1) The Story.

You respond to a call from a very small farming community for a "snake bite" of a 13 year old boy. The report through dispatch states the dispatching unit is a state trooper and he is non-medical. His assessment was "this is really bad". The local ALS has been called as well but they are 2.5 hours out as the only ALS unit is currently delivering a trauma mech to the city.

On arrival the story you get from the family is as follows:

4 days ago, while walking a local trail the 13 year old boy was looking at some plants and was struck in the hand by a snake. His dad quickly killed the offending animal and has it here in a bag if you would like to see it (how nice).

The family felt that the wound would take care of itself (the dad had been struck before and did fine) so they simply wrapped it and gave the child advil for pain. Recently the child has had severe chills and the parents state his arm has gotten "much worse". The boy has been passing out on them.

2) History

No Hx

3) Meds

advil

4) Allg.

none known

5) Obvious Pertinent Physcial findings

Upon entering the house you find the boy in the living room with a wet towel over his affected hand and one over his forehead. He is moaning in obvious pain. When you enter he does not seem to acknowledge your presence.

On examination you see the pics posted below. You notice that the child is pale and diaphoretic looking very "sick". He is either lethargic or in severe distracting pain as he does not answer questions well. While talking to him you notice he drifts in and our of conciousness.

Vitals On arrival:
BP 70/40 HR: 140 9 RR: 19 Sat: 94 % Temp: 103.2

Obvious findings:
- Pt has snake bite marks to affected palm
- Pt has severe swelling of affected forearm and hand
- Pt appears to be lethargic with periods of unconciousness
- Pt is 4 days post bite.
- You note red streaks up his shoulder

6) Images

All examples not actual patient.


Patients Hand where bite was


Comparison of arms


Dead Snake


7) Discussion Points

The discussion points are:

Facility appropriateness
Possible secondary Differential Diagnosis
Concerns
Treatment plan

Issues:

Nearest hospital with an ER is 50 min by air. Nearest trauma facility is 55.

Is Venom ER around ?

I'll go first:

1) High flow O2

2) IV x 2, to unaffected side, start fluid challenge

3) Get dad to put snake in a small cooler (if it is 4 days dead, it probably won't have any reflexes left, but I don't need to take the chance)

4) Dry sterile dressing to wound (is it sloughing like the picture shows?). Splint the entire arm. Do not elevate it. Don't even think about a tourniquet.

5) Decide if pt requires RSI (no offense, but if you were my partner on this, Mike, I would elect for the RSI now. Your pt's seem to always take a dive enroute with a long ETA)

6) Get going in the general direction of the hospitals. Make contact enroutre with whoever has the bigger/better ICU to see if they can handle pt needs. No reason to come back for an IFT later if there is only a 5 minute difference of ETA now. Take him to the most appropriate facility the first time.

7) BP coming up with fluid challenge? If not, start the vasopressors.

8) Continual reassessments. RSI if required at any time.

9) Consider measuring circumference at arrival and at destination for documentation purposes later.

10) Consider raiding the parents medicine cabinet for PR tylenol. Have the parents administer it if you don't have protocols to do it yourself. Otherwise, start some type of cooling measures also.

What does the EKG show?

The snake appears to be a Western Diamondback or Mojave rattlesnake. What area of the country is this in?

Mike,

Obviously ABC's, He needs to go to a trauma facility,

1. Rattlesnake Bite
2. Supportive care enroute for BP, HR, Airway
3. Crotaline Fab is TX of choice for this snake.
4. Pt will need at a minimum I & D of hand.
5. Pt will probably get a faschiotomy of hand and upper extremity based on my many years working in surgery.
6. Pt will need to be watched for Coagulopathies, as they are common from a rattlesnake bite.
7. Rhabdo is another complication that needs to be looked out for.
8. PICU BED

Here is a link for a GREAT article by the MD on VENOM ER, who is pretty much the leading authority on this stuff. This will tell you everything you ever wanted to know about this snakebite.

http://www.emedicine.com/emerg/topic540.htm

Respectfully,

Mike,

Where in the world do you get this stuff? The pictures are fantastic!
I agree with the above treatments. Get to the closest peds critical care facility, and I would consider RSI at this point,as well.
Thanks for continuing to work the brain cells on the forum. I work in an area that is not unfamiliar to snake handling...food for thought.

