Emergency Department Management of North American Snake Envenomations -

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Sophia Sheikh, MD

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

 

Patrick Leffers, PharmD

Emergency Medicine/Clinical Toxicology Fellow, Florida Poison Information Center at Jacksonville, University of Florida Health, Jacksonville, FL

 

Peer Reviewers

 

Daniel J. Sessions, MD

Medical Toxicologist, South Texas Poison Center, San Antonio, TX

 

Andy Jagoda, MD, FACEP

Professor and Interim Chair, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, 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 snakes will be discussed, along with a review of the current controversies.

 

Excerpt From This Issue

A 4-year-old boy is brought to your ED by his distraught parents. An hour ago, he was in the backyard by the pool, playing with what they thought was a toy. He started screaming, and when the mother moved closer, she saw a foot-long black, yellow, and red snake in his hand. She frantically pulled it off him and threw it into the bushes. 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 dad took a picture of the snake with his phone and you can tell quickly that it was a coral snake. The child is asymptomatic currently, but the nearest pediatric ICU is over 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?

A 26-year-old man arrives to the ED via private vehicle with his arm in a makeshift sling. He reports that his pet rattlesnake bit him on his right index finger about 45 minutes ago. His hand and wrist are swollen. He reports that he has no past medical history besides his 3 previous visits for snakebites. He reports having a “reaction” to the snakebite antidote during his last visit. You wonder whether the patient is immune . . . or should you give antivenom again?