Rattle Snake Envenomation Treatment & Management

  • Author: Sean P Bush, MD, FACEP; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Nov 2, 2010
 

Prehospital Care

Do nothing to injure the patient or impede travel to the ED.

  • Give general support of airway, breathing and circulation per advanced cardiac life support (ACLS) protocol with oxygen, monitors, 2 large bore intravenous lines, and fluid challenge. Minimize activity (if possible), remove jewelry or tight-fitting clothes in anticipation of swelling, and transport the patient to the ED as quickly and as safely as possible. Use a pen to mark and time the border of advancing edema often enough to gauge progression.
  • In some studies, no benefit was demonstrated when a negative pressure venom extraction device (eg, The Extractor from Sawyer Products) was evaluated; additional injury can result.[17, 18] Incision across fang marks is not recommended. Mouth suction is contraindicated. A recent study suggests that the Extractor (SawyerA recent study suggests that the Extractor (Sawyer Products) does not reduce swelling after rattlesnake envenomation and may be associated with skin necrosis beneath the suction cup. Photo by Sean Bush, MD.
  • Lymphatic constriction bands and pressure immobilization techniques may inhibit the spread of venom, but whether they improve outcome is not clear.[19, 20] Limiting venom spread actually may be deleterious for pit viper envenomation if it increases local necrosis or compartment pressure. Tourniquets are not recommended.
  • Maintain the extremity in a neutral position.
  • First aid techniques that lack therapeutic value or are potentially more harmful than the snakebite include electric shock, alcohol, stimulants, aspirin, placing ice on the wound, and various folk and herbal remedies. Cost and risk of acute adverse reactions generally preclude field use of antivenom.
  • Attempts to capture or kill the snake cannot be recommended because of the risk of additional injury. If uncertainty exists about whether a particular snake is venomous, consider taking photographs of the snake from a safe distance of at least 6 feet away using a digital or Polaroid camera.
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Emergency Department Care

Adequate hydration with intravenous fluids is indicated. Patients with hypotension should be resuscitated first with two isotonic sodium chloride solution challenges (eg, 20 mL/kg). Treat persistent shock with colloids, followed by pressors as indicated.

Administer antivenom for signs of envenomation progression or imminent risk of an acute complication of envenomation (see Complications). Because CroFab appears safer than Antivenin Crotalidae Polyvalent,[21, 22] it is indicated even if the envenomation is minimal or mild.[23, 24] It should be given as a preventative measure if any signs of envenomation exist. Do not wait for the envenomation to get worse—permanent injury could result.

It is emphasized that grading envenomations is a dynamic process and additional antivenom should be given as indicated by a worsening clinical course. When considering the use of antivenom, the risk of adverse reaction to antivenom must be weighed against the benefits of reducing venom toxicity.[25] Alternatives (eg, a different type of antivenom, if available) should be considered as well.

  • Nonenvenomation, ie, dry bite (probably occurs in < 10% of rattlesnake bites, although estimates as high as 50% exist)
    • Local effects - Puncture wounds only
    • Systemic effects - None
    • Coagulation abnormalities - No laboratory evidence of coagulation abnormalities and no clinical evidence of abnormal bleeding or clotting
  • Minimal or mild envenomation
    • Local effects - Swelling, pain, tenderness, and/or ecchymosis confined to the immediate bite area
    • Systemic effects - None
    • Coagulation abnormalities - No laboratory evidence of coagulation abnormalities and no clinical evidence of abnormal bleeding or clotting
  • Moderate envenomation
    • Local effects - Swelling, pain, tenderness, and/or ecchymosis extending beyond the immediate bite area but involving less than the entire part
    • Systemic effects - Present but not life threatening; may include nausea, vomiting, oral paresthesias or unusual tastes, fasciculations (myokymia), mild hypotension (systolic blood pressure < 90 mm Hg), mild tachycardia (heart rate < 150 bpm), and tachypnea
    • Coagulation abnormalities - Laboratory evidence of coagulation abnormalities may be present, but no clinical evidence of abnormal bleeding or clotting exists; rattlesnake venom-induced coagulopathies commonly include thrombocytopenia, decreased fibrinogen, and/or elevated PT
  • Severe envenomation
    • Local effects - Swelling, pain, tenderness, and/or ecchymosis extending beyond the entire extremity or threatening the airway
    • Systemic effects - May include severe hypotension or shock, severe tachycardia or tachypnea, respiratory insufficiency, and/or severe altered mental status
    • Coagulation abnormalities - Markedly abnormal with serious bleeding or severe threat of bleeding
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Consultations

The American Association of Poison Control Centers may assist in the management of envenomations.