Sue

Hey Mike,
It's been awhile since I"ve been able to post a reply here.
Facility: let's head towards the trauma center and have our dispatcher make some phone calls to alert the ED and arrange for antivenom to either be ready or on the way (maybe delivered from a nearby zoo or university). He needs a PICU bed, hopefully available at the same trauma center, but at least he can begin tx there. I agree with usdalum97 about not wanting to turn this into an IFT later if we can avoid it.
Differential Dx: it is a rattlesnake. The sn & sx are consistent with severe envenomation. Possible coagulopathy, rhabdo.
Concerns: Based on your description I'm giving him a GCS around 7, we need to be prepared for seizures and vomitting so RSI would be a good idea now instead of later. We also need to be careful with IVs and excessive bleeding from possible coagulopathy, especially if placing a central line. He has no known allergies, but may be latex sensitive which can result in anaphylaxis when the CroFab is administered.
My questions for you are: What is the quality of his radial pulses? CRT? (I"m betting it's terrible) do the parents know his blood type?
Tx plan: RSI, 2 large bore IVs, keep arm immobilized in neutral position after ensuring all constrictive items have been removed (no ice, x-marks on the bite, tourniquet, alcohol, venom extractors, etc.) Dry, sterile dsg to wound. Initial 20cc/kg challenge and consider colloids if no BP response before beginning pressors. cooling measures. He needs a dT, Rocephin, CroFab and the idea of PR tylenol is good. Labs: CBC, platelets, PT, PTT, INR, UA, type and crossmatch. Also needs I & D and probably a fasciotomy. measure the initial circuference of the arm for later comparison.
Alright Mike, what happens next?

Tx--Airway--quick eval, RSI, PEEP if pulmonary edema is present, IV fluids to bring pressure up...if that does not work, then pressors, active cooling measures. We do not carry antivenom, so that is out. I would put the affected arm / side down for transport.

As far as what to do with the snake: most cell phones these days have the ability to take a picture. That or a regular camera should be enough for the receiving hospital.

Transport should be to a hospital preferrably with: plenty of antivenom or quick access to some, PICU, and Burn Center for continuing care of the arm once the swelling subsides and healing begins. I have a feeling that he will need a fasciotomy and then will require skin grafts and lots of OT/PT down the road.

Other complications due to time frame of four days could be septicemia, loss of circulation to the extremity, or even necrosis at or distal to the site.

Mike, since this is one of your patients, we might as well plan for a few months down the road. Since I am sure that good ole Cousin Eddie (from National Lampoons Vegas Vacation) and his wife do not have much money, call ahead for arrangements at the nearby Ronald McDonald House. Also contact any social worker that has good connections to keep the kid at or near the hospital until he is healed enough to once again be 2.5 hours away from appropriate care facilities.

Thanks again.....

Hey All

Glad yer liking the case!

I am headed to philly tommorrow am for 3 days. I will be back then and if there isnt an inet connection in my hotel that will be my next post

Sorry for the delay, gives yah thinkin time and time for others to post !

OK. Time to jump in face first on this one.
Agree with most of the treatment , but you do not want to cool the pt or the extermity, normothermic is best. it helps to keep the toxins from doing to much damage when pooled.
Use the handy dandy cell phone camera and send a picture of the snake to the receiving facility for ID.
I see that you list nkda but when is he sensitive to horse serum based meds, ie tetnus. If so then he needs a different type of antivenum(Most are horse serum based).
Next how big is the critter?(Size is directly related to the amount of venom available for injection).
Now for my big question. After four days of the venum running around how good will the RSI work with a neurotoxic venum? Is this a time for an intubation using versed or valium alone?(Pt is fairly obtunded already).
As for receiving facility, any will do that has the appropriate setup for treatment.(And LOTS of antivenum )

Thom

PS How'd I do, Mike.

1. trauma center with PICU
2. I would elect to intubate
3. pressor of choice should be epinephrine as first line
4. antivenin is actually very hazardous and only given if there is no other choice since once you have it, you should never have it again. (at least the old stuff of 10 years ago is like this...alas I date myself)
5.agree with splinting and not raising arm, fantastic care there.
6. morphine is pain med of choice.....no demerol.
7. since i hate snakes, i think the idea of taking a picture of it is brilliant, then it can stay where dead snakes stay.....ie: not in the helicopter. Ugh.

Fly safe everyone!!

Pt clearly needs trauma facility as they are the most likely to have Crofab. Agree with everyone else's plan. RSI, fluid challenge then pressors if bp does not come up. Dry sterile dressing to wound. I love the picture with the cell phone idea! Fly safe.

I am in agreement with everyone so far, Airway RSi, fluids Normal saline boluses 20cc/kg, PALS Definate Pit Viper, Get to Appropriate center that has the services needed Crofab /Antivenon Possible surgical intervention if compartment syndrome develops , CBC Chem Pt PTT TS lactate UA foley central line TD,Rocephin/Ancef PICU, Given the risk benefit for crofab and this patient has nkda I would give it and pretreat the reactions Epi, H1 H2 blockers. Nice Case !

Glad somebody finally mentioned morphine - good Lord, if you're not going to intubate - and with that GCS I'd be checking BGL first - let's keep our pediatric trauma patients comfy!!

