Snakebites - that would be a big one

[ckroll 101]

RE: snakebites. Over 2 inches between primary fang marks would be the mother of all pit vipers. Many snakes, even non venomous ones will have larger teeth in the canine position that can mimic fang marks. My burmese python could leave marks you'd swear were fangs but were just over developed incisors. A snake will not strike at something too large to eat unless under extreme stress and will release as quickly as possible. Snakes' upper jaws are quite flexible. In the process, a snake can bite, release and reset some distance over. The result, if one is not careful, will appear to be a bite much larger than a single bite.

In any case, if it were an adult pit viper, it did the right thing and delivered a dry bite as a warning. I believe that Hudson Valley Hospital Center has anti-venin. I will check on this, but as recently as 2 years ago the rep was giving us an in-service on using it. And one is seldom wrong to fly to Jacobi where they have cases of the stuff, and the staff is prepared for the sequelae associated.

Important to know is that Jacobi is the place to go for snakebites. NYC gets a lot of imported creatures on its docks and the Bronx Zoo keeps anti-venin on hand for all its creatures. Sounds like a job well done.

[NHFD21255 141]

Seems like this could be a good topic to talk about.

CKROLL in reference to your post I'm not sure but I dont believe Hudson Valley has any anti venom. I know our 911 center made some phone calls and came up with Jacoby. I did hear for sure West Med did not have any. I think we made it pretty much policy now to fly any of our snake bite vics to Jacoby after the one we had a couple years ago (please dont quote that because I'm not 100%) , Unless your 100% you know what kind of snake it was. The problem we had a couple years ago was the local Hospital we sent the girl to ran out of anti venom and they sent her to Jacoby after much wasted time anyway. She was in real bad shape and that was from what we belive was a copperhead bite.

There are Timber Rattlers all over the Hudson Valley and I'm really supprised we dont get more bites with all the people in the woods. I guess my question is does anyone have any protocols for snake bites.

[mfc2257 464]

In Miami, snake bites are such a concern that there is a local agency that runs emergency vehicals (Venom 1 and Venom 2) with medics specifically trained for snake bites and admin of anti venom which they carry.

http://www.miamidade.gov/mdfr/emergency_special_venom.asp

Edited August 6, 2009 by mfc2257

[rfdu39 89]

There will be no bites so long as people do not mess with the snakes. If you hear a rattle snake you need to turn around.

[WAS967 97]

If you hear a rattle snake you need to turn around.

If you hear the rattle of a rattler, you are already on top of it. Best bet is to stop where you are, don't make any sudden moves, get a general idea of where it is, and either A) slowly move away from it or let it move away from you. The snake IS more scared of you than you are of it. It WILL get away from you ASAP.

Remember, most striking snakes can only strike out to about 2/3 their body length. Around here the crotalids max out at about 6 feet, so you are talking a striking distance of 4 feet max. And statistically, a lot of bites from venomous snakes to humans (over 50% I believe if you look at the stats. [EDIT - MY bad...it's far less at 20%....see below.]) are "dry" bites - ie...no venom is injected.

Venomous snake bites around here are as rare as the rattlesnakes are (they are endangered too so don't go shooting them just because your dog is barking at one) but it's beneficial to become familiar with the basic treatment of same. Westchester still has some spots where even rattlesnakes can be an uncommon site (Ward Pound Ridge, Camp Smith to name a few).

I thought MOST hospitals have at least ONE dosage of Crofab on hand. I know FEW have more than that because of the expense of the antivenom. I believe NWH has one dose on hand (I know the head pharmacist well and yes I've asked but that was a while ago and that status could have changed). I'm surprised that HVHC and (especially) WMC wouldn't have at least one dose on hand. Pays to call ahead I guess. But even so, if there is a confirmed envenomation (sp?), the average adult may need 6-8 doses, so they will likely get transfered anyways. One of the best things you can do as a prehospital provider is keep the patient calm and monitor for signs of envenomation. If there are no signs, it is unlikely they will get antivenom prophylactically as the negatives of giving it without symptoms far outweight the pros.

[EDIT: More information]

Here is a very good article from JEMS on the subject. NOTE: MY stats for the Crotalids above seems to have gotten mixed up with the ones regarding coral snakes (actually in the cobra family). Dry bites from coral snakes seem to be in the 50-60% range, whereas the crotalids are much less at about 20%. I stand corrected.

