Brown Snake Envenomation Treatment & Management

  • Author: David Cheng, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 20, 2011
 

Prehospital Care

The goals of prehospital treatment include implementing basic and advanced life support algorithms and ensuring an adequate airway. Consider immobilization of the cervical spine if trauma to the cervical spine is suspected.

  • Assess if breathing is adequate. Consider endotracheal intubation if indicated.
  • Provide fluid support for hypotension, as well as cardiopulmonary resuscitation (CPR), and administer chemical adjuncts for cardiovascular compromise if necessary.
  • Remove patient from further potential harm and institute local wound care. This includes immobilizing the affected limb and maintaining it at the level of the heart. Do not tamper with the bite and avoid potentially harmful procedures such as mouth suction, local application of electrical shock or ice, or cauterization or incision of the bite. Possible complications of these techniques may result in ischemia, gangrene, damage to nerves, congestion, edema, or increased bleeding.
  • An elastic bandage placed at the bite site and wrapped proximally to include the entire limb may delay absorption of the neurotoxin into the systemic circulation. Care should be taken not to remove the compression bandage until antivenin therapy is instituted. The bandage should not compromise arterial circulation.
  • Attempt to identify the snake, but avoid protracted attempts to locate or capture the snake. If the snake is from a research center or zoo, send specific antivenin with the patient if possible.
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Emergency Department Care

  • Stabilization of airway, breathing, and circulation
  • Oxygen
  • Avoid nasotracheal intubation to prevent epistaxis.
  • Intravenous access, cardiac monitoring, and continuous pulse oximetry
  • Tetanus prophylaxis

Administer antivenin therapy as soon as possible if any signs of systemic involvement are present because the antivenin may reverse coagulopathy. Skin testing before administration of antivenin is not recommended because it delays treatment of this very toxic venom. Furthermore, larger initial doses should be considered if severe envenomation from multiple bites is evident. The dose of antivenom for children should not be reduced since the amount of venom injected by the snake is independent of the victim's size. The improvement of fibrinogen levels, coagulation parameters, and the patient's condition function as surrogate indicators of venom neutralization. A recent study suggests that 5 ampules will adequately treat two thirds of the patients with severe envenomation, but 10 ampules will adequately treat 89% of these patients.[2]

Before the antivenin is given, premedicate the patient with an antihistamine, and continue the antihistamine for 5 days to prevent anaphylaxis.

Administer corticosteroids if any history of previous serum sickness or allergic reaction to the antivenin is present or for administration of large doses of antivenin.

Pregnancy is not a contraindication to giving antivenin.

Edrophonium, neostigmine, and atropine may be given to temporarily reverse respiratory weakness until antivenin is obtained, but it should not delay necessary intubation.

In the treatment of venom-induced consumptive coagulopathy, administration of FFP and/or cryoprecipitate is controversial; it has been associated with faster resolution of coagulopathy but no change in outcomes.[3]

The most common reasons for antivenom administration were coagulopathy, neurotoxicity, myotoxicity, and nonspecific systemic effects.[4]

Hypersensitivity reaction to antivenom occurred in 25% cases, with nearly half the hypersensitivity cases considered to be anaphylaxis to the antivenom.[4]

Swab the bite for analysis with a CSL Venom Detection Kit, if available.

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Consultations

  • Regional Poison Control Center
  • Toxicologist or snake expert
  • Local zoos
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Contributor Information and Disclosures
Author

David Cheng, MD  Associate Professor of Emergency Medicine, Education Director, Associate Emergency Medicine Residency Director, Case Medical Center

David Cheng, MD is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, Council of Emergency Medicine Residency Directors, International Society for Mountain Medicine, National Association of EMS Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Daniel J Dire, MD, FACEP, FAAP, FAAEM  Clinical Professor, Department of Emergency Medicine, University of Texas Medical School at Houston; Clinical Professor, Department of Pediatrics, University of Texas Health Sciences Center San Antonio

Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US

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.

David Eitel, MD, MBA  Associate Professor, Department of Emergency Medicine, York Hospital; Physician Advisor for Case Management, Wellspan Health System, York

David Eitel, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, American Society of Pediatric Nephrology, Society for Academic Emergency Medicine, and Society of Critical Care Medicine

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, Shaun J Chun, MD, to the development and writing of this article.

References

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  2. Yeung JM, Little M, Murray LM, Jelinek GA, Daly FF. Antivenom dosing in 35 patients with severe brown snake (Pseudonaja) envenoming in Western Australia over 10 years. Med J Aust. Dec 6-20 2004;181(11-12):703-5. [Medline].

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Pseudonaja guttata (speckled brown snake).
Pseudonaja textilis (eastern brown snake).
Pseudonaja modesta (ringed brown snake).
Pseudonaja nuchalis (western brown snake).
 
 
 
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