Population of Interest

All patients injured by snakes.

Intent (Expected Outcomes)

1. All snakebite patients should be managed according to the steps outlined in the Universal Approach to Snakebite Assessment, Diagnosis, and Treatment section.

2. Assessment, diagnosis, and treatment of snakebite patients should be based on the clinical syndrome of envenomation and not the identity of the snake species responsible for the bite.

When a broad-spectrum antivenom does not exist for a given syndrome in a given area, follow the steps outlined in the regional algorithms to determine the most appropriate antivenom therapy for the patient.

3. Snakebites are dynamic events and patients must be frequently reassessed for signs of neurotoxic, hemotoxic, and cytotoxic syndromes throughout the course of care as some syndromes will develop than others.

4. There are no absolute contraindications to antivenom administration for a patient with a symptomatic snake envenomation.

5. Antivenom administration should be performed by medical providers capable of providing advanced life support and trained to a minimum level of paramedic (or DoD equivalent) and higher (i.e. SOCM, 18D, PJ, IDC, IDMT, RN, PA, MD or DO, etc.)

6. Early antivenom treatment is the standard of care for snake envenomations worldwide. Whenever possible, the appropriate antivenom should be administered in the field prior to medevac to neutralize circulating venom before significant and potentially irreversible damage has occurred.

7. If antivenom is not available, the patient should be transferred to a facility that maintains a stock of the appropriate antivenom. Confirm that the receiving facility has the correct antivenom in stock prior to transfer. If the receiving facility does not have the correct product(s) in stock, then that facility should be bypassed for a facility that is stocking the appropriate products.

8. Antivenom dosage, preparation, and administration procedures for each product should be performed as detailed for each specific product.

9. Tetanus prophylaxis should be given prior to discharge when needed.

10. Fasciotomy is contraindicated for snakebite and all cases of suspected compartment syndrome should be managed with additional doses of antivenom and elevation ≥ 60 degrees to reduce oncotic pressure in the bitten limb.

11. Initiate a telemedicine consult with a qualified snakebite expert for any questions, concerns, or unusual manifestations that arise.

12. Do not attempt to kill or capture the snake for identification purposes as treatment is based on clinical findings. If a photo of the snake is available it can be sent to an expert for identification, but this should not delay antivenom treatment in a symptomatic patient with signs and symptoms of any envenomation syndrome.

Performance/Adherence  Metrics

  1. Administration of antivenom to any patients with clinical signs and symptoms of neurotoxic, hemotoxic, or cytotoxic envenomations
  2. Early administration of appropriate antivenoms to symptomatic patients in the field
  3. Rapid transfer of patients to a facility stocking the appropriate antivenom if not available on site
  4. Antivenom administration should be performed by an advanced life support qualified provider trained to the paramedic level (or DoD equivalent) or higher
  5. Tetanus prophylaxis as needed
  6. Manage elevated intracompartmental pressures with antivenom and do not perform fasciotomies.

DATA  SOURCES

System  Reporting  &  Frequency

The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed annually; additional PI monitoring and system reporting to FDA through Force Health Protection (FHP), U.S. Army Medical Materiel Development Activity (USAMMDA) are required under AR 40-7 (see Appendix B for complete reporting requirement).

Responsibilities

It is the trauma team leader’s responsibility to ensure familiarity, appropriate compliance and PI monitoring at the local level with this CPG.