Page 129 - Journal of Special Operations Medicine - Winter 2014

a practical method to guide treatment. Epidemiologic Table 4 Snakebite Management Guidelines
awareness and clinical assessment, supplemented by the
20-minute whole-blood clotting test (20MWBCT; Fig- • Notify evacuation authority.
ure 4) is sufficient to determine an appropriate treat- • Notify medical chain of command.
ment algorithm. • Move all suspected envenomation patients to a level of
care capable of resuscitation/antivenin administration,
Figure 4 Twenty-minute whole-blood clotting test. if indicated.
• Immobilize entire patient and splint affected limb. Do
NOT apply a tourniquet.
• If snake has been killed, transport with patient but DO
NOT seek snake for identification. Be aware that a
dead snake is still venomous.
• Initiate cardiopulmonary monitoring and appropri-
ate documentation (serial vital signs, mental status/
Glasgow Coma Scale score, and clinical signs of
envenomation).
• Airway management per standard protocols. Please
note that antivenin is unlikely to reverse respiratory
paralysis in neurotoxic envenomations, so aggressive
airway management should be considered early re-
gardless of the availability of antivenin.
• Initiate two large-bore IV lines (IO access if unable to
obtain IV).
The decision to administer antivenin is the crux of ther- • Pain management with acetaminophen or opioids (do
apy; however, administration of antivenin should be not administer NSAIDs).
performed in at least a Role 2 facility with appropriate • Prepare adjunctive measures for antivenin administration.
monitoring and emergency treatment resources avail- o Advanced airway management (endotracheal intu-
able. All antivenins carry a risk of anaphylaxis and sub- bation equipment, LMA, cricothyroidotomy kit)
sequent serum sickness. Currently available antivenin o IVF (NS or LR)
has a defined range of therapeutic efficacy and there are o Epinephrine (or other vasopressor as clinical situa-
several species for which no antivenin is available (Table tion dictates)
– Patient with cardiopulmonary compromise may
3). Antivenin is in short supply, has a limited shelf life, not respond to IM injection of epinephrine and
requires dependable cold storage, and is available only IV epinephrine may be necessary. 1mg of 1:1000
through a select few manufacturers. Up-to-date infor- epinephrine can be diluted in 9mL of NS to make
22
mation on reputable antivenin manufacturers and prod- 1:10,000 solution for IV use. Central line is pre-
uct availability can be obtained at the websites listed in ferred, but proximal large-bore IV access can be
Table 3. used if emergent.
o Antihistamine – diphenhydramine 25–50mg or
Table 3 Sources for Antivenin Information equivalent
o Antipyretic – acetaminophen or equivalent
Internet Hyperlinks
o Corticosteroid – Solumedrol 125mg IV or equivalent
www.toxinfo.org/antivenoms/synopsis.html • Be aware that resuscitation can lead to increased circu-
http://globalcrisis.info/latestantivenom.htm lation of venom from previously underperfused tissue
http://www.who.int/bloodproducts/animal_sera/en/ and appropriate supportive care precautions should be
http://www.toxinology.com/ applied.
https://intellipedia.intelink.gov/wiki/Antivenom_Resources
• When laboratory services are available, draw pertinent
laboratory studies
o CBC, electrolytes, glucose, renal function, liver en-
The criteria for administering antivenin include neuro- zymes, urinalysis, type and cross, fibrinogen, fibrin
toxicity, spontaneous systemic bleeding, incoagulable degradation products, creatinine kinase, PT/PTT
blood (20MWBCT), cardiovascular instability, exten- (consider cardiac enzymes if significant cardiopul-
sive swelling, rapidly progressive swelling, and bites on monary compromise)
fingers or toes. Antivenin is not FDA approved for use • Fasciotomy is rarely indicated for snake envenomation.
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unless waiver authority has been granted through com- Every effort should be made to document an elevated
compartment pressure before deciding to perform a
mand medical channels and procedures are followed to fasciotomy.
administer the antivenin under IND protocols. In the • Empiric antibiotics are not indicated for snakebites.
event of a suspected envenomation, there are a series
of administrative and clinical steps to facilitate care of (continues)
the patient (Table 4). Many of these steps should occur

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