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IMMEDIATE FIRST AID
for bites by
United States & Canadian Rattlesnakes
(Crotalus species)

In the event of an actual or probable bite from a U.S. or Canadian rattlesnake, execute the following first aid measures without delay.

Snake:

  1. Make sure that the responsible snake or snakes have been appropriately and safely contained, and are out of danger of inflicting any additional bites.

Transportation:

  1. Immediately call for transportation.

Telephone:

Victim:

  1. Keep the victim calm and reassured. Allow him or her to lie flat and avoid as much movement as possible. If possible, allow the bitten limb to rest at a level lower than the victim's heart.
  2. Identify the bite site, looking for fang marks, and apply the Sawyer Pump extractor with the largest cup possible over the bite site. If there are two or more fang marks noted on the limb, apply the pump extractor over at least one fang mark. If more than one pump extractor is available, they may be applied to the additional fang marks.
  3. Immediately wrap a large constricting band snugly about the bitten limb at a level just above the bite site, ie. between the bite site and the heart. The constricting band should be as tight as one might bind a sprained ankle, but not so tight as to constrict blood flow.
  4. DO NOT remove the constricting band until the victim has reached the hospital and is receiving Antivenom.
  5. Have the Wyeth Crotalidae Polyvalent Antivenom ready for the emergency crew to take with the victim to the hospital. Give them the following:
    1. the available antivenom (at least 10 vials)
    2. the accompanying instruction (Protocol) packet
    3. the victim's medical packet (if available)

DO NOT cut or incise the bite site.
DO NOT apply ice to the bite site.


Summary for Human Bite
by
United States & Canadian Rattlesnakes
(Crotalus species)

The bite of rattlesnakes is rarely fatal. Victims will usually complain of pain at the bite site and swelling may be evident. Tremendous local tissue destruction can ensue. Prompt medical therapy avoids this problem. Please read the attached and respond appropriately.

  1. First Aid:
    1. Apply constricting band if not already present, proximal to bite on arms, legs, hands, or feet.
    2. Transport to a medical center emergency or trauma service.
  2. Medical Management:
    1. Call your local Poison Control Center, or the San Diego Regional Poison Control Center (800 876-4766). They should locate a consultant to help you treat this patient.
    2. Observe for Signs and Symptoms of Envenomation.
    3. If signs or symptoms are present, perform the following:
      1. Apply intradermal skin test.
      2. Administer Lactated Ringers intravenously at a

rate of 200 cc/hour. Obtain appropriate blood and urine laboratory data.

      1. Wait 20 minutes.
      2. Reconstitute 5 vials of antivenom in 50 cc Lactated Ringers.
      3. If no reaction to intradermal skin test, administer antivenom by intravenous infusion 1 vial (10 cc) every 5-10 minutes. The constriction band can be removed after the first vial has been infused.
      4. Monitor signs, symptoms, and laboratory data and

administer additional aliquots of 5 vials of antivenom as needed to neutralize signs and symptoms. Average treatment is 15 vials (range 0-40 vials).

      1. If patient is allergic to horse serum, administer 1 gram Solu-Medrol IV push, wait 30-45 minutes, and then begin intravenous antivenom. Be prepared to administer Benadryl and epinephrine.
      2. In case of intravenous envenomation, administer

antivenom IV push, 1 vial every 1 minute, until symptoms improve, then continue by intravenous infusion until signs and symptoms are titrated.


MEDICAL MANAGEMENT
for bites by
United States & Canadian Rattlesnakes
(Crotalus species)

This person has received a bite and probable envenomation from a rattlesnake. There are several species of rattlesnakes within the United States and Canada, envenomation by all of which will be covered by this protocol. Those snakes which are indigenous to Mexico, Central America, and South America, whose ranges do not overlap into the United States, will be covered in separate protocols. Fatalities in modern times are infrequent. The venom can produce a wide spectrum of clinical manifestations, including local tissue destruction, cardiovascular collapse, coagulopathy, and with some species neurotoxic and neuromuscular symptoms.

Please read and execute the following procedures without delay.

  1. A constricting band should be in place proximal to the bite site. If present leave in place, if not apply a penrose drain as if for venipuncture. This retards venom absorbtion. DO NOT remove until the patient has arrived at the hospital and is receiving the antivenom.
  2. Make sure that at least 20 vials of Crotalidae Polyvalent Antivenom (Wyeth) are available. This antivenom contains the necessary fractions to neutralize the venoms of all United States and Canadian rattlesnakes.
  3. If the patient has been envenomated, the initial treatment is 5 to 10 vials of intravenous antivenom. Envenomation is diagnosed by the presence of characteristic signs and symptoms. Necessary information follows and is organized in sections:

Signs and Symptoms of Envenomation

Medical Management

General Considerations

Special Considerations

Consultants

References

Signs and Symptoms of Envenomation:

The specific signs and symptoms which may manifest in a patient who has been envenomated will vary in presence and in severity, depending on several factors noted in the General Considerations below. The time course of development will also vary considerably from case to case. The following list of signs and symptoms represent a general compilation enumerated from a series of 100 cases of rattlesnake envenomation (Russell, 1983). Not all of the symptoms will necessarily develop, even with severe envenomation.

Sign or Symptom

Frequency

Pain

65-95/100

Swelling, Edema

74/100

Weakness

72/100

Sweating and or Chills

64/100

Numbness, tingling
(circumoral, lingual, scalp, feet, etc.)

