Snakes Bites

Recognize concerning signs and symptoms of snake bites (slides 160-162)

Bleeding from the wound

Blurred vision

Loss of muscle coordination

Metallic/mint/rubber taste in the mouth

Rattlesnakes (rapid symptom onset): Venom induced consumption coagulopathy (VICC) (basically venom induced DIC), hypotension, shortness of breath, ptosis, paralysis, painful bite

Cottonmouths & Copperheads (rapid symptom onset): VICC, hypotension, shortness of breath

Coral snakes (Delayed onset of symptoms- hours): Hypotension, shortness of breath, convulsions, excessive secretions, paralysis, dysphagia, airway edema, abdominal pain

We are very concerned with paralysis because it can affect your chest wall muscles and affect your breathing

Also patient with snake bites oftentimes develop rhabdomyolysis. Concerning because it can lead to kidney issues leading to electrolyte issues leading to dysrhythmias

You would know if someone had rhabdomyalosys if the had tea colored urine and with the two labs: creatinine/kinase will be elevated and myoglobin will be elevated as well

Identify medical and nursing care priorities for snake bite victims (slides 163-166)

treatment:

• Initial focus: airway, breathing, and circulation

  • Face or neck bites may require early intubation

• Fluid resuscitation with isotonic fluids for signs of hemodynamic stability (20-40ml/kg)

• 5% Albumin may be trial if patient is unresponsive to isotonic fluids (10-20 ml/kg)

  • Protein that increases oncotic pressure (attracts fluid and keeps fluid intravascular).

  • We don’t start with albumin because when the blood vessel is dilated and leaky and you give albumin it will leak right out and water will follow

• Vasopressors should be used when a patient is hypotensive, and no longer responding to fluids and albumin

• Thorough history and physical

• BMP or CMP, CBC, coags or TEG, type/screen, LFTs, CK, testing of urine or blood for myoglobin

  • BMP: looking for kidney/ electrolye issues. Damaged cells release potassium so they can become hyperkalemic.

  • CBC: looking for WBC count. If they are showing signs of bleeding we are worried about their H&H

  • Coags/TEG: with pit vipers we worry about coagulation issues

  • Type and screen: patients can develop VVIC but you should not treat VIC with blood products unless some expections (platelet count is really low and they are bleeding out

  • LFT: look for any signs of liver daamge

  • CK and myoglobin: check for rhabdomyolosis

• ABG, EKG, and CXR in cases of severe envenomation

  • Venom could be cardiotoxic, if they swell up that could affect their breathing so there could be some blood gas changes

• IVF to treat rhabdomyolysis

  • Flush their kidneys

• IV Antivenom ASAP

• Anticholinesterase inhibitors (e.g. neostigmine) for bites from snakes with neurotoxins (coral snakes and rattle snakes)

Nursing 101:

• Wash the affected area with soap and water, and cover wound with a sterile dressing

• Restrict movement of body part that was bitten (splints help); keep the affected area below the heart

• Torniquets, incision and drainage of the area, icing the area, and taking NSAIDS for pain are not advised!

• Remove jewelry as tissue edema is common-> constriction

• Monitor vital signs closely- watch for shock!

• Monitor coagulation labs closely- many venomous snake bites cause VICC

• Rhabdomyolysis is common, and monitoring for signs of renal failure is important

• Keep the patient strictly NPO for possible intubation

• Document what the patient or family knows about the color, shape, size of the snake

  • The snake does not need to be brought in! Digital photos from a distance help

  • Snakes can bite from a reflex several hours after death

• Place two large bore IVs ASAP

• Administer anti-venom in a timely manner

  • Monitor for signs of a hypersensitivity reactions including anaphylaxis and serum sickness- tachycardia, hypotension, rigoring, vomiting, urticaria, dyspnea, wheezing/stridor

• Circle snake bite site with permanent marker

• Identify time of bite

• Initial measurement of radius of body part bitten (often a hand, foot, arm), and serial measurements (every 1-2 hours initially)

• Assess for neurotoxic effects

  • Descending neuromuscular paralysis beginning with the eyes (ptosis)

  • Paralysis of facial muscles and others innervated by cranial nerves

  • Progresses to respiratory failure and generalized flaccid paralysis

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