Category: Moms

Snake envenomation management

Snake envenomation management

Please manageemnt your name Please enter your Snake envenomation management Your email is Snake envenomation management. Crotalid envebomation can cause neurotoxicity, tissue necrosis, hemolysis, and Sanke North American elapid envenomation can cause neurotoxicity; and Australian elapid envenomation can cause neurotoxicity, myotoxicity, coagulopathy, and hemolysis. Support for this browser is being discontinued for this site Internet Explorer 11 and lower We currently support Microsoft Edge, Chrome, Firefox and Safari.

Skip directly to site content Skip directly to Snake envenomation management options Manwgement Snake envenomation management to A-Z Snake envenomation management. The National Institute envenomatioh Occupational Safety and Health NIOSH. Snake envenomation management Navigation.

Snake envenomation management Twitter LinkedIn Syndicate. Envebomation Related Envenomstion. Photos manzgement of Sean P. First Aid Workers should take Insulin pump training steps Snake envenomation management a snake manatement them: Seek medical attention Snaie soon as possible dial managemennt call local Emergency Manwgement Services [EMS].

Physician-formulated Fat Burner is the enveenomation for serious snake envenomation. The sooner antivenom can be started, the Snae irreversible managemdnt from venom can be envenomatiom. Driving oneself to the hospital Snake envenomation management not advised because people with snakebites Snake envenomation management become Snakr or pass envenomtion.

Take a photograph of the envnomation from a safe distance envenomationn possible. Identifying the snake can Protein supplements for fitness with treatment of the snakebite. Managemwnt calm.

Inform your supervisor. Envenomaton first aid while manzgement for EMS staff envenomaiton get you to the hospital. Lay or sit down with the bite in a neutral position of comfort. Remove rings and watches before swelling starts. Wash the bite with soap and water. Cover the bite with a clean, dry dressing.

Do NOT do any of the following: Do not pick up the snake or try to trap it. NEVER handle a venomous snake, not even a dead one or its decapitated head. Do not wait for symptoms to appear if bitten, get medical help right away. Do not apply a tourniquet. Do not slash the wound with a knife or cut it in any way.

Do not try to suck out the venom. Do not apply ice or immerse the wound in water. Do not drink alcohol as a painkiller. Do not take pain relievers such as aspirin, ibuprofen, naproxen. Do not apply electric shock or folk therapies.

Page last reviewed: June 28, Content source: National Institute for Occupational Safety and Health. home Workplace Safety and Health Topics.

Hazards to Outdoor Workers. Related Topics Protective Clothing Skin Exposures and Effects. Follow NIOSH Facebook Pinterest Twitter YouTube. Links with this icon indicate that you are leaving the CDC website.

The Centers for Disease Control and Prevention CDC cannot attest to the accuracy of a non-federal website. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. You will be subject to the destination website's privacy policy when you follow the link.

CDC is not responsible for Section compliance accessibility on other federal or private website. For more information on CDC's web notification policies, see Website Disclaimers. Cancel Continue.

: Snake envenomation management

Snakebite and Spiderbite: Management Guidelines - South Australia | SA Health Treatment is Snake envenomation management supportive; antivenom, when Snake envenomation management, can Sake helpful envenomatio reducing clinical signs and manageent recovery. Myotoxicity muscle pain, tenderness, rhabdomyolysis Manageemnt Symptoms see history and examination table below VICC : Snake envenomation management enbenomation coagulopathy abnormal INR, high aPTT, fibrinogen very Performance recovery supplements for athletes, D-dimer high. The Monash Health clinical toxicologist on-call should be consulted in all cases of suspected snakebite. And so, I think […] it would potentially push me to encourage the patient to use the treatment if there was something where cost was a satisfactory part of the consideration. St John Ambulance Australia has a quick guide to the first aid management of snake bites. Those with coagulopathies should undergo evaluation for an underlying hereditary abnormality or an acquired disease, such as disseminated intravascular coagulation or idiopathic thrombocytopenic purpura. Remove rings and watches before swelling starts.
Managing snakebite

So would they have gotten better on their own? Those with experience using unfractionated antibody antivenoms, which are no longer in use, usually tried to refrain from antivenom use in general. Unfractionated antibody antivenoms had much worse side effects and the majority of their patients eventually recovered.

Even with the newer forms available that are safe and low-risk, such practitioners do not view antivenom as vital for the care of mild cases. When it comes to venomous exotic snakes or severe copperhead bites, there was no hesitancy to treat in order to save life or limb.

Institutions without an institutional treatment protocol generally had physicians with differing opinions on treatment plans and more treatment hesitancy.

One physician, however, mentioned that, based on available data, his institution tends to treat snakebites more aggressively with antivenom than other medical professionals might:.

Other factors contributing to treatment hesitancy included skepticism of scientific data supporting antivenom for non-life-threatening conditions based on funding sources of studies, and the belief that financial costs to the patient would potentially outweigh the clinical benefit of receiving antivenom treatment.

Emergency physicians typically did not have the opportunity to follow up with their patients to gather anecdotal evidence, so they reported the absence of an intuitive sense for how well or poorly patients recover and their long-term outcomes. The perceived value of anecdotal experience was demonstrated by one participant who did not recommend antivenom to a neighbor, who later said that his chronic pain after the bite was so bad that he wished to have been treated with antivenom if insurance covered it.

Seeing how the prolonged symptoms impacted his social and work life gave the physician a new perspective on treating snake envenomation patients. After that experience, he saw the value in receiving follow-up data, saying that this information could help physicians gain more confidence in their treatment decisions and shared decision-making:.

And so, I think […] it would potentially push me to encourage the patient to use the treatment if there was something where cost was a satisfactory part of the consideration. The availability and accessibility of antivenom was not cited as a major concern for treating snakebite patients within our study sample.

One participant states:. Other potential barriers for optimal treatment were identified. In some cases, antivenom was not kept in stock at the facility, requiring transfer of either the patient or the antivenom.

In such cases, distance, mode of available transportation, and road or weather conditions could impact timely access to care. Access to institutions with available antivenom and experts to treat snakebite patients may be limited due to small clinics, which are not part of larger networks, not being aware of any nearby expert centers, and lack of awareness where to search for referral centers.

Accessing antivenom for exotic snakebites could be a challenge depending on the snake type if a local institution or zoo does not have any in stock, and it might have to be delivered from distant locations for very rare bites. The level of didactic training received during EM residency did not seem to shape the general acceptance of antivenom, but more so the clinical approaches of local experts and mentors during residency.

In areas with little to no snakebite patients, the education mainly consisted of didactic training, as well as how to use available resources like the Poison Center Call line and under what circumstances to refer patients.

All interviewees agreed that if administering antivenom would be a lifesaving treatment, cost would not be an influencing factor in their decision-making. However, cost would become an influencing factor when antivenom was used to prevent tissue damage in non-life-threatening conditions.

Physicians typically informally weighed the costs and benefits of antivenom in these situations, with the caveat that those who primarily only treat severely toxic bites usually do not consider the cost of antivenom. One physician explicitly named the cost of the antivenom to be a risk factor to take into account.

When it comes to the transparency of the cost of antivenom itself, most were not aware of the exact costs per vial for the hospital to acquire it, as well as for the patient to receive it.

Those who were more acutely aware of the pricing had made a deliberate effort to find the information, and sometimes those who did still could not obtain a clear answer.

There was uncertainty regarding national standard pricing, a lack of transparency within hospitals, and further uncertainty when it comes to how much insurance may cover. So a single vial of [fab antivenom] can cost the hospital between three and four thousand dollars. And depending on the charge master and what the hospital wants to charge [a] patient with or without insurance, that could go up, you know, seven times upwards to twenty thousand dollars per vial.

Despite this uncertainty, physicians were aware that the financial cost was high, and patients may be partly or fully responsible for covering it.

Cost emerged as the biggest barrier to antivenom treatment. Some participants expressed that, if costs were minimal, they would be more likely to treat more aggressively in mild cases to decrease chronic morbidity.

However, some maintained that they still did not see mild cases as being an indication for antivenom, no matter the cost:. Table 3 provides an overview of the available resources and influencing factors that impacted their utilization.

While resources seemed to be readily available, some physicians pointed out that clinical judgement and personal experience may take precedence over general guidelines. The Poison Center Call line generally was thought to be a valuable and high-quality resource for physicians at bedside.

However, if experts were available within their own institution, the physicians would consult them prior to using Poison Center Call lines.

The benefits of Poison Center Call lines were that they were always available over the phone and potentially on bedside, yet one physician who worked for Poison Center Call lines raised the concern that over the phone consultations may result in hesitancy to follow their recommendations by the treating physicians.

None of the other study participants who used Poison Center Call lines as a resource shared that concern. However, small nuances in their recommendations could occur based on the individual consultant.

Overall, the available information on toxicology and pathology in the United States was thought to be of high quality and the physicians generally trusted the guidelines, recommendations as well as the safety of antivenom. In terms of antivenom though, some physicians voiced concerns about the trustworthiness of the data behind maintenance vial recommendations in regards of quality and the limited available evidence of its necessity:.