Am I seeing a cross-hatch wound in the palm? I'd want to ask the parents what first aid they did at home - besides the Advil. Red streaks up the arm? So not good. Could be tetanus from the "home snakebite care", could be staph from those nasty, nasty fangs. Poor kiddo. I'd want to take him to a *pediatric* trauma care center. Fluid boluses and then pressors if needed.

No snakes on board. Not even allegedly dead ones. Noooo....

Beautiful Western DiamondbackCrotalus atrox (I think, from his tail bands, although other rattlesnakes in Arizona certainly also have black/white tail bands, notably Mojaves, but he looks like a large snakes and Mojaves small, ~ likely severely envenomated by a crotalid, and management will be based on his clinical presentation, not the species biting, although there are characteristics of presentation that differ amongst different species in the same genus. From his body and tail he looks large and old - what a waste to kill him...

The child may have a negative PMH, but he certainly has a positive FH of just absolutely freaking stupid.

I'm with USDAlum all the way about the airway. Supportive care, pain control with fentanyl, aggressive volume resuscitation, don't hesitate to add a pressor if perfusion deficit responds poorly to crystalloid challenge. He needs Abx. I'm not so sure I'd be concerned with the destination hospital's ACS trauma verification, but I would most certainly overfly hospitals in favor of a pediatric tertiary center. If that hospital happens to be the one with the state poison center on campus and easy in-person access to a medical toxicologist (as well as pediatric surgeon, plastics, and a good PICU), that's all the better.

From a medical herpetology standpoint, while that animal doesn't pack the greatest punch in terms of venom C. atrox is generally regarded to be the species that is responsible for the most snakebite-related mortalities in the United States. Snakes have very dirty mouths. His hemodynamic instability could be related to envenomation, infection, or both.

The Venom ER guy people are alluding to (Sean Bush) is well published, and in fact, in the past couple of years specifically published on the effect of surgical intervention after Crotalus envenomation. Maybe metal won't be the answer after all for this kid, but, if there is infection, all pus must come out.

Airway- Keep a close eye on but it...let's try those fluid boluses (if his lungs tolerate it) and see if that improves LOC. If it doesn't, he buys a tube.

Breathing- 15lpm NRB, what are the lungs sounds like? Massive vasodilation may mean pulmonary edema. PPV may be in order here.

Circulation- IV's LR... yes I said LR. LR has a higher pH than NS. The kid doesn't need any help developing acidosis at this stage of the game. OK... we know the kid's hypotensive... Take care of it... fluids 20cc/kg, pressors if necessary... I like Dopamine.

Disability- Once again monitor for changes with treatment. What's the Blood Glucose?

Exposure/Environmental concerns- Any other rashes or markings on the body? What's the ambient temp/humidity is he not able to control that hyperthermia. Let's try cooling his environment... Have Mom and Dad had him bundled up. Consider Rectal APAP but if temp comes down with cooling measures, may not be necessary.

I think I would consider Fentanyl for pain when his HR comes down and pressure comes up. Morphine has a long half-life and is likely to cause hypotension and nausea. Also consider phenergan or zofran. If available some IV antibiotics wouldn't be a bad thing either. A foley to moniter output is a wonderful thing. BTW what's his urine look like? All of that hemolyzing snake venom may cause renal concerns.

I easily found a half a dozen articles using google relating viper and pit viper envenomations to Acute Renal Failure, hypotension, and DIC. Many of these cases are also many days post-bite and antivenin is no longer even an option. It really isn't a concern here being 4 days post bite.

Definitely have two mechanisms working here. The initial bite, which, big snake or small snake; we have no idea the amount or potency... just that the kid has beat it damn well to this point, but now has a secondary infection, probably due to the necrosis caused by pit viper envenomation, but possibly due to a home treatment. Bottom lline... the primary envenomation didn't kill him in the first 12 hours. It's not going to be the cause of his demise. (i.e. Burn victims are rarely killed by their burns)

Transport Considerations- Yeah, a level one is great, but if we know of a tertiary facility with reputable toxicoligical services, it may be worth our while to go there, assuming they are full service. Important factors are availability of the blood bank and dialysis.

Food for thought

I'm certainly no expert on snake bites, so can someone help me on this one? I thought antivenom was only supposed to be given within the first few hours after the bite? Is it really effective 4 days later?

Also, are there any services actually carrying it for field use?

Thanks for the help.

The symptoms would have peaked long before this, so things like elevation or dependency are almost pointless. Snake venom components have a half-life of somewhere between 24 and 96 hours. (D.Warrell pers.comm.), so the antivenom is almost a waste of time. However, the patient is in extremis and is circling the drain. Coagulopathy is a given this far out from the bite. The hypotension could be due to a multitude of factors, but is the clue that the patient is in the final stages of envenomation sydrome. DIC is probable. Tissue necrosis is in full swing, and the toxins produced by the necrotic material is definitely making things worse.

