Snakebite in children: Texts

Text A

Background

Snakebite is uncommon in Victoria and envenomation (systemic poisoning from the bite) is rare. The bite site
may be evidenced by fang marks, one or multiple scratches. The bite site may be painful, swollen or bruised,
but usually is not for snakes in Victoria.

There are no sea snakes in Victoria, but land-based snakes can swim.

Major venomous snakes in Victoria and effects of envenomation:

Systematic Cardiovascular
Snake Coagulopathy Neurotoxicity Myotoxicity TMA
symptoms effects

- Collapse (35%)
Brown VICC Rare and mild 50% 10%
Cardiac arrest (5%)

Tiger VICC 30% 20% Common Rare 5%

Red- Mild increase - Uncommon Common - -

bellied
Text C in aPITT and Often
black INR with significant
normal bite site pain
fibrinogen, and limb
usually no swelling
significant
bleeding

VICC: Venom-induced consumptive coagulopathy (abnormal INR, high aPTT, fibrinogen very low, D-dimer
high).

Myotoxicity muscle pain, tenderness, rhabdomyolysis

Systemic Symptoms see history and examination.

TMA: thrombotic microangiography. Haemolysis with fragmented red blood cells on blood film,
thrombocytopenia and a rising creatinine.
 Text B

Assessment

Focus on evidence of envenomation.

• Once the possibility of snakebite has been raised, it is important to determine whether a child
has been envenomed to establish the need for antivenom.
• This is usually done taking into consideration the combination of circumstances, symptoms,
examination and laboratory test results.
• Most people bitten by snakes in Australia do not become significantly envenomed.

History and Examination

Circumstances Symptoms Examinations

- Confirmed or witnessed - Headache - Evidence of a bite/ multiple

bite versus suspicion that - Diaphoresis bites
bite might have occurred - Evidence of venom movement
Text C - Nausea or vomiting
- Abdominal pain (e.g. sowllen or tender draining
- Were there multiple bites?
- Diarrhoea lymph nodes)
- When?
- Where? - Blurred or double vision - Neurotix paralysis (ptosis,
- First aid? - Slurring of speech ophthalmoplegia, diplopia,
- Past history? - Muscle weakness dysarthria, limb weakness,
- Medications? - Respiratory distress respiratory muscle weakness)
- Allergies? - Bleeding from the bite site or - Coagulopathy (bleeding gums,
elsewhere prolongued bleeding from
- Passing dark or red urine venepuncture sites or other
- Local pain or swelling at bite wounds, including bite site)
site - Muscle damage (muscle
- Muscle pain tenderness, pain on movement
- Pain in lymph nodes draining weakness, dark or red urine
the bite area indicating myoglobinuria)
- Loss of consciousness/collapse
and/or convulsions
Text C

Snakebite Management Flowchart

 Text D

Giving Antivenom

• Antivenom is indicated in all children where there is evidence of envenomation.

• Giving antivenom should occur in consultation with a clinical toxicologist.
• Dilute one vial in 100mls of 0.9% saline and give IV over 15-30 min.
• If the child is in cardiac arrest and this is thought to be due to envenomation, then give undiluted
antivenom via rapid IV push.
• There is no weight based calculation for antivenom (the snake delivers the same amount of venom
regardless of the size of the child). One vial of antivenom is enough to neutralise the venom that can be
delivered by one snake. Clinical recovery takes time after antivenom administration and multiple vials do
not speed recovery.

At discharge, ensure that the family is given advice on how to recognise serum sickness:

• Occurs in about 30% of children given antivenom.

• Tends to occur 4 – 14 days following antivenom administration.
• Consists of flu-like symptoms, fever, myalgia, arthralgia and rash.
• A letter should also be written to the child’s GP regarding this.