What is the management approach for a snakebite?

Snakebite Management

For snakebites, immediately activate emergency services, immobilize the bitten extremity at or below heart level, remove all constricting objects, and transport rapidly to a hospital for antivenom—the only definitive treatment—while avoiding harmful interventions like suction, tourniquets, ice, or electric shock. 1, 2

Immediate Field Actions

Critical First Steps

• Activate emergency medical services immediately for any venomous or possibly venomous snakebite, as time to antivenom is the most important prognostic factor for survival 1, 2
• Remove rings, watches, and all constricting objects from the bitten extremity before swelling develops, as progressive edema 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, as walking or activity accelerates systemic venom absorption 1, 2

Transport Priority

• Transport the victim to a medical facility as quickly as possible, as antivenom is available only in hospital settings and is the cornerstone of definitive treatment 1, 2, 3
• Do not delay transport to attempt field interventions, as time to antivenom administration is critical 1

Geographic-Specific Pressure Immobilization

North American Snakebites (Pit Vipers)

• Do NOT use pressure immobilization bandaging for North American pit viper bites (rattlesnakes, copperheads, cottonmouths), as it may worsen local tissue injury by trapping cytotoxic venom at the bite site 1, 2
• Pit vipers produce hemotoxic/cytotoxic venom causing progressive local tissue necrosis, coagulopathy, and thrombocytopenia 1, 3

Neurotoxic Snakes (Coral Snakes, Elapids)

• For neurotoxic snakes, apply pressure immobilization bandaging with 40-70 mm Hg in the upper extremity or 55-70 mm Hg in the lower extremity around the entire length of the bitten limb 4, 1
• The bandage should be snug enough that a finger can barely slip underneath 1
• This technique slows lymphatic dissemination of neurotoxic venom, which causes minimal local injury but progressive paralysis and respiratory failure 1, 5

Contraindicated First Aid Measures

Absolutely Avoid These Interventions

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

Wound Care

• Irrigate the wound with copious amounts of water for cleaning, though this does not remove venom 4, 1
• Clean the bite site with hydrogen peroxide or clean water, but avoid alcohol or alcoholic disinfectants 6

Critical Clinical Pitfalls to Avoid

Delayed Recognition of Envenomation

• Never assume no envenomation based on absence of immediate pain or swelling, as neurotoxic bites cause life-threatening systemic toxicity despite minimal local findings 1, 5
• Neurotoxic symptoms can be delayed up to 13 hours despite minimal local findings at the bite site 1, 5

Technique Misapplication

• Do not apply pressure immobilization techniques developed for neurotoxic snakes to North American pit viper bites, as this worsens cytotoxic tissue damage 1, 2
• Failing to remove constricting items leads to ischemic injury as swelling progresses 1, 2

Transport Delays

• Do not delay transport to attempt ineffective field interventions, as time to antivenom is the most important prognostic factor 1
• Excessive movement of the victim increases venom absorption through the lymphatic system 2

Hospital Management Priorities

Definitive Treatment

• Antivenom is the gold standard and only definitive treatment for venomous snakebites and must be administered as rapidly as possible in a hospital setting 1, 2, 5, 3
• Antivenom therapy is most effective when given within four hours of the snakebite 7

Monitoring Requirements

• For neurotoxic envenomation, hospitalize for a minimum of 48 hours with continuous monitoring, as neurotoxicity onset can be delayed up to 13 hours despite minimal local findings 1
• Perform clinical chemistry and ECG for all patients, and evaluate tetanus immunization status 6

Supportive Care

• Administer plasma expanders, pain medication, diazepam, tetanus toxoid, antiseptics, and antibiotics as needed 7
• Analgesic therapy can be administered for pain, but avoid anti-inflammatory drugs 6
• Monitor for compartment syndrome via serial physical examination and compartment pressure measurement, as surgical intervention may rarely be required 3