In addition, some felt that most of the evidence and available guidelines were snake-specific and non-transferrable. In terms of the quality of the available resources, the validity of online resources was questioned by a few participants, and one physician suggests increasing efforts in distributing better information to reach the physicians at bedside.

While scientific literature was, in a few cases, used as a tool to discuss treatment indications with the patients, the physicians also stated that personal experiences and beliefs might take precedence in choosing and recommending treatment options. Very few physicians were aware of studies investigating the effect of antivenom on pain or other long-term functional outcomes.

In fact, several physicians reported a lack of awareness of ongoing scientific efforts and advancements in snakebite research and were unaware of available high-quality studies to guide their treatment decisions.

In addition, skepticism of the available data was raised when funded by pharmaceutical companies, voicing the need for different funding sources, as well as skepticism surrounding the quality of available research data supporting antivenom for non-life-threatening conditions.

Table 4 provides an overview of recommendations the physicians provided specifically to enhance the scientific research and literature surrounding snakebite management.

One physician pointed out that, while there were many suggestions on new evidence-based guidelines, we should also seek to understand what keeps treating physicians from following the already existing guidelines and then move forward promoting a socially and fiscally responsible practice:.

Generally, the physicians agreed that to improve patient care, focus should be on high-quality evidence and guidelines, continuing education, patient-friendly information, increased transparency of long-term outcomes for EM physicians, and reassessing the cost for patients.

Table 5 provides an overview of the suggestions provided by the study participants. And that is so that EM-RAP [Emergency Medicine Reviews and Perspectives] is a great way of doing it, number 1.

And number 2: I think if there was a very easy website that someone could just [find] snakebite guidelines and […] anybody from anywhere could easily [access], and then it goes through these different tabs so you know, indications, diagnostics, evaluations, patient education, what to notify a patient, and […] that you could easily print out […] and give it to a patient and go over information.

Treatment approaches and perceptions of antivenom usage were influenced by a wide variety of factors in snake envenomation. Barriers to using antivenom were rooted in a wide variability in experience, awareness, and trust in available resources and evidence to inform physician decision-making.

Some participants primarily relied on textbooks, raising questions on the timeliness and inclusion of current advancements in snakebite management. Aside from the Poison Control Center call line, there was little overlap of widely used and accepted resources by our participants.

Having such a variability in resources including local expert opinions, on-site toxicologists, websites, apps and blogs increases the challenges to ensure consistent evidence-based recommendations. Participants echoed this notion and called for a systematic and high-quality national guideline, with precise and applicable clinical treatment recommendations.

Our sample did not appear to be broadly aware of the detailed national guidelines that already exist [ 17 , 18 ].

Available scientific data, when funded by pharmaceutical companies, was often met with skepticism by our participants, especially when the findings recommended antivenom for milder cases. The fact that the majority of clinical trials in medicine are funded by industry did not seem to influence this belief [ 19 , 20 ].

Another consideration the majority of study participants brought up was the potential financial burden for patients, lack of transparency surrounding cost, and the need for cost—benefit analyses regarding initial doses and maintenance vials of antivenom.

Our study demonstrates how cost is an important factor that providers consider when advising patients on snakebite envenomation treatment options. In addition to the possible financial burden influencing decision-making processes, some physicians based their clinical decision-making on their clinical experiences and conversations with colleagues and mentors, instead of current scientific evidence.

Potential reasoning behind the experience-based medicine approach, instead of evidence-based [ 26 ], was the lack of trust in the data, as well the perceived superior value of clinical experience and competence. Providers, as well as patients, tend to be hesitant in accepting treatment suggestions based on poorly designed studies, increasing the value of expert opinions in the decision-making process [ 27 ].

Clinical judgment is a cornerstone of clinical practice to interpret clinical data. It is known that physicians are highly variable in their interpretation of clinical data. Other influencing factors in clinical decision-making may also include autonomy, education, understanding the patient status and awareness of the situation.

Another challenge is the successful translation from research findings into clinical practice. Grimshaw et al. emphasize the importance of synthesizing research findings of specific topics to facilitate the integration in clinical practice.

An assessment of barriers and facilities among different groups and settings is deemed critical to identify opportunities for successful knowledge translation into clinical practice patterns [ 29 ].

Lastly, we have found perceived safety and accessibility of antivenom were not considered barriers to treating snakebite patients with antivenom. Given the history of antivenom and strong side effects of the early forms of treatment, it would have not been surprising if some participants, especially those who were trained when the older equine whole immunoglobulin antivenom was available, to base their reservations on antivenom usage on the perceived high risks for patients.

Copperhead snakebites were generally not considered a life-threatening condition requiring immediate antivenom treatment. This was felt to provide additional time to determine if antivenom is necessary, despite evidence that copperhead snakebite is likely a time-dependent disease [ 10 ]. Some limitations to the current study exist, though measures were taken to minimize their effect on the quality of the study.

The Principal Investigator was known to some of our study participants, which could have influenced their participation in this study. In order to control for that, we informed the participants that the interviews will be de-identified and sent out for their approval before the PI would have access to the data.

In addition to that, the majority of our study sample practiced in North Carolina and academic or teaching hospitals, limiting the representation across the US and community hospital providers. The lack of awareness and trust in available scientific evidence regarding the benefits and indications for antivenom especially in non-life-threatening conditions led to a wide variability in treatment approaches by practicing physicians.

In addition, the lack of cost transparency further contributed to hesitancy among providers in their treatment approaches. Our study emphasized the need for a widely accepted best practice guideline that is evidence based, includes concise clinical indicators developed by topic experts, and is implemented by practicing physicians.

Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Article Authors Metrics Comments Media Coverage Reader Comments Figures. Abstract Introduction Antivenom is currently considered standard treatment across the full spectrum of severity for snake envenomation in the United States.

Methods We conducted a qualitative study including in-depth interviews via online video conferencing with physicians practicing in emergency departments across the United States.

Findings Sixteen in-depth interviews with physicians from nine states across the US were conducted. Conclusions A major barrier to physician use of antivenom is a concern about cost, cost transparency and cost—benefit for the patients.

Introduction The WHO estimates a global yearly count of 2. Methods Ethics statement This study has been approved by the Duke Health Institutional Review Board, Protocol Number: Pro Study design We conducted an exploratory qualitative descriptive study following, using semi-structured in-depth interviews and an inductive thematic analysis approach [ 14 ].

Research team and reflexivity Personal characteristics. Relationship with participants. Recruitment We aimed to include physicians working in emergency departments EDs across the US, regardless of specialty or level of experience treating snakebites. Interview procedure Physicians implied consent by scheduling an interview, as communicated to them in the invitation email.

The transcripts were sent back to participants for review and approval. Data analysis Data were analyzed through an inductive content analysis by the two interviewers, based in an idiographic approach.

Findings For this manuscript, we use a selection of the emergent codes that were analyzed and grouped into open, axial, and selected codes S1 File. Download: PPT. Participant characteristics A total of 69 physicians were invited to participate in this study, 29 responded to the email invitation, 7 declined participation.

Perceptions on antivenom Indications and effectiveness. Risks and side effects. Willingness to administer antivenom Treatment hesitancy by the providers. Influencing factors in the choice for or against antivenom Availability and accessibility. Prior education of EM residents in snakebite management.

Usage and perceptions on available resources. The role of scientific evidence and general suggestions to improve patient care. Table 4. Recommendations to improve scientific evidence base on snakebite management practices.

Table 5. Suggestions to improve patient centered clinical best practices in snakebite management. Limitations Some limitations to the current study exist, though measures were taken to minimize their effect on the quality of the study.

Conclusion The lack of awareness and trust in available scientific evidence regarding the benefits and indications for antivenom especially in non-life-threatening conditions led to a wide variability in treatment approaches by practicing physicians. Supporting information. S1 Checklist.

COREQ COnsolidated criteria for REporting Qualitative research checklist. s PDF. S1 File. Full coding overview. s DOCX. S1 Scheme. Acknowledgments We thank all our study participants for offering their insight and expertise with us.

References 1. World Health Organization. What is snakebite envenoming? WHO, Snakebite Envenoming. Venomous Snakes NIOSH CDC [Internet].

html 3. Dart RC, Seifert SA, Boyer LV, Clark RF, Hall E, McKinney P, et al. A randomized multicenter trial of crotalinae polyvalent immune Fab ovine antivenom for the treatment for crotaline snakebite in the United States.

Arch Intern Med. Dart RC, Seifert SA, Carroll L, Clark RF, Hall E, Boyer-Hassen LV, et al. Affinity-purified, mixed monospecific crotalid antivenom ovine Fab for the treatment of crotalid venom poisoning.

Ann Emerg Med. Initial experience with Crotalidae polyvalent immune Fab ovine antivenom in the treatment of copperhead snakebite. Offerman SR, Bush SP, Moynihan JA, Clark RF.

Crotaline Fab antivenom for the treatment of children with rattlesnake envenomation. Bush SP, Ruha A-M, Seifert SA, Morgan DL, Lewis BJ, Arnold TC, et al. Clin Toxicol. View Article Google Scholar 8. Ruha A-M, Curry SC, Beuhler M, Katz K, Brooks DE, Graeme KA, et al.

