius fulvius, Micrurus fulvius tenere, venom, antivenin

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Contributor Information and Disclosures

Author

Brian James Daley, MD, MBA, FACS, Associate Program Director, Professor, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee School of Medicine
Brian James Daley, MD, MBA, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Lisa Kirkland, MD, FACP, CNSP, MSHA, Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital
Lisa Kirkland, MD, FACP, CNSP, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, and Society of Hospital Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Daniel R Ouellette, MD, FCCP, Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System
Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Boehringer Ingleheim Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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