Edited August 6, 2009 by WAS967

[WAS967 97]

And before people start jumping on the whole "OMG why was the patient taken ALL the way to Jacobi" bandwagon, I offer the following quote from the above mentioned article:

"Definitive treatment for crotalid envenomation is antivenin. Prehospital providers should know which hospitals regularly stock antivenin. Regional variations in hospital pharmacy practices make generalizations difficult to make. When in doubt about local hospital antivenin supplies, diversion to a tertiary care trauma center would be most appropriate to ensure timely access to antivenin."

[Tapout 42]

There will be no bites so long as people do not mess with the snakes.

Really? Kids don't mess with snakes. They run around as kids will and come upon them by accident. It happens often at my kid's camp- but luckily, so far, they've all been harmless gardeners. But all it takes is 1 rattler or copperhead in the same situation and the kid is going to get hurt. My point: don't blame the kid.

[aviator70 16]

Really? Kids don't mess with snakes. They run around as kids will and come upon them by accident. It happens often at my kid's camp- but luckily, so far, they've all been harmless gardeners. But all it takes is 1 rattler or copperhead in the same situation and the kid is going to get hurt. My point: don't blame the kid.

I hate snakes! There is actually a condo complex in Orange County (Central Valley) that is built into a hilll that has Rattelsnake dens that can not be disturbed as they are protected. I read several years ago they are seen frequently and there are very problems and very few bites, but lot's of snakes. The belief is that people and snakes there have adapted to live within close proximity together in harmony.

[Tapout 42]

I hate snakes! There is actually a condo complex in Orange County (Central Valley) that is built into a hilll that has Rattelsnake dens that can not be disturbed as they are protected. I read several years ago they are seen frequently and there are very problems and very few bites, but lot's of snakes. The belief is that people and snakes there have adapted to live within close proximity together in harmony.

HARMONY?????? Oh, Good God no. I hate them too-- I was enjoying a day in my herb garden one day last spring, thinking "what a great day to relieve stress by weeding my great garden... oh, the awesome recipes I'm gonna come up with... nothing beats fresh herbs..." and what do I come upon but a @#$#$%%^^^^!!@@@@ing copperhead baby snake chillin' in my garden. And right next to cute little baby copperhead was the skin of its momma-- about 4feet long!!! I haven't been back to the garden since.

Fast forward to last week-- I'm visiting my son's camp for the day, so happy to be getting away from my office... enjoying a stress-free day in the country for a change... and there is a flipping 3 or 4 foot long black snake hanging out right next to where all the kids hang their wet swim trunks.

I HATE SNAKES!

Edited August 6, 2009 by Tapout

[ckroll 101]

I've got a query into HVHC. I know as a certainty that they had antivenin several years ago. By no means should all snakebites go to Jacobi. Confirmed hot bites in children and small adults, yes, but a lot of snake bites are ordinary water snakes. Venomous exotics and, in Florida, coral snakes are elapids and the venom is neurotoxic, so there will be only minimal pain. We are fortunate to have as natives only copperheads, [a docile snake], and Timber Rattlers, who are both crotalids--pit vipers-- that have hemolytic venom that destroys tissue and is very painful. Shortly after a 'hot' crotalid bite, there will be bruising at the point of injection and incredible pain. Swelling takes hours to develop, so there is a larger window for initial treatment... assuming it is a first bite. Subsequent bites may trigger an allergic reaction that can be fatal if not treated, so in these circumstances, the closest hospital is the best. As people who get bitten once have habits that often get them bitten twice, that is something to consider. Keep in mind that both copperheads and rattlesnakes are upland vipers that live in high, dry, wild terrain. They tend to come down some in dry years if their prey has moved down. Anywhere near water in New York, the greatest likelihood is that the large snake is a harmless water snake... who suffers mightily by being marked somewhat like a copperhead. In 20 years I've seen 3 copperheads locally, and that's looking for them.

As for snakes... they are the sweetest of creatures. I relocate snakes for those who do not want to live with them. I ask if they have had a mouse problem....and the answer is invariably yes. I ask if the mouse problem has gone away recently and the answer is yes. I ask them if I had the perfect mouse trap... one that resets itself, is silent, turns mice into small brown pellets, moves itself to areas of greatest infestation if they would want one and they ask yes where do you buy them. I tell them it's called a snake. If you have a snake it's because you have mice. Love them and learn to live with them; they are a gift.

[ckroll 101]

As for protocols, I know of none. It is a poisoning or toxic injection. You can call poison control. Any agency that has resident populations of venomous snakes ought to discuss what their options are. The concern is not so much the bite itself. Loss of circulation, pain, long term infection secondary to a large open wound are all bigger issues.

