What is the treatment for rhabdomyolysis (muscle breakdown) resulting from a snake bite?

Treatment of Rhabdomyolysis from Snake Bite

Aggressive intravenous fluid resuscitation is the cornerstone of treatment for snake bite-induced rhabdomyolysis, combined with antivenom administration as the definitive therapy for the underlying envenomation. 1, 2

Immediate Management Priorities

First Aid and Transport

• Activate emergency medical services immediately and transport the victim to a medical facility as quickly as possible, as definitive treatment (antivenom) is only available in healthcare settings 1
• Rest and immobilize the bitten extremity to reduce systemic venom absorption 1, 3
• Remove rings and other constricting objects from the bitten extremity to prevent ischemic damage as swelling progresses 1, 3

Critical Actions to AVOID

• Do NOT apply suction devices - they remove virtually no venom (only 0.04% of venom load), provide no clinical benefit, and may cause tissue injury 4, 1
• Do NOT apply ice to the wound as it has no proven benefit and may cause additional tissue injury 4, 1
• Do NOT use tourniquets as they worsen local tissue injury and can exacerbate rhabdomyolysis 1, 3
• Do NOT apply electric shock - it is completely ineffective and potentially harmful 1, 3

Hospital-Based Treatment

Antivenom Administration

• Antivenom is the cornerstone of definitive treatment and should be administered as soon as possible, ideally within 4 hours of the bite 5, 6
• Ensure airway management and establish intravenous access before antivenom administration 3
• Test for hypersensitivity to antivenom before administration, as acute anaphylactic reactions can occur within an hour of exposure 7, 6
• The newer sheep-derived antigen binding fragment (CroFab) is significantly less allergenic than traditional equine-derived antivenin 5

Aggressive Fluid Resuscitation for Rhabdomyolysis

• Initiate aggressive intravenous hydration immediately to prevent acute tubular necrosis and acute renal failure, which are the primary complications of rhabdomyolysis from snake envenomation 2
• Monitor for signs of acute renal failure including oliguria, elevated creatinine, and electrolyte abnormalities 2
• The goal is to maintain high urine output to flush myoglobin through the kidneys before it causes tubular damage 2

Renal Replacement Therapy

• Initiate hemodialysis if oliguria develops despite adequate fluid resuscitation, or if acute renal failure progresses 2
• Daily hemodialysis may be required until renal function recovers 2
• Most patients with snake bite-induced rhabdomyolysis and acute tubular necrosis will recover normal renal function with appropriate supportive care 2

Adjunctive Therapies

• Administer plasma expanders as needed for shock or circulatory insufficiency 6
• Provide pain medication for symptom control 6
• Give tetanus toxoid prophylaxis 6
• Consider antibiotics for wound care, though routine prophylactic antibiotics are not universally indicated 6
• Administer diazepam if seizures or severe muscle spasms occur 6

Monitoring Requirements

Laboratory Surveillance

• Obtain comprehensive baseline labs including creatine kinase (CK), myoglobin, creatinine, electrolytes, coagulation studies, complete blood count, and urinalysis 2, 5
• Monitor for hematologic abnormalities including coagulopathy and disseminated intravascular coagulation, which commonly accompany rhabdomyolysis in snake envenomation 2, 5
• Serial monitoring of renal function and muscle enzymes is essential to guide therapy 2
• Check blood gases and plasma osmolarity in severe cases 8

Clinical Observation

• Observe patients receiving antivenom closely for acute reactions (within first 1-2 hours) and delayed serum sickness reactions (5-14 days post-administration) 7
• Monitor for cardiovascular, neurologic, and pulmonary complications 5, 6

Common Pitfalls to Avoid

• Delaying transport to attempt ineffective first aid measures - time to antivenom is critical 1, 3
• Inadequate fluid resuscitation - aggressive hydration is essential to prevent renal failure from myoglobin precipitation 2
• Failing to monitor for delayed complications - acute renal failure can develop despite initial antivenom and hydration 2
• Using pressure immobilization in North America - this technique is appropriate for neurotoxic snakes (like Australian elapids) but may worsen tissue injury with the cytotoxic venoms of North American pit vipers 1, 3
• Attempting to achieve complete acid-base correction too rapidly - in metabolic acidosis from rhabdomyolysis, stepwise correction over 24-48 hours prevents rebound alkalosis 8