63/100

Pulse rate changes

60/100

Faintness, dizziness

57/100

Ecchymosis

51/100

Nausea and/or vomiting

48/100

Blood pressure changes

46/100

Numbness, tingling in the affected part

42/100

Decreased blood platelets

42/100

Fasciculations

41/100

Vesicles or boli

40/100

Regional lymph adenopathy

40/100

Respiratory rate changes

40/100

Increased blood clotting time

39/100

Decreased hemoglobin

37/100

Thirst

34/100

Change in body temperature

31/100

Local tissue necrosis

27/100

Abnormal electrocardiogram

26/100

Glycosuria

20/100

Increased salivation

20/100

Spearing of red cells

18/100

Cyanosis

16/100

Proteinuria

16/100

Hematemesis, hematuria, melena

15/100

Unconsciousness

12/100

Blurring of vision

12/100

Muscle contraction

6/100

Increased blood platelets

4/ 25

Swollen eyelid

2/100

Retinal hemorrhage

2/100

Convulsions

1/100

Fang Marks: Fang marks may be present as one or more well defined punctures, as a series of small lacerations or scratches, or there may not be any noticeable or obvious markings where the bite occurred. The absence of fang marks does not preclude the possibility of a bite (especially if a juvenile snake is involved). However with rattlesnake envenomation, fang marks are invariably present and are generally seen on close examination. Bleeding may persist from the fang wounds. The presence of fang marks does not always indicate envenomation; rattlesnakes when striking in defense will frequently elect not to inject venom with the bite, resulting in a dry bite (i.e. no envenomation). Manifestations of signs and symptoms of envenomation is necessary to confirm the diagnosis of snake venom poisoning.

Medical Management:

  1. Admit patient to an emergency or trauma service and call the consultant identified by the Poison Control Center.
  2. Begin a peripheral intravenous infusion (18 gauge catheter) of Lactated Ringers Solution at the rate of 250 cc/hr.
  3. Draw blood from the contralateral arm, and collect urine for the following laboratory tests. Mark STAT.
    1. Type and Cross Match TWO units of whole blood.
    2. CBC with differential and platelets.
    3. Coagulation Parameters:
      1. Prothombin Time (PT)
      2. Partial Thromboplastin Time (PTT)
      3. Fibrinogen levels
      4. Fibrin Degradation Products
    4. Serum Electrolytes, BUN/Creatinine, Calcium, Phosphorus.
    5. Lactate Dehydrogenase (with Isoenzyme analysis). Isoenzyme analysis may indicate multiple targets of venom components which may dictate further management.
    6. Urinalysis (Macroscopic and Microscopic Analysis).

Must include analysis for:

      1. Free Protein
      2. Hemoglobin
      3. Myoglobin
    1. Electrocardiogram (Sinus Tachycardia would be expected).
    2. Intermittent or indwelling Foley Catheter to monitor

urine output may be necessary in the conscious, impaired patient.

    1. Additional tests as needed or indicated by the patient's hospital course.
    2. It may be necessary or practical to repeat some of the above serum and urine tests periodically over the hospital course to monitor the effects of antivenom therapy or to detect late changes in laboratory values.
  1. OBSERVE PATIENT CLOSELY for signs and symptoms of envenomation, which usually manifest between 15 minutes and two hours after the bite occurred.
    1. If NONE of the signs or symptoms have been noted after two hours, there is a possibility that the patient received a dry bite (no venom injected).
      1. Remove the constricting band, watching carefully for any changes in the patient's status. If any changes occur, assume the patient has been envenomed, and prepare to give antivenom immediately (as directed below).
    2. If signs and symptoms still fail to manifest, continue CLOSE observation of the patient for an additional 12 to 24 hours.
  2. IF ANY SIGN OR SYMPTOM becomes apparent or has been noted during the course of treatment, begin Antivenom Therapy as follows:
    1. Patients manifesting severe symptoms or who are suspected of having an intravenous injection of venom, should be treated immediately with antivenom and should not undergo skin testing. Corticosteroid adjuncts may facilitate the delivery of rapid infusion. One should use the dilutions below, but infuse at a rate of 1 vial (10 cc) per minute.
    2. If the patient is exhibiting envenomation, inject intracutaneously the skin test sample included in the antivenom package, sufficient to raise a small weal.
    3. The skin test should be read after 15 minutes, but it is wise to check the test area and observe the patient constantly during the period following the injection. If there is no evidence of erythema or vesicular response, the test should be considered negative.
    4. A positive test IS NOT a contraindication to giving antivenom, but should alert the clinician that the rate at which the antivenom is delivered and/or the use of corticosteroids may need to be adjusted to control potential untoward responses.
    5. Assuming that the above skin testing precautions have been done, reconstitute the contents of 5 vials of Wyeth Crotalidae Polyvalent Antivenom in Lactated Ringers Solution. Vigorously shake the vials to assure that the contents are thoroughly mixed, and that there is a minimum of undissolved particles. Transfer the dissolved solution via a syringe to an IV piggyback setup with a volumetric regulator. Make sure that there are no undissolved particles in the solution transfer.
    6. Administer the diluted antivenom intravenously over a period of 10 minutes for the first vial (1 cc/minute).
    7. Should any signs of ALLERGY/ANAPHYLAXIS (e.g. coughing, dyspnea, urticaria, itching, increased oral secretions, etc.) develop, immediately discontinue the administration of antivenom and treat symptoms with Corticosteroids, Epinephrine, Benadryl, Atarax, and/or other Antihistamines as necessary. As soon as the patient is stabilized, continue the antivenom infusion at a slower rate.
    8. After 10 minutes of antivenom administration, the constricting band may be removed.
    9. Assuming that the patient is tolerating the infusion well, additional antivenom may be given at a rate of 1 vial every 5-10 minutes. The first 5 vials should be given over the first hour of treatment.
  3. Antivenom Therapy is the mainstay of treatment for rattlesnake envenomation. Many of the symptoms are ameliorated or entirely eliminated by the antivenom alone. Other symptoms will require additional modalities of therapy to correct.
    1. Hematologic symptoms may present as Disseminated Intravascular Coagulopathy, and are treated essentially as other DICs.
    2. Neurological symptoms: If the patient is suspected of having been bitten by the Mojave rattlesnake (Crotalus scutulatus), the patient may develop neurological symptoms including respiratory obstruction or failure which must be treated as an immediate emergency. The neurologic symptoms, as others, should be improved by antivenom. If breathing becomes impaired, respiratory assistance may be necessary, and intubation and ventilation may be appropriate adjuncts in certain clinical settings. Secretions may become copious, necessitating suctioning.
  4. It is important to keep venom neutralization current and continuous. The best method to accomplish this is to keep a close watch on the patient's status. If the present condition does not improve, or should it worsen for any reason, additional antivenom should be administered. Give all additional antivenom in 5 vial increments. Again, dilute the antivenom thoroughly in Lactated Ringers, transfer the solution to an IV piggyback setup, and deliver over a period of 5-10 minutes per vial. Most bites today are treated with 15 to 20 vials of antivenom. The range is 5 to 40 vials.
  5. It is advisable to check periodic serum and urine analyses during therapy as outlined above.
  6. It is always best to keep the patient in an Intensive Care setting until free of major symptoms for 24 hours. The patient should be observed in the hospital for at least 24 hours after the major symptoms abate.

