Snakebite

Traci Denton RN, CCRN

 Snakes in Tennessee

 Tennessee is home to 32 species of snakes; 4 of

which are venomous.

 Poisonous is not the correct terminology (poison is

ingested and venom is injected.)

 All of Tennessee’s venomous snakes are from the Pit

Viper family. They get that name from having a
heat sensing pit just behind each nostril, which they
use in sensing their prey.

 The 4 venomous snakes in Tennessee are:

 The Western Cottonmouth

Of all the venomous snakes in Tennessee, the Cottonmouth has the meanest
temperament. They will stand their ground when encountered, and they will
give you a good dose of venom with each bite. It can bite underwater. All
snakes in Tennessee have white mouths; so do not base your identification
on that criterion alone.
 The Timber Rattlesnake

Timber rattlesnakes are a secretive, nonaggressive species. Their main defense is to

lie motionless on the forest floor, relying on their color and pattern to camouflage
them from predators.
 The Northern and
Southern Copperhead

The Copperhead is a relatively shy snake, but they account for the most
reported bites each year in Tennessee. They inject venom based on the
amount required to render its prey inactive. They know that they cannot
digest a human, so roughly 50% of their bites are dry bites (no venom
injected)
 The Western Pigmy
Rattlesnake

This is one of the smallest species of rattlesnakes in North America. The

end of the tail has a small rattle on it that is seldom louder than a buzzing
insect and is often not heard or even seen. The bite from this species is
rarely fatal.
 Worldwide, there are 50,000 deaths from venomous
snakebites each year.

 Only 12-15 are in the USA

 In Tennessee, only 4 snakebite related deaths have been

reported since 1960.

 Most Tennessee snakes are nocturnal during summer

months and only lay in midday sun to warm.

 In early spring and late fall, they are more prevalent in

daylight hours when temperatures are higher.

 Tennessee snakes hibernate in winter and prefer

temperatures > 50 F and < 100 F.
 Most bites occur when people are trying to kill or
handle a snake. Snakes will always flee an area
rather than strike, unless they are harassed or
startled. More people die from bee stings and
lightening strikes annually .

 Immediate medical help should be sought in case a

bite occurs.
This is where we come
in…..
Coagulation abnormalities are due directly to snake
venom interference with the coagulation cascade
 Pharmacotherapy Pearls

 Minimal envenomation: Swelling, pain, and bruising are

limited to immediate bite site: no systemic signs and
symptoms; normal coagulation parameters; no clinical
evidence of bleeding.
 Moderate envenomation: Swelling, pain, and bruising
are limited to less than a full extremity (or<50 cm if bite
was on head or trunk); systemic signs and symptoms are
not life threatening (nausea, vomiting, oral paresthesia,
unusual taste, mild hypotension, mild tachycardia,
tachypnea); coagulation parameters may be abnormal;
no bleeding other than minor hematuria, gum bleeding
or nosebleeds, if not severe.
 Severe envenomation: Swelling, pain, and bruising
involve more than the entire extremity or threaten
the airway; systemic signs and symptoms are
markedly abnormal (severe alteration of mental
status, severe hypotension, severe tachycardia,
tachypnea, respiratory insufficiency); coagulation
parameters are abnormal; serious bleeding or severe
threat of bleeding.
 Treatment……..

CroFab is a venom-specific fragment of IgG, which binds and neutralizes

Venom toxin, helping to remove the toxin from the target tissue and
Eliminate it from the body.
 Dosing: Adult
Crotalid envenomation
 Initial dose: 4-6 vials, dependent upon patient
response. Treatment should begin within 6 hours of
snakebite; monitor for 1 hour following infusion.
Repeat with an additional 4-6 vials if control is not
achieved with initial dose. Continue to treat with 4-
6 vial doses until complete arrest of local
manifestations, coagulation tests and systemic signs
are normal. Monitor closely.
 Maintenance dose: Once control is achieved, administer 2 vials
every 6 hours for up to 18 hours. Optimal dosing past 18 hours
has not been established; however, treatment may be continued if
deemed necessary based on the patient’s condition.

 Dosing: Geriatric Refer to adult dosing

 Dosing: Pediatric Refer to adult dosing

 Note: Clinical trials included patients as young as 11 years of age.

Specific pediatric studies have not been conducted. Because the
absolute venom dose is expected to be the same in adults and
children, adult dosing should be used.