Course of action is purely supportive. IV fluid bolus with NS and get the pressure up to at least 120sys, cut back if this induces pulmonary edema. O2 device determined by LOC/Sat/Breath sounds and patentcy of airway. This guy should be RSI'd ASAP. He can only benefit from it.

The big rattlesnakes, Eastern and Western diamondbacks feed on large prey items and have a lot of big metalloproteinases in their venom. These tend to cause bleeding in a multitude of areas in the body. Organ failure is typically due to prolonged hypotension, so the patient could certainly benefit from a fluid bolus and O2. Also, in the latter stages, the venom will cause an increase in capillary permeability, particularly pulmonary capillary permeability. So if this patient doesn't have pulmonary edema, that's definitely a plus. Renal failure is surely a probability in this case. Find out what you can about urine output. Also, check for hematochezia.

Transport this patient to the trauma center. And by the way, ANY snakebite patient should be transported to the nearest facility with antivenom. Delaying AV administration is guaranteed to be harmful to a symptomatic snakebite patient. Nature intends for the patient to get worse, and he will.

Always involve poison control. If you can reach them, call Arizona Poison Control and ask for Jude McNally or Leslie Boyer. Tell them Chris Harper sent you. ;-)

http://www.VenomousReptiles.org


PS - That arm comparison pic is actually a juvenile Green mamba bite. That nasty hand pic was a severely mismanaged Western diamondback bite. He lost 95% of the use of his hand due to a drastic delay in antivenom administration.

Oh by the way, since we know that these bites peak sometime between 12 and 36 hours, and that the venom has basically burnt itself out, the necrosis is probably causing a systemic infection. The patient is more than likely septic, as indicated by the temp. It's a lot less about treating "snakebite", and a lot more about treating the probable sepsis.

Chris Harper, NREMT-P
webmaster@VenomousReptiles.org

My dx for this kid would be multi-system organ failure d/t the toxins and cell break down from the snake bite that was ignored.
Treatment plan would include: RSI ( I think this kid needs the support, he has been working 4 days to keep ahead of this process)
His MAP at the time of the assessment is 50 and by his ALOC I would bet that it has been that way for some time. I would also bet that he is not putting out much urine. Being able to manage the airway and respiratory effort would help with balancing the need for the fluid boluses and vasopressors.
Meds for pain and sedation. Splinting of the arm to minimize movement from a pain aspect.
Air transport to the nearest Level 1 with a PICU would be my choice.
I had the same questions about the AV, would it be helpfull at this point, and see the answers posted. So I think this kids best bet would be supportive and aggressive care that he would receive at a level 1. He will be lucky if he keeps that arm.
Thanks for the case, hope I am close with some of my reasoning....
Stay safe,
rnhvn

Agree with this kid needing to be intubated, but first (I agree with rpm911), Fentanyl with a lot of IV fluids, instead of Morphine.

Would be interested in what the HR would be after 1 to 2 liters of NS and some Fentanyl (and Ativan when intubated).

If HR still over 120, then my first choice for continued SBPs in the 70s would be IV neosynephrine, 2nd choice Levophed, and 3rd choice would be Dopamine.

Facility appropriateness
Trauma
Possible secondary Differential Diagnosis
Septic, Organ/ Renal failure
but its almost like the bite/necrosis is secondary @ this point
Treatment plan
Supportive
Stablize BP, RSI, blood cultures

Please be gentile if I screw up.
First- Oxygen 15lpm consider intubation.
2nd- go to trauma ctr- its probably worth the extra 5 min.
3rd- IV's and fluid- watch lung sounds
4th- if pressure comes up try pain relief
5- cold packs to extremity
6-Monitor EKG- is there any arrythmias

This looks like an infection that is progressing to sepsis. Do this patient have any S&S of allergic reaction/anaphylaxis? What are his lung sounds and ventilatory status?
DO flight crews carry antibiotics? Would it be beneficial to start them?

How did I do???

Everyone's treatment plan sounds exceptional.
I would definately want to treat ABC's hypotention etc. Fluid bolus', pressors, snake venom antidote.

Sorry this is so short but I am work.

Could we also be dealing with Necrotizing Fasciitis as well as sepsis and snake envenomation?

Don't know where Mike's hanging out but just a few comments.

Overall, everyone has obviously demonstrated that this is a sepsis picture and this board is awesome for disseminating new ideas and educating and I again commend you guys.

However, I've noticed one thing in almost all of the posts over the last several months.

When you guys see a fever (of any type) you instantly want to kill it with tylenol and/or cooling measures.

This is NOT good! Fever is an excellent way to rev up your bodies immune system and is an important part of a healthy immune response. It gets your metabolic machine cranking and makes i a more inhospitable environment for bugs (bacteria, viruses etc...) to live and replicate.

