Emergency Department Management of North American Snake Envenomations - Trauma EXTRA Supplement (Trauma CME and Pharmacology CME)

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Publication Date: February 2024 (Volume 26, Supplement 2)

CME Credits: 4 AMA PRA Category 1 Credits™ and 4 AOA Category 2-B CME credits. CME expires 02/15/2027.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma and 1 Pharmacology credits, subject to your state and institutional approval.

Authors

Chiemela B. Ubani, PharmD, DABAT

Managing Director, Southeast Texas Poison Center, University of Texas Medical Branch, Galveston, TX

Dawn R. Sollee, PharmD, DABAT, FAACT

Professor, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, FL

Sophia Sheikh, MD

Associate Professor, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville; Medical Director, Florida/USVI Poison Information Center-Jacksonville at UF Health, Jacksonville, FL

Peer Reviewers

Elizabeth Moore, DO

Assistant Professor of Clinical Emergency Medicine, Weill Cornell Medicine, New York, NY

Abstract

There are approximately 10,000 emergency department visits in the United States for snakebites every year, and one-third of those involve venomous species. Venomous North American indigenous snakes include species from the Crotalinae (pit vipers) and Elapidae (coral snakes) subfamilies. Treatment relies on supportive care, plus antivenom for select cases. While certain principles of management are widely accepted, controversies exist with regard to prehospital use of pressure immobilization, antivenom use, coagulation testing after copperhead envenomation, and fasciotomy. An evidence-based approach to management of North American venomous snakebites will be discussed, along with a review of the current controversies.

Case Presentations

CASE 1

A 4-year-old boy is brought to your ED by his distraught parents an hour after being bitten by a snake in his backyard…

The mother states that it was a foot-long black, yellow, and red snake. She reports that she had to pull quite hard before it would release.
The child has several small marks on the palm of his left hand. There is minimal redness, and no swelling is apparent.
The father took a picture of the snake with his phone. You recognize it as a coral snake.
The child is asymptomatic currently, but the nearest pediatric ICU is more than an hour away. You wonder: should you transfer this patient to the ICU, or can you observe him in the ED—and should you start antivenom?

CASE 2

A 26-year-old man arrives at the ED via private vehicle with his arm in a makeshift sling after being bitten by his pet rattlesnake…

He reports that the snake bit him on his right index finger about 45 minutes ago.
His hand and wrist are swollen.
He reports no past medical history except his 3 previous visits for snakebites. He says he had a “reaction” to the snakebite antidote during his last visit.
You wonder whether you should you give this patient antivenom again...

CASE 3

A 51-year-old man with a history of a rattlesnake bite approximately 4 days ago presents to your ED…

He was directed to go to the ED by his primary care physician's office due to ”abnormal lab results.“
He reports easy bruising and some bleeding when he brushes his teeth, but is otherwise asymptomatic.
You wonder how you should manage this patient...

Accreditation:

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