Pediatric emergency medicine trisk 2023 2023
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perfusion is necessary because of progressive edema; the constriction band should
be shifted to remain proximal to the swelling. To be effective, the band must be
applied initially within 1 hour of the pit viper bite. It may be removed when
antivenin therapy is started.
Incision and suction (extractors) of the pit viper wound is no longer advised.
The usefulness of extractors can be supported only if applied within minutes of
the bite and even then, recovery of venom is variable in the laboratory setting.
Animal studies do not demonstrate an increase in survival.
In the rare situation in which skilled personnel and supplies are at the scene and
a long transport is expected, it is reasonable to allow one or two attempts at IV
access. Many authorities also suggest capturing or killing the snake for later
verification, but again, prudence dictates that time not be wasted and that an
inexperienced person not risk the bite of an agitated snake. If the snake arrives in
the ED, treat it with respect—decapitated snakes can bite reflexively for up to 1
hour.
Management
If the history and physical examination on arrival in the ED are consistent with a
venomous snakebite, immediate laboratory evaluation and IV access are
indicated. A CBC, coagulation studies, platelet count, urinalysis, and blood
crossmatching should be obtained, as blood may be difficult to crossmatch after
massive hemolysis. In moderate or severe poisoning, analyses of serum
electrolytes, BUN, creatinine, liver function tests, creatine kinase, fibrinogen, and
ABG are also indicated. Hemolysis, anemia, thrombocytopenia,
hypofibrinogenemia, prolonged bleeding times, and metabolic acidosis all may be
seen in severe poisoning. Repeat the laboratory studies every 6 hours to ensure no
significant changes occur. For patients with complaints of chest pain, a 12-lead
ECG, a chest radiograph, and troponin levels should be ordered. Patients require
serial comprehensive neurologic examinations. If there is a concern for a
hemorrhagic cerebrovascular accident, a noncontrast CT scan of the head should
be obtained. Similarly, when intra-abdominal bleeding is suspected with the
presence of abdominal tenderness or distention, clinicians may consider an
abdominal ultrasound or CT scan.
Therapy will be based on the clinician’s overall grading of venom toxicity.
Local and systemic manifestations, as well as laboratory findings, weigh heavily
in this judgment. The clinical pattern may change as the venom’s effects unfold
and frequent reassessment is crucial. The physician should measure and record
the circumference of the injured extremity at the leading point of edema and 10
