Snake bites in children

Abstract

LOUDED BY SUPERSTITION and mystery, confused by multiple methods of treatment, the physician faced with a child bitten by a poisonous snake rarely has a clear-cut approach toward management. For centuries (as in the Western movies) apart from a prayer and magic potions the suggested treatment was the application of a tight tourniquet, a good “shot of whiskey,” and suction to the wound. With the development of polyvalent antivenin and a better understanding of the pathophysiology of envenomation, more effective methods of treatment evolved. It has been estimated that approximately 7000’ people are bitten by poisonous snakes annually in the United States, usually on an extremity. Most occur in males between the years of 5-19. The majority are reported from the Southwest Central Area of the United States. It is the aim of this paper to present the methods of management used in the treatment of children at the Driscoll Foundation Children’s Hospital after envenomation by the rattlesnake (C. atrox) and the cottonmouth moccasin (Agkistrodon piscivorus leucostoma). Apart from the coral snake, all North American poisonous snakes are pit vipers. The western diamondback rattlesnake in South Texas, may attain lengths of up to 8 ft. Its bite can cause loss of digits, extremities, crippling, and, occasionally, death. The venom is made up of 5-15 enzymes, 3- 12 nonenzymatic proteins, and several other substances, making them among the most complex poisons.2,3 The predominant effects of the Crotalus venom are rapid destruction of local tissues, changes in the cardiovascular system, and alterations in blood coagulation and cells. Capillary permeability may be altered leading to loss of plasma and blood into the extravascular space. Hematuria, melena, hematemesis and hemoptysis can occur. Red blood cells become swollen (sphering) and there may be a dramatic drop in the platelet count.4 The prothrombin and bleeding times may be prolonged. In severe cases, pulmonary edema, intrapulmonary hemorrhage, and bleeding into the peritoneum, kidneys, and heart may develop. Bradykinin. released by the effect of venom on tissues, can cause pooling in the major blood vessels of the chest and lungs leading to sudden collapse and death. The combined effects of destruction of the endothelial lining of blood vessels, hemolysis, and intravascular thrombosis probably play a major role in the development of renal failure and anuria. All venoms contain hyaluronidase, the