Management in the Emergency Department

Wingert suggested a multi-step guideline for treatment of snakebite enveno-mation, beginning with establishing a physiologic baseline. This includes rapid evaluation of signs and symptoms and obtaining laboratory tests (CBC and platelet count, INR and PTT, fibrin split products, fibrinogen, CPK, urine dipstick for occult blood, electrolytes, BUN and creatinine, and type and cross for possible transfusion) (27).

Next, determine the severity of the envenomation (Table 32.4). An unremarkable physical and laboratory exam at presentation does not reliably indicate an insignificant envenomation. It is recommended that physicians observe patients with a history of crotalid snakebite for at least 6 to 8 hours and for Mojave rattlesnake (C. scutulatus) or an elapid bite monitor for 12 to 24 hours, before the bite is termed non-envenomated (9,65).

Intravenous lines are started to infuse fluids and antivenin if necessary (see below). Do not start IV in affected extremity. Treat bleeding complications first with antivenin, then with fresh frozen plasma and blood. Treat hypotension with crystalloid fluids and rhabdomyolysis with fluids and sodium bicarbonate. Monitor oximetry and arterial blood gases as necessary. Treat pain, but avoid potent narcotics because of possible respiratory depression. Give tetanus toxoid or human immune tetanus globulin if immunization status is questionable.

Monitor local swelling at 20 to 60 minute intervals with measurements of limb circumference at the point of edema and assessment of circulation, and repeat laboratory tests. Splint the extremity in a position of function. Clean the wound and debride if necessary. Prophylactic antibiotics are not indicated in patients with rattlesnake bites (66).

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