It's NORMAL and BENEFICIAL to someone in sepsis to have a fever. You don't want to just empirically quash a fever and cool these people. A fever up to about 103.5-104 is NOT EVER A PROBLEM. It's GREAT!

this is NOT a case of hyperthermia (example of thyrotoxicosis or heat stroke etc...) where you have to hurry up and cool them down.

this is infection fever and that's great!

There is data coming in all the time about the higher mortality rates in ICU's for fevers being treated in sepsis. It correlates with less cytokines (the good bug killers) and increases death.

Fever control in septic shock: beneficial or harmful?
Su F, Nguyen ND, Wang Z, Cai Y, Rogiers P, Vincent JL.

Department of Intensive Care, Erasme Hospital, Free University of Brussels, Brussels, 1070-B, Belgium.

The beneficial effects of interventions to control fever in sepsis are controversial. We investigated whether the use of acetaminophen and external cooling is beneficial to control fever in septic shock. We studied 24 fasted, anesthetized, invasively monitored, mechanically ventilated female sheep (27.0 +/- 4.6 kg) that received 0.5 g/kg body weight of feces into the abdominal cavity to induce sepsis. Ringer's lactate (RL) was titrated to maintain pulmonary artery occlusion pressure (PAOP) at baseline levels throughout the experimental period. During the 2 h after the surgical operation, animals were placed in the hypothermia group if their temperature fell below 36.0 degrees C; the other animals were randomized to three groups: high fever (T > 39.0 degrees C), mild fever (37.5 degrees C Survival time was longer in the high fever group (25.2 +/- 3.0 h) than in the mild fever (17.7 +/- 3.5 h), normothermia (16.0 +/- 1.9 h), and hypothermia (18.5 +/- 2.5 h) groups (P In this clinically relevant septic shock model, the febrile response thus resulted in better respiratory function, lower blood lactate concentration, and prolonged survival time. Antipyretic interventions including acetaminophen and external cooling were associated with lower circulating HSP70 levels. These data challenge the temperature control practices often used routinely in acutely ill patients.

The effect of antipyretic therapy upon outcomes in critically ill patients: a randomized, prospective study.
Schulman CI, Namias N, Doherty J, Manning RJ, Li P, Alhaddad A, Lasko D, Amortegui J, Dy CJ, Dlugasch L, Baracco G, Cohn SM.

Division of Trauma and Surgical Critical Care, University of Miami Leonard M. Miller School of Medicine, Miami, Florida 33101, USA. carl@miami.edu

BACKGROUND: Despite the large body of evidence suggesting a beneficial role of fever in the host response, antipyretic therapy is commonly employed for febrile critically ill patients. Our objective was to evaluate the impact of antipyretic therapy strategies on the outcomes of critically ill patients. METHODS: Patients admitted to the Trauma Intensive Care Unit over a nine-month period were eligible for inclusion, except those with traumatic brain injury. Patients were randomized on day three of the ICU stay into aggressive or permissive groups. The aggressive group received acetaminophen 650 mg every 6 h for temperature of >38.5 degrees C and a cooling blanket was added for temperature of >39.5 degrees C. The permissive group received no treatment for temperature of >38.5 degrees C, but instead had treatment initiated at temperature of >40 degrees C, at which time acetaminophen and cooling blankets were used until temperature was The study was stopped after the first interim analysis due to the mortality difference, related to the issues of waiver of consent and the mandate for minimal risk. CONCLUSIONS: Aggressively treating fever in critically ill patients may lead to a higher mortality rate.

This stuff is 2006 research! I can't even keep up with it. this has been known now for about 5 years and the data is staggering.

Treating fever just because they have one is NOT good practice and is slowly dying across the countries medical centers.

so just food for thought.

be safe!

Hey All

Nice post MDEMT-P.

Fever is something we should be afriad of yet everyone is taught to treat it at the first signs. Excellent point. Makes me remember the days where tylenol and ibuprophen were used in an alternating fashion to decrease fever in kiddies. In anycase, i think its important to understand why low grade fevers are treated, and thats for the parents benefit (so their kid, and they, can sleep!).

Now, Onto the case.

I dont have the sepecifics with me as im in philly, but i can give a little new info.

I think everyone has quickly gotten on the correct track that this is not longer a "snake poision" issue but sepsis. Well done!

Here is some more info.

- Initially, the calculated GCS of the pt is 10. He appears to be protecting his own airway.

- what assessment should be foremost in regards to that arm? (sorry if i missed a post with it done!)

- Would you consider antibiotics? I dont carry them, but some services do. What might you give and why?
(good question by B Nolan!)

- Is this kid in septic shock? Post 500 cc fluid bolus his pressure is still 70/40. What phase of septic shock is he in right now if you believe this is septic shock?