Initial postmarketing experience with crotalidae polyvalent immune Fab for treatment of rattlesnake envenomation. Gerardo CJ, Quackenbush E, Lewis B, Rose SR, Greene S, Toschlog EA, et al. The Efficacy of Crotalidae Polyvalent Immune Fab Ovine Antivenom Versus Placebo Plus Optional Rescue Therapy on Recovery From Copperhead Snake Envenomation: A Randomized, Double-Blind, Placebo-Controlled, Clinical Trial.

Anderson VE, Gerardo CJ, Rapp-Olsson M, Bush SP, Mullins ME, Greene S, et al. Early administration of Fab antivenom resulted in faster limb recovery in copperhead snake envenomation patients. Read more on St John Ambulance Australia website.

Snake bites can occur on Australian farms. Read more Read more on National Centre for Farmer Health website. Read more on Sydney Children's Hospitals Network website. There are many hazards to consider after cyclones, floods and other disasters including asbestos contamination, mosquitoes, poisons, chemicals, pesticides, snakes, rodents and other wildlife.

Read more on WA Health website. People in contact with tropical fish and reptiles such as turtles, lizards and snakes may be at risk of infections and illness due to germs such as bacteria, viruses and parasites carried on the animals. Read more on Better Health Channel website.

When returning to a flood-affected area, remember that wild animals, including rats, mice, snakes or spiders, may be trapped in your home, shed or garden. First aid tips for bites and stings from some of the most venomous creatures in the world - snakes, spiders, jellyfish, blue ringed octopus and cone snail - all of which are found in Australia.

Read more on myDr website. First aid information about what to do If for common bites and stings. Includes - spiders, snakes, scorpions, bees, ticks, wasps, octopus, jellyfish and other sea creatures. Although relatively few bites and stings are seriously dangerous to humans, it may be difficult to distinguish which bites and stings are serious from those which are not.

Basic first aid procedures should be applied in all circumstances followed promptly by appropriate medical treatment. Read more on Queensland Health website. Even the mildest chemicals, medicines, animals and plants can be poisonous to your family but preventing poisoning at home can be simple.

Poisoning occurs when an individual ingests, inhales, injects or absorbs through the skin a substance that is harmful to human health. Poisoning may cause illness, injury or even death. More than people or 1 in every are poisoned every year in Australia.

Read more on Ausmed Education website. When a vein or artery is injured and begins to leak blood, a sequence of clotting steps and factors called the coagulation cascade is activated by the body.

Read more on Pathology Tests Explained website. Reproduced with permission from The Royal Australian College of General Practitioners. Read more on RACGP - The Royal Australian College of General Practitioners website.

Healthdirect Australia is not responsible for the content and advertising on the external website you are now entering. Healthdirect Australia acknowledges the Traditional Owners of Country throughout Australia and their continuing connection to land, sea and community.

We pay our respects to the Traditional Owners and to Elders both past and present. We currently support Microsoft Edge, Chrome, Firefox and Safari. For more information, please visit the links below:.

You are welcome to continue browsing this site with this browser. Some features, tools or interaction may not work correctly. Brown snake. There is a total of 5 error s on this form, details are below. Please enter your name Please enter your email Your email is invalid. Please check and try again Please enter recipient's email Recipient's email is invalid.

Please check and try again Agree to Terms required. Thank you for sharing our content. A message has been sent to your recipient's email address with a link to the content webpage.

Your name: is required Error: This is required. Your email: is required Error: This is required Error: Not a valid value.

Send to: is required Error: This is required Error: Not a valid value. Error: This is required I have read and agree to the Terms of Use and Privacy Policy is required.

Venomous Snake Bites: Symptoms & First Aid

Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. Most snakes aren't dangerous to people.

These snakes are called venomous. In North America, these include the rattlesnake, coral snake, water moccasin, also called cottonmouth, and copperhead. Their bites can cause serious injuries and sometimes death.

If a venomous snake bites you, call or your local emergency number right away, especially if the bitten area changes color, swells or is painful. Many emergency rooms have antivenom drugs, which may help you. Most snakebites happen on the arms, wrists or hands. Typical symptoms of a nonvenomous snakebite are pain, injury and scratches at the site of the bite.

After a venomous snakebite, there usually is serious pain and tenderness at the site. This can worsen to swelling and bruising at the site that may move all the way up the arm or leg.

Other symptoms are nausea, labored breathing and feelings of weakness, as well as an odd taste in the mouth. Some snakes, such as coral snakes, have toxins that affect the brain and nerves. This can cause symptoms such as upper eyelid drooping, tingling fingers or toes, difficulty swallowing, and muscle weakness.

Most venomous snakes in North America have eyes like slits and are called pit vipers. Their heads are triangle-shaped and they have fangs. One exception is the coral snake, which has a cigar-shaped head and round pupils.

Nonvenomous snakes typically have rounded heads, round pupils and no fangs. Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press.

This content does not have an English version. This content does not have an Arabic version. Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations.

Request Appointment. Table 1 outlines emergent themes and codes used for this analysis. A total of 69 physicians were invited to participate in this study, 29 responded to the email invitation, 7 declined participation. Another 6 participants were lost to follow up after providing initial consent.

One quarter of respondents completed a fellowship in clinical toxicology. The years of clinical experience as well as numbers of snakebites treated were fairly evenly distributed. According to participants, antivenom use would be indicated by laboratory abnormalities, progression of swelling especially across joint lines , systemic toxicity, coagulopathy, compartment syndrome, widespread ecchymosis, signs of tissue damage, changes in hematologic status and if symptoms severely impacted mobility.

Antivenom was reported to always be indicated if there was a perceived risk of losing life or limb. Generally, the greater the number of bites and level of perceived dysfunction based on the bite location, the more likely antivenom is to be administered. Participants explained that antivenom would not be indicated for dry bites or patients with no signs of envenomation.

In less severe cases with mild swelling or a minimal envenomation syndrome, most physicians agreed that observation and routine supportive care would be sufficient. While one participant specifically pointed out that, in her opinion, pain alone was not a sufficient indication for administering antivenom, others mentioned that antivenom is effective in controlling pain.

One participant mentioned that antivenom use in snakebite patients could limit opioid prescriptions. Effectiveness of antivenom treatment was believed to vary between patients, depending on their underlying health conditions, the time to treatment and complicating factors that would cause their envenomation to be more severe.

Antivenom was perceived as being very effective for decreasing swelling and swelling-related pain and tissue damage. Those more familiar with the snakebite treatment literature mentioned decreased morbidity and faster return to function with antivenom; however, there was no overall consensus among participants if those potential benefits would be significant enough to indicate antivenom use for milder envenomations.

The vast majority of participants mentioned allergic reactions, including hives and itching, as the main side effect of antivenom; however, they perceived the administration of antivenom to be safe and low risk.

Other potential risks included serum sickness and hypersensitivity. While risks and side effects did not seem to be strong barriers to antivenom treatment, the majority of physicians reported being generally hesitant to administer antivenom to their patients. The threshold at which physicians decided to treat with antivenom seemed to be influenced by personal practice and individual risk tolerance.

However, potential risks or side effects did not contribute to treatment hesitancy:. Rather, lack of experience in treating snakebite patients may either lead to hesitancy to treat to avoid unknown risks associated with the treatment or to early treatment with fewer indications to reduce the risk of progression of symptoms.

Some participants expressed that increasing confidence and perceived competence in snakebite management required personal and practical experience through, for example, being trained in high-prevalence areas, while reading the available literature alone would not be sufficient.

Among our interviewees, those with more clinical and snakebite treatment experience generally felt more comfortable withholding antivenom to avoid what they saw as unnecessary treatment. More experienced physicians trained with fewer resources would rely more heavily on clinical judgement.

Because that patient would have gotten sicker. So would they have gotten better on their own? Those with experience using unfractionated antibody antivenoms, which are no longer in use, usually tried to refrain from antivenom use in general.

Unfractionated antibody antivenoms had much worse side effects and the majority of their patients eventually recovered. Even with the newer forms available that are safe and low-risk, such practitioners do not view antivenom as vital for the care of mild cases.

When it comes to venomous exotic snakes or severe copperhead bites, there was no hesitancy to treat in order to save life or limb. Institutions without an institutional treatment protocol generally had physicians with differing opinions on treatment plans and more treatment hesitancy.

One physician, however, mentioned that, based on available data, his institution tends to treat snakebites more aggressively with antivenom than other medical professionals might:. Other factors contributing to treatment hesitancy included skepticism of scientific data supporting antivenom for non-life-threatening conditions based on funding sources of studies, and the belief that financial costs to the patient would potentially outweigh the clinical benefit of receiving antivenom treatment.

Emergency physicians typically did not have the opportunity to follow up with their patients to gather anecdotal evidence, so they reported the absence of an intuitive sense for how well or poorly patients recover and their long-term outcomes.

The perceived value of anecdotal experience was demonstrated by one participant who did not recommend antivenom to a neighbor, who later said that his chronic pain after the bite was so bad that he wished to have been treated with antivenom if insurance covered it.

Seeing how the prolonged symptoms impacted his social and work life gave the physician a new perspective on treating snake envenomation patients. After that experience, he saw the value in receiving follow-up data, saying that this information could help physicians gain more confidence in their treatment decisions and shared decision-making:.

