Snakebite Follow-up

  • Author: Brian James Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 14, 2010
 

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.
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Further Outpatient Care

Limit outpatient care to local wound care.

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Deterrence/Prevention

Wear protective clothing and never handle snakes.

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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.[10]
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Prognosis

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

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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.
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Contributor Information and Disclosures
Author

Brian James Daley, MD, MBA, FACS, FCCP, CNSC  Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC 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.

Coauthor(s)

A Mariah Alexander, MD  Resident Physician, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville

A Mariah Alexander, MD is a member of the following medical societies: American College of Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St 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

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Weinstein S, Dart R, Staples A, White J. Envenomations: an overview of clinical toxinology for the primary care physician. Am Fam Physician. Oct 15 2009;80(8):793-802. [Medline].

  2. Spiller HA, Bosse GM. Prospective study of morbidity associated with snakebite envenomation. J Toxicol Clin Toxicol. 2003;41(2):125-30. [Medline].

  3. Scharman EJ, Noffsinger VD. Copperhead snakebites: clinical severity of local effects. Ann Emerg Med. Jul 2001;38(1):55-61. [Medline].

  4. Sotelo N. Review of treatment and complications in 79 children with rattlesnake bite. Clin Pediatr (Phila). Jun 2008;47(5):483-9. [Medline].

  5. Corneille MG, Larson S, Stewart RM, et al. A large single-center experience with treatment of patients with crotalid envenomations: outcomes with and evolution of antivenin therapy. Am J Surg. Dec 2006;192(6):848-52. [Medline].

  6. Dart RC, Seifert SA, Boyer LV, et al. A randomized multicenter trial of crotalinae polyvalent immune Fab (ovine) antivenom for the treatment for crotaline snakebite in the United States. Arch Intern Med. Sep 10 2001;161(16):2030-6. [Medline].

  7. Lavonas EJ, Gerardo CJ, O'Malley G, et al. Initial experience with Crotalidae polyvalent immune Fab (ovine) antivenom in the treatment of copperhead snakebite. Ann Emerg Med. Feb 2004;43(2):200-6. [Medline].

  8. Vohra R, Cantrell FL, Williams SR. Fasciculations after rattlesnake envenomations: a retrospective statewide poison control system study. Clin Toxicol (Phila). Feb 2008;46(2):117-21. [Medline].

  9. Richardson WH, Goto CS, Gutglass DJ, Williams SR, Clark RF. Rattlesnake envenomation with neurotoxicity refractory to treatment with crotaline Fab antivenom. Clin Toxicol (Phila). Jun-Aug 2007;45(5):472-5. [Medline].

  10. Cannon R, Ruha AM, Kashani J. Acute hypersensitivity reactions associated with administration of crotalidae polyvalent immune Fab antivenom. Ann Emerg Med. Apr 2008;51(4):407-11. [Medline].

  11. Cowles RA, Colletti LM. Presentation and treatment of venomous snakebites at a northern academic medical center. Am Surg. May 2003;69(5):445-9. [Medline].

  12. Holstege CP, Singletary EM. Images in emergency medicine. Skin damage following application of suction device for snakebite. Ann Emerg Med. Jul 2006;48(1):105, 113. [Medline].

  13. Hunsaker DM, Hunsaker JC 3rd, Clayton T, Spiller HA. Lethal envenomation: medicolegal aspects of snakebites and religious snake handlers in Kentucky: a report of three cases with comment on medical, legal, and public policy ramifications. J Ky Med Assoc. Nov 2005;103(11):542-56. [Medline].

  14. Jordan GH, Deitch EA, Britt LD. Management of Poisonous Snakebites. American College of Surgeons: Consensus statement. 1997.

  15. Kravitz J, Gerardo CJ. Copperhead snakebite treated with crotalidae polyvalent immune fab (ovine) antivenom in third trimester pregnancy. Clin Toxicol (Phila). 2006;44(3):353-4. [Medline].

  16. Kularatne SA, Kumarasiri PV, Pushpakumara SK, et al. Routine antibiotic therapy in the management of the local inflammatory swelling in venomous snakebites: results of a placebo-controlled study. Ceylon Med J. Dec 2005;50(4):151-5. [Medline].

  17. Lavonas EJ, Gerardo CJ, O'Malley G, et al. Initial experience with Crotalidae polyvalent immune Fab (ovine) antivenom in the treatment of copperhead snakebite. Ann Emerg Med. Feb 2004;43(2):200-6. [Medline].

  18. Schmidt JM. Antivenom therapy for snakebites in children: is there evidence?. Curr Opin Pediatr. Apr 2005;17(2):234-8. [Medline].

  19. Shires TG, Thal ER, Jones RC. Trauma. Principles of Surgery. 1994;6:183-5.

  20. Stewart RM, Page CP. Wounds, Bites, and Stings. Trauma. 1996;3:929-34.

  21. Sullivan JB, Wingert WA, Norris Jr RL. North American Venomous Reptile Bites. Wilderness Medicine: Management of Wilderness and Environmental Emergencies. 1995;3:680-709.

  22. Whitley RE. Conservative treatment of copperhead snakebites without antivenin. J Trauma. Aug 1996;41(2):219-21. [Medline].

 
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Snakebite. Western diamondback rattlesnake.
Snakebite. Western coral snake.
Snakebite. Southern Copperhead snake, from snakesandfrogs.com
Snakebite. Copperhead bite day 3; initial wounds to finger.
Snakebite. Copperhead bite day 3; initial wounds to finger.
Snakebite. Copperhead bite day 3; initial wounds to finger.
Snakebite. Comparison of the harmless Lampropeltis triangulum annulata (Mexican milksnake) (top) with Micrurus tener (Texas coral snake) (bottom). Photo by Charles Alfaro.
Snakebite. Juvenile southern Pacific rattlesnake (Crotalus oreganus helleri). Photo by Sean Bush, MD.
Snakebite. Moderate rattlesnake envenomation in a toddler after treatment with antivenom. Photo by Sean Bush, MD.
 
 
 
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