Is Transaminitis an Indication for Antivenom in Snake Bite?
Transaminitis (elevated liver enzymes) is an indication for antivenom administration in snake bite, as it represents systemic envenomation requiring definitive treatment. 1
Understanding Transaminitis as a Systemic Envenomation Marker
Elevated transaminases indicate hepatocellular injury from venom, which represents systemic envenomation rather than just local tissue damage. 1 This is a critical distinction because:
- Systemic symptoms including hepatocellular injury warrant immediate antivenom administration, as these indicate venom has entered the circulation and is causing organ damage 2
- Hepatocellular injury has been documented with hematotoxic snake bites, particularly Russell's viper and green pit viper envenomations 1
- One documented case showed transaminitis alongside coagulopathy and neurological symptoms that improved after appropriate antivenom administration 1
The Critical Time Window for Antivenom
Early antivenom administration is essential because many venom-mediated effects become irreversible once established. 2
- Antivenom works by binding circulating toxins and preventing further toxic injury, but cannot reverse damage already done to tissues 2
- The time between bite and antivenom administration must be minimized to prevent irreversible organ damage 2
- Early assessment based on systemic symptoms (nausea, vomiting, headache, abdominal pain) is key to early decision-making for antivenom 2
Practical Dosing Considerations
When antivenom is indicated for systemic envenomation:
- Administer 10 vials of CroFab as a practical initial dose for hemorrhagic snake bites (for crotaline envenomation in North America) 3
- Have epinephrine readily available (0.3-0.5 mg IM for adults, 0.01 mg/kg up to 0.3 mg for children) for potential anaphylactic reactions 3
- Acute adverse reactions to antivenom are common but usually mild, though severe systemic anaphylaxis may develop within an hour of exposure 4
Critical Clinical Pitfall
Never delay antivenom while waiting for laboratory confirmation if systemic symptoms are present. 2 The key to preventing irreversible organ damage is early clinical assessment and decision-making based on systemic manifestations, not laboratory results alone. 2 Transaminitis represents established hepatocellular injury and confirms the need for antivenom, but treatment should ideally begin before such organ damage becomes evident. 2