Part 4

The routine admission history and physical examination should provide and record, if possible, the identity and length of the snake, the time of the bite, and the details of all first aid measures employed, including the time lapse for each and the mode of transportation to the hospital. The record should state whether a tourniquet, incision and suction, or the ligature-cryotherapy technique has or has not been used. Inquiry should be made concerning previous bites, allergic manifestations in general, and whether or not the patient had previously received horse serum. The admission examination should provide information from which the severity of the envenomation can be estimated as a guide to the need for the administration of antivenin and other therapy. Sensitivity tests should be instituted promptly during admission if not previously begun.

When the patient enters the hospital, blood should be drawn immediately for typing, matching and coagulation studies.

Although envenomation by one of the snakes of North America may present severe signs and symptoms, death is rare except in children or following envenomation by a large snake. However, permanent damage of an involved extremity is frequent following a bite by certain of the North American venomous snakes; plastic or orthopedic surgical repair to restore function, or amputation, are not unusual consequences. Early and continuing close observation is needed to determine if certain therapeutic measures prevent or promote undesirable results.

_Laboratory Tests_

No rigid set of rules regarding therapy can be justified; the responsible physician must use his best judgment in his choice of tests to be performed as a guide to procedures to be used.

Clinical studies could include items such as repeated hematologic tests, hepatic and renal function studies, serial electrocardiograms, electroencephalograms, and other studies to therapy, depending on the composition of the venom involved and within the limits of personnel, time and equipment available.

_Therapeutic Procedures_

A. Systemic

1. Immobilization. During transportation, admission procedures, and most of the early hospitalization period, immobilization of the affected part and absolute rest should be continued. A sedative or analgesic may be administered to relieve restlessness and anxiety; ice bags may be applied to alleviate severe pain. The extremity should be immobilized in the position of function, and active and passive exercises to prevent contracture started after the third day if consistent with the patient’s condition.

2. Blood Transfusion. Postmortem examinations have at times revealed extensive retroperitonial and intraperitonial hemorrhage, and hemorrhage into the viscera, including the liver and kidney. Progressive decrease in the total volume of circulating red blood cells has been attributed to the development of a massive hemolytic anemia or internal hemorrhage. Blood transfusions may be necessary and at times have been followed by marked improvement. Studies of the several factors involved in blood clotting may be useful as guides to treatment. The first and subsequent specimens of urine should be especially examined for the presence of red blood cells, hemoglobin, and protein.

3. Electrolyte Balance. Abnormality of fluid and electrolyte balance should be detected and corrected on a continuing basis.

4. Antivenin. Polyvalent or specific antivenins prepared from venoms of snakes in the same geographic area should be administered in therapeutic quantity as recommended by the manufacturer only with full realization that the hazard of immediate allergic reaction or delayed serum sickness are factors to be evaluated in the decision to carry out this type of treatment. During hospitalization, antivenin should be given intravenously, provided that sensitivity tests indicate that the patient is not allergic to the antiserum to be used. Desensitization, if necessary, should precede the administration of antivenin by any route. The use of antivenin in such cases should be carefully evaluated. Injection in normal muscles in other extremities would be the second choice, since local injections into the deposit site do not diffuse efficiently into the entire damaged area and would increase the hazard of pressure ischemia leading to increased tissue necrosis. Epinephrine should be available for immediate use when foreign protein is being administered.

5. Corticosteroids. The use of corticosteroids should be restricted to the prevention or treatment of late manifestations of allergy following administration of antivenins.

6. Antibiotics. A broad-spectrum antibiotic should be administered promptly in appropriate dosage if the reaction to envenomation is severe. Since the nature of the injury markedly predisposes to infection, and pathogenic bacteria are found in the wound, this use of antibiotics seems justified. Laboratory sensitivity tests, if available, should control the continuing choice of antibiotics to be used. A massive wound infection with severe systemic reaction could be mistaken for severe envenomation. Repeated blood and wound cultures would be of help in making the distinction.

7. Tetanus Prophylaxis. Tetanus toxoid should be administered upon admission if it has not been given as a first aid measure.

