Snake bites in children

Coral snake bites and envenomation in children: a case series

OBJECTIVE

North America is home to 2 families of venomous snakes, Crotalinae (pit viper family) and Elapidae (coral snake family). Although there are several published reports describing and reviewing the management of pit viper snakebites in children, there are no recent similar publications detailing the clinical course and management of coral snake envenomation.

METHODS

Our case series describes the hospital course of children with coral snake bites admitted to our regional pediatric intensive care. We also reviewed prior published case reports of coral snake bites in the United States.

RESULTS

We identified 4 patients with either confirmed or suspected coral snake envenomation from our hospital's records. In 2 cases, the snakebite occurred after apparent provocation. Antivenom was administered to 3 patients. The regional venom response team was consulted for management advice and supplied the antivenom. One patient had a prolonged hospital course, which was complicated by respiratory failure, bulbar palsy, and ataxia. All survived to discharge.

CONCLUSIONS

Admission to pediatric intensive care is warranted after all Eastern coral snake bites. A specialized regional or national venom response team can be a useful resource for management advice and as a source of antivenom.

Is there a role for fasciotomy in Crotalinae envenomations in North America?

CONTEXT

The local effects of Crotalinae envenomation can cause significant tissue destruction, pain, paresthesias, and deformity of the limb, which mimic findings of compartment syndrome, despite rare subfascial penetration of the fangs. Complicating this are the various techniques and ideas about what determines compartment syndrome combined with the fact that elevated intracompartmental pressures have been documented after Crotalinae envenomation, without clear evidence of compartment syndrome or tissue hypoperfusion.

OBJECTIVE

The purpose of this review is to evaluate the North American literature to provide an evidenced-based conclusion about the indications for fasciotomy in Crotalinae envenomations.

METHODS

The search was conducted with studies published only in the English language. The search included all human and animal publications, regardless of the format of study. The Cochrane Central Register, MEDLINE/ Pub Med, Scopus, and Biological Science databases were searched. Citations from all the articles were also cross-referenced if they were pertinent to the review. Major toxicology and emergency medicine and surgical textbooks were also referenced. Abstracts from the North American Congress of Clinical Toxicology, Poisonidex®, and personal articles were also scanned to complete the process, resulting in a total of 640 sources. Papers were excluded if they were duplicates, non-North American, involved excisional therapy, or did not discuss fasciotomy. This left 99 publications applicable to our study.

FINDINGS

No randomized controlled trials, 8 animal experiments, 1 human prospective observational study, 24 retrospective reviews, 32 review articles, 10 case reports, 15 textbooks references, 2 abstracts, and 7 editorials were included in the analysis. Controlled animal experiments show that crotaline Fab antivenin reduces intracompartmental pressure and increases tissue perfusion, while fasciotomy either has no beneficial effect or worsens myonecrosis. The case reports and opinions supporting fasciotomy come from the surgical literature and precede the modern crotaline Fab antivenin.

CONCLUSION

The current evidence does not support the use of fasciotomy or dermotomy following Crotalinae envenomation with elevated intracompartmental pressures. At present, early and adequate administration of crotaline Fab antivenin is the treatment of choice. Fasciotomy cannot be recommended until further well-designed investigations are completed.

Snakebite envenomation in children: a 10-year retrospective review

OBJECTIVE

To describe the epidemiology, short-term outcomes, and clinical characteristics of rattlesnake bites (RSB) in children.

METHODS

This was a 10-year retrospective chart review of all patients who were <13 years old admitted to a medical toxicology referral service in a major metropolitan area of the southwestern United States with a diagnosis of RSB.

RESULTS

Sixty-six children (mean age, 6.33 years) presented to or were transferred to our center with a diagnosis of RSB. Sixty-three percent were male, and the majority of bites (71.93%) occurred on the lower extremities. Forty-nine children (85.96%) developed coagulopathies, and 50 children (87.72%) received Antivenin (Crotalidae) Polyvalent (ACP) administration. Of the 50 children receiving ACP, 19 developed an immediate hypersensitivity reaction. Five cases of morbidity resulted, but no deaths were recorded.