And so, I think […] it would potentially push me to encourage the patient to use the treatment if there was something where cost was a satisfactory part of the consideration. The availability and accessibility of antivenom was not cited as a major concern for treating snakebite patients within our study sample.

One participant states:. Other potential barriers for optimal treatment were identified. In some cases, antivenom was not kept in stock at the facility, requiring transfer of either the patient or the antivenom.

In such cases, distance, mode of available transportation, and road or weather conditions could impact timely access to care. Access to institutions with available antivenom and experts to treat snakebite patients may be limited due to small clinics, which are not part of larger networks, not being aware of any nearby expert centers, and lack of awareness where to search for referral centers.

Accessing antivenom for exotic snakebites could be a challenge depending on the snake type if a local institution or zoo does not have any in stock, and it might have to be delivered from distant locations for very rare bites.

The level of didactic training received during EM residency did not seem to shape the general acceptance of antivenom, but more so the clinical approaches of local experts and mentors during residency.

In areas with little to no snakebite patients, the education mainly consisted of didactic training, as well as how to use available resources like the Poison Center Call line and under what circumstances to refer patients.

All interviewees agreed that if administering antivenom would be a lifesaving treatment, cost would not be an influencing factor in their decision-making. However, cost would become an influencing factor when antivenom was used to prevent tissue damage in non-life-threatening conditions.

Physicians typically informally weighed the costs and benefits of antivenom in these situations, with the caveat that those who primarily only treat severely toxic bites usually do not consider the cost of antivenom.

One physician explicitly named the cost of the antivenom to be a risk factor to take into account. When it comes to the transparency of the cost of antivenom itself, most were not aware of the exact costs per vial for the hospital to acquire it, as well as for the patient to receive it. Those who were more acutely aware of the pricing had made a deliberate effort to find the information, and sometimes those who did still could not obtain a clear answer.

There was uncertainty regarding national standard pricing, a lack of transparency within hospitals, and further uncertainty when it comes to how much insurance may cover. So a single vial of [fab antivenom] can cost the hospital between three and four thousand dollars. And depending on the charge master and what the hospital wants to charge [a] patient with or without insurance, that could go up, you know, seven times upwards to twenty thousand dollars per vial.

Despite this uncertainty, physicians were aware that the financial cost was high, and patients may be partly or fully responsible for covering it. Cost emerged as the biggest barrier to antivenom treatment.

Some participants expressed that, if costs were minimal, they would be more likely to treat more aggressively in mild cases to decrease chronic morbidity. However, some maintained that they still did not see mild cases as being an indication for antivenom, no matter the cost:. Table 3 provides an overview of the available resources and influencing factors that impacted their utilization.

While resources seemed to be readily available, some physicians pointed out that clinical judgement and personal experience may take precedence over general guidelines.

The Poison Center Call line generally was thought to be a valuable and high-quality resource for physicians at bedside. However, if experts were available within their own institution, the physicians would consult them prior to using Poison Center Call lines.

The benefits of Poison Center Call lines were that they were always available over the phone and potentially on bedside, yet one physician who worked for Poison Center Call lines raised the concern that over the phone consultations may result in hesitancy to follow their recommendations by the treating physicians.

None of the other study participants who used Poison Center Call lines as a resource shared that concern. However, small nuances in their recommendations could occur based on the individual consultant.

Overall, the available information on toxicology and pathology in the United States was thought to be of high quality and the physicians generally trusted the guidelines, recommendations as well as the safety of antivenom. In terms of antivenom though, some physicians voiced concerns about the trustworthiness of the data behind maintenance vial recommendations in regards of quality and the limited available evidence of its necessity:.

In addition, some felt that most of the evidence and available guidelines were snake-specific and non-transferrable.

In terms of the quality of the available resources, the validity of online resources was questioned by a few participants, and one physician suggests increasing efforts in distributing better information to reach the physicians at bedside.

While scientific literature was, in a few cases, used as a tool to discuss treatment indications with the patients, the physicians also stated that personal experiences and beliefs might take precedence in choosing and recommending treatment options. Very few physicians were aware of studies investigating the effect of antivenom on pain or other long-term functional outcomes.

In fact, several physicians reported a lack of awareness of ongoing scientific efforts and advancements in snakebite research and were unaware of available high-quality studies to guide their treatment decisions.

In addition, skepticism of the available data was raised when funded by pharmaceutical companies, voicing the need for different funding sources, as well as skepticism surrounding the quality of available research data supporting antivenom for non-life-threatening conditions.

Table 4 provides an overview of recommendations the physicians provided specifically to enhance the scientific research and literature surrounding snakebite management.

One physician pointed out that, while there were many suggestions on new evidence-based guidelines, we should also seek to understand what keeps treating physicians from following the already existing guidelines and then move forward promoting a socially and fiscally responsible practice:.

Generally, the physicians agreed that to improve patient care, focus should be on high-quality evidence and guidelines, continuing education, patient-friendly information, increased transparency of long-term outcomes for EM physicians, and reassessing the cost for patients.

Table 5 provides an overview of the suggestions provided by the study participants. And that is so that EM-RAP [Emergency Medicine Reviews and Perspectives] is a great way of doing it, number 1. And number 2: I think if there was a very easy website that someone could just [find] snakebite guidelines and […] anybody from anywhere could easily [access], and then it goes through these different tabs so you know, indications, diagnostics, evaluations, patient education, what to notify a patient, and […] that you could easily print out […] and give it to a patient and go over information.

Treatment approaches and perceptions of antivenom usage were influenced by a wide variety of factors in snake envenomation. Barriers to using antivenom were rooted in a wide variability in experience, awareness, and trust in available resources and evidence to inform physician decision-making.

Some participants primarily relied on textbooks, raising questions on the timeliness and inclusion of current advancements in snakebite management. Aside from the Poison Control Center call line, there was little overlap of widely used and accepted resources by our participants. Having such a variability in resources including local expert opinions, on-site toxicologists, websites, apps and blogs increases the challenges to ensure consistent evidence-based recommendations.

Participants echoed this notion and called for a systematic and high-quality national guideline, with precise and applicable clinical treatment recommendations. Our sample did not appear to be broadly aware of the detailed national guidelines that already exist [ 17 , 18 ].

Available scientific data, when funded by pharmaceutical companies, was often met with skepticism by our participants, especially when the findings recommended antivenom for milder cases.

The fact that the majority of clinical trials in medicine are funded by industry did not seem to influence this belief [ 19 , 20 ]. Another consideration the majority of study participants brought up was the potential financial burden for patients, lack of transparency surrounding cost, and the need for cost—benefit analyses regarding initial doses and maintenance vials of antivenom.

Our study demonstrates how cost is an important factor that providers consider when advising patients on snakebite envenomation treatment options. In addition to the possible financial burden influencing decision-making processes, some physicians based their clinical decision-making on their clinical experiences and conversations with colleagues and mentors, instead of current scientific evidence.

Potential reasoning behind the experience-based medicine approach, instead of evidence-based [ 26 ], was the lack of trust in the data, as well the perceived superior value of clinical experience and competence. Providers, as well as patients, tend to be hesitant in accepting treatment suggestions based on poorly designed studies, increasing the value of expert opinions in the decision-making process [ 27 ].

Clinical judgment is a cornerstone of clinical practice to interpret clinical data. It is known that physicians are highly variable in their interpretation of clinical data.

Other influencing factors in clinical decision-making may also include autonomy, education, understanding the patient status and awareness of the situation. Another challenge is the successful translation from research findings into clinical practice.

Grimshaw et al. emphasize the importance of synthesizing research findings of specific topics to facilitate the integration in clinical practice. An assessment of barriers and facilities among different groups and settings is deemed critical to identify opportunities for successful knowledge translation into clinical practice patterns [ 29 ].

Antivenoms available against North American pit vipers include equine-derived polyvalent antivenom, ovine-origin polyvalent F ab fragment antivenom, and equine-origin polyvalent F ab 2 fragment antivenom. The F ab antivenoms use the F ab components of the immunoglobulin molecule, resulting in an antivenom that has lower risk of allergic reaction, faster reconstitution, and potency similar to that of the polyvalent immunoglobulin.

In the unlikely event of an anaphylactic reaction to the antivenom in a dog or cat, antivenom administration should be discontinued and epinephrine 0. In severe envenomations, multiple vials of antivenom may be required, although this is frequently cost-prohibitive in veterinary patients.

Antivenom generally helps considerably in managing the pain of a crotalid bite. Opioid analgesics may be used as needed for residual pain; NSAIDs are not recommended.

read more , 3 References Venomous snakebites are emergency situations requiring prompt veterinary attention. read more should be administered. Hemoglobin glutamer bovine or hetastarch may be helpful to manage hypovolemia; however, colloids should be used with caution because of their potential to leak out of damaged vessels and pull fluids into tissue beds.

Several potential pathogens, including Pseudomonas aeruginosa , Clostridium spp, Corynebacterium spp, and staphylococci have been isolated from the mouth of rattlesnakes. However, the incidence of wound infection after snakebites is low, and many veterinarians use antimicrobials only when notable tissue necrosis is present.

