PROBLEM or PURPOSE:
To present a case involving a snakebite and consider possible remedies to the lack of effective procedures, training and communications with regard to venomous snakebite treatment.
TOTAL IN STUDY: 1
SIGNALMENT: 26 year old adult Caucasian male in normal health
The author is not a medical doctor, primary care provider or other medical professional. Nothing in this Case Study is to be construed as medical advice or the practice of medicine.
Victim was climbing in remote Rockies, bitten by an unknown snake in patellar region of left leg. I arrived via helicopter approx. 1 Hr. 15 mins. after incident as first-in EMS team. No care of any type had been administered. Two lay-people were attending victim on arrival. One told us that he was “just getting ready to cut they guys leg and suck out the poison”. Victim was multi-symptomatic, with distinct puncture wounds showing tissue swelling, edema, some ecchymosis, and distention at posterior of injury region. Chief complains were dizziness, nausea & pain in bite region as well as tightness in chest. Initial triage indicated extreme shock trauma, trauma related stress, elevated respiration, pulse and BP. Pupils showed uneven dialation and were generally non-responsive to light. IV (lactated Ringer’s) & ECG were started.
A combination of EMS and herpetological knowledge prompted me to believe that the wound was inflicted by a relatively large, venomous species, and that a neurotoxin (rather than a hemotoxin) was most likely introduced. These conclusions were formed based on puncture wound separation, edema and symptomolgy. I contacted the nearest US Forest Service Field Office via FERN radio and requested that he call for advance prep. at the nearest trauma center (which will remain nameless) approx. 30 mins flight time from incident scene. The USFS Ranger relayed my instruction incorrectly and told them our victim was “poisoned”. Patient became increasingly non-responsive and developed respiratory distress in-flight and was intubated.
On arrival at trauma center (Class 2) we were met by a resident who was the “poison expert” at the facility. He had no experience or practical dealing with snakebite. One of the ER/trauma techs. at the facility who was a member of Rocky Mountain Rescue Group, and had training (though no practical) with snakebite trauma. He had the presence to call the Poison Control Center and request the location of the nearest antivenin storage facility. By this time, the victim was experiencing extreme duress, advanced trauma and was in danger of pulmonary and/or cardiac arrest. The ER team (now 9+ people) diligently addressed the symptoms, but no attention was given to the cause.
Local site necrosis developed, as well as acute pulmonary paralysis. Upon my insistence (with help from the ER Tech.) a helicopter. was started from a (Class 1) trauma center in a major city where the nearest antivenin (Trivalent) was located. At no time did anyone from the storage facility ask what kind of venom was introduced or the snakes identity. The victim suffered total pulmonary arrest approx. 45 mins. post admit, with cardiac arrest following. A “lively” discussion ensued re: the merits of administering the now arrived antivenin serum.
No one, including myself had any clinical experience with administration technique on a respirated post-arrest patient. Following a bout with arrhythmia that prompted the use of electro-cardiac therapy the patients vitals were stabilized enough to address the neurotoxic symptomolgy. I called the facility where the serum was obtained to seek further advice. Following the advice of a researcher (Doctorate of Biochemistry), the serum was introduced via saline IV flow in increasing amounts. Patient showed signs of responding to treatment almost immediately.
Following what appeared to be full stabilization of vitals, patient suffered an acute reaction to the serum and underwent total cardio-pulmonary paralysis. Urticarial reaction was diagnosed. The decision was made by the chief attending physician to treat the patient surgically, where open heart massage was administered prior to patient being placed on heart/lung system. Patient remained in intensive care in comatosis for 168 hours, at which time consciousness was regained following various therapies to which I was not party, including removal from HL system. Patient was released to OPCTF 2 weeks later, exhibiting signs of paralysis, neurological damage as well as complete amnesia. Subsequent queries as to patient’s condition have revealed partial regaining of motor function in upper torso, heightened response to physical therapy, and increased memory of events prior to but not proximate to incident.
OBSERVATIONS & SUMMARY:
Due to the infrequency of this type of casualty in the USA, no real system is in place to deal with this type of incident. Countries such as Singapore, India and most of Africa have detailed and efficient procedures for diagnosis, pre-hospital EMS care and antivenin location communications. Traumas such as these are often treated as routinely as a common laceration. Pre-hospital care providers and M.D.’s in most other countries where elaipdae are not prevalent are often not specifically trained in venom type identification and antivenin administration.
I am working to change this. As an EMS caregiver (EMT-P/IV/MAST with dive, jump, cave, trench, mountain rescue and HazMat training/experience formerly with USAF Pararescue, RMRG, vol. FireMedic) I see a desperate need for better communication & training to pre-hospital care providers & OPCF/medical facilities, since most incidents occur outside the immediate range of a trauma center. Caregivers should be instructed to call the PCC immediately in these cases. The PCC maintains current and detailed data re: antivenin availability, type and administration as well as referring specialists. Taxonomists, venom researchers, neurological specialists and chemists/enzyme researchers often study the same topics without communication between the sciences. Those with useful allegorical data, the herpetologists and hot keepers, are rarely consulted.
The Cobra Information Site, and the “Cobras Who’s Who” have been formed in an attempt to rectify this. My hope is that by providing a means through which all of these diverse factions can communicate, I can facilitate this exchange of information. By providing a central repository for current taxonomic, chemical and herpetological research information, accessible to all, I hope to remove the bottleneck often created by more traditional medical & scientific community communications.