Page 63 - JSOM Summer 2020

INTENT (EXPECTED OUTCOMES) 2. Early administration of appropriate antivenoms to symptom-
1. All snakebite patients should be managed according to the atic patients in the field
steps outlined in the “Universal Approach to Snakebite As- 3. Rapid transfer of patients to a facility stocking the appropriate
sessment, Diagnosis, and Treatment” antivenom if not available on site
2. Assessment, diagnosis, and treatment of snakebite patients 4. Antivenom administration should be performed by an ad-
should be based on the clinical syndrome of envenomation vanced life support qualified provider trained to the paramedic
and not the identity of the snake species responsible for the level (or DoD equivalent) or higher
bite. 5. Tetanus prophylaxis as needed
a. When a broad-spectrum antivenom does not exist for a 6. Manage elevated intracompartmental pressures with anti-
given syndrome in a given area, follow the steps outlined venom and do not perform fasciotomies.
in the regional algorithms to determine the most appro- DATA SOURCE
priate antivenom therapy for the patient.
3. Snakebites are dynamic events and patients must be fre- 1. Patient record
quently reassessed for signs of neurotoxic, hemotoxic, and 2. Department of Defense Trauma Registry (DODTR)
cytotoxic syndromes throughout the course of care as some SYSTEM REPORTING & FREQUENCY
syndromes will develop than others. The above constitutes the minimum criteria for PI monitoring
4. There are no absolute contraindications to antivenom adminis- of this CPG. System reporting will be performed annually; addi-
tration for a patient with a symptomatic snake envenomation. tional PI monitoring and system reporting may be performed as
5. Antivenom administration should be performed by medical needed. The system review and data analysis will be performed by
providers capable of providing advanced life support and the Joint Trauma System (JTS) Director and the JTS Performance
trained to a minimum level of paramedic (or DoD equivalent) Improvement Branch.
and higher (i.e. SOCM, 18D, PJ, IDC, IDMT, RN, PA, MD
or DO, etc.) Performance Improvement (PI) Monitoring
6. Early antivenom treatment is the standard of care for snake RESPONSIBILITIES
envenomations worldwide. Whenever possible, the appropri- It is the trauma team leader’s responsibility to ensure familiarity,
ate antivenom should be administered in the field prior to appropriate compliance and PI monitoring at the local level with
medevac to neutralize circulating venom before significant this CPG.
and potentially irreversible damage has occurred.
a. Field-stable, broad-spectrum antivenom options are in-
cluded in this CPG for all combatant commands except Acknowlegments
Defense Committee on Surgical Combat Casualty Care
for EUCOM.
i. Appropriate regional products listed in the CPG should (CoSCCC)
be stocked in role 2 and role 3 medical facilities. JTS Director: COL Stacy A. Shackelford, MD, FACS, USAF, MC
Far-forward units with paramedic level providers JTS Senior Enlisted Advisor: MSG Michael A. Remley, ATP, SFC,
should be equipped with field-stable, broad-spectrum MC, USA
antivenoms that can be stocked in the aid station and DCoT Chair, CoSCCC Chair: COL Jennifer M. Gurney, MD,
carried into the field for extended periods of times at FACS, MC, USA
high temperatures without loss of efficacy. Global Snake Envenomation Management Working Group
7. If antivenom is not available, the patient should be trans- Authors
ferred to a facility that maintains a stock of the appropriate Jordan Max Benjamin, NRP, Asclepius Snakebite Foundation
antivenom. Confirm that the receiving facility has the correct Nicklaus Brandehoff, MD, Asclepius Snakebite Foundation
antivenom in stock prior to transfer. If the receiving facility CPT Bryan Wilson, MD
does not have the correct product(s) in stock, then that fa- Lt Col Andrew Hall, MD
cility should be bypassed for a facility that is stocking the Spencer Greene, MD
appropriate products. CAPT (Ret) Edward Otten, MD
8. Antivenom dosage, preparation, and administration proce- Lt Col Joseph Maddry, MD
dures for each product should be performed as detailed for Marcos Collazo, NRP/EMT-P
each specific product in Appendix B. CPT Justin Grisham, DO
9. Tetanus prophylaxis should be given prior to discharge when Dennis Jarema, 18D
needed. SSG Collin Dye, ATP
10. Fasciotomy is contraindicated for snakebite and all cases of SSG Jihoon Lee, ATP
suspected compartment syndrome should be managed with Contributors
additional doses of antivenom and elevation ≥ 60 degrees to Ben Abo, DO, Asclepius Snakebite Foundation
reduce oncotic pressure in the bitten limb.
11. Initiate a telemedicine consult with a qualified snakebite ex- COL (Ret) Sean Keenan, MD
SFC Paul Loos, 18D
pert for any questions, concerns, or unusual manifestations MSG Michael Remley, ATP
that arise. CPT Karen Muschler, MD
12. Do not attempt to kill or capture the snake for identifica- MAJ Kevin Maskell, MD
tion purposes as treatment is based on clinical findings. If a COL Carl Skinner, MD
photo of the snake is available it can be sent to an expert for Robert French, MD
identification, but this should not delay antivenom treatment CAPT (Ret) Frank Butler, MD
in a symptomatic patient with signs and symptoms of any COL (Ret) Elizabeth Mannsalinas, PhD, RN
envenomation syndrome.
COL Jennifer Gurney, MD
PERFORMANCE/ADHERENCE MEASURES COL Stacey Shackelford, MD
1. Administration of antivenom to any patients with clinical signs and Corresponding Author: Jordan Max Benjamin
symptoms of neurotoxic, hemotoxic, or cytotoxic envenomations jordan@snakebitefoundation.org

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