Toxinology Emergencies 193SNAKE BITES(d) myotoxic effects including muscle pain or tenderness with
creatine kinase (CK) >1000 U/L, myoglobinuria and renal
failure.
(iii) Sudden collapse, convulsions and cardiac arrest (especially brown
snake).4 Gain i.v. access and send blood for full blood count (FBC), urea and electro-
lytes (U&Es), CK and coagulation profile including INR, activated partial
thromboplastin time (aPTT) and fibrinogen. Attach a cardiac monitor and
pulse oximeter to the patient.
5 Send urine for protein, haemoglobin and myoglobin estimation.
6 Attempt to identify the snake species with a venom detection kit (VDK)
analysis from a bite-site swab (carefully taken from a window cut in the
pressure-immobilization bandage), or on the urine.
(i) Visual inspection and an amateur ‘guess’ at the species is
unreliable and misleading, and is a waste of time unless you are a
trained herpetologist.
7 Perform an electrocardiogram (ECG), chest radiograph (CXR) and spiro-
metry in significant envenoming.
MANAGEMENT1 Make sure that first aid has been applied to impede the spread of venom
through local lymphatics, using the pressure-immobilization technique:
(i) Apply a broad firm bandage around the bite site and extend
proximally up the limb to cover it completely, as tight as one
would bandage a sprained ankle.
(ii) Splint the dependent limb and organize for transport to be
brought to the patient.
(iii) Keep the immobilization bandage in place until the first set
of bloods are negative and the patient is asymptomatic, or if
envenomed until definitive treatment has been instituted and the
patient is systemically improved.
2 Give high-f low oxygen via face mask and watch for any signs of airway
compromise.
3 Give antivenom for definite systemic envenomation. Do not use antivenom
for a positive VDK result alone, if no other abnormal clinical or laboratory
features are present:
(i) Indications for antivenom therefore include the presence of
any clinical signs, particularly impending respiratory arrest,
refractory hypotension, cardiac arrhythmias, renal failure
and/or abnormal laboratory findings, including consumption
coagulopathy.