[BFD2553 75]

If you hear the rattle of a rattler, you are already on top of it. Best bet is to stop where you are, don't make any sudden moves, get a general idea of where it is, and either A) slowly move away from it or let it move away from you. The snake IS more scared of you than you are of it. It WILL get away from you ASAP.

Remember, most striking snakes can only strike out to about 2/3 their body length. Around here the crotalids max out at about 6 feet, so you are talking a striking distance of 4 feet max. And statistically, a lot of bites from venomous snakes to humans (over 50% I believe if you look at the stats. [EDIT - MY bad...it's far less at 20%....see below.]) are "dry" bites - ie...no venom is injected.

Venomous snake bites around here are as rare as the rattlesnakes are (they are endangered too so don't go shooting them just because your dog is barking at one) but it's beneficial to become familiar with the basic treatment of same. Westchester still has some spots where even rattlesnakes can be an uncommon site (Ward Pound Ridge, Camp Smith to name a few).

I thought MOST hospitals have at least ONE dosage of Crofab on hand. I know FEW have more than that because of the expense of the antivenom. I believe NWH has one dose on hand (I know the head pharmacist well and yes I've asked but that was a while ago and that status could have changed). I'm surprised that HVHC and (especially) WMC wouldn't have at least one dose on hand. Pays to call ahead I guess. But even so, if there is a confirmed envenomation (sp?), the average adult may need 6-8 doses, so they will likely get transfered anyways. One of the best things you can do as a prehospital provider is keep the patient calm and monitor for signs of envenomation. If there are no signs, it is unlikely they will get antivenom prophylactically as the negatives of giving it without symptoms far outweight the pros.

[EDIT: More information]

Here is a very good article from JEMS on the subject. NOTE: MY stats for the Crotalids above seems to have gotten mixed up with the ones regarding coral snakes (actually in the cobra family). Dry bites from coral snakes seem to be in the 50-60% range, whereas the crotalids are much less at about 20%. I stand corrected.

Re: Dry Bites Coral Snakes are rear-fanged and actually have to "chew" up to where their fangs are to envenomate.

[ckroll 101]

http://www.krpc.com/proffed/snake/Snakebite.cfm

This is an excellent overview, and it comes with a test. Sounds like self study credit to me.

[TCD0415 26]

There will be no bites so long as people do not mess with the snakes. ...

Another thing to keep in mind....... When the tones go off for a Brush Fire, you may end up in the woods (in their hood) and if there is a fire they probably wont be too happy when you get there anyway. Raking, clearing, just walking.........

Keep your eyes open.

[ny10570 745]

You have hours to administer anti venom in the vast majority of envenomations. There really is no need to fly someone out. Take them to the nearest or if you feel up for the drive go visit the Bronx. As ckroll mentioned the biggest issue is anaphylaxis.

[NHFD21255 141]

You have hours to administer anti venom in the vast majority of envenomations. There really is no need to fly someone out. Take them to the nearest or if you feel up for the drive go visit the Bronx. As ckroll mentioned the biggest issue is anaphylaxis.

I have to disagree with you on this one , here is a quote from the link above.

Pre-hospital

The most important measure is rapid transport to a health care facility that has the ability to administer antivenin. Many different pre-hospital treatments have been proposed.8 Their efficacy is generally controversial. Immobilization of the patient is recommended. Movement may promote propagation of the venom and increase risk of systemic effects prior to reaching the controlled hospital environment. Local ice should not be used as necrosis related to vasoconstriction in poorly perfused tissues may occur. Some authors recommend constricting bands, but only if they can be precisely pressure regulated so as to obstruct lymphatic and superficial drainage without obstructing venous or arterial flow. Constricting bands carry the risk of increasing tissue necrosis distal to the band.

With this being said and the lack of anti-venom up in hudson valley hospitals I think the best way is by air. It would be about an hour ride by ground to the bronx in the best of traffic (Plus the time you were on scene). Now how long would it take durning rush hour , or how long from dutchess or Orange county. The best thing would be for our local hospitals to carry anti-venom but with the cost of it I dont see that happening anytime soon.

[67R93 5]

I heard that Vassar Bros. Medical Center in Poughkeepsie has a limited supply of anti-venom. Any truth to this? It would be interesting to know. Thanks.

[WAS967 97]

I heard that Vassar Bros. Medical Center in Poughkeepsie has a limited supply of anti-venom. Any truth to this? It would be interesting to know. Thanks.

I don't get up there often but the people at the Pharmacy are usually accommodating. I shall try to remember to ask next time I'm at the ER.

