Sea Snake Envenomation Workup

  • Author: Dimitrios Papanagnou, MD, MPH; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Feb 8, 2011
 

Laboratory Studies

  • Obtain arterial blood gas (ABG) measurements if the patient's respiratory status is questionable.
  • Myoglobinuria may be found on urinalysis, 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 CBC count. A leukocytosis higher than 20,000 cells/mm3 suggests significant envenomation.
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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.
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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.
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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.

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

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, James Foster, MD, to the development and writing of this article.

References

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  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].

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

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  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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Technique for application of pressure immobilization in field management of sea snake bites. Figure 1, Apply a broad-pressure bandage over the bite site as soon as possible. Do not take off jeans because the movement of doing so assists venom to enter the bloodstream. Keep the bitten leg still. Figure 2, The bandage should be as tight as would be applied to a sprained ankle. Figure 3, Extend the bandage as high as possible.
Technique for application of pressure immobilization in field management of sea snake bites. Figure 4, Apply a splint to the leg. Figure 5, Bind the splint firmly to as much of the leg as possible. If the bandages and splint are applied correctly, they will be comfortable and may be left on for several hours. They should not be taken off until the patient has reached medical care. The doctor will decide when to remove the bandages. If venom has been injected, it will move into the bloodstream quickly once the bandages are removed. The doctor should leave the bandages and splint in position until he or she has assembled appropriate antivenom and drugs that may need to be used when the dressings and splint are removed. Figure 6, For bites on a hand or forearm, bind to the elbow with bandages, use a splint to the elbow, and use a sling.
Yellow-belly pelagic sea snake.
 
 
 
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