Bedside Snake ID Workflow (When Antivenom Choice Depends on ID)

1. Stabilize ABCs; start syndrome guided care (airway equipment ready for neurotoxicity; pressure immobilization only when indicated; analgesia).

2. If snake photos (or dead snake) AVAILABLE:

a. Contact DoD Advisor at +1 (833) 238-7756, request toxicology, tell them you have photos or a dead snake with the patient.

b. Ideally, photos show the full body/pattern as well as several clear angles of the head (top, front, sides). Ventral side photos can be helpful but dorsal more important.

c. DO NOT take risks to obtain photos! Never touch the head with your hands - even a decapitated snake head can bite and inject venom >24 hours after the bite.

3. If snake photos (or dead snake) NOT AVAILABLE:

a. Ask the patient about where the bite occurred (location / estimated elevation), what type of habitat it was (e.g., dry rocky hillside, wading through creek), what the patient was doing when the bite occurred, what the snake looked like, and if they remember anything about how it behaved (e.g., rose up and hooded its neck).

b. Review ID tips (habitat/location) in Antivenom Algorithm: INDOPACOM AOR in the CPG regional pages for INDOPACOM. Review the location/habitat text on the sub-regional arrows for your area, this may provide an answer.

c. Review snake description and habitat/location tips in the AV RAPID REFERENCE table in the CPG: Antivenoms that require species ID have tips for identification based on location/habitat and snake description.

d. Classify the syndrome(s): NEURO, HEMO, CYTO, or mixed (e.g. HEMO/CYTO). If mixed, identify the dominant syndrome.

e. Scan history / description for strong signals (hooding/spitting; sea exposure; nocturnal bed bite with minimal local signs).

4. Make a presumptive ID à Select antivenom per regional algorithm for the most likely group à treat without delay.

5. Reassess frequently: If the clinical course and labs do not improve after adequate dosing, reopen the differential and switch antivenom per algorithm or after DoD ADVISOR consultation.

6. Sometimes, it may be necessary to try more than one antivenom in these cases – this is often done in Taiwanese hospitals.