In Case Of Venomous Snakebite....

This account is not a medical prescription or a recommendation of what you should do if you are bitten by an exotic (non native) venomous snake. This is a personal account of what I would do if I suffered a serious snakebite. Because there is a lack of qualified physicians with experience in successfully treating snakebite, it is a good idea to thoroughly educate yourself about your options and discuss your potential treatment with a doctor in advance.

Do not assume that a random emergency room physician will administer the proper antivenom even if you have your own stock and bring it in with you. Exotic antivenom is not FDA approved and many doctors have refused to administer it for this reason. You have a much better chance if you have established a good working relationship with a doctor ahead of time who will agree to manage your case and use your antivenom when it's needed. Otherwise you may be sitting on a ventilator with your antivenom on the bed next to you for many hours while your friends have to threaten the hospital with malpractice suits. This isn't just a what-if scenario; this is what actually happened in several cases that I personally know of here in Florida.

You also cannot assume that a random emergency room physician will have any experience with native snake envenomation cases, or that your local hospital will stock antivenom. I have also seen a number of cases where native envenomations were very badly mismanaged. In fact I know of more cases that were poorly managed than otherwise - insufficient quantities of antivenom and fasciotomy in the absence of true compartment syndrome are very common. It is an unusually lucky patient who ends up in the care of a doctor who has some familiarity with envenomation and who can make the right decisions fast enough.

If you work with venomous snakes, it is your responsibility to make sure ahead of time that your doctor is up to date on the best and most modern ways to medically manage a snake bite. Some of the older protocols which are still officially on the books at some hospitals are definitely not the ones you want applied to your case.

    The list of my priorities in order:

  • Apply pressure immobilization bandage (PI) and splinting of the limb to any neurotoxic bite and to any very serious bite by a large cytotoxic snake likely to have systemic effects.
  • Yell for help. Call (or have my partner call, since I don't work snakes alone) my prearranged contacts. My contacts include experts who will have additional antivenom waiting for me at the hospital and be able to advocate intelligently for me if the hospital does not have a good venomous snakebite protocol for the species I was bitten by. I may also call an ambulance and wait quietly for it to arrive, if I am sure I have been envenomated.
  • Pay close attention to my local and general symptoms to determine whether or not any envenomation has occurred. If envenomation has occurred, I would attempt to carefully record the progression of these symptoms (eg, mark on my arm the increases in swelling over time) in order to determine its severity. A familiarity with the expected progression of such symptoms for the species you are working with is necessary to be able to perform this important step. Serious envenomations by some species (Micrurus in particular, also Dispholidus) may result in no visible symptoms for many hours, then sudden and cascading organ failure. If I am bitten by one of these snakes, I will get myself to the hospital for extensive bloodwork and close observation. The immediate administration of antivenom may be warranted even with no visible symptoms.
  • If envenomation is confirmed by the symptoms observed, in the presence of trained EMT's and life support equipment, I would administer antivenom to myself in the proper doses and in the proper manner. It is necessary to research this protocol beforehand as it may vary by species and by type of antivenom. If I have already fallen unconscious, my partner will have instructions to do this for me. The EMT will be warned to watch out for a severe allergic reaction. Not only might I be allergic to the antivenom, but as a long-time keeper, there is a very good chance I may be allergic to the venom itself from long exposure to the snakes and aerosolized venom. The EMT will be told that some of my symptoms may be due to anaphylaxis rather than envenomation.
  • I have good medical snakebite protocols printed out and ready to take with me to the hospital. These protocols have the author's name and contact information printed on them (eg, Dr. Sean Bush, Loma Linda University Medical Center) so that the doctors will a) take them seriously, and b) be able to phone immediately for expert advice if needed. I will also bring the AZA Antivenom Index and extensive printouts of medical papers available on the subject of envenomation.
  • My antivenom vials, whether they are legally expired or not, will be labelled with a date that is scientifically accurate rather than legally accurate. I will research the real expiration period for the antivenom I have, and label it accordingly. This method is more realistic, more economically feasible for me, and gives the doctor fewer legal headaches.

It is not a good idea to administer antivenom to yourself at home because of the danger of an immediate anaphylactic reaction. Because of the unfortunate fact that physicians are often reluctant to administer an unfamiliar drug that is often from a foreign country and not approved by the FDA, even if it has been clinically proven in obscure journals of medical herpetology and in its country of origin to be perfectly effective, I would go to extreme lengths to be sure I did get antivenom. Here's how I would do it.

I would call an ambulance and request that the EMT "help me take my own medicine", which they are legally allowed to do. I would warn the EMT that I was at risk of severe anaphylactic shock and might require life support. I would ask for an IV drip (Lactated Ringer's or normal saline, 200-250 ml/hour), and administer the antivenom to myself through the IV in the dilution recommended in the insert. I would hand the EMT the following written instructions in case I lost consciousness.

"Please continue to help me take this medicine, because if I do not get a significant quantity of this medicine in me over the next few hours, I am at very serious risk of death or permanent impairment. In the event of anaphylactic shock, give me this medicine more slowly in a more dilute solution, but do not stop giving it until I have had at least 5 vials." Hopefully by this time one of my designated emergency contacts (some of whom are physicians with experience managing exotic envenomations) will have taken over the medical management of my case.

If the bite were serious, I would put a 1 in front of the 5, assuming I had 15 vials handy. Hopefully before I'd finished one vial, we would be at the hospital and so would one or more snakebite experts who could help me argue my case for continuing to get the antivenom. I'd want to get one vial about every 10 to 15 minutes, or every 20 minutes if I was showing a bad reaction to the AV.

Peter Mirtschin recommends 0.3 mg epinephrine (adrenalin) subcutaneous prophylactically, but as long as it's standing by, along with diphenhydramine (Benadryl, 50 mg IV), it's not a big deal. This is also SOP in allergy cases.

I would also use pressure immobilization and splinting while I was waiting for the ambulance, using an Ace bandage to wrap the bitten extremity firmly but not so tightly as to cut off circulation. There are some arguments about the effectiveness of PI and the continued administration of AV in the case of anaphylactic reaction. For myself, I have read the clinical material, listened to the experts and made my considered choices. You are invited to go and do likewise.

I cannot recommend that anyone else do as I have done, especially without doing the research first and coming to their own conclusions with the help of a qualified doctor. The only thing I do recommend very strongly is that you educate yourself thoroughly about the medical management of exotic snakebite, because your average hospital in the US or the UK is *not* going to have a doctor on call who has any clue what to do. You should have written protocol ready to give to your doctors, but since they may not be interested in listening to you or reading anything a layperson hands them, you should also have an "emergency advocate" who is also well educated on the subject and prepared to make legal threats if necessary to force a reluctant doctor to administer antivenom.

Click here to view some photos of a Trimeresurus hageni envenomation. Because of the scarcity of clinical data on exotic snakebite (particularly this species), the physicians who treated this case had to do a lot of guesswork. You may face similar problems if you are bitten by an exotic venomous snake. You should be prepared before your life or health depends on it.

Written protocols that you should keep in your snake room:
eMedicine envenomation article by Dr. Brian Daley
Snakebite Protocol is a large collection of multi species bite protocols by Dr. Terence Davidson.
Steve Grenard's Snakebite Emergency Page
Dr. Sean Bush's article on rattlesnake envenomation
Coral snake envenomation
Mojave rattlesnake envenomation
Water moccasin envenomation
Cobra envenomation by Dr. Robert Norris and Sherman Minton
Antivenom Index (AZA publication)

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