- EKG shows sinus tach

- Sats after u place on an NRM = 97%

- Yup its a W. Diamond back

- What migh you expect if this patient is in rhabdo?

- Thanks to Snakebite medics (Chris Harper) site VenomousReptiles.org for the pics! I actually found them off gogole images in my search for something that looked similar! Thanks Chris!!

- Lot of people choosing fent. as opposed to MS for both pain control and potential RSI. Why?

Ok ill be flying back to AZ tommorrow and post again once im home. Fire Away!

Mike,

I would say a broad spectrum IV antibiotic at this point would be a safe bet, based on S/S he has at least one if not multiple infections, they may or may not be systemic.

It's time to throw the hail mary 'cause this kid ain't gonna wait around for you to draw cultures, isolate, then determine what antibiotic he needs. Nope, Broad Spectrum early on this kiddo.

Also a note on the Fentanyl... One could make the argument for Morphine, but one would also be meeting with the medical director explaining why they gave morphine to a 13 y/o with a pressure of 70/40. Also increase the risk of nausea ergo vomiting, and that of course leads to vasovagal stimulation. If we weren't tubing the kid before... we are now. Except now we get to suction all the vomitus out first.

Leave me and my silly little clan of my Fentanylites to our funky new analgesic.

Lol

"Fentanylites" is going right into the archive for later use, im certainly a disciple!

Im a major fentanyl user, both for pain and cardiac.

I wont say anything else so others can post on the benefits issues b/t ms and fent and how to mitigate them.

Distributive shock,
I would continue with fluid Resusitation large volumes were talking an adolescent here with a great heart.
SIRS, hopefully we can keep him out of MODS Possible case for Xigris here? Blood cultures should be done asap Ab choice Zosyn , Rocephin and or Streptomycin to treat the infection. These are good broad spectrums .
Grossly red urine would be an indicator (myoglobin) for rhabdo as well as elevated CPK>10,000 confirmed with analysis. Urine alkalization with NAHCO3.
As for the fentanyl vs morphine debate fentanyl has a short duration of action vs morphine and has minimal hemodynamic effects, morphine can cause a delayed resp depression due to metabolites if the kid goes into RF. and by the case looking there's that possibility Standing Bye

One thing that I should point out here to the people that want to treat the hypotension with pressors, is that hypotension in the initial stages of envenomation, i.e., the first 6 hours, doesn't respond well at all to these drugs. Hypotension initially caused by some North American rattlesnakes is caused by kallikreins in the venom that increase vascular permeability and cause a release of bradykinin, which induces peripheral vasodilation - sometimes profoundly.

Per my good friend friend at VenomDoc.com, here are some other toxins that may be found in snake venoms:
BNP – Potent induction of hypotension.
CRISP – Paralysis of peripheral smooth muscle.
Crotamine – myonecrosis, some derivations have significant neurotoxicity.
Cystatin – Inhibition of the body’s defensive enzymes.
NGF – immunomodulatory effects mediated through histamine release and plasma extravasation. Can cause an almost “anaphylactic-like reaction”.
Vespryn – induction of hypolocomotion and hyperalgesia.

Sometimes with rattlesnake induced hypotension, you are essentially dealing with a flaccid vascular system. I've seen a Dopamine drip at 20mcg not even touch the BP of a Timber rattlesnake bite pt. with a systolic of 60.

But back to the case study which is 4 days after the bite, and probably has no venom components still in circulation - with Western diamondbacks, it is inevitable that there are hemmorhagins at work. Hypovolemia is a definite possibility. But in this case, vasodilation as a result of sepsis is also a possibility. Normally a fever wouldn't be worrisome, but in light of the 70 sys BP, it definitely is. Because until proven otherwise, shock + temp= septic shock. Letting this fever run it's course may be fatal. Volume expanders and antibiotics are definitely called for. Some snakebites are prone to become gangrenous, particularly cottonmouth bites. Rattlesnake bites without treatment are bound to become necrotic - see the snakebite section of my photo albums.

But we are talking pre-hospital here right? Some of the answers make me think you guys work in-hospital, where the course of treatment is obviously a bit different.

By the way, if anyone wants to use pics for educational purposes from my website, go ahead. Our mission statement is public education based. Just don't publish them in a book. That might get me in trouble.

Also, I teach an extensive class on snakebite, and have plenty of recommendation letters if anyone is interested. As a matter of fact, I'll be teaching one at Emory Flight in Jefferson, GA on Friday the 5th.

Chris Harper, NREMT-P
http://www.VenomousReptiles.org

For those that carry antibiotics and use them pre-hospital, do you draw cultures before you administer them?

In this case, the kid has been sick for 4 days. I think it is wise to delay antibiotics for 50 minutes so that we can obtain a good BC sample. This way, we know in a few days if what we are treating him with IS the right choice. Otherwise, you may never know.

