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Snake Envenomation, Sea: Differential Diagnoses & Workup

Author: Dimitrios Papanagnou, MD, MPH, Staff Physician, Department of Emergency Medicine, Bellevue Hospital Center
Coauthor(s): Susi U Vassallo, MD, FACEP, FACMT, Assistant Professor of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center
Contributor Information and Disclosures

Updated: Nov 6, 2008

Differential Diagnoses

Guillain-Barré Syndrome
Snake Envenomations, Moccasins
Rhabdomyolysis
Snake Envenomations, Rattle
Snake Envenomation, Mohave Rattle
Snake Envenomations, Cobra
Snake Envenomations, Coral

Workup

Laboratory Studies

  • Obtain arterial blood gas (ABG) measurements if the patient's respiratory status is questionable.
  • Urinalysis
    • Myoglobinuria may be found, typically 3-6 hours following envenomation.
    • The urine may test positive for protein and occult blood 1 hour before myoglobin is detected.
  • Creatine kinase (CK) level may be elevated secondary to muscle damage.
  • Serum glutamic-oxaloacetic transaminase (SGOT) level may be elevated secondary to muscle damage.
  • Electrolyte levels may reveal hyperkalemia from myonecrosis.
  • Assess blood urea nitrogen (BUN) and creatine levels to monitor renal function.
  • Obtain a complete blood count (CBC). A leukocytosis higher than 20,000 cells/mm3 suggests significant envenomation.

Imaging Studies

  • Chest radiography: This is useful to exclude other causes of respiratory distress and is mandatory in patients requiring intubation and mechanical ventilation.
  • Soft tissue and bone films of the bitten extremity: Radiographs may reveal embedded fangs and/or underlying osseous injury.
  • Bedside ultrasonography: As ultrasonography is becoming a more useful adjunct to physical examination in the emergency department, bedside imaging may facilitate identifying retained fangs at the site of venomous inoculation.

Other Tests

  • An electrocardiogram (ECG) is useful to look for signs of hyperkalemia, including peaked T waves, a widened QRS complex, or ventricular arrhythmias.
  • Before antivenom administration, if time permits, skin testing to assess for allergy to horse serum is indicated, but it is not mandatory if the patient is unstable. The results of skin testing are not completely reliable.
    • Intradermal injection of 0.02-0.03 mL of a 1:10 dilution of normal horse serum is the most commonly described technique; however, the test is more accurate if a 1:10 dilution of actual reconstituted antivenom is used.
    • Skin test results are positive if a wheal develops in 5-30 minutes.

More on Snake Envenomation, Sea

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

  1. Food and Agriculture Organization. Sea Snakes. United Nations; August 2007. [Full Text].

  2. Ditmars RL. The MacMillan Company. Reptiles of the World, Revised Edition. 1933:329, pp 89.

  3. Auerbach PS. Marine envenomations. N Engl J Med. Aug 15 1991;325(7):486-93. [Medline].

  4. Auerbach PS. Marine envenomations. In: Auerbach PS, ed. Wilderness Medicine: Management of Wilderness and Environmental Emergencies. 3rd ed. Mosby-Year Book; 1995:1327-74.

  5. Baxter EH, Gallichio HA. Cross-neutralization by tiger snake (Notechis scutatus) antivenene and sea snake (Enhydrina schistosa) antivenene against several sea snake venoms. Toxicon. May 1974;12(3):273-8. [Medline].

  6. Chetty N, Du A, Hodgson WC, et al. The in vitro neuromuscular activity of Indo-Pacific sea-snake venoms: efficacy of two commercially available antivenoms. Toxicon. Aug 2004;44(2):193-200. [Medline].

  7. Dunson WA. The Biology of Sea Snakes. Baltimore, Md: University Park Press; 1975.

  8. Guenin DG, Auerbach PS. Trauma and envenomations from marine fauna. In: Tintinalli, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw-Hill; 1996:868-73.

  9. Heatwole H. Sea Snakes. Krieger Publishing Company; 1999.

  10. Minton SA Jr. Paraspecific protection by elapid and sea snake antivenins. Toxicon. Jul 1967;5(1):47-55. [Medline].

  11. Pinney R. Sea snakes. Reptile & Amphibian. 1994;26:22-34.

  12. Reid HA. Antivenom in sea-snake bit poisoning. Lancet. Mar 15 1975;1(7907):622-3. [Medline].

  13. Reid HA. Epidemiology of sea-snake bites. J Trop Med Hyg. May 1975;78(5):106-13. [Medline].

  14. Reid HA, Chan KE. The paradox in therapeutic defibrination. Lancet. Mar 9 1968;1(7541):485-6. [Medline].

  15. Senanayake MP, Ariaratnam CA, Abeywickrema S. Two Sri Lankan cases of identified sea snake bites, without envenoming. Toxicon. Jun 1 2005;45(7):861-3. [Medline].

  16. Tu AT. Biotoxicology of sea snake venoms. Ann Emerg Med. Sep 1987;16(9):1023-8. [Medline].

  17. Tu AT, Fulde G. Sea snake bites. Clin Dermatol. Jul-Sep 1987;5(3):118-26. [Medline].

  18. Vick JA. Medical studies of poisonous land and sea snakes. J Clin Pharmacol. Jun 1994;34(6):709-12. [Medline].

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Further Reading

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Keywords

sea snake envenomation, sea snake bite, sea snakes, snake bite, Hydrophiidae, Pelamis platurus, P platurus, Enhydrina schistosa, E schistosa, sea snake venom, neurotoxins, myotoxins, snake envenomations, sea snake neurotoxin, sea snake wound

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Contributor Information and Disclosures

Author

Dimitrios Papanagnou, MD, MPH, Staff Physician, Department of Emergency Medicine, Bellevue Hospital Center
Dimitrios Papanagnou, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Student Association/Foundation, and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Coauthor(s)

Susi U Vassallo, MD, FACEP, FACMT, Assistant Professor of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center
Susi U Vassallo, MD, FACEP, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, New York Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robert L Norris, MD, Associate 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.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & 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.

Managing Editor

James Steven Walker, DO, MS, Clinical Professor of Surgery, Department of Surgery, University of Oklahoma Health Sciences Center
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.

CME Editor

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

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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