General Considerations:

  1. It is important that the patient be placed at rest, kept warm, and avoid unnecessary movement.
  2. Symptom variability: As noted above, the variability of symptoms in rattlesnake envenomation can be great. It is important to note the continual progression of symptoms throughout the course of therapy, and give additional antivenom as necessary to titrate these symptoms.
  3. Neurotoxic symptoms: In the United States one species of rattlesnake, the Mojave Rattlesnake (Crotalus scutalatus), is known to produce a clinical picture with predominantly neurotoxic symptoms. The onset and progression of the symptoms may be rapid and subtle. In addition, they are more rapidly reversed in their early stages than when fully developed. It may be necessary to wake the patient and perform a brief neurologic check every hour or so to assure that breathing and other vital functions are not impaired. Carefully note the progression of respiratory paralysis which may be present. Be prepared to intubate and ventilate as necessary.

Other rattlesnake species in the United States may have neurotoxic components in their venom. However generally speaking, these are at low levels and do not usually manifest significant clinical symptoms.

  1. Compartment Syndrome: It should be noted that fascial compartment syndrome in rattlesnake envenomations is very rare. Limbs may swell significantly, but rarely involve specific fascially bound compartments. If however the logistics of the bite raise a high index of suspicion for Compartment Syndrome, monitoring with a Wick Catheter or appropriate pressure devices may be necessary. Fasciotomy is rarely if ever recommended in these patients.

References:

The following references are recommended for further indepth reading. This material includes case histories, guidelines, and recent findings in crotalus literature. These should be read only after treatment has begun, and the patient is in stable status.

  1. Russell, F.E.: Snake Venom Poisoning. Scholium International, Inc. Great Neck, New York, 1983.
  2. Parrish, H.M.: Incidence of treated snakebite in the United States. Public Health Rep. 81: 269-276, 1966.
  3. Russell, F.E., Cawlson, R.W., Wainschel, J., Osborne, A.H.: Snake venom poisoning in the United States. JAMA 233: 341-344, 1975.
  4. Schmidt, K.P. and Inger, R.F.: Living Reptiles of the World. New York: Doubleday & Company 1957.
  5. Gans, C., Bellairs, A. and Parsons, T. (Eds.): Biology of the Reptilia, Volume 1. London: Academic Press. 1969
  6. Phelps, T.: Poisonous Snakes. Poole, Dorset: Blandford Press. 1981
  7. Klauber, L.M.: Rattlesnakes, Volume I. Berkeley: University of California Press. 1972
  8. Klauber, L.M.: Rattlesnakes, Volume II. Berkeley: University of California Press. 1972
  9. Klauber, L.M.: Rattlesnakes. Berkeley: University of California Press. 1982
  10. Minton, S.A., and Minton, M.R.: Venemous Reptiles. New York: Scribner's Sons. 1969
  11. Bronstein, A.C., Russell, F.E., Sullivan, J.B.: Negative pressure suction in the field treatment of rattlesnake bite victims.
  12. Davidson, T.M.: Intravenous Rattlesnake Envenomation. West J Med, 148: 45-47, 1988.

 
IMMEDIATE FIRST AID
for bites by
Puff Adder
(Bitis arietans)

In the event of an actual or probable bite from a Puff Adder, execute the following first aid measures without delay.

Snake:

  1. Make sure that the responsible snake or snakes have been appropriately and safely contained, and are out of danger of inflicting any additional bites.

Transportation:

  1. Immediately call for transportation.

    Telephone:

Victim:

  1. Keep the victim calm and reassured. Allow him or her to lie flat and avoid as much movement as possible. If possible, allow the bitten limb to rest at a level lower than the victim's heart.

  2. Immediately wrap a large crepe bandage snugly around the bitten limb starting at the site of the bite and working proximally up the limb (the full length if possible). The bandage should be as tight as one might bind a sprained ankle.

  3. Secure the splint to the bandaged limb to keep the limb as rigid and unmoving as possible. Avoid bending or moving the limb excessively while applying the splint.

  4. DO NOT remove the splint or bandages until the victim has reached the hospital and is receiving Antivenom.

  5. Have the SAIMR (South African Institute for Medical Research) polyvalent antivenom ready for the Lifeflight crew to take with the victim to the hospital. Give them the following:

    1. the available antivenom (at least 10 vials)
    2. the accompanying instruction (Protocol) packet
    3. the victim's medical packet

    DO NOT cut or incise the bite site
    DO NOT apply ice to the bite site


Summary for Human Bite
by
Puff Adder
(Bitis arietans)

The bite of the Puff Adder with subsequent envenomation is a medical emergency and can be fatal if the patient is not treated appropriately. Please read the attached Medical Management Protocol and respond appropriately.

  1. First Aid:

    1. Bandage and immobilize the bitten limb with crepe bandages and splint as described in the Immediate First Aid section. Rest this extremity below the level of the patient's heart (if practical).

    2. Transport to U.C.S.D. Medical Center Trauma Service.

  2. Medical Management:

    1. Call your local Poison Control Center, or the San Diego Regional Poison Control Center (800 876-4766). They should locate a consultant to help you treat this patient.

    2. Observe for Signs and Symptoms of Envenomation.

    3. If significant systemic signs or symptoms are present, perform the following:

      1. Administer Lactated Ringers Solution at 200 to 250 mls per hour.

      2. Draw samples and collect initial laboratory data.

      3. Dilute the contents of 5 vials of SAIMR Polyvalent Antivenom in Lactated Ringers Solution to a total volume of 300ml. Administer the antivenom I.V. piggyback over 75 minutes at a rate of 240ml/hour (i.e. one vial per 15 minutes). The combined rate of diluted antivenom and Lactated Ringers Solution is now approximately 500ml/hour. The rate of Lactated Ringers Solution may be adjusted accordingly to avoid fluid overload, however a brisk urine output should be a treatment goal.