Broad-spectrum antimicrobials such as amoxicillin potentiated with clavulanate or cephalosporins are preferred. Tetanus Tetanus in Animals Tetanus is caused by the neurotoxin produced by Clostridium tetani , which is found in soil and intestinal tracts and usually introduced into tissues through deep puncture wounds.

read more antitoxin also should be considered, especially in horses, and other supportive treatment should be administered as needed eg, blood or plasma transfusions in the case of hemolytic or anticoagulant venoms. In most cases, surgical excision of tissue is impractical or unwarranted.

Antihistamines have been reported to be contraindicated; however, diphenhydramine hydrochloride 10—50 mg, SC or IV, once has been shown to be helpful to manage fractious patients and may possibly assist in minimizing risk of allergic reactions to antivenom.

Animals bitten by elapids may be treated with supportive care as needed IV fluid therapy, ventilatory support, anticonvulsants, etc and antivenom, if available. Antivenom against coral snake venoms is no longer manufactured in the US, although some practitioners have received special permission to import coral snake antivenom from Mexico.

In Australia, several antivenoms are available for use in veterinary patients. A polyvalent antivenom is available for use when the identity of the snake cannot be ascertained, and many veterinarians prefer to use the polyvalent antivenom for all envenomations. Additionally, animals bitten by Australian elapids should be monitored for development of coagulopathy, hemolysis, renal injury, cardiovascular abnormalities, or rhabdomyolysis; appropriate treatment should be instituted as needed.

As with crotalid bites, broad-spectrum antimicrobial therapy may be indicated if there is risk of infection of the bite wound.

Mcalees TJ, Abraham LA. Australian elapid snake envenomation in cats: clinical priorities and approach. J Feline Med Surg. DOI: Whitaker BR, Gold BS. Chapter Working with Venomous Species: Emergency Protocols.

In: Mader DR, ed. Reptile Medicine and Surgery. Rothrock K. Snake Envenomation, Crotalid Canine. In: VINcyclopedia of Diseases. The prognosis of snakebite depends on the type and species of snake, location of the bite, size of the victim, extent of envenomation, and time interval between the bite and the institution of treatment.

Animals that survive elapid bites generally make full recoveries; however, crotalid bites can result in long-term sequelae due to tissue necrosis amputation, loss of function, etc , depending on severity of the bite and promptness and aggressiveness of treatment.

Clinical course will vary with the species of snake, extent of envenomation, and characteristics eg, age, size, and location of bite of the patient. Treatment is largely supportive; antivenom, when available, can be helpful in reducing clinical signs and speeding recovery. read more.

The Merck Veterinary Manual was first published in as a service to the community.

Snakebites in Animals Get Snake envenomation management Sodium-rich vs sodium-poor foods Clinic app. Envenomatio were analyzed Mangement an inductive content analysis by the two managemennt, based in an idiographic approach. Media Requests. National Library of Medicine Rockville Pike Bethesda, MD The anatomy of medical research: US and international comparisons. Other potential risks included serum sickness and hypersensitivity. The bite site may be painful, swollen or bruised, but usually is not for snakes in Victoria.

Snake envenomation management -

Then, investigators cross-validated the results by discussing the codes and themes of each interview to reach a consensus. The analysts then jointly created analytic memos based on the emergent themes, that served as a basis for discussion with the rest of the study team. All participants received a presentation of the emergent themes and preliminary results to validate the content and ensure accuracy of interpretation.

For this manuscript, we use a selection of the emergent codes that were analyzed and grouped into open, axial, and selected codes S1 File. The available codes were grouped further into the following themes for this manuscript and the specific study objectives: perceptions of antivenom, willingness to administer and influencing factors to administer antivenom.

Table 1 outlines emergent themes and codes used for this analysis. A total of 69 physicians were invited to participate in this study, 29 responded to the email invitation, 7 declined participation.

Another 6 participants were lost to follow up after providing initial consent. One quarter of respondents completed a fellowship in clinical toxicology. The years of clinical experience as well as numbers of snakebites treated were fairly evenly distributed.

According to participants, antivenom use would be indicated by laboratory abnormalities, progression of swelling especially across joint lines , systemic toxicity, coagulopathy, compartment syndrome, widespread ecchymosis, signs of tissue damage, changes in hematologic status and if symptoms severely impacted mobility.

Antivenom was reported to always be indicated if there was a perceived risk of losing life or limb. Generally, the greater the number of bites and level of perceived dysfunction based on the bite location, the more likely antivenom is to be administered. Participants explained that antivenom would not be indicated for dry bites or patients with no signs of envenomation.

In less severe cases with mild swelling or a minimal envenomation syndrome, most physicians agreed that observation and routine supportive care would be sufficient. While one participant specifically pointed out that, in her opinion, pain alone was not a sufficient indication for administering antivenom, others mentioned that antivenom is effective in controlling pain.

One participant mentioned that antivenom use in snakebite patients could limit opioid prescriptions. Effectiveness of antivenom treatment was believed to vary between patients, depending on their underlying health conditions, the time to treatment and complicating factors that would cause their envenomation to be more severe.

Antivenom was perceived as being very effective for decreasing swelling and swelling-related pain and tissue damage. Those more familiar with the snakebite treatment literature mentioned decreased morbidity and faster return to function with antivenom; however, there was no overall consensus among participants if those potential benefits would be significant enough to indicate antivenom use for milder envenomations.

The vast majority of participants mentioned allergic reactions, including hives and itching, as the main side effect of antivenom; however, they perceived the administration of antivenom to be safe and low risk. Other potential risks included serum sickness and hypersensitivity. While risks and side effects did not seem to be strong barriers to antivenom treatment, the majority of physicians reported being generally hesitant to administer antivenom to their patients.

The threshold at which physicians decided to treat with antivenom seemed to be influenced by personal practice and individual risk tolerance.

However, potential risks or side effects did not contribute to treatment hesitancy:. Rather, lack of experience in treating snakebite patients may either lead to hesitancy to treat to avoid unknown risks associated with the treatment or to early treatment with fewer indications to reduce the risk of progression of symptoms.

Some participants expressed that increasing confidence and perceived competence in snakebite management required personal and practical experience through, for example, being trained in high-prevalence areas, while reading the available literature alone would not be sufficient.

Among our interviewees, those with more clinical and snakebite treatment experience generally felt more comfortable withholding antivenom to avoid what they saw as unnecessary treatment. More experienced physicians trained with fewer resources would rely more heavily on clinical judgement.

Because that patient would have gotten sicker. So would they have gotten better on their own? Those with experience using unfractionated antibody antivenoms, which are no longer in use, usually tried to refrain from antivenom use in general.

Unfractionated antibody antivenoms had much worse side effects and the majority of their patients eventually recovered. Even with the newer forms available that are safe and low-risk, such practitioners do not view antivenom as vital for the care of mild cases. When it comes to venomous exotic snakes or severe copperhead bites, there was no hesitancy to treat in order to save life or limb.

Institutions without an institutional treatment protocol generally had physicians with differing opinions on treatment plans and more treatment hesitancy. One physician, however, mentioned that, based on available data, his institution tends to treat snakebites more aggressively with antivenom than other medical professionals might:.

Other factors contributing to treatment hesitancy included skepticism of scientific data supporting antivenom for non-life-threatening conditions based on funding sources of studies, and the belief that financial costs to the patient would potentially outweigh the clinical benefit of receiving antivenom treatment.

Emergency physicians typically did not have the opportunity to follow up with their patients to gather anecdotal evidence, so they reported the absence of an intuitive sense for how well or poorly patients recover and their long-term outcomes.

The perceived value of anecdotal experience was demonstrated by one participant who did not recommend antivenom to a neighbor, who later said that his chronic pain after the bite was so bad that he wished to have been treated with antivenom if insurance covered it.

Seeing how the prolonged symptoms impacted his social and work life gave the physician a new perspective on treating snake envenomation patients. After that experience, he saw the value in receiving follow-up data, saying that this information could help physicians gain more confidence in their treatment decisions and shared decision-making:.

And so, I think […] it would potentially push me to encourage the patient to use the treatment if there was something where cost was a satisfactory part of the consideration. The availability and accessibility of antivenom was not cited as a major concern for treating snakebite patients within our study sample.

One participant states:. Other potential barriers for optimal treatment were identified. In some cases, antivenom was not kept in stock at the facility, requiring transfer of either the patient or the antivenom. In such cases, distance, mode of available transportation, and road or weather conditions could impact timely access to care.

Access to institutions with available antivenom and experts to treat snakebite patients may be limited due to small clinics, which are not part of larger networks, not being aware of any nearby expert centers, and lack of awareness where to search for referral centers.

Accessing antivenom for exotic snakebites could be a challenge depending on the snake type if a local institution or zoo does not have any in stock, and it might have to be delivered from distant locations for very rare bites.

The level of didactic training received during EM residency did not seem to shape the general acceptance of antivenom, but more so the clinical approaches of local experts and mentors during residency. In areas with little to no snakebite patients, the education mainly consisted of didactic training, as well as how to use available resources like the Poison Center Call line and under what circumstances to refer patients.

All interviewees agreed that if administering antivenom would be a lifesaving treatment, cost would not be an influencing factor in their decision-making.

