Brown Snake Envenomation Treatment & Management

Updated: May 12, 2017
  • Author: David Cheng, MD; Chief Editor: Joe Alcock, MD, MS  more...
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Treatment

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

Initial care is as follows:

  • 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. [10] For mild envenomation, two vials may be used to start.

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. [11]

The most common reasons for antivenom administration were coagulopathy, neurotoxicity, myotoxicity, and nonspecific systemic effects. [12]

Hypersensitivity reaction to antivenom occurred in 25% cases, with nearly half the hypersensitivity cases considered to be anaphylaxis to the antivenom. [12] . Serum sickness reaction to antivenom occurred in 17%. [13]

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

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Further Care

Warn the patient of potential serum sickness. Instruct the patient to return if serum sickness develops. Follow up with the patient closely.

Admit any person who has been bitten by a brown snake to an intensive care unit.

Because of the potential lethality of this toxin and since symptoms may be delayed, observe asymptomatic patients in an ICU setting for at least 24 hours.

Corticosteroids and antihistamines should be continued for at least 5 days.

Transfer patient to facility capable of intensive care monitoring; and, in case patient develops renal failure and hemodialysis, arrange for transportation to facility with dialysis capabilities.

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Consultations

Consulations include the following:

  • Regional Poison Control Center
  • Toxicologist or snake expert
  • Local zoos
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Prevention

Professional snake keepers should wear protective gloves when handling all brown snakes.

The appropriate antivenin must be readily available.

Wear long pants and covered shoes when traveling to areas inhabited by venomous snakes.

Avoid approaching or handling snakes, even dead snakes.

Travel with a companion in case any disability from a snakebite occurs, and be aware of the locations of the nearest medical facilities.

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