      4. When one complete vial has been infused (i.e. 15 minutes, 60 cc), remove the splints and crepe bandage slowly over a period 10 minutes. If symptoms progress rapidly, reapply the bandage, wait 10 minutes, and then again release the bandage slowly over 10 minutes while antivenom administration is continuing.

      5. Allergic or untoward reactions to the antivenom should be treated with Benadryl, Epinephrine, and/or Corticosteroids. A patient with known sensitivity to horse serum may be pretreated with 1 gm of Solumedrol, administered I.V. push.

      6. Monitor Signs, Symptoms, and Laboratory data, and administer additional antivenom in 1 vial increments at a rate of one vial every 15 minutes as necessary to control the progression of symptoms.

      7. The required amount of antivenom will vary with the severity of envenomation. One should anticipate using (including the initial dose):

        5 vials for a minor bite with envenomation

        10 vials may be necessary for moderate or severe bites.

        The use of less than five vials of antivenom in the treatment of a bite with systemic envenomation increases the risk for complications and may even result in death.


MEDICAL MANAGEMENT
for bites by
Puff Adder
(Bitis arietans)

This person has received a bite and probable envenomation from a Puff Adder (Bitis arietans). This is a very venomous and dangerous snake native to much of Africa and portions of Saudi Arabia. Studies have shown that more than 50% of severe envenomations left untreated result in death. Envenomation may cause severe hypotension/shock as well as hemolytic, coagulopathic, hemorrhagic, and local reactions. Death may ensue rapidly but more commonly occurs in 12-24 hours.

Please read and execute the following procedures without delay.

  1. A crepe bandage and splint have been applied as immediate first aid adjuncts to retard the absorption of the venom. DO NOT remove until the patient has arrived at the hospital and is receiving the antivenom.

  2. Make sure 10 vials of SAIMR Polyvalent Antivenom are present with the patient. This antivenom is specific and is only available directly from the San Diego Zoo Reptile Department. Refrigerate the antivenom upon arrival to the hospital.

  3. If the patient has been envenomated, the treatment is at least 5 vials of intravenous antivenom. Envenomation is diagnosed by the presence of characteristic signs and symptoms. Necessary information follows and is organized into the following sections:

    Signs and Symptoms of Envenomation
    Medical Management
    General Considerations
    Special Considerations
    Consultants
    References

Signs and Symptoms of Envenomation:

  1. Local Affects:

    Pain and swelling: onset almost immediately after bite
    Blistering, bleb formation
    Ecchymosis
    Tissue necrosis: onset usually days after bite

  2. Cardiovascular:

    Hypotension: onset immediately
    Bradycardia
    Tachycardia

  3. Hematological:

    Coagulation defects
    Thrombocytopenia: onset within four hours after bite
    Spontaneous bleeding:
    Mucosal bleeding: within 4 hours after bite
    Epistaxsis
    Ecchymosis
    Gastrointestinal bleeding
    Internal hemorrhage
    Hematuria
    Anemia: secondary to bleeding into bitten limb,
    spontaneous bleeding, microangiopathic hemolysis etc.

  4. Renal/Urinary:

    Hematuria
    Hemoglobinuria
    Myoglobinuria
    Renal failure

  5. General:

    Nausea/Emesis
    Fever
    Regional Lymphadenopathy

  6. Fang Marks: The presence of fang marks does not always imply envenomation as the Puff Adder is known to bite without injecting venom into the victim. However, the absence of fang marks does not necessarily preclude the possibility of a bite, nor does it give any indication of the severity of the bite. Fang marks may be present as one or more well defined punctures, as a series of small lacerations or scratches, or there may not be any noticeable or obvious markings where the bite occurred. Finally, multiple bites inflicted by a single snake are possible and should be noted if present.

    Those signs and symtoms which give strong evidence for systemic envenomation include spontaneous bleeding, thrombocytopenia, hypotension, bradycardia, and local swelling of more than half the affected limb. Antivenom should be administered without delay in such cases.

Medical Management:

  1. Admit patient to the Trauma Service and call consultants listed on the last page. Terence M. Davidson, M.D. is the local consultant for snake bites, and should be notified immediately.

  2. Begin a peripheral intravenous infusion (16 gauge catheter) of Lactated Ringers Solution at a rate of 250 cc/hour.

  3. Draw blood from the contralateral arm, and collect urine for the following laboratory tests. Mark STAT.

    1. Type and Cross Match TWO units of Whole blood. Obtain fresh, frozen plasma.

    2. CBC with differential and quantitive platelet count.

    3. Coagulation Parameters:

      a. Prothrombin Time (PT)
      b. Partial Thromboplastin Time (PTT)
      c. Fibrinogen Levels
      d. Fibrin Degradation Products

    4. Serum Electrolytes, BUN/Creatinine, Calcium, Phosphorus.

    5. Lactate Dehydrogenase (with Isoenzyme analysis). Isoenzyme analysis may indicate multiple targets of the venom components which may dictate further management.

    6. Urinalysis (Macroscopic and Microscopic Analysis).

      Must include analysis for:

      1. Free Protein
      2. Hemoglobin
      3. Myoglobin

    7. Electrocardiogram (Sinus Tachycardia would be expected).

    8. Continuous Urine Output Monitoring (In dwelling Foley Catheter if unconscious). Watch for possible oliguria or anuria.

    9. Additional tests as needed or indicated by the patient's hospital course.

      1. The patient's vital signs should be monitored frequently the first 48 hours after the bite for evidence of hypotension, bradycardia, or circulatory shock.

      2. Coagulation parameters should be repeated at four hour intervals until coagulation factors begin to recover.

      3. CBC with platelet counts should be repeated periodically. Plateletes and hematocrit levels may continue to decline up to 48 hours after the bite especially in the undertreated patient.

      4. It may be necessary or practical to repeat some of the above serum and urine tests over the hospital course to monitor the effects of antivenom therapy or to detect late changes in laboratory values.

  4. OBSERVE PATIENT CLOSELY for signs and symptoms of envenomation which usually manifest between 15 minutes and two hours after the bite occurred.

    1. If NONE of the signs or symptoms have been noted after TWO hours, there is the possibility that the patient received a dry bite (no venom injected).