CONCLUSIONS

Serious morbidity is infrequent in children following RSB.

Crotalid envenomation in children: selective conservative management

Snake bites in children remain an uncommon injury. In general, there is a wide disagreement by knowledgeable authorities on a uniform approach to therapy. In the last 5 years, 29 children have been treated in our institution for snake bites, all with signs of envenomation. Treatment consisted of diagnostic laboratory studies, intravenous fluids, tetanus prophylaxis, antibiotics, bed rest, elevation, and observation. There were no deaths. A fasciotomy was required in three children. Cryotherapy initiated elsewhere resulted in tissue loss. Seven children received antivenin. All developed signs and symptoms to serum sickness. From this experience, it appears that the majority of snake bites in children, especially copperhead bites, can be treated selectively and conservatively. Care must be exercised in using antivenin as it is associated with a high rate of serum sickness. Cryotherapy adds to the morbidity of the bite and is not to be used.

Rattlesnake bites and surgical decompression: results using a laboratory model

Studies were performed on the hind limbs of dogs and their anterolateral compartments to evaluate the effect of fasciotomy on tissue pressure and necrosis following pit viper envenomation. Venom from the southern Pacific rattlesnake, Crotalus viridis helleri, was injected into either the subcutaneous tissues, the intact anterolateral compartment or the anterolateral compartment following fasciectomy. Interstitial fluid pressure measurements, as well as limb girth and surface temperatures, were obtained over the first 48 hr following venom injection, after which time the compartment contents were examined microscopically. The results demonstrated intracompartment tissue pressure elevations only following intracompartment injections. Fasciectomy prior to injection did not prevent muscle necrosis, though it did reduce maximum compartment pressures. Clinically the limbs in each group could not be differentiated. Intracompartment pressure measurements were able to distinguish between muscle and subcutaneous envenomations by the differences in compartment pressures. These results demonstrate the value of tissue pressure measurements in the evaluation of patients envenomated by rattlesnakes. They also indicate the objectivity necessary to determine the need for surgical decompression.

Acute renal failure in children following snake bite

Snake venom poisoning accounted for 1.4% of 4360 infants and children admitted to a south Indian hospital during the years 1976-1979 and was the commonest cause of acute renal failure encountered. Most of the 42 children with anuria following snake bite had evidence of intravascular coagulation and acute tubular necrosis. Russell's viper was the only snake recognized in all the cases of anuria in which species identification was possible. Renal failure complicating snake bite was relatively more frequent and more severe in children than in adults.

The management of upper extremity pit viper wounds

In a series of 56 rattlesnake bites, there were 31 injuries involving the upper extremity and hand with a clinical complication rate of 32% that ranged from Volkmann's contracture to coagulopathies. The most frequent was tissue necrosis with functional joint stiffness and loss of sensibility. Because these patients were treated with a variety of regimens, an animal model was developed to determine the efficacy of the individual treatments. Sublethal intramuscular injections of Crotalus atrox venom were made in the extremity of New Zealand white rabbits. Tissue reaction monitored by swelling and hemorrhage was decreased significantly (P less than 0.05) with antivenin and antivenin-steroids, but no treatment modality prevented tissue necrosis. Clinical and laboratory experience indicates that one cannot rely on injectable medications to prevent tissue necrosis in pit viper envenomations and that operative treatment should be used in conjunction with other forms of therapy.

Adder bites in children

16 children with adder bites were admitted to hospital in Southampton in the years 1969--77. Two children were severely poisoned; these 2, and a 3rd, fulfilled suggested criteria for antivenom administration but they recovered without it. Three children had no treatment, and 9 children no analgesia. Prolonged morbidity was not seen in these children. Careful observation in hospital was the most important factor in management, with early clinical improvement obviating the need for antivenom.