[Guest]

Texas is "fortunate" enough to be home to all 4 of North Americas native venomous snakes; The Copperhead, Water mocasin (Cottonmouth), Rattlesnake, and the ever elusive Coral Snake. As well as a "s*** ton" of other non-venoumous, sometimes mimicking snakes.

I live in houston, and it is FLAT, and WET! The only elevation we have is skyscrapers, and freeway overpasses. And is also home to all 4 of the above rechedly disgusting creatures. I DESPISE snakes.

Here is the run down. Rattlesnakes are the least of my worries. They will generally give you ample warning. Diamondbacks can grow to enourmous size and are generally pretty non confrontational unless as stated above you step on them. Copperheads can be found in just about anyones front yard in the flowerbeds, and arent that big in stature, but pack a big punch, and account for a good number of snake bites. Coral snakes... Good luck finding one. I have lived in Texas my entire life and have only seen 1. Water moccasins on the other hand are the foulest of them all. They are big, fat, ugly, and smell. You are pretty much guaranteed to find them near any lake, pond, creek, bayou, or estuary... Oh and they are MEAN! They will chase you. Water moccasins are very terratorial, and agressive.

The houston zoo is a wonderfull place, and home to a rather large reptile research facility. Also conviniently right across the street from the Texas Medical Centre. They have drothes of anti-venom for some of the rarest snakes in the world to include the bushmaster, and black mamba.

I just found out the other day that oddly enough they do not carry anti-venom for Copperheads, or Water moccasin (Both pit-viper)... Found that odd. The anti-venom for those is stored at Brekenridge Zoo in San Antonio. Leave it to Texans to do something like this back-asswards.

[WAS967 97]

Do they have antivenom for Rattlesnakes? If so, it's good for copperhead and water moccasins as well. (Crofab)

[ckroll 101]

I have to disagree with you on this one , here is a quote from the link above.

Pre-hospital

The most important measure is rapid transport to a health care facility that has the ability to administer antivenin. Many different pre-hospital treatments have been proposed.8 Their efficacy is generally controversial. Immobilization of the patient is recommended. Movement may promote propagation of the venom and increase risk of systemic effects prior to reaching the controlled hospital environment. Local ice should not be used as necrosis related to vasoconstriction in poorly perfused tissues may occur. Some authors recommend constricting bands, but only if they can be precisely pressure regulated so as to obstruct lymphatic and superficial drainage without obstructing venous or arterial flow. Constricting bands carry the risk of increasing tissue necrosis distal to the band.

With this being said and the lack of anti-venom up in hudson valley hospitals I think the best way is by air. It would be about an hour ride by ground to the bronx in the best of traffic (Plus the time you were on scene). Now how long would it take durning rush hour , or how long from dutchess or Orange county. The best thing would be for our local hospitals to carry anti-venom but with the cost of it I dont see that happening anytime soon.

Well...... rapid is pretty much always better for anything EMS related, and yet we don't use helicopters for every call. The window for antivenin is several hours. I think the admonition to seek rapid attention is in part directed at the drunk 18 year old male who is ill advised to wait to until morning to seek help. A consideration is whether concentration or dilution of the venom is the better approach for crotalids. If it were my hand, I'd opt for dilution [ no lymph band] and more aggressive treatment as local damage to a hand can have consequences. If it were my calf and I were several hours hike from a trailhead, I'd consider slowing venom to the core with a light lymph band on the grounds that local damage to the calf was less of an issue than getting to civilization prior to potentially getting shocky in the backcountry. That said, if I was OK at the trailhead, I probably would not seek emergency treatment at all. But then I'd carry a sawyer extractor as well. Lymph bands are controversial to say the least and have no value for questionable envenomations. I'd never make that decision for a patient without contacting medical control.

Just as important, it's not necessary to make a circus out the event. I got called...and this was over a decade ago... to assist with a snake bite situation. A group of teenage campers were wailing and sobbing, the bitten person was off lights and sirens to the hospital...... all over a medium sized northern watersnake. The hospital insisted on seeing the snake for identification, I wouldn't let the officer kill it. So I had to go in the back of a patrol car, also lights and sirens even though I'd told everyone it was harmless. In the intervening 20 minutes, the snake's size and ferocity had grown in the telling so that by the time I walked into the ER with a remarkably healthy 4 foot water snake, it was nothing less than a scene from 'Snakes on a plane.'

The camper never needed medical attention at all, and some cooler heads might have prevented unnecessary panic. The poor snake was terrified.