SNAKE BITE MANAGEMENT

See Snake Bite Assessment

• Regardless of the apparent condition of the patient, IMMEDIATELY compress and immobilise limb
• DO NOT remove first aid unless there is no clinical or laboratory evidence of envenomation
• If there is already evidence of clinical or laboratory envenomation do not remove first aid measures
• Seek help early duty ED physician, Dr. Julian White (via Women's and Children's hospital), Poison's information 131126 or duty CU consultant 

First aid

• Remove surrounding clothing (and retain for later analysis)
• Do not wash bite site
• Firmly wrap compression bandage over bite site and extend proximally as possible (without compromising blood flow). 
• Apply splint to immobilise the limb
• Advise patient to avoid moving or bearing weight on the limb

DO NOT incise the bite site or apply an arterial tourniquet

Establish IV access

Resuscitation

Major complications to address

• Haemorrhagic shock due to coagulopathy
• Major intracererbral bleed
• Respiratory paralysis

Give correct antivenom as per:

• Toxicologist's/ED physician's instructions (call Poison's information 131126) - see also Distribution of snake species in Australia
• VDK result

(Do not rely on a layperson's identification of snake species)

Correct dosing of antivenom (see Empiric dosing for various snakebites)

• Coagulopathy: > 2 ampoules (up to 3-6 if it a major coagulopathy especially in a brown snake bite)
• Significant weakness: > 2 ampoules
• Remember that dose is based on amount of venom delivered NOT on weight of victim
• Further doses may be required if envenomation persists
• The treatment of persistent coagulopathy (no rise in fibrinogen) is further anti-venom - NOT blood products e.g. cryoprecipitate/FFP

Method of administration

• Dilute anti-venom up to 1 in 10 of any isotonic fluid (5% Dextrose, NS)
• Prepare a adrenaline infusion in case anaphylaxis occurs
• Give anti-venom over 15-30 min
• Observe closely for anaphylaxis
• (repeat as required)

Ongoing management

• Do not remove first aid measure whilst there is still clinical or laboratory evidence of envenomation
• Following removal of first aid measure, repeat laboratory assessment again and thence every 2 hours - give further anti-venom as required

Follow-up/Disposition

Admit to ICU

• Any patient who requires anti-venom

Admit for 24 hours to EECU (after discussion with ED consultant

• Bites without clinical or laboratory evidence of envenomation

Discharge when:

• Clinical features have resolved
• Laboratory values remain normal for 24 hours

Any person receiving anti-venom requires 50mg  prednisolone daily (5 days) to prevent serum sickness