For assistance regarding use of CroFab for a patient bitten by a snake, contact the CroFab hotline at 1-87-SERPDRUG (1-877-377-3784).

Consider consulting a surgeon (eg, general, orthopedic, hand) if compartment syndrome is suspected.

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Contributor Information and Disclosures
Author

Sean P Bush, MD, FACEP  Professor of Emergency Medicine, Loma Linda University School of Medicine; Consulting Staff, Envenomation Specialist, Department of Emergency Medicine, Loma Linda University Medical Center

Sean P Bush, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, International Society on Toxicology, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Protherics Consulting fee Consulting; Nycomed (formerly Fougera) Grant/research funds Speaking and teaching; Rare Disease Therapeutics Grant/research funds Research; Bioclon Grant/research funds Research

Specialty Editor Board

Robert L Norris, MD  Professor, Department of Surgery, Chief, Division of Emergency Medicine, Stanford University Medical Center

Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, California Medical Association, International Society of Toxinology, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

James Steven Walker, DO, MS  Clinical Professor of Surgery, Department of Surgery, University of Oklahoma College of Medicine

James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

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

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  16. Spaite D, Dart R, Sullivan JB. Skin testing in cases of possible crotalid envenomation. Ann Emerg Med. Jan 1988;17(1):105-6. [Medline].

  17. Bush SP. Snakebite suction devices don't remove venom: they just suck. Ann Emerg Med. Feb 2004;43(2):187-8. [Medline].

  18. Bush SP, Hegewald KG, Green SM, Cardwell MD, Hayes WK. Effects of a negative pressure venom extraction device (Extractor) on local tissue injury after artificial rattlesnake envenomation in a porcine model. Wilderness Environ Med. Fall 2000;11(3):180-8. [Medline].

  19. Bush SP, Green SM, Laack TA, Hayes WK, Cardwell MD, Tanen DA. Pressure immobilization delays mortality and increases intracompartmental pressure after artificial intramuscular rattlesnake envenomation in a porcine model. Ann Emerg Med. Dec 2004;44(6):599-604. [Medline].

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  21. Consroe P, Egen NB, Russell FE, Gerrish K, Smith DC, Sidki A, et al. Comparison of a new ovine antigen binding fragment (Fab) antivenin for United States Crotalidae with the commercial antivenin for protection against venom-induced lethality in mice. Am J Trop Med Hyg. Nov 1995;53(5):507-10. [Medline].

  22. Bush SP, Wu VH, Corbett SW. Rattlesnake venom-induced thrombocytopenia response to Antivenin (Crotalidae) Polyvalent: a case series. Acad Emerg Med. Feb 2000;7(2):181-5. [Medline].

  23. Bush SP, Green SM, Moynihan JA, Hayes WK, Cardwell MD. Crotalidae polyvalent immune Fab (ovine) antivenom is efficacious for envenomations by Southern Pacific rattlesnakes (Crotalus helleri). Ann Emerg Med. Dec 2002;40(6):619-24. [Medline].

  24. Dart RC, Seifert SA, Carroll L, Clark RF, Hall E, Boyer-Hassen LV, et al. Affinity-purified, mixed monospecific crotalid antivenom ovine Fab for the treatment of crotalid venom poisoning. Ann Emerg Med. Jul 1997;30(1):33-9. [Medline].

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  29. Clark RF, Selden BS, Furbee B. The incidence of wound infection following crotalid envenomation. J Emerg Med. Sep-Oct 1993;11(5):583-6. [Medline].

 
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Juvenile southern Pacific rattlesnake (Crotalus oreganus helleri). Photo by Sean Bush, MD.
A recent study suggests that the Extractor (Sawyer Products) does not reduce swelling after rattlesnake envenomation and may be associated with skin necrosis beneath the suction cup. Photo by Sean Bush, MD.
Moderate rattlesnake envenomation in a toddler after treatment with antivenom. Photo by Sean Bush, MD.
 
 
 
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