8. Respiratory Paralysis. If respiratory paralysis develops following envenomation by one of the _Elapidae_ (this family includes the coral snake), the use of tracheostomy and intermittent positive pressure artificial respiration is indicated.

9. Renal Shutdown has been an occasional occurrence following massive envenomation. An awareness of this possible complication can do much toward the prevention and treatment of secondary effects arising after its occurrence. Routine daily tests such as B.U.N., CO₂ combining power, and serum potassium levels are indicated in severe cases.

B. Local Measures During Hospitalization

1. Tourniquet (Constricting band). A tourniquet applied following a bite by a venomous North American snake should be removed if envenomation seems mild or after a potent antivenin is given in therapeutic quantity. The prolonged use of a tourniquet or of a constricting band would increase local tissue damage due to the action of venom and might delay the vascular transport of antivenin into envenomated areas.

2. Incision and Suction. Substantial amounts of venom can be removed during the first half-hour from subcutaneous deposits by incision and suction. On the other hand, if the casualty is admitted to the hospital one hour or more following envenomation, an attempt to remove venom by incision and suction at the site of the bite would be of little value. However, if marked subcutaneous pitting edema develops, interstitial pressure can be relieved by several longitudinal incisions extending into the subcutaneous tissues. Suction and fasciotomy may be required at times.

Parrish (1961), using a modification of Wood, Hoback and Green’s (1955) clinical classification of pit viper venenations, has proposed the following guide for determining the severity of a poisonous snake bite. This classification is based upon present signs and symptoms and the clinical course of the patient during the first 12 hours of hospitalization. It will be useful as a guide in treatment.

Grade O (No venenation). Fang or tooth marks present, minimal pain, less than one inch of surrounding edema and erythema, and no systemic involvement.

Grade I (Minimal venenation). Fang or tooth marks present, moderate pain, from one to five inches surrounding edema and erythema in the first 12 hours after bite, and no systemic involvement.

Grade II (Moderate venenation). Fang or tooth marks present, severe pain, six to 12 inches of surrounding edema and erythema in the first 12 hours after bite, with systemic involvement—nausea, vomiting, giddiness, shock or neurotoxic symptoms present.

Grade III (Severe venenation). Fang or tooth marks present, severe pain, more than 12 inches of surrounding edema and erythema in the first 12 hours after bite, with systemic involvement (as in Grade II).

BIBLIOGRAPHY

Boys, Floyd and Hobart M. Smith. _Poisonous Amphibians and Reptiles._ Charles C. Thomas Co., Springfield, 1959.

Brown, Bryce C. _An Annotated Check List of the Reptiles and Amphibians of Texas._ Baylor University Press, Waco, 1950.

Buckley, Eleanor and Nandor Porges (Editors). _Venoms._ Publication No. 44, American Association for the Advancement of Science, Washington, D. C., 1956.

Conant, Roger. _A Field Guide to the Reptiles and Amphibians of Eastern North America._ Houghton Mifflin Co., Boston, 1958.

Curran, C. H. and Carl F. Kaufield. _Snakes and Their Ways._ Harper Brothers Publishers, New York, 1937.

Emery, Jerry A. and Findlay E. Russell. _Studies with Cooling Measures Following Injection of Crotalus Venom._ Copeia, no. 3 pp. 322-326, September, 1961.

Fischer, F. J., H. W. Ramsey, J. Simon and J. F. Gennaro. _Antivenin and Antitoxin in the Treatment of Experimental Rattlesnake Venom Intoxication (Crotalus adamanteus)._ American Journal of Tropical Medicine, vol. 10, pp. 75-79, 1961.

Gloyd, Howard K. _The Rattlesnakes, Genera Sistrurus and Crotalus._ Chicago Academy of Sciences, Special Publication no. 4, 1940.

Harman, R. W. and C. B. Pollard. _Bibliography of Animal Venoms._ University of Florida Press, Gainesville, 1949.

Kauffeld, Carl F. Staten Island Zoo.

Keegan, Hugh L., Frederick Whittemore, Jr., and James F. Flanigan. _Heterologous Antivenin in Neutralization of North American Coral Snake Venom._ Public Health Reports, vol. 76, no. 6, pp. 540-542, 1961.