However, cost would become an influencing factor when antivenom was used to prevent tissue damage in non-life-threatening conditions. Physicians typically informally weighed the costs and benefits of antivenom in these situations, with the caveat that those who primarily only treat severely toxic bites usually do not consider the cost of antivenom.

One physician explicitly named the cost of the antivenom to be a risk factor to take into account. When it comes to the transparency of the cost of antivenom itself, most were not aware of the exact costs per vial for the hospital to acquire it, as well as for the patient to receive it.

Those who were more acutely aware of the pricing had made a deliberate effort to find the information, and sometimes those who did still could not obtain a clear answer. There was uncertainty regarding national standard pricing, a lack of transparency within hospitals, and further uncertainty when it comes to how much insurance may cover.

So a single vial of [fab antivenom] can cost the hospital between three and four thousand dollars. And depending on the charge master and what the hospital wants to charge [a] patient with or without insurance, that could go up, you know, seven times upwards to twenty thousand dollars per vial.

Despite this uncertainty, physicians were aware that the financial cost was high, and patients may be partly or fully responsible for covering it. Cost emerged as the biggest barrier to antivenom treatment.

Some participants expressed that, if costs were minimal, they would be more likely to treat more aggressively in mild cases to decrease chronic morbidity. However, some maintained that they still did not see mild cases as being an indication for antivenom, no matter the cost:.

Table 3 provides an overview of the available resources and influencing factors that impacted their utilization. While resources seemed to be readily available, some physicians pointed out that clinical judgement and personal experience may take precedence over general guidelines.

The Poison Center Call line generally was thought to be a valuable and high-quality resource for physicians at bedside. However, if experts were available within their own institution, the physicians would consult them prior to using Poison Center Call lines.

The benefits of Poison Center Call lines were that they were always available over the phone and potentially on bedside, yet one physician who worked for Poison Center Call lines raised the concern that over the phone consultations may result in hesitancy to follow their recommendations by the treating physicians.

None of the other study participants who used Poison Center Call lines as a resource shared that concern. However, small nuances in their recommendations could occur based on the individual consultant. Overall, the available information on toxicology and pathology in the United States was thought to be of high quality and the physicians generally trusted the guidelines, recommendations as well as the safety of antivenom.

In terms of antivenom though, some physicians voiced concerns about the trustworthiness of the data behind maintenance vial recommendations in regards of quality and the limited available evidence of its necessity:.

In addition, some felt that most of the evidence and available guidelines were snake-specific and non-transferrable. In terms of the quality of the available resources, the validity of online resources was questioned by a few participants, and one physician suggests increasing efforts in distributing better information to reach the physicians at bedside.

While scientific literature was, in a few cases, used as a tool to discuss treatment indications with the patients, the physicians also stated that personal experiences and beliefs might take precedence in choosing and recommending treatment options.

Very few physicians were aware of studies investigating the effect of antivenom on pain or other long-term functional outcomes. In fact, several physicians reported a lack of awareness of ongoing scientific efforts and advancements in snakebite research and were unaware of available high-quality studies to guide their treatment decisions.

In addition, skepticism of the available data was raised when funded by pharmaceutical companies, voicing the need for different funding sources, as well as skepticism surrounding the quality of available research data supporting antivenom for non-life-threatening conditions.

Table 4 provides an overview of recommendations the physicians provided specifically to enhance the scientific research and literature surrounding snakebite management. One physician pointed out that, while there were many suggestions on new evidence-based guidelines, we should also seek to understand what keeps treating physicians from following the already existing guidelines and then move forward promoting a socially and fiscally responsible practice:.

Generally, the physicians agreed that to improve patient care, focus should be on high-quality evidence and guidelines, continuing education, patient-friendly information, increased transparency of long-term outcomes for EM physicians, and reassessing the cost for patients.

Table 5 provides an overview of the suggestions provided by the study participants. And that is so that EM-RAP [Emergency Medicine Reviews and Perspectives] is a great way of doing it, number 1. And number 2: I think if there was a very easy website that someone could just [find] snakebite guidelines and […] anybody from anywhere could easily [access], and then it goes through these different tabs so you know, indications, diagnostics, evaluations, patient education, what to notify a patient, and […] that you could easily print out […] and give it to a patient and go over information.

Treatment approaches and perceptions of antivenom usage were influenced by a wide variety of factors in snake envenomation.

Barriers to using antivenom were rooted in a wide variability in experience, awareness, and trust in available resources and evidence to inform physician decision-making. Some participants primarily relied on textbooks, raising questions on the timeliness and inclusion of current advancements in snakebite management.

Aside from the Poison Control Center call line, there was little overlap of widely used and accepted resources by our participants. Having such a variability in resources including local expert opinions, on-site toxicologists, websites, apps and blogs increases the challenges to ensure consistent evidence-based recommendations.

Participants echoed this notion and called for a systematic and high-quality national guideline, with precise and applicable clinical treatment recommendations. Our sample did not appear to be broadly aware of the detailed national guidelines that already exist [ 17 , 18 ].

Available scientific data, when funded by pharmaceutical companies, was often met with skepticism by our participants, especially when the findings recommended antivenom for milder cases.

The fact that the majority of clinical trials in medicine are funded by industry did not seem to influence this belief [ 19 , 20 ]. Another consideration the majority of study participants brought up was the potential financial burden for patients, lack of transparency surrounding cost, and the need for cost—benefit analyses regarding initial doses and maintenance vials of antivenom.

Our study demonstrates how cost is an important factor that providers consider when advising patients on snakebite envenomation treatment options.

In addition to the possible financial burden influencing decision-making processes, some physicians based their clinical decision-making on their clinical experiences and conversations with colleagues and mentors, instead of current scientific evidence.

Potential reasoning behind the experience-based medicine approach, instead of evidence-based [ 26 ], was the lack of trust in the data, as well the perceived superior value of clinical experience and competence.

Providers, as well as patients, tend to be hesitant in accepting treatment suggestions based on poorly designed studies, increasing the value of expert opinions in the decision-making process [ 27 ].

Clinical judgment is a cornerstone of clinical practice to interpret clinical data. It is known that physicians are highly variable in their interpretation of clinical data.

Other influencing factors in clinical decision-making may also include autonomy, education, understanding the patient status and awareness of the situation.

Another challenge is the successful translation from research findings into clinical practice. Grimshaw et al. emphasize the importance of synthesizing research findings of specific topics to facilitate the integration in clinical practice.

An assessment of barriers and facilities among different groups and settings is deemed critical to identify opportunities for successful knowledge translation into clinical practice patterns [ 29 ]. Lastly, we have found perceived safety and accessibility of antivenom were not considered barriers to treating snakebite patients with antivenom.

Given the history of antivenom and strong side effects of the early forms of treatment, it would have not been surprising if some participants, especially those who were trained when the older equine whole immunoglobulin antivenom was available, to base their reservations on antivenom usage on the perceived high risks for patients.

Copperhead snakebites were generally not considered a life-threatening condition requiring immediate antivenom treatment. This was felt to provide additional time to determine if antivenom is necessary, despite evidence that copperhead snakebite is likely a time-dependent disease [ 10 ]. Some limitations to the current study exist, though measures were taken to minimize their effect on the quality of the study.

The Principal Investigator was known to some of our study participants, which could have influenced their participation in this study. In order to control for that, we informed the participants that the interviews will be de-identified and sent out for their approval before the PI would have access to the data.

In addition to that, the majority of our study sample practiced in North Carolina and academic or teaching hospitals, limiting the representation across the US and community hospital providers. The lack of awareness and trust in available scientific evidence regarding the benefits and indications for antivenom especially in non-life-threatening conditions led to a wide variability in treatment approaches by practicing physicians.

In addition, the lack of cost transparency further contributed to hesitancy among providers in their treatment approaches. Our study emphasized the need for a widely accepted best practice guideline that is evidence based, includes concise clinical indicators developed by topic experts, and is implemented by practicing physicians.

Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Article Authors Metrics Comments Media Coverage Reader Comments Figures. Abstract Introduction Antivenom is currently considered standard treatment across the full spectrum of severity for snake envenomation in the United States.

Methods We conducted a qualitative study including in-depth interviews via online video conferencing with physicians practicing in emergency departments across the United States. Findings Sixteen in-depth interviews with physicians from nine states across the US were conducted.

Conclusions A major barrier to physician use of antivenom is a concern about cost, cost transparency and cost—benefit for the patients. Introduction The WHO estimates a global yearly count of 2. Methods Ethics statement This study has been approved by the Duke Health Institutional Review Board, Protocol Number: Pro Study design We conducted an exploratory qualitative descriptive study following, using semi-structured in-depth interviews and an inductive thematic analysis approach [ 14 ].

Research team and reflexivity Personal characteristics. Relationship with participants. Recruitment We aimed to include physicians working in emergency departments EDs across the US, regardless of specialty or level of experience treating snakebites. Interview procedure Physicians implied consent by scheduling an interview, as communicated to them in the invitation email.

The transcripts were sent back to participants for review and approval. Data analysis Data were analyzed through an inductive content analysis by the two interviewers, based in an idiographic approach.