      1. VERY SLOWLY begin to remove the bandages and splint watching carefully for any changes in the patient's status. If any changes occur, assume the patient has been envenomated and prepare to give antivenom immediately (as directed below).

    2. If signs and symptoms still fail to manifest, continue CLOSE observation of the patient for an additional 12 to 24 hours.

  5. IF SIGNIFICANT SYSTEMIC SIGNS OR SYMPTOMS become apparent, begin antivenom therapy as follows:

    1. Dilute the contents of 5 vials of SAIMR Polyvalent Antivenom in Lactated Ringers Solution to a total volume of 300ml. Administer the antivenom I.V. piggyback over 75 minutes at a rate of 240ml/hour (i.e. one vial per 15 minutes). The combined rate of diluted antivenom and Lactated Ringers Solution is now approximately 500ml/hour. The rate of Lactated Ringers Solution may be adjusted accordingly to avoid fluid overload, however a brisk urine output should be a treatment goal.

    2. Should any signs of ALLERGY/ANAPHYLAXIS (e.g., coughing, dyspnea, urticaria, itching, increased oral secretions, etc.) develop, immediately discontinue the administration of antivenom, and treat symptoms with Corticosteroids, Epinephrine, Benadryl, Atarax and/or Antihistamines. As soon as the patient is stabilized, continue the antivenom infusion at a slower rate. (i.e. 120ml/hour).

    3. After 15 minutes of antivenom administration, the splint and the bandages may be removed. This should be done VERY SLOWLY over a period of 10 minutes to prevent a bolus release of venom. If the patient's condition worsens, reapply the crepe bandage, wait 10 minutes and release the bandage again slowly over 10 minutes while antivenom administration is continuing.

  6. Antivenom Therapy is the mainstay of treatment for Puff Adder snake envenomation. Many of the symptoms are ameliorated or entirely eliminated by the antivenom alone. Other symptoms will require additional therapeutic modalities in order to be corrected.

    1. Cardiovascular status: The administration of antivenom alone will help correct hypotension, bradycardia, and signs of circulatory shock provided the patient is not hypovolemic. Intravenous administration of Lactated Ringers Solution is warranted in all cases. Cardiovascular stability and a brisk diuresis are desired.

    2. Hematological signs and symptoms: Puff Adder venom has both procoagulant and anticoagulant activity, and thus bite victims may show a variety of responses. In addition the venom is toxic to vascular endothelial tissue and has hemorrhagic activity as well. Bite victims frequently develop thrombocytopenia, decreased fibrinogen levels, and spontaneous bleeding. Disseminated intravascular coagulopathy and anemia may likewise occur. Case reports reveal no consistent change in the PT or PTT; these parameters may be normal or prolonged. Death from severe envenomation is usually the result of internal hemorrhage and circulatory shock. The patient should be monitored closely and blood products including whole blood, packed RBC's platelets, cryoprecipitate, and fresh frozen plasma should be given when indicated.

    3. Renal: Puff Adder venom binds to renal tissue resulting in hematuria. Hemoglobinuria and myoglobinuria may likewise affect renal function, and if severe, acute renal failure may necessitate peritoneal dialysis.

    4. Neurological symptoms are uncommon with Puff Adder bites.

  7. It is important to keep venom neutralization current and continuous. The best method to accomplish this is to monitor the patient's status. If the present condition does not improve, or should it worsen for any reason, additional antivenom should be administered. Give all additional antivenom in one vial increments. Dilute the antivenom in Lactated Ringers as before and administer the antivenom I.V. piggyback over approximately 15 minutes. Bites with envenomation require at least 5 vials but severe envenomations may require up to 10 vials of antivenom.

  8. It is advisable to perform periodic serum and urine analyses during therapy (as outlined above).

  9. It is always best to keep the patient in an Intensive Care setting until free of major symptoms for 24 hours. The patient should be observed in the hospital for at least 24 hours after all symptoms abate.

General Considerations:

  1. It is important that the patient remain resting and warm. Avoid unnecessary movement.

  2. Symptom variability: There is a marked variability of symptoms in response to a Puff Adder bite. It is important to note the continual progression of signs and symptoms throughout the course of therapy and to give additional antivenom as necessary.

  3. Circulatory Shock: Hypotension and bradycardia are frequent complications of Puff Adder bites. Plasma expanders and/or vasopressor agents may be given when appropriate, but will be most effective if adequate antivenom has been appropriately administered.

  4. Fluid Management: The patient should be well hydrated, and a brisk urine output should be maintained. Blood products should not be given until circulating venom has been neutralized with antivenom.

  5. Compartment Syndrome: It should be noted that fascial compartment syndromes in Puff Adder bites are uncommon. Limbs may swell significantly, but rarely involve specific fascially bound compartments. If however the logistics of the bite raise a high index of suspicion for compartment syndrome, monitoring with a Wick Catheter or appropriate pressure device may be necessary. Fasciotomy is rarely, if ever, recommended.

  6. Tetanus Prophylaxis should be current.

  7. Antibiotics are not recommended prophylactically.

  8. Antivenom is the best treatment for all signs and symptoms of Puff Adder bites and should be utilized prior to other treatment modalities.

Special Considerations:

  1. Multiple Bites:

    1. It is possible for a Puff Adder to deliver more than one bite in a single attack. If there is evidence that such an attack occurred (i.e., history or multiple bite sites), give the initial dose of 5 vials but be prepared to give a total of 10 vials to adequately treat the bite. Titrate antivenom administration to signs and symptoms as discussed previously.

  2. Testing for Equine Protein Sensitivity:

    1. It is NOT ADVISABLE to utilize subcutaneous or intradermal testing for sensitivity to equine products in that such testing may be unreliable, and may unnecessarily delay antivenom therapy which must be used if any signs of Puff Adder envenomation are present.

    2. If there is reason to believe that the patient may be sensitive to equine protein products:

      1. Premedicate the patient with 1 gm Solumedrol, administered I.V. push. Assuming the patient's condition is stable, wait 15-30 minutes before administering the antivenom.

      2. Administer the diluted antivenom at a rate as tolerated by the patient beginning at a rate of 120ml/hour (as opposed to the normal 240ml/hour rate). If the patient tolerates this, increase the rate up to 240ml/hour.

