Abstract
Snakebite is a potential medical emergency and must receive high-priority assessment and treatment, even in patients who initially appear well. Patients should be treated in hospitals with onsite laboratory facilities, appropriate antivenom stocks and a clinician capable of treating complications such as anaphylaxis. All patients with suspected snakebite should be admitted to a suitable clinical unit, such as an emergency short-stay unit, for at least 12 hours after the bite. Serial blood testing (activated partial thromboplastin time, international normalised ratio and creatine kinase level) and neurological examinations should be done for all patients. Most snakebites will not result in significant envenoming and do not require antivenom. Antivenom should be administered as soon as there is evidence of envenoming. Evidence of systemic envenoming includes venom-induced consumption coagulopathy, sudden collapse, myotoxicity, neurotoxicity, thrombotic microangiopathy and renal impairment. Venomous snake