Treatment for snake bite: principles of hospital management

See Summary of the acute management of suspected snake bite in Australia for a summary of the acute management of suspected snake bite in Australia.

Manage all patients with suspected snake bite in a hospital that has all of the following:

adequate antivenom
a 24-hour onsite laboratory that can perform coagulation studies
critical care facilities where antivenom can be safely administered and anaphylaxis can be treated.

If the hospital has adequate antivenom and critical care facilities, but no laboratory, antivenom can be given (if indicated) and the patient transferred to a hospital with a laboratory later.

The three critical steps in the management of a snake bite are to:

determine if the patient has evidence of systemic envenoming (see Evidence of systemic envenoming from snake bite)
if so, determine if antivenom is indicated
if so, determine which snake group(s) are likely to be responsible for the bite, to guide the choice of antivenom(s).

For antivenom dosing, see here.

Take blood for key investigations. If the patient is going to be transferred to a different hospital, ensure the blood samples accompany the patient.

Even if the patient has no clinical evidence of systemic envenoming, do not remove the pressure bandage unless antivenom therapy has started, or laboratory assessment confirms there is no evidence of systemic envenoming.

For treatment of the major complications of snake bite, see here.

Figure 1. Evidence of systemic envenoming from snake bite

Most envenomed patients have multiple clinical or laboratory abnormalities suggestive of systemic envenoming.

Clinical evidence of systemic envenoming includes:

neurotoxicity
myotoxicity
coagulopathy
acute kidney injury
nonspecific systemic symptoms: nausea, vomiting, headache, abdominal pain, diarrhoea, sweating
early cardiovascular collapse (eg hypotension, cardiac arrest, unconsciousness, seizures)
significant local bite site effects.

Laboratory evidence of systemic envenoming includes:

INR more than 1.2
prolonged APTT
low or undetectable fibrinogen concentration
raised quantitative D-dimer (more than 2.5 mg/L)Isbister 2022
serum creatine kinase concentration more than 1000 units/L
raised serum creatinine concentration
evidence of thrombotic microangiopathy—thrombocytopenia, red cell fragments or spherocytes on blood film, raised serum lactate dehydrogenase concentration
raised white cell count.

Note:

APTT = activated partial thromboplastin time; INR = international normalised ratio

Figure 2. Summary of the acute management of suspected snake bite in Australia.
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