      3. Monitor Pulse and Blood Pressure carefully. Be prepared to treat for Anaphylaxis.

  3. Clinical Experience with the Puff Adder:

    1. The Puff Adder (Bitis arietans) probably accounts for more deaths than any other snake in Africa. An adult Puff Adder may have enough venom to kill 4-5 men and studies show severe envenomations have a 52% mortality rate. The utilization of antivenom dramatically reduces the mortality rate but deaths have occurred when inadequate amounts of antivenom (i.e. four vials or less) have been administered.

    2. Prompt recognition of clinical envenomation, and adequate amounts of antivenom delivered early in the treatment course will facilitate a good recovery. The use of at least 5 vials of antivenom reduces the incidence of serious complications.

References:

The following references are recommended for further reading. This material includes case histories, guidelines and recent findings in treatment of Puff Adder bites. These should be read only after treatment has begun, and the patient is stable.

  1. Warrell, D.A., Ormerod, L.D., Davidson, N. NcD., Bites by

    Puff-Adder (Bites arietans) in Nigeria, and value of antivenom, British Medical Journal, 1975, 4:697.

  2. Mebs, D., Pohlman, S., Von Tenspolde, W., Snake venom hemorrhagins: neutralization by commerical antivenoms, Toxicon, 1988, 26:453.

  3. Brink, S., Steytler, J.G., Effects of Puff-Adder venom on coagulation, fibrinolysis and Platelet aggregation in the baboon, South African Medical Journal, 1974, 48:1205.

  4. Homma, H., Tu, A.T., Morphology of local tissue damage in experimental snake envenomation, British Journal of Experimental Pathology, 1971, 52:538.


 
IMMEDIATE FIRST AID
for bites by
Gaboon Viper
(Bitis gabonica)

In the event of an actual or probable bite from a Gaboon Viper, execute the following first aid measures without delay.

Snake:

  1. Make sure that the responsible snake or snakes have been appropriately and safely contained, and are out of danger of inflicting any additional bites.

Transportation:

  1. Immediately call for transportation.

    Telephone

Victim:

  1. Keep the victim calm and reassured. Allow him or her to lie flat and avoid as much movement as possible. If possible, allow the bitten limb to rest at a level lower than the victim's heart.

  2. Immediately wrap a large crepe bandage snugly around the bitten limb starting at the site of the bite and working proximally up the limb (the full length if possible). The bandage should be as tight as one might bind a sprained ankle.

  3. Secure the splint to the bandaged limb to keep the limb as rigid and unmoving as possible. Avoid bending or moving the limb excessively while applying the splint.

  4. DO NOT remove the splint or bandages until the victim has reached the hospital and is receiving Antivenom.

  5. Have the SAIMR (South African Institute for Medical Research) polyvalent antivenom ready for the Lifeflight crew to take with the victim to the hospital. Give them the following:

    1. the available antivenom (at least 10 vials)
    2. the accompanying instruction (Protocol) packet
    3. the victim's medical packet

DO NOT cut or incise the bite site
DO NOT apply ice to the bite site


Summary for Human Bite
by
Gaboon Viper
(Bitis gabonica)

The bite of the Gaboon Viper with subsequent envenomation is a medical emergency and can be fatal if the patient is not treated appropriately. Please read the attached Medical Management Protocol and respond appropriately.

  1. First Aid:

    1. Bandage and immobilize the bitten limb with crepe

      bandages and splint as described in the Immediate First Aid section. Rest this extremity below the level of the patient's heart (if practical).

    2. Transport to U.C.S.D. Medical Center Trauma Service.

  2. Medical Management:

    1. Call your local Poison Control Center, or the San Diego Regional Poison Control Center (800 876-4766). They should locate a consultant to help you treat this patient.

    2. Observe for Signs and Symptoms of Envenomation.

    3. If significant systemic signs or symptoms are present, perform the following:

      1. Administer Lactated Ringers Solution at 200 to 250 mls per hour.

      2. Draw samples and collect initial laboratory data.

      3. Dilute the contents of 5 vials of SAIMR Polyvalent Antivenom in Lactated Ringers Solution to a total volume of 300ml. Administer the antivenom I.V. piggyback over 75 minutes at a rate of 240ml/hour (i.e. one vial per 15 minutes). The combined rate of diluted antivenom and Lactated Ringers Solution is now approximately 500ml/hour. The rate of Lactated Ringers Solution may be adjusted accordingly to avoid fluid overload, however a brisk urine output should be a treatment goal.

      4. When one complete vial has been infused (i.e. 15 minutes, 60 cc), remove the splints and crepe bandage slowly over a period 10 minutes. If symptoms progress rapidly, reapply the bandage, wait 10 minutes, and then again release the bandage slowly over 10 minutes while antivenom administration is continuing.

      5. Allergic or untoward reactions to the antivenom should be treated with Benadryl, Epinephrine, and/or Corticosteroids. A patient with known sensitivity to horse serum may be pretreated with 1 gm of Solumedrol, administered I.V. push.

      6. Monitor Signs, Symptoms, and Laboratory data, and administer additional antivenom in 1 vial increments at a rate of one vial every 15 minutes as necessary to control the progression of symptoms.

      7. The required amount of antivenom will vary with the severity of envenomation. One should anticipate using (including the initial dose):

        5 vials for a minor bite with envenomation

        10 vials may be necessary for moderate or severe bites.


MEDICAL MANAGEMENT
for bites by
Gaboon Viper
(Bitis gabonica)

This person has received a bite and probable envenomation from a Gaboon Viper (Bitis gabonica). This is a very venomous and dangerous snake native to high rainfall areas of West, Central, and East Africa. Although there are no documented deaths from the bite of the Gaboon Viper, many of the complications from envenomation are life threatening.

Please read and execute the following procedures without delay.

  1. A crepe bandage and splint have been applied as immediate first aid adjuncts to retard the absorption of the venom. DO NOT remove until the patient has arrived at the hospital and is receiving the antivenom.

  2. Make sure 10 vials of SAIMR Polyvalent Antivenom are present with the patient. This antivenom is specific and is only available directly from the San Diego Zoo Reptile Department. Refrigerate the antivenom upon arrival to the hospital.