 Products contain thimerosal with 0.11 mg of mercury per vial ,

which in high doses has been associated with neurological and
renal toxicity. Fetuses and very young children are most
susceptible for mercury related toxicities.
 Reconstitution:

 Reconstitute each vial with 10 mL sterile water for

injection and mix by gentle swirling. Further dilute
total dose in 250 ml NS: use within 4 hours of
reconstitution.

 Note: Reconstitution with 25 mL sterile water for

infusion and hand rolling/inverting may result in
shorter dissolution times and allow for more rapid
administration.
 Administration: I.V.

 Administer I.V. over 60 minutes at a rate of 25-50

mL/hour for the first 10 minutes. If no allergic
reaction is observed, increase rate to 250 mL/hour.
Monitor closely. Epinephrine and
diphenhydramine should be available during the
infusion.

 Decreasing the rate of infusion may help control

some adverse effects.
 Contraindications:

 Hypersensitivity to any component of the

formulation (including papaya or papain), unless
benefits outweigh the risks and appropriate
management for anaphylaxis is readily available.

 Processed with papain and my cause

hypersensitivity reactions in patients allergic to
papaya, other papaya extracts, papain,
chymopapain, or the pineapple-enzyme bromelain.
There may also be cross allergencity with dust mite
and latex allergens.
 Adverse effects:

 Hypersensitivity reactions: Derived from sheep

plasma; anaphylaxis and anaphylactoid reactions
are possible, especially in patients with known
allergies to sheep protein. Immediate treatment
(including epinephrine 1:1000) for anaphylactoid
and/or hypersensitivity reactions should be
available. Incidence of acute hypersensitivity
reactions may be lower than previously thought.
This product lacks the immunogenic Fc fragments
and proteins found in the older equine-derived
product. Sensitization may occur with repeated
doses.
 Adverse Reactions:

 Cardiovascular: Hypotension

 Central nervous system: Chills

 Dermatologic: Pruritus, rash, urticaria

 Respiratory: Asthma, cough, dyspnea, wheezing

 Miscellaneous: Anaphylaxis, anaphylactoid

reaction, hypersensitivity reactions (5% to 19%),
serum sickness (5%)
 Drug Interactions:

 There are no known significant interactions.

 Lactation: Excretion in breast milk unknown/use

caution
 Disease-related concerns:

 CroFab should be used within 4-6 hours of snakebite to

prevent clinical deterioration and development of
coagulation abnormalities. These are due directly to
snake venom interference with the coagulation cascade.
Recurrent coagulopathy occurs in approximately 50% of
patients and may persist for 1-2 weeks or more. Repeat
dosing may be indicated. Patients should be monitored
for at least 1 week and evaluated for other pre-existing
conditions associated with bleeding disorders. In severe
envenomations, a decrease in platelets may occur, lasting
hours to several days. Blood products are generally
ineffective as they are rapidly consumed by circulating
venom.
 Monitoring:

 Parameters: Vital signs, CBC, platelet count,

prothrombin time, aPTT, fibrinogen levels, fibrin
split products, clot retraction, bleeding and
coagulation times, BUN, electrolytes, bilirubin, size
of bite area (repeat every 15-30 minutes); intake and
output, signs and symptoms of
anaphylaxis/allergy.

 CBC, platelet counts, and clotting studies are

evaluated at 6-hour intervals until patient is stable.
Size of bite area marked
every 15 minutes
 Cost

 Generic not available in the U.S.

 Pricing (www.drugstore.com) is $4687.76 (2vials)

 References

 Buchanan JA, Varney SM, Mlynarchek SL, et al, “Immediate Adverse Events (AEs) After
Administration of Crotalidae Polyvalent Immune Fab,” Clin Toxicol, 2009, 47(7):703.

 Cannon R, Ruha AM, and Kashani J, “Acute Hypersensitivity Reactions Assocoated With
Administration of Crotalidae Polyvalent Immune Fab Antivenom”, Ann Emergency Medicine,
2008, 51(4):407-11.

 Crotalidae Polyvalent Immune

 Duke, J, “The Venomous Snakes in Tennessee”, About.com Guide.

 Levonas EJ, Kokko J, Schaeffer TH, et al “Short-Term outcomes After Fab Antivenom Therapy
for Severe Crotaline Snakebite,” Ann Emerg Med, 2011, 579(2): 128-37[PubMed20952098].

 Ohio Valley Poisonous Snakes: Kentucky, Ohio, Tennessee, West Virginia, and Indiana,
OhioValleyFishing.com, 2011.

 Quan, AN, Quan D, and Curry SC, “Improving Crotalidae Polyvalent Immune Fab
Reconstitution Times, “Am J Emerg Med,2010, 28(5):593-3 {PubMed 20579555]