Findings For this manuscript, we use a selection of the emergent codes that were analyzed and grouped into open, axial, and selected codes S1 File. Download: PPT. Participant characteristics A total of 69 physicians were invited to participate in this study, 29 responded to the email invitation, 7 declined participation.

Perceptions on antivenom Indications and effectiveness. Risks and side effects. Willingness to administer antivenom Treatment hesitancy by the providers.

Influencing factors in the choice for or against antivenom Availability and accessibility. Prior education of EM residents in snakebite management. Usage and perceptions on available resources.

The role of scientific evidence and general suggestions to improve patient care. Table 4. Recommendations to improve scientific evidence base on snakebite management practices. Table 5. Suggestions to improve patient centered clinical best practices in snakebite management.

Limitations Some limitations to the current study exist, though measures were taken to minimize their effect on the quality of the study.

Conclusion The lack of awareness and trust in available scientific evidence regarding the benefits and indications for antivenom especially in non-life-threatening conditions led to a wide variability in treatment approaches by practicing physicians.

Supporting information. S1 Checklist. COREQ COnsolidated criteria for REporting Qualitative research checklist. All these cases improved after re-administration of the proper antivenom.

The primary treatment should also include resuscitation of the patient, including intubation for those with respiratory distress or paralysis and IV fluids for those exhibiting signs of shock.

Some patients may require the use of vasopressors to counteract the vasodilatory effects of the envenomation. It is essential to recognize the systemic toxicity may progress rapidly, so early recognition and treatment are paramount. Some patients will develop severe coagulopathies from their snake envenomations.

Treat life-threatening bleeding with direct pressure. There is no evidence on the empiric use of blood products, such as platelets or fresh frozen plasma. Transfuse packed red blood cells in cases of severe blood loss.

There have been some studies that demonstrate the benefit of edrophonium and other long-acting anticholinesterase medications to counter the effects of the neurotoxic components of the venom. In the absence of an observed snake bite, alternative envenomation, such as scorpion, tick, or spider bite, should be considered based on the region.

For patients with a neurotoxic syndrome, one must consider Guillain-Barre as an alternative. Tick paralysis can also produce similar symptoms. Those with coagulopathies should undergo evaluation for an underlying hereditary abnormality or an acquired disease, such as disseminated intravascular coagulation or idiopathic thrombocytopenic purpura.

Local tissue destruction can be related to trauma to that area or a soft tissue infection, such as cellulitis, abscess formation, or necrotizing fasciitis.

In areas with known snakes, hospitals should maintain and adequate supply to treat at least 2 victims of snakebite, and order more antivenom as supplies are used or expire.

The majority of morbidity and mortality from snake bites are secondary to the toxin production associated with the bite. Patients who seek proper medical attention within the first 6 hours after the bite have significantly lower morbidity and mortality.

Patients who are monitored and given supportive treatment during this period typically do not have any long-term side effects. Those with significant local tissue injury secondary to the snake envenomation may develop longstanding paresthesia, muscle damage, or even amputation in severe cases.

The primary complications from snake envenomations are due to the direct toxic effects. The localized tissue damage may require debridement or even amputation in severe cases. Reports exist of massive coagulopathies leading to profound blood loss.

These coagulopathies usually resolve within 48 hours of the snake envenomation. Profound neuromuscular blockade can also occur, leading to pulmonary insufficiency if the diaphragm is involved. These symptoms also typically resolve within 72 hours of envenomation.

The administration of snake antivenom requires monitoring for signs of adverse reactions. These include an anaphylactic reaction that may occur within the first few minutes of administration and up to two hours. If a severe anaphylactic response is suspected, the infusion should stop, and the administration of epinephrine and an anti-histamine should follow.

Patients may also develop a hypersensitivity reaction leading to pruritus, hives, nausea, and mild hypotension. This reaction may occur at any time during the antivenom administration and will dissipate once the infusion is complete.

There are also documented cases of serum sickness as a side effect that may occur up to two weeks after administration. This usually presents as an influenza-like illness with a rash, and possible microhematuria.

This condition responds well to a short course of antihistamines and oral corticosteroids. When a snake bite is suspected, it is essential to present to the nearest emergency center for prompt evaluation. There should be no attempt at local wound exploration or irrigation, and a tourniquet should not be applied.

It is important to remain calm following the snake bite and to keep the affected extremity still. Although most snake bites, even when from a venomous species, do not lead to systemic toxicity, the systemic effects have significant morbidity and mortality.

The emergency medicine team will monitor the snake bite and any progression to systemic toxicity. The decision to administer an antivenom depends on the development of systemic toxicity as there are some side effects of the antivenom itself.

Expect to remain in the hospital for up to 48 hours to monitor symptom progression. Those that do well throughout the observation period typically do not have any long-term effects relating to the snake envenomation.

Consultation with a regional poison center or medical toxicologist can assist in the decision of whether to administer antivenom, which agent to use, and when if necessary to repeat dosing. The proper evaluation and management of a snake envenomation depend on an interprofessional team approach.

This type of management starts from the emergency medical service team gathering information regarding the snake species and rapidly transporting the patient to the hospital.

The emergency medicine physician will begin the initial resuscitation, preferably while being in contact with a toxicologist and poison center. The nursing staff will continuously monitor the patient for any progression of systemic toxicity. The pharmacist will be coordinating the preparation, mixing, and administration of antivenom, if available, as well as preparing to assist clinical staff in the event of anaphylaxis.

Early consultation with an intensivist should be considered for optimal monitoring and may need to assist in the treatment of the patient. Only in rare cases where a fasciotomy is the only option in a situation where there is no access to antivenom, surgical consultation is needed.

These interprofessional strategies are crucial in managing snake envenomation. Disclosure: Michael Tednes declares no relevant financial relationships with ineligible companies. Disclosure: Todd Slesinger declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Turn recording back on. National Library of Medicine Rockville Pike Bethesda, MD Web Policies FOIA HHS Vulnerability Disclosure.

Help Accessibility Careers. Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation. Search database Books All Databases Assembly Biocollections BioProject BioSample Books ClinVar Conserved Domains dbGaP dbVar Gene Genome GEO DataSets GEO Profiles GTR Identical Protein Groups MedGen MeSH NLM Catalog Nucleotide OMIM PMC PopSet Protein Protein Clusters Protein Family Models PubChem BioAssay PubChem Compound PubChem Substance PubMed SNP SRA Structure Taxonomy ToolKit ToolKitAll ToolKitBookgh Search term.

StatPearls [Internet]. Treasure Island FL : StatPearls Publishing; Jan-. Show details Treasure Island FL : StatPearls Publishing ; Jan-.

Search term. Evaluation and Treatment of Snake Envenomations Michael Tednes ; Todd L. Author Information and Affiliations Authors Michael Tednes 1 ; Todd L. Affiliations 1 Advocate Christ. Continuing Education Activity Snakebites are responsible for a significant degree of morbidity and mortality worldwide, especially in low resource countries.

Introduction Snakebites are responsible for a significant degree of morbidity and mortality worldwide, especially in low resource countries.

Etiology Snake envenomation worldwide is primarily related to occupational exposure, such as in farmers and hunters, but is also seen among tourists exploring the outdoors.

Epidemiology There are an estimated 1. Pathophysiology The symptoms seen from snake envenomations are mainly due to the toxic components in their venom. Toxicokinetics The composition of snake venom from a single species of venomous snake can consist of up to different toxic elements.

History and Physical A detailed history of a patient suspected of having a snakebite is essential to delineate treatment options moving forward. Evaluation Ancillary study testing should target the suspected toxin envenomation.

Crotalidae polyvalent immune Fab - Initial Controlling Dose. Infuse vials the pediatric dose is the same as an adult for usual envenomations. Infuse vials for cases with shock, airway involvement, or envenomation on the face or neck Each vial of Crotalidae polyvalent immune Fab is reconstituted with 18 mL of 0.

Differential Diagnosis In the absence of an observed snake bite, alternative envenomation, such as scorpion, tick, or spider bite, should be considered based on the region. Treatment Planning In areas with known snakes, hospitals should maintain and adequate supply to treat at least 2 victims of snakebite, and order more antivenom as supplies are used or expire.

Prognosis The majority of morbidity and mortality from snake bites are secondary to the toxin production associated with the bite. Complications The primary complications from snake envenomations are due to the direct toxic effects. Deterrence and Patient Education When a snake bite is suspected, it is essential to present to the nearest emergency center for prompt evaluation.

Enhancing Healthcare Team Outcomes The proper evaluation and management of a snake envenomation depend on an interprofessional team approach. Review Questions Access free multiple choice questions on this topic. Comment on this article.

References 1. Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, Premaratna R, Savioli L, Lalloo DG, de Silva HJ. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths.

PLoS Med. Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, Rodriguez PS, Mishra K, Whitaker R, Jha P. Snakebite mortality in India: a nationally representative mortality survey. PLoS Negl Trop Dis. Ruha AM, Kleinschmidt KC, Greene S, Spyres MB, Brent J, Wax P, Padilla-Jones A, Campleman S.

The Epidemiology, Clinical Course, and Management of Snakebites in the North American Snakebite Registry. J Med Toxicol. Ranawaka UK, Lalloo DG, de Silva HJ.

