Management of Snake Bite in Children
The management of a snake bite in a child should include immediate immobilization of the bitten extremity, prompt transport to emergency medical care, and appropriate antivenom administration when indicated, while avoiding harmful practices such as applying suction, ice, or tourniquets. 1
Initial First Aid Management
DO:
- Call emergency services immediately
- Keep the child calm and restrict movement
- Remove constricting jewelry and watches
- Immobilize the bitten extremity in a functional position
- Rest and keep the affected limb at or below heart level
DO NOT:
- Apply suction to the wound (no clinical benefit and may worsen injury) 2
- Apply ice (contraindicated for snake bites) 1
- Use tourniquets or pressure immobilization bandages for North American pit vipers
- Apply electric shock
- Cut the wound
- Attempt to capture or kill the snake (increases risk of additional bites)
Medical Management
Assessment and Monitoring
- Evaluate for signs of envenomation:
- Local: Progressive swelling, ecchymosis, pain
- Systemic: Coagulopathy, neurotoxicity, hypotension
- Monitor vital signs closely
- Assess for respiratory compromise (may require early intubation in severe cases) 1
Laboratory Evaluation
- Complete blood count
- Coagulation studies (PT, PTT, fibrinogen)
- Comprehensive metabolic panel
- Urinalysis (to check for hematuria/myoglobinuria)
- Type and cross-match if severe envenomation
Risk Stratification
Patients with higher risk factors require more aggressive management:
- Severe leucocytosis on day 1 (independent predictor of mortality) 3
- Platelet count below 120,000/mm³ 4
- AST over 50 IU/L 4
- Evident ecchymosis 4
Antivenom Administration
Indications for Antivenom:
- Progressive local tissue injury
- Coagulopathy or thrombocytopenia
- Systemic effects (hypotension, altered mental status)
- Significant swelling that crosses a major joint
Administration Protocol:
- Initial dose of 4-6 vials as soon as possible after envenomation 1
- Additional doses until initial control is achieved (when local injury progression stops, systemic symptoms resolve, and coagulation parameters normalize) 1
- Monitor for allergic reactions during administration
Complications Management
Acute Kidney Injury
- Aggressive fluid resuscitation with normal saline
- Monitor urine output and renal function
- Consider dialysis if severe (AKI is an independent predictor of mortality) 3
Compartment Syndrome
- Measure compartment pressures if suspected based on neurovascular examination
- Fasciotomy is rarely needed (only 1.8-9.1% of cases) 4, 5
Tissue Necrosis
- Wound care and debridement as needed
- Some cases may require amputation (3.9-9.1% for digits) 4
Follow-up Care
- Monitor for recurrent coagulopathy for at least one week 1
- Long-term follow-up is essential as persistent renal involvement may occur 1
- Physical therapy may be needed for affected limbs
Common Pitfalls to Avoid
- Unnecessary antibiotic use: Prophylactic antibiotics are not routinely indicated for snake bites 5
- Overuse of antivenom: Many children with mild to moderate envenomation can be managed conservatively 5, 6
- Excessive laboratory testing: For children with lower envenomation scores (1-2), extensive coagulation studies may not be necessary 6
- Delayed administration of antivenom: When indicated, antivenom should be given promptly
- Inappropriate use of pressure immobilization: While effective for some neurotoxic snake venoms, this technique is not recommended for North American pit vipers 2
Most children bitten by pit vipers can be managed conservatively with analgesics and elevation of the affected extremity, with careful monitoring for progression of symptoms 5.