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Snake Envenomation, Rattle: Follow-up
Updated: Jul 24, 2008
Follow-up
Further Inpatient Care
- All patients with rattlesnake envenomation should be admitted to the hospital and remain there while undergoing treatment with antivenom. Close observation and frequent measurements of swelling (every 1-2 h) for approximately 24 hours after initial control is recommended.
- Patients who are believed to have a dry bite in which no venom effects develop should be observed for at least 8 hours. A close follow-up and/or recheck examination is recommended.
- Several reports in the literature have documented instances in which patients who were initially discharged with a mild envenomation returned in several hours with significant injury and required antivenom and admission.
Further Outpatient Care
- Discharge instructions should include the following:
- Return immediately if swelling worsens or pain becomes severe.
- Return immediately if any abnormal bleeding or bruising, petechiae, dark tarry stools, or severe headache occur.
- Return for signs of wound infection, such as swelling, excessive tenderness, redness or streaks, heat, or drainage (pus).
- Return or follow up if a fever, itchy rash, joint pain, or swollen lymph nodes occur any time during the next few weeks.
- Do not take nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Motrin, Advil), or naproxen (Naprosyn, Aleve) for 2 weeks after the snakebite. Acetaminophen (Tylenol) or a prescribed pain medication can be taken.
- Do not participate in contact sports, undergo elective surgery, or have dental work for 2 weeks after the snakebite.
- Drink plenty of liquids. Return if urine decreases in amount or becomes cola colored.
- Referral to a physical therapist or surgeon may be indicated. If bitten on the foot or leg, crutches and crutch training should be provided. Elevate and mobilize affected extremity as tolerated.
- Next day wound check should be performed at the physician's discretion on a case-by-case basis. The patient should return to the ED or follow up every 3 days for 2 weeks with repeat CBC, PT/INR, and fibrinogen. Laboratory results may need to be rechecked more or less frequently or for a longer or shorter duration on a case-by-case basis.
Inpatient & Outpatient Medications
- Administer antihistamines if serum sickness develops. Steroids may be indicated for more severe cases of serum sickness.
Transfer
- All hospitals should have enough antivenom to treat at least one patient. However, antidote stocking varies and shortages do occur. Therefore, if antivenom is not available at the presenting hospital, the patient should be transferred to a facility where antivenom may be administered. However, if it is available, antivenom may be necessary to optimize stabilization of a patient prior to transfer.
Deterrence/Prevention
- Never handle a rattlesnake, even if it is believed to be dead. Serious, even fatal, envenomations have been documented to occur after handling the decapitated head of a rattlesnake up to 90 minutes after it was severed.
- Do not reach or step into places outdoors that are not visible.
- At home, remove debris in which snakes might hide (eg, log piles). Remove items, such as bird feeders, that might attract snakes—seeds that fall from bird feeders attract rodents, which attract snakes.
- Heavy clothing (such as hiking boots) may retard some strikes.
- Young children should be closely supervised, and older children should be educated to avoid snakes in indigenous areas.
- Keep the garage door closed to prevent rattlesnakes from seeking shelter in the garage.
- Many cases of envenomation involve alcohol. Do not use alcohol and place oneself in an environment that may be shared with rattlesnakes or play with snakes while intoxicated.
Complications
- Bleeding, such as gastrointestinal or intracranial
- Compartment syndrome
- Necrosis with resulting tissue loss or loss of function
- Rhabdomyolysis, myoglobinuric renal failure
- Infection
- Respiratory difficulty
- Death (rare in the United States)
- Antivenom-associated complications
- Anaphylaxis is a type I (immediate) hypersensitivity reaction, which may be life threatening. It is characterized by urticaria, airway swelling, wheezing, and shock. Some degree of anaphylaxis may occur in as many as 25% of patients given Antivenin (Crotalidae) Polyvalent. Risk factors include previous exposure to horse serum or antivenom or a history of reactive airways. Immediate hypersensitivity is treated with epinephrine, antihistamines, steroids, and ventilatory/circulatory support, as needed. Although experience is limited, immediate hypersensitivity is less common after treatment with CroFab.
- Serum sickness is a type III (delayed) hypersensitivity reaction. It is characterized by fever, urticaria, lymphadenopathy, and arthritis and may occur 3 days to 3 weeks after Antivenin (Crotalidae) Polyvalent administration in as many as 50% of patients. Serum sickness is dose-related; it almost always occurs when more than 8 vials of Antivenin (Crotalidae) Polyvalent are administered. Although serum sickness can be uncomfortable, it is usually benign and self-limited and is treated with steroids and antihistamines. Delayed hypersensitivity is much less common after treatment with CroFab, although experience with this relatively new medication is limited.
Prognosis
- Before antivenom, estimates of mortality rates ranged from 5-25%.
- Since the development of antivenom, rapid EMS transport, and emergency/intensive care, mortality rates have improved to less than 0.28% when antivenom is administered and to 2.6% when antivenom is not administered.
- Less specific figures are available for morbidity data, although most patients recover fully after rattlesnake envenomation. The best estimates suggest that rattlesnake envenomation results in tissue loss, deformity, or loss of function in approximately 10% of patients.
Patient Education
- Call professionals, such as animal control, to move snakes (if it is necessary to move the snake).
- Never attempt to handle, possess, or kill venomous reptiles.
- For patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education article Snakebite.
Miscellaneous
Medicolegal Pitfalls
- Medicolegal problems may occur when a patient is sent home with a diagnosis of mild or no envenomation but subsequently returns with significant envenomation and requires antivenom and/or admission.
- Failure to treat with antivenom, when indicated, is a pitfall.
- Delays from the time the patient seeks medical care and the time the patient is treated are often cited in litigation.
- If possible, obtain informed consent before administering antivenom.
- Inform the patient that loss of tissue or function may result from rattlesnake envenomation and that antivenom and/or surgery may not prevent it.
Special Concerns
- Envenomation is an uncommon occurrence with an extremely variable presentation, ranging from no ill effects to multisystem failure and death.
- Treatment of envenomation is often based on speculation and anecdote, and much of the literature is contradictory. Although controversy exists, the authors have attempted to keep recommendations in agreement with the most current standards of care.
- These are guidelines, and the clinician should use judgment for individual patient encounters.
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References
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Further Reading
Keywords
rattlesnake, rattlesnake bite, rattlesnake venom, rattlesnake envenomation, Crotalus species, Sistrurus species, rattle snake envenomation, pit vipers
