What is the management of a patient presenting with a hemorrhagic snake bite?

Management of Hemorrhagic Snake Bite

For hemorrhagic (hemotoxic/cytotoxic) snakebites, immediately activate emergency services, remove all constricting objects, immobilize the extremity at or below heart level, minimize patient movement, and transport rapidly to a hospital for antivenom administration—do NOT apply pressure immobilization bandaging, tourniquets, ice, or suction devices, as these worsen local tissue injury. 1, 2

Immediate Field Management

Critical First Actions

• Activate emergency medical services immediately and transport to a medical facility as quickly as possible, as antivenom is only available in hospital settings and time to antivenom is the most important prognostic factor 1, 2
• Remove all rings, watches, jewelry, and constricting objects from the bitten extremity immediately before progressive edema develops, as swelling can cause ischemic injury to digits and tissues 1, 2
• Immobilize the bitten extremity and keep it at or below heart level to minimize venom absorption through the lymphatic system 1, 2
• Minimize all physical exertion by the victim during transport—walking or activity accelerates systemic venom absorption 1, 2

Geographic-Specific Considerations for Hemorrhagic Bites

• For North American pit viper bites (rattlesnakes, copperheads, cottonmouths), do NOT use pressure immobilization bandaging, as it traps cytotoxic venom at the bite site and worsens local tissue necrosis 1, 2
• Pressure immobilization is only appropriate for neurotoxic snakes (coral snakes, sea snakes, exotic species), NOT for hemorrhagic/hemotoxic bites 1, 2

Contraindicated Interventions (Class III Evidence)

Harmful Practices That Worsen Outcomes

• Do NOT apply ice or cold therapy—it causes additional tissue injury without removing venom 3, 1, 2
• Do NOT use suction devices (with or without incision)—they remove negligible venom amounts and may aggravate tissue injury 3, 1, 2, 4
• Do NOT apply tourniquets—they worsen local tissue injury without preventing systemic envenomation 1, 2, 5
• Do NOT use electric shock therapy—it is completely ineffective and potentially harmful 1, 2

Hospital-Based Definitive Treatment

Antivenom Administration

• Antivenom is the cornerstone and standard of care for hemorrhagic snakebite treatment 2, 4, 5, 6
• Antivenom therapy is most effective when administered within 4 hours of the bite 5
• Modern sheep-derived antigen binding fragment (CroFab) is preferred over older equine-derived antivenin due to significantly lower allergenic potential 4, 6

Clinical Monitoring and Workup

• Comprehensive laboratory evaluation is essential: complete blood count with platelet count, coagulation studies (PT/INR, aPTT, fibrinogen), renal function, and electrolytes 4, 7
• Monitor for progressive coagulopathy—platelet count can gradually decrease to <100,000/mm³ due to platelet aggregation activity of hemotoxic venom 7
• If venom is directly injected into a blood vessel, platelet count can rapidly plummet to <10,000/mm³ within 1 hour 7
• Watch for disseminated intravascular coagulation (DIC) with fibrinolytic phenotype, hypofibrinogenemia, and elevated fibrin degradation products 7

Adjunctive Therapies

• Viscoelastometry-guided transfusion (rotational thromboelastometry) can guide correction of coagulopathy in severe cases 8
• Tranexamic acid may have a role in achieving hemostasis when combined with antivenom, though this requires further study 8
• Cryoprecipitate administration for severe hypofibrinogenemia needs additional exploration 8

Clinical Presentation of Hemorrhagic Envenomation

Local Manifestations

• Pain and progressive swelling spreading gradually from the bite site 4, 7
• Ecchymoses and local tissue necrosis at or near the injection site 4, 5
• Swelling typically develops within 30 minutes for highly venomous species 7

Systemic Manifestations

• Hematologic toxicity: coagulopathy, thrombocytopenia, hemorrhage 4, 7
• Cardiovascular: hypotension, shock 4, 7
• Renal: acute kidney injury, renal failure 4
• Gastrointestinal: vomiting 7
• Severe cases: cyanosis, loss of consciousness 7

Critical Pitfalls to Avoid

• Never delay transport to attempt ineffective field interventions—time to antivenom is the single most important prognostic factor 1
• Do not apply pressure immobilization techniques developed for neurotoxic snakes to hemorrhagic/cytotoxic snake bites—this worsens tissue damage in North American pit viper envenomations 1, 2
• Failing to remove constricting items leads to ischemic injury as progressive edema develops 1, 2
• Excessive victim movement increases venom absorption through the lymphatic system 1, 2
• Do not assume minimal envenomation based on initial presentation—systemic toxicity can develop over hours 4, 7

Wound Care

• Irrigating the wound with copious amounts of water is reasonable for cleaning but does not remove venom 1, 2
• Apply clean dressing after irrigation 5
• Administer tetanus prophylaxis and consider antibiotics 5

Surgical Considerations

• Fasciotomy is now reserved for rare cases of true compartment syndrome 6
• Close monitoring via serial physical examination and compartment pressure measurement is the reliable method for determining if surgical intervention is needed 6
• Most patients respond to extremity elevation, observation, and antivenom without requiring surgery 6