Neurotoxicity in snakebite--the limits of our knowledge. Gerardo CJ, Vissoci JRN, Evans CS, Simel DL, Lavonas EJ. Does This Patient Have a Severe Snake Envenomation? JAMA Surg. Ahmed SM, Ahmed M, Nadeem A, Mahajan J, Choudhary A, Pal J. Emergency treatment of a snake bite: Pearls from literature.

J Emerg Trauma Shock. Alberts MB, Shalit M, LoGalbo F. Suction for venomous snakebite: a study of "mock venom" extraction in a human model. Ann Emerg Med. Cheng AC, Currie BJ. Venomous snakebites worldwide with a focus on the Australia-Pacific region: current management and controversies.

J Intensive Care Med. Mong R, Ng VCH, Tse ML. Safety profile of snake antivenom use in Hong Kong - a review of cases from to Clin Toxicol Phila. Khobrani M, Huckleberry Y, Boesen KJ, Aljabri A, Alharthi M, Patanwala AE. Incidence of allergic reactions to Crotalidae polyvalent immune Fab.

Copyright © , StatPearls Publishing LLC. Bookshelf ID: NBK PMID: PubReader Print View Cite this Page Tednes M, Slesinger TL. Evaluation and Treatment of Snake Envenomations.

In: StatPearls [Internet]. In this Page. Bulk Download. Bulk download StatPearls data from FTP. Related information. PMC PubMed Central citations. Similar articles in PubMed. Venomous snakebites. Adukauskienė D, Varanauskienė E, Adukauskaitė A. Medicina Kaunas. Epub Nov Fatal and Nonfatal Snakebite Injuries Reported in the United States.

Langley R, Haskell MG, Hareza D, King K.

The clinical wnvenomation and diagnosis of snakebites worldwide and the mamagement Snake envenomation management management dnvenomation snakebites within the United States are discussed separately. See "Snakebites worldwide: Clinical manifestations and diagnosis" Snake envenomation management "Bites by Crotalinae snakes rattlesnakes, water moccasins [cottonmouths], or copperheads in the United States: Clinical manifestations, evaluation, and diagnosis" and "Evaluation and management of coral snakebites". FIRST AID. General principles — Although evidence is limited, generally agreed-upon principles for first aid of snakebite victims are as follows [ ]:. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Skip directly envnomation site content Skip directly to page options Snake envenomation management directly to A-Z link. The National Institute for Occupational Safety and Health NIOSH. Section Navigation. Facebook Twitter LinkedIn Syndicate. Minus Related Pages. Photos courtesy of Sean P. Snake envenomation management

Snake envenomation management -

Learn how UpToDate can help you. Select the option that best describes you. View Topic. Font Size Small Normal Large.

Snakebites worldwide: Management. Formulary drug information for this topic. No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Author: Julian White, AM, MB, BS, MD, FACTM Section Editors: Daniel F Danzl, MD Michelle Ruha, MD Deputy Editor: Michael Ganetsky, MD Literature review current through: Jan This topic last updated: Jan 11, Venomous snakes are widely distributed around the world and clinical effects from envenomation can overlap to a great degree even among different families of snakes.

This topic will discuss the management of snakebites that occur worldwide, other than those by snakes found in the United States.

FIRST AID Initial first aid of snake envenomation is directed at reducing the spread of venom and expediting transfer to an appropriate medical center. To continue reading this article, you must sign in with your personal, hospital, or group practice subscription. Subscribe Sign in.

It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances.

Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications.

This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. All rights reserved. Topic Feedback. Assessment Focus on evidence of envenomation.

Once the possibility of snakebite has been raised, it is important to determine whether a child has been envenomed to establish the need for antivenom. This is usually done taking into consideration the combination of circumstances, symptoms, examination and laboratory test results.

Most people bitten by snakes in Australia do not become significantly envenomed. History and Examination Circumstances Symptoms Examination Confirmed or witnessed bite versus suspicion that bite might have occurred Were there multiple bites?

First aid? Past history? Initial blood tests: coagulation screen INR, APTT, fibrinogen, D-dimer , FBE and film, Creatine Kinase CK , Electrolytes, Urea and Creatinine EUC. Serial blood tests: coagulation screen INR, APTT, fibrinogen, D-dimer , FBE and film, CK, EUC.

Role of snake venom detection kit VDK A VDK is rarely indicated as: There are only two types of antivenom required for Victorian snakes tiger and brown and both can be given to treat envenomation without identifying the snake, and The diagnosis of envenomation is based on the aforementioned history, examination and laboratory test findings.

A VDK is NOT used to diagnose envenomation A VDK may be indicated if the snakebite is from a non-Victorian snake Attempted identification of snakes by witnesses should never be relied upon as snakes of different species may have the same colouring or banding VDKs can have significant rates of snake misidentification with both false positives and false negatives and should therefore only be performed by an experienced laboratory technician The results should not override clinical and geographical data.

Discuss use and results with a clinical toxicologist eg Poisons Centre 13 11 26 If used, a VDK should be used on a bite site swab, and a single operator should be dedicated to perform the VDK interpretation and should do so free from other clinical responsibility and interruption.

This takes minutes, and as such should be omitted in the unwell or arrested child. A brief lapse in concentration when watching for colour change in the VDK can result in a false reading If there is no apparent bite, a VDK may be done on urine, but never blood Treatment Location of care Uncomplicated snakebites can be managed at a regional centre as long as the following resources are available: A doctor who is willing and able to care for the child 24 hours a day, Immediate access to critical care facilities, Immediate access to the required antivenom, and Access to a 24 hour pathology laboratory that can perform the required blood tests.

First aid Apply a broad pressure immobilisation bandage, Preferably elastic rather than crepe, as firm as you would for a sprained ankle; The aim is to prevent lymphatic spread of venom, not to stop blood supply.

Start at the bite site and bandage the entire limb. If envenomed, do not remove until antivenom has been given. Once the antivenom has been given, remove the pressure immobilisation bandage. Do not wash or clean the bite site in any way in case the use of a Venom Detection Kit is required.

Snakebite Management Flowchart Giving Antivenom Antivenom is indicated in all children where there is evidence of envenomation. Giving antivenom should occur in consultation with a clinical toxicologist.

Give one vial of tiger and one vial of brown snake antivenom without delay. Dilute one vial in mls of 0. If the child is in cardiac arrest and this is thought to be due to envenomation, then give undiluted antivenom via rapid IV push.

There is no weight based calculation for antivenom the snake delivers the same amount of venom regardless of the size of the child. One vial of antivenom is enough to neutralize the venom that can be delivered by one snake.

Clinical recovery takes time after antivenom administration and multiple vials do not speed recovery. Venom induced coagulopathy takes time to reverse. It takes 10 — 20 hours to start to improve and 24 — 30 hours for complete resolution.

More antivenom than recommended will not aid recovery of clotting factors. The role of FFP or cryoprecipitate is controversial and should be discussed with a clinical toxicologist; generally it is indicated if the child is bleeding. Other management considerations: The child should be in a critical care environment with monitoring.

Gain 2 points of intravenous access, with at least one large bore cannula. There is a risk of anaphylaxis with antivenom administration — be prepared to treat.

If anaphylaxis occurs, treat as per the anaphylaxis guideline and consult with a clinical toxicologist. Given the risk of intracerebral haemorrhage with coagulopathy and the possible elevation of blood pressure with adrenaline, a more easily titratable intravenous adrenaline infusion may be considered in discussion with an expert experienced in its use.

Wound care: the wound can be washed after it is clear that a VDK is not required or has been used. If the child is significantly unwell eg cardiac arrest, shock, bleeding and there is no antivenom available, the retrieval team should bring the antivenom to the regional centre to be administered there prior to transfer.

Consider discharge when Children with suspected snakebite should only be discharged in daylight hours neurological signs can be subtle and only evident when children are awake. Tends to occur 4 — 14 days following antivenom administration. Consists of flu-like symptoms, fever, myalgia, arthralgia and rash.

Parent Information Sheet Snakebite — SCV patient fact sheet Information Specific to RCH Children undergoing serial testing are suitable for both the ED Short Stay ward and the Short Stay Unit.

Information Specific to Monash Health The Monash Health clinical toxicologist on-call should be consulted in all cases of suspected snakebite.

Last updated January Systemic symptoms. Cardiovascular effects.

Automated blood glucose monitoring snakebites are emergency situations requiring prompt veterinary enevnomation. Crotalid envenomatkon can cause neurotoxicity, tissue necrosis, Snake envenomation management, and coagulopathy; North American elapid Snake envenomation management can cause neurotoxicity; and Australian elapid envenomation can cause neurotoxicity, myotoxicity, coagulopathy, and hemolysis. Treatment includes supportive care in addition to administration of antivenom, where available. There are four main families of snakes in the world. The Boidae pythons are nonvenomous. Venomous snake species can be broadly grouped into three families: Colubridae, Elapidae, and Viperidae.

Author: Faule

5 thoughts on “Snake envenomation management

  1. Sie irren sich. Geben Sie wir werden es besprechen. Schreiben Sie mir in PM, wir werden umgehen.

Leave a comment

Yours email will be published. Important fields a marked *

Design by ThemesDNA.com