Klauber, Lawrence M. _Rattlesnakes, Their Habits, Life Histories, and Influence on Mankind._ 2 vols. University of California Press, Berkeley, 1956.

Minton, Sherman A. _Snakebite._ Scientific American, vol. 196, no. 1, pp. 114-118, 120, 122, 1957.

National Academy of Sciences, National Research Council. _Interim Statement on First-aid Therapy for Bites by Venomous Snakes._ Mimeographed. pp. 1-5, 1960.

National Academy of Sciences, National Research Council. _Statement on Hospital Care Following Bites by Venomous Snakes._ Mimeographed. pp. 1-4, 1960.

Oliver, James A. _The Prevention and Treatment of Snakebite._ Animal Kingdom, vol. 55, no. 3, pp. 66-83, 1952.

Parrish, Henry M. _The Poisonous Snake Bite Problem in Florida._ Journal of the Florida Academy of Sciences, vol. 20, no. 3, pp. 185-204, 1957.

Parrish, Henry M. _Poisonous Snakebites Resulting in Lack of Venomous Poisoning._ Virginia Medical Monthly, vol. 86, pp. 396-___, 1959.

Parrish, Henry M. _Snake Venom Poisoning._ Medical Times, vol. 89, no. 6, pp. 595-602, 1961.

Pope, Clifford H. _Snakes Alive and How They Live._ Viking Press, New York, 1937.

Pope, Clifford H. and R. Marlin Perkins. _Differences in the Patterns of Bites of Venomous and of Harmless Snakes._ Archives of Surgery, vol. 49, pp. 331-336, 1944.

Russell, Findlay E. _Rattlesnake Bites in Southern California._ American Journal of the Medical Sciences, vol. 239, no. 1, pp. 51-60, 1960.

Russell, Findlay E. _Injuries by Venomous Animals in the United States._ Journal of the American Medical Association, vol. 177, pp. 903-907, 1961.

Russell, Findlay E. and Jerry A. Emery. _Incision and Suction Following Injection of Rattlesnake Venom._ American Journal of the Medical Sciences, vol. 241, no. 2, pp. 160-166, 1961.

Stimson, A. C. and H. T. Engelhardt. _The Treatment of Snakebite._ Journal of Occupational Medicine, vol. 2, no. 4, pp. 163-168, 1960.

Strecker, J. K. _Reptiles and Amphibians of Texas_, 1915.

Wood, John T. _A Survey of 200 Cases of Snakebite in Virginia._ American Journal of Tropical Medicine and Hygiene, vol. 3, pp. 936-943, 1954.

Wood, John T. _A Critique on the “L-C” Treatment of Snakebites._ Southern Medical Journal, vol. 49, pp. 749-751, 1956.

Wood, John T., W. W. Hoback and T. W. Green. _Treatment of Snake Venom Poisoning with ACTH and Cortisone._ Virginia Medical Monthly, vol. 82, pp. 130-135, 1955.

Wright, A. H. and A. A. Wright. _Handbook of Snakes of the United States and Canada._ Comstock Publishing Associates, Ithaca, 1957.

Ya, P. M. and John F. Perry, Jr. _Experimental Evaluation of Methods for the Early Treatment of Snake Bite._ Surgery, vol. 47, no. 6, pp. 975-981, 1960.

Young, Nettie. _Snakebite: Treatment and Nursing Care._ American Journal of Nursing, vol. 40, pp. 657-660, 1940.

FILMS

A 16 mm. motion picture film in color, entitled, “Poisonous Snakes,” is available from the Texas Parks and Wildlife Department, Reagan State Office Building, Austin, Texas. It deals with snake bite prevention, poisonous snake identification and first aid treatment.

FIELD NOTES

Transcriber’s Notes

—Retained publication information from the printed edition: this eBook is public-domain in the country of publication.

—Corrected a few palpable typos.

—Collated Table of Contents, and re-ordered entries, or added headings, to coordinate with the actual contents.

—In the text versions only, text in italics is delimited by _underscores_.