  3. If the patient has been envenomated, the treatment is at least 5 vials of intravenous antivenom. Envenomation is diagnosed by the presence of characteristic signs and symptoms. Necessary information follows and is organized into the following sections:

    Signs and Symptoms of Envenomation
    Medical Management
    General Considerations
    Special Considerations
    Consultants
    References

Signs and Symptoms of Envenomation:

  1. Local Affects:

    Pain and swelling: onset almost immediately after bite
    Blistering, bleb formation
    Hemorrhagic edema
    Tissue necrosis: onset usually days after bite
    Ecchymosis

  2. Cardiovascular:

    Severe Hypotension: onset immediately
    Cardiac arrythmias:
    Tachycardia
    Prolonged QT intervals
    Supraventricular tachycardia
    Inverted T waves
    Cardiac arrest

  3. Hematological:

    Coagulation defects
    Spontaneous bleeding:
    Mucosal bleeding
    Hematemesis
    Epistasis
    Ecchymoses/petechiae
    Gastrointestinal bleeding
    Internal hemorrhage
    Hemolysis

  4. Pulmonary

    Pulmonary edema
    Tachypnea
    Dyspnea

  5. Renal/Urinary

    Hematuria
    Hemoglobinuria
    Myoglobinuria
    Renal failure

  6. General:

    Nausea/Emesis
    Fever
    Abdominal pain
    Regional Lymphadenopathy

  7. Fang Marks: The presence of fang marks does not always imply envenomation as the Gaboon Viper is known to bite without injecting venom into the victim. However, the absence of fang marks does not necessarily preclude the possibility of a bite, nor does it give any indication of the severity of the bite. Fang marks may be present as one or more well defined punctures, as a series of small lacerations or scratches, or there may not be any noticeable or obvious markings where the bite occurred. Finally, multiple bites inflicted by a single snake are possible and should be noted if present.

    Those signs and symtoms which give strong evidence for systemic envenomation include hypotension, dyspnea, cardiac arrythmias, spontaneous bleeding, and local swelling of more than half the affected limb. Antivenom should be administered without delay in such cases.

Medical Management:

  1. Admit patient to the Trauma Service and call consultants listed on the last page. Terence M. Davidson, M.D. is the local consultant for snake bites, and should be notified immediately.

  2. Begin a peripheral intravenous infusion (16 gauge catheter) of Lactated Ringers Solution at a rate of 250 cc/hour.

  3. Draw blood from the contralateral arm, and collect urine for the following laboratory tests. Mark STAT.

    1. Type and Cross Match TWO units of Whole blood.

    2. CBC with differential and quantitive platelet count.

    3. Coagulation Parameters:

      1. Prothrombin Time (PT)
      2. Partial Thromboplastin Time (PTT)
      3. Fibrinogen Levels
      4. Fibrin Degradation Products

    4. Serum Electrolytes, BUN/Creatinine, Calcium, Phosphorus.

    5. Lactate Dehydrogenase (with Isoenzyme analysis). Isoenzyme analysis may indicate multiple targets of the venom components which may dictate further management.

    6. Urinalysis (Macroscopic and Microscopic Analysis).

      Must include analysis for:

      1. Free Protein
      2. Hemoglobin
      3. Myoglobin

    7. Electrocardiogram (Sinus Tachycardia would be expected).

    8. Continuous Urine Output Monitoring (In-dwelling Foley Catheter if unconscious). Watch for possible oliguria or anuria.

    9. Additional tests as needed or indicated by the patient's hospital course.

      1. The patient's vital signs should be monitored frequently over the first 48 hours after the bite for evidence of circulatory shock.

      2. It may be necessary or practical to repeat some of the above serum and urine tests over the hospital course to monitor the effects of antivenom therapy or to detect late changes in laboratory values.

  4. OBSERVE PATIENT CLOSELY for signs and symptoms of envenomation which usually manifest between 15 minutes and two hours after the bite occurred.

    1. If NONE of the signs or symptoms have been noted after TWO hours, there is the possibility that the patient received a dry bite (no venom injected).

      1. VERY SLOWLY begin to remove the bandages and splint watching carefully for any changes in the patient's status. If any changes occur, assume the patient has been envenomated and prepare to give antivenom immediately (as directed below).

    2. If signs and symptoms still fail to manifest, continue CLOSE observation of the patient for an additional 12 to 24 hours.

  5. IF SIGNIFICANT SYSTEMIC SIGNS OR SYMPTOMS become apparent, begin antivenom therapy as follows:

    1. Dilute the contents of 5 vials of SAIMR Polyvalent Antivenom in Lactated Ringers Solution to a total volume of 300ml. Administer the antivenom I.V. piggyback over 75 minutes at a rate of 240ml/hour (i.e. one vial per 15 minutes). The combined rate of diluted antivenom and Lactated Ringers Solution is now approximately 500ml/hour. The rate of Lactated Ringers Solution may be adjusted accordingly to avoid fluid overload, however a brisk urine output should be a treatment goal.

    2. Should any signs of ALLERGY/ANAPHYLAXIS (e.g., coughing, dyspnea, urticaria, itching, increased oral secretions, etc.) develop, immediately discontinue the administration of antivenom, and treat symptoms with Corticosteroids, Epinephrine, Benadryl, Atarax and/or Antihistamines. As soon as the patient is stabilized, continue the antivenom infusion at a slower rate. (i.e. 120ml/hour).

    3. After 15 minutes of antivenom administration, the splint and the bandages may be removed. This should be done VERY SLOWLY over a period of 10 minutes to prevent a bolus release of venom. If the patient's condition worsens, reapply the crepe bandage, wait 10 minutes and release the bandage again slowly over 10 minutes while antivenom administration is continuing.

  6. Antivenom Therapy is the mainstay of treatment for Gaboon Viper snake envenomation. Many of the symptoms are ameliorated or entirely eliminated by the antivenom alone. Other symptoms will require additional therapeutic modalities in order to be corrected.