I don't think he is going home in the next 72 hours, so he will still be there to get the results and change treatments accordingly.

Remember out definitions of SIRS, sepsis, severe sepsis, septic shock and MODS>

These all exist in a continuum.

this is NOT SIRS. This most definately is severe sepsis and likely septic shock (we don't know if his hypotension is responsive to fluids yet).

SIRS would be me with the flu. Heart rate greater than 90 (he's got that), and temp greater than 38C (he's got that). So he meets 2 of the 4 SIRS criteria (thus he's got SIRS).

However, if you have SIRS plus an presumed source of infection (necrotic bite in extremity) you now have sepsis.

he has sepsis for sure.

Now, if you take the fact that he has organ system dysfunction (mental status is an organ system and CV collapse) he has SEVERE SEPSIS at a minimum which carries a 35% mortality.

He's probably got septic shock (which carries a 50% mortality), because he's hypotensive, but technically he has to be non-responsive to fluids and require pressors to define him as septic shock.

looking forward to more info mike.

oh,and agree with fentanyl and good choice for hemodynamic reasons.

Yes He is in septic shock No doubt and No argument here on SIRS and the chain to MODS patho. And Yes his mortality is extreemly Great and I agree with the 50% mortality. A pressor that might be considered, phenylephrine 5-20mcg/kg IV bolus then 0.1 to 0.5 mcg/kg/min IV.

Just picking your guy's brains a little.

Curious as to why many of you are suggesting the use of neosynephrine for the BP if fluids don't work?

This is sepsis and in the adult your first line would be dopamine or norepi.

It should also be first line in a child with sepsis.

The international pediatric consesus conference in 2005 regarded dopamine first....then epi......then norepi or epi for pressors if unresponsive to fluids.

Vasopressin can also be used if resistant to norepi/epi.

Are you concerned about his heart rate? Remember the reason he's tachycardic is more likely do to having virtually NO preload and I'm guessing/hoping he should respond to vigorous fluid resuscitation and his pulse should come down some.

Of course nobody would give pressors to this kid until they've given at least probably 60ml/kg fluid boluses and assessed the response.

Pulmonary edema as a result of aggressive fluid resusicitation is almost unheard of in pediatric patients. So you can go up to 80ml/kg on fluid if need be and not be too concerned about volume overload.

Of course if fluids don't help then onto the vasopressors as you've all alluded to.

good stuff everyone!

I don't believe pulmonary edema can be taken out of the equation on any septic patient regardless of age especially with a snakebite.

Of course they do have a new fangled high-tech test for pulmonary edema now, it's called auscultation.

I read about it in a journal last week, or maybe it was webMD, then again maybe it was my 'Weekly Reader'?... Teacher always has us read those right after lunch and recess. Come on that's nap time!!!

The tool they used looked a lot like this thing my doctor used to wear around his neck when I was a kid. He would put it against my chest and tell me to breath.

Yeah, like I was holding my breath anyways.

So far need to add/clarify that distal neurovasculars would be checked. Also we need to mark the arm to see if the infection spreads while we have contact with him. This may be what you are looking for and most of us probably did this automatically, but now it is actually "documented," so it really did happen.

MDEMTP

Thanks for your reply regarding IV vasopressors.

My comment was for using neosynephrine for continued hypotension and tachycardia after the patient had received a couple liters of fluids and pain management. If I could raise the blood pressure without adding to the tachycardia, is their some additional reason why I should try Dopamine first?

thanks, ian

Nicely said.

Septic and neuro shock isnt a primary volume problem (though it can be both) but a dilation problem. In sepsis there is a release of cytokinin and non-cytokinin mediators which cause an systemic inflammatory response. Then the body sortof screws itself by releasing mediators with vasoldilitary and endotoxic properties causing hypotension such as, prostaglandins, thromboxane A2, and nitric oxide.

So when i treat these individuals i go for a pure alpha and the one i like the best is levophed (norepi). There have been a number of trials (one done at a local hospital) on vasopressin drips for septic shock which showed good results as well, however its considered a last resort.

The basics = Septic shock and neuro shock dilate the pipes to the point on severe hypotension resulting in a compensatory tachycardia

The Tx = Clamp the pipes chemically and increase the SVR you end up with increase BP and, theoretically, a decreased HR.


Now as to fentanyl vs MS.

Here is the thing. Fentanyl is 100X more powerful and about 10X faster acting than MS (100 mcg = 10 mg ms). That alone is a great reason to use it. While pharmacologically, fentanyl has the same hypotensive potential as MS, thats only true in extremely large doses, not the 200-400 mcgs we typically give in an aircraft. So essentially, you have lots of room to play.

The really big issue is histamine release. As many of us are aware, MS administration can essentially, cause a mild allergic reaction resulting in a histamine release. This can end with mild-severe hypotension depending on the severity of the reaction. Fentanyl has proven not to have even 1/100 of the histamine release hence its superiority.

