Mohave Rattle Snake Envenomation Follow-up

  • Author: Sean P Bush, MD, FACEP; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: May 3, 2011
 

Further Inpatient Care

Admit

Strongly consider admission for all Mohave rattlesnake envenomations. Because patients with severe Mohave envenomation may present with only minimal local tissue effects, underestimation of a significant injury can easily occur. Because of the relative infrequency of the injury, admitting all patients with suspected Mohave rattlesnake envenomations is probably prudent and cost effective.

Effects of Mohave rattlesnake envenomation may be prolonged and have been shown to improve with late administration of antivenom.

  • Anaphylaxis
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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, 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.
  • Wound check at the physician's discretion on a case-by-case basis. Return to the ED or follow up every 3 days for 2 weeks with repeat CBC, PT/INR, and fibrinogen. Laboratory studies may need to be rechecked more or less frequently or for a longer or shorter duration on a case-by-case basis.
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Inpatient & Outpatient Medications

  • Administer antihistamines and steroids if serum sickness develops.
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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, patients 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.
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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.
  • Keep garage doors closed to prevent rattlesnakes from seeking shelter in garages.
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Complications

Antivenom-associated complications

Anaphylaxis is a type I (immediate) hypersensitivity reaction that may be life threatening. It is characterized by urticaria, wheezing laryngeal edema, 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. Anaphylaxis is treated with epinephrine, antihistamines, steroids, and ventilatory/circulatory support. Although experience is limited, immediate hypersensitivity is less common after treatment with CroFab.[7, 8]

Serum sickness is a type III (delayed) hypersensitivity reaction. It is characterized by fever, urticaria, lymphadenopathy, and arthritis and may occur 5 days to 3 weeks after Antivenin (Crotalidae) Polyvalent administration in as many as 50% of patients. Serum sickness is dose related and almost always occurs when more than 8 vials of antivenin (Crotalidae) polyvalent are administered. Although serum sickness can be an uncomfortable experience, 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.

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Prognosis

  • Full recovery is usually anticipated.
  • Before antivenom, estimates of mortality rates ranged from 5-25%.
  • Because of the development of antivenom, rapid EMS transport, and emergency/intensive care, mortality rates have improved to 0.28% (or better) when antivenom is administered and to 2.6% when antivenom is not administered.
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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.
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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
  1. French WJ, Hayes WK, Bush SP, Cardwell MD, Bader JO, Rael ED. Mojave toxin in venom of Crotalus helleri (Southern Pacific Rattlesnake): molecular and geographic characterization. Toxicon. Dec 1 2004;44(7):781-91. [Medline].

  2. Farstad D, Thomas T, Chow T, Bush S, Stiegler P. Mojave rattlesnake envenomation in southern California: a review of suspected cases. Wilderness Environ Med. May 1997;8(2):89-93. [Medline].

  3. Hardy DL. Envenomation by the Mojave rattlesnake (Crotalus scutulatus scutulatus) in southern Arizona, U.S.A. Toxicon. 1983;21(1):111-8. [Medline].

  4. Hardy DL. Fatal rattlesnake envenomation in Arizona: 1969-1984. J Toxicol Clin Toxicol. 1986;24(1):1-10. [Medline].

  5. Wingert WA, Chan L. Rattlesnake bites in southern California and rationale for recommended treatment. West J Med. Jan 1988;148(1):37-44. [Medline].

  6. Glenn JL, Straight RC. Intergradation of two different venom populations of the Mojave rattlesnake (Crotalus scutulatus scutulatus) in Arizona. Toxicon. 1989;27(4):411-8. [Medline].

  7. Bush SP, Jansen PW. Severe rattlesnake envenomation with anaphylaxis and rhabdomyolysis. Ann Emerg Med. Jun 1995;25(6):845-8. [Medline].

  8. Bush SP, Jansen PW. Severe rattlesnake envenomation with anaphylaxis and rhabdomyolysis. Ann Emerg Med. Jun 1995;25(6):845-8. [Medline].

  9. Jansen PW, Perkin RM, Van Stralen D. Mojave rattlesnake envenomation: prolonged neurotoxicity and rhabdomyolysis. Ann Emerg Med. Mar 1992;21(3):322-5. [Medline].

  10. Bronstein AC, Spyker DA, Cantilena LR Jr, Green J, Rumack BH, Heard SE. 2006 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clin Toxicol (Phila). Dec 2007;45(8):815-917. [Medline].

  11. Carroll RR, Hall EL, Kitchens CS. Canebrake rattlesnake envenomation. Ann Emerg Med. Jul 1997;30(1):45-8. [Medline].

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

  13. 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].

  14. 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].

  15. Bush SP, Cardwell MD. Mojave rattlesnake (Crotalus scutulatus scutulatus) identification. Wilderness Environ Med. Spring 1999;10(1):6-9. [Medline].

  16. Clark RF, Williams SR, Nordt SP, Boyer-Hassen LV. Successful treatment of crotalid-induced neurotoxicity with a new polyspecific crotalid Fab antivenom. Ann Emerg Med. Jul 1997;30(1):54-7. [Medline].

  17. 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].

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Mohave rattlesnake (Crotalus scutulatus). Note the diamond pattern fades into bands along the caudal third of the back and the white tail rings are wider than the black. Photo by Sean Bush, MD.
This is the typical appearance of a southern California Mohave rattlesnake bite site. Photo by Sean Bush, MD.
Mohave rattlesnake (Crotalus scutulatus). Photo by Sean Bush, MD.
A red diamond rattlesnake (Crotalus ruber). The postocular light stripe extends above the angle of the mouth in Mohave rattlesnakes. Photo by Sean Bush, MD.
This is a juvenile Mohave rattlesnake (postmortem). Note that the diamondback pattern fades into bands along the latter part of the snake's dorsum. Photo by Sean Bush, MD.
A western diamondback rattlesnake (Crotalus atrox). Photo by Sean Bush, MD.
 
 
 
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