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arrhythmias occur.
- Limit the systemic spread of the venom thru methods described below:
a. Keep the patient as calm and inactive as possible. Reassure. Give benzodiazepam (e.g., Valium 5 mg)
po as needed.
b. Gently clean around the bite site to remove any venom from the skin.
c. Immobilize the bitten limb in a dependant position.
d. Suctioning the bite site (NOT with mouth) within minutes after bite is reasonable if remote from hospital
care. Do not incise over the puncture site. The use of suction is controversial but all agree: never use
the mouth to apply suction.
e. Do not apply tourniquets, ligatures, or constricting bands unless the snake is primarily neurotoxic
(Australian elapid, sea snake, krait, cobra or other neurotoxic species). Neurotoxic bites only: apply
a constricting band approximately 1 in. wide 2-4 inches above the bite and loose enough to admit
a finger. Alternatively, wrap the bitten extremity with an elastic bandage or place it in an air splint.
Another method: Place a thick pad over the area of the bite and hold it in place with a
tight wrap, wrapping from distal to proximal. If more than 30 minutes after the bite, do not apply a
constricting band. Do NOT treat pit viper bites with these methods. Always check for a pulse after
applying – this is not a tourniquet!
f. Measure the circumference of a bitten extremity 10 cm proximal to the bite. Track this measurement
and pulses over time. - Remove all jewelry from bitten extremity.
- Insert Foley catheter, record urine output and monitor fluid balance. Check urine for myoglobin (positive for
blood on urine dipstick but no RBCs on microscopic exam) and blood. Avoid overhydration (rales,
wheezing, orthopnea, respiratory distress, and distended jugular veins). Cautiously hydrate to maintain
urine output > 30-50 cc/hr (adults). Administer furosemide (Lasix) up to 100 mg to promote urine output as
needed. Give low dose dopamine (2.5 kg/minute) by continuous infusion if necessary to
maintain urine output. Give adult victims with myoglobinuria and decreased urine output 25 grams of
Mannitol and 100 mEq (generally two ampules) sodium bicarbonate added to 1 liter 5% dextrose and
infused over 4 hours to prevent myoglobinuric nephropathy. - Treat pain with acetaminophen and opiates as required. Avoid NSAIDs, which interfere with platelet
function. - Treat nausea/vomiting with Compazine (give slowly if administering by IV - this can cause/worsen
hypotension). - Give tetanus toxoid as required.
- DO NOT cauterize, incise, or amputate the bite site. DO NOT apply electric shock or pack bitten limb
in ice. - If the snake can be SAFELY killed, bring in for identification (see below). Avoid handling the snake. Be sure
it is dead. WARNING – dead snakes can still reflexively bite! - Give antivenin, which is the only proven therapy for snakebite, only if it is specific for the snake involved
(monovalent), or if the envenomation is severe (polyvalent). See (and follow) package insert for
antivenin-specific instructions. The administration of any type of antivenin has a risk of allergic
reaction and serum sickness that can be life-threatening. DO NOT administer antivenin unless the
specific criteria for administration are met. Remember: death from snakebite is rare and snakebite without
envenomation is common. Inappropriate administration of antivenin can kill a patient who would otherwise
have survived without permanent sequelae. In the U.S. even when the offending snake is venomous, and
envenomation has occurred (e.g., copperhead), antivenin administration is often not necessary. - Be prepared to treat anaphylaxis after giving antivenin with epinephrine 0.3 cc 1:1000 IM and diphen-
hydramine 50 mg IM. If patient rapidly becomes hypotensive and/or develops acute severe respiratory
distress it may necessary to give 1mg (10cc) 1:10000 epinephrine slowly by IV.
NOTES: 1. Snakebites on the extremities can produce extensive swelling that may (but rarely does) lead to
the development of a compartment syndrome (pain on passive stretching and active exing of the involved
muscle groups, distal paresthesias, pulselessness, tense overlying tissues). Doing a fasciotomy in a patient
with a venom-induced bleeding disorder and local tissue necrosis may cause signicant, even life-threatening,