Now, what happens when you do now have fentanyl and you have MS only? Well, if the hypotension is causes primarily by histamine release.... Give a preload dose of antihistamine, benedryl! About 12.5 - 25 is more than enough IV to counter the release due to MS and you wont have the hypotension. This essentially mediates the problem.

Hope that helps!

Ill be going back home today and post again this evening on the case!

1st we are assuming that this 13year old has a central line, as infusion of Dopamine should only be thru a central line. 2nd I chose Neo as the lesser of the evils due to dopamine's inherent cardiac irritability, 3rd the development of pulmonary edema does not signal the end of fluid resusitation. Neo is an a-adrenergic drug which stimulates norepi release and exerts direct effects ideally it is suited for severe septic shock which clinically this patient is in.Granted it is not the drug of choice for a kid with Heart damage ,which this kid doesn't have, nor has his heart been oxygen deprived. I believe that neo at a small dose will get the results were looking for, Why do we chose Dopamine?? good question as we have so many Vasopressors today, My guess is tried and true just like Lidocaine, thoughts ??

Good case, but sick kid!
The overall impression:
State trooper had it right "this is really bad!". Mom & Dad - well what can you do, I figure my education of the parents "knowledge deficit" won't be easily corrected due my need to attend to other priorities. Get an expanded history of exact measures taken following the "bite". Also, I might take a pic, but under NO circumstance will I board any type of transport with any creature. NO SNAKES, SPIDERS, LIZARDS, MONKEYS, ETC. Just a bad idea.

Transport Decision: No question here! If the "extra" 5 min in transit buys a tertiary care center with toxicology, PICU and all the soon to be necessary specialties - it was time well spent.

Diagnosis: Gets a little tougher!
I'm going with probable septic shock r/t snakebite. Altered mental status, necrotic upper extremity. I'd also bet on serious issues with bleeding/clotting disruptions (including possible DIC), renal failure, electrolyte disturbances (possible arrhythmia) rhabdo, possible compartment syndrome

Treatment: Fairly straightforward. Supportive in the field, more definitive later in facility. Rapid scene care/transport!!
A & B: Sure, he may be breathing & protecting his airway - but my rule of medic airway management still fits - altered GCS that is not transient = definite field control. This kiddo has been getting worse over past 4 days, now he is rapidly de-compensating. Mechanical ventilation lowers O2 consumption and makes more available to all the tissues, so....
High flow O2, prepare for RSI as soon as practical (hypnotic/sedative/analgesic/paralytic - in some combination).
C: IV access x 2, or central access if necessary, (if you can draw the labs great, worried about blood cx - just prep the site and hold a syringe full with sterile cap for placement in culture medium later) Fluid resuscitation at 20/kg repeat up to x 4, then pressors. Pt on cardiac monitor, NIBP. Also, the HR may not go down alot, even if pressure increases because of febrile state. Also, compare CSM, mark (time) along all the associated margins of the wound. This marking can be very important to quantify the spread - can help locate Nec vs. less aggressive gangrenes. Ultimately, the focus of the infective process will need definite care.
Other considerations:
CroFab (seems to be 96 hours post bite, so... not sure of the benefit)wound care (dry, sterile dressing - in the field) antibiotics (broad coverage/pseudomonas is common), UTD immunizations?, blood/FFP/Platelets as needed, foley cath & measure UOP, possible NaHCO3, correct any electrolyte issues, fever control, monitoring/treatment to preserve use of hand/arm, social service consult for mom/dad.
Are we there yet???
Great case! Great to play here vs. pray here! Hope I helped the patient - thanks for making me "think", I've not really had to do much of that lately! ('')

I think it interesting the father reported being bit in the past with no significant problem. It points out an important fact that a great deal of venomous snake bites never envenamate. I believe smaller, younger snakes actually have a higher percentage of envenamation. They don't have the same ability to control the venom sacs as mature snakes.

As for management, I agree with much of what has been stated previously. Distal CMS is important to check periodically. I would also utilize Fentanyl for it's more friendly hemodynamic properties. However, I disagree with many about the use of pressors. I would steer clear of pressors especially alpha ones for as long as possible. I would focus on fluid resuc. Especially in a child as the good Dr. said. Good for the Kidneys, and good for the exremity. I would avoid Alpha agents because of the negative effects on the extremity. You don't want vasoconstriction on a patient with envenomation and serious necrotic injury. He could loose that limb. It would be an absolute last resort for me.
I would also choose a broad spec antibiotic, I think I would use Levaquin.

As for destination, I would consider who has hyperbarics. This child and his limb could benefit greatly from hyperbaric therapy. I wouldn't worry about who had antivenom. He doesn''t need it. I would look for a good childrens friendly facility with a dive chamber.