    1. Cardiovascular status: Gaboon Viper venom is known to be cardiotoxic and causes arrythmias as well as decreases in stroke volume and cardiac output. In addition the venom results in a lowering of peripheral vascular resistance and thus gives rise to hypotension. The administration of antivenom alone will dramatically improve hypotension and signs of circulatory shock provided the patient is not volume depleted. Intravenous administration of Lactated Ringers Solution is warranted if the patient is hypovolemic but is only efficacious if antivenom has been administered. Cardiac arrythmias, specifically prolonged QT intervals, inverted T waves, and supraventricular tachycardia may persist for days after the initial envenomation. Severe arrythmias may require the use of a temporary pacemaker to ensure adequate cardiac output and to prevent cardiac arrest.

    2. Hematological signs and symptoms: Gabbon Viper venom has a thrombin-like enzyme which quickly depletes serum fibrin levels thus rendering the blood incoagulable. In addition the venom has hemorrhagic activity as it causes widespread damage to the microvasculature. Of note, the lungs and gastrointestinal tract are extremely sensitive to this hemorrhagic activity. Finally, disseminated intravascular coagulopathy and anemia may also occur. The patient should be monitored closely and blood products including whole blood, packed RBC's platelets, cryoprecipitate, and fresh frozen plasma should be given when indicated.

    3. Pulmonary: The hemorrhagic activity of the venom results in pulmonary edema, tachypnea, and dyspnea.

    4. Renal: The hemorrhagic activity of Gaboon Viper venom may result in hematuria. In addition, hemoglobinuria and myoglobinuria may likewise affect renal function, and if severe, (Acute Renal Failure), may necessitate peritoneal dialysis.

    5. Laboratory: Gaboon Viper venom has been noted to cause transient increases in serum SGOT, SGPT, and LDH levels suggesting damage to liver and kidney tissue.

    6. Neurological symptoms are uncommon with Gaboon Viper bites. Respiratory distress is nearly always secondary to pulmonary edema rather than muscle paralysis.

  7. It is important to keep venom neutralization current and continuous. The best method to accomplish this is to monitor the patient's status. If the present condition does not improve, or should it worsen for any reason, additional antivenom should be administered. Give all additional antivenom in one vial increments. Dilute the antivenom in Lactated Ringers as before and administer the antivenom I.V. piggyback over approximately 15 minutes.

    BITES WITH ENVENOMATION REQUIRE AT LEAST 5 VIALS BUT SEVERE ENVENOMATIONS MAY REQUIRE UP TO 10 VIALS OF ANTIVENOM.

  8. It is advisable to perform periodic serum and urine analyses during therapy (as outlined above).

  9. It is always best to keep the patient in an Intensive Care setting until free of major symptoms for 24 hours. The patient should be observed in the hospital for at least 24 hours after all symptoms abate.

General Considerations:

  1. It is important that the patient remain resting and warm. Avoid unnecessary movement.

  2. Symptom variability: As noted already there is marked symptom variability in response to a Gaboon Viper bite. It is important to note the progression of symptoms throughout the course of therapy and give additional antivenom as necessary to titrate these symptoms.

  3. Respiratory Failure: Pulmonary edema and subsequent dyspnea may necessitate the use of supplemental oxygen. If severe, the use of a ventilator may be indicated.

  4. Cardiac Arrest: The cardiotoxic nature of Gaboon Viper venom necessitates careful monitoring of the patient's cardiac status the first 24-48 hours after envenomation.

  5. Fluid Management: The patient should be well hydrated, and a brisk urine output should be maintained. Blood products should not be given until circulating venom has been neutralized with antivenom.

  6. Compartment Syndrome: It should be noted that fascial compartment syndromes in Gaboon Viper bites are uncommon. Limbs may swell significantly, but rarely involve specific fascially bound compartments. If however the logistics of the bite raise a high index of suspicion for a compartment syndrome, monitoring with a Wick Catheter or appropriate pressure device may be necessary. Fasciotomy is rarely, if ever, recommended in these patients.

  7. Tetanus Prophylaxis should be current.

  8. Antibiotics are not recommended prophylactically.

  9. Antivenom is the best treatment for all signs and symptoms of Gaboon Viper bites and should be utilized prior to other treatment modalities.

Special Considerations:

  1. Multiple Bites:

    1. It is possible for a Gaboon Viper to deliver more than one bite in a single attack. If there is evidence that such an attack occurred (i.e., history or multiple bite sites), give the initial dose of 5 vials but be prepared to give a total of 10 vials to adequately treat the bite. Titrate antivenom administration to signs and symptoms as discussed previously.

  2. Testing for Equine Protein Sensitivity:

    1. It is NOT ADVISABLE to utilize subcutaneous or intradermal testing for sensitivity to equine products in that such testing may be unreliable, and may unnecessarily delay antivenom therapy which must be used if any signs of Gaboon Viper envenomation are present.

    2. If there is reason to believe that the patient may be sensitive to equine protein products:

      1. Premedicate the patient with 1 gm Solumedrol, administered I.V. push. Assuming the patient's condition is stable, wait 15-30 minutes before administering the antivenom.

      2. Administer the diluted antivenom at a rate as tolerated by the patient beginning at a rate of 120ml/hour (as opposed to the normal 240ml/hour rate). If the patient tolerates this, increase the rate up to 240ml/hour.

      3. Monitor Pulse and Blood Pressure carefully. Be prepared to treat for Anaphylaxis.

  3. Clinical Experience with the Gaboon Viper:

    1. There are very few documented cases of Gaboon Viper bite envenomation in the literature. As such, other complications of envenomation may occur which have previously not been described.

    2. The Gaboon Viper (Bitis gabonica) is considered to produce more venom than any other venomous snake. A single adult animal may have enough venom to inject lethal doses into 30 individual men. Despite these statistics, the Gaboon Viper is noted for its docile nature and this may account for the very few reported bites in the literature. Although no documented deaths have been attributed to Gaboon Viper bites, the snake should not be considered less dangerous as many of the complications of envenomation are life threatening.

    3. Prompt recognition of clinical envenomation and adequate amounts of antivenom delivered early in the treatment course will facilitate a good recovery. The use of at least 5 vials of antivenom reduces the incidence of serious complications.

References:

    The following references are recommended for further reading. This material includes case histories, guidelines and recent findings in treatment of Gaboon Viper bites. These should be read only after treatment has begun, and the patient is stable.

  1. Marsh, N.A., Whaler, B.C., The Gaboon Viper (Bitis gabonica): its biology, venom components and toxinology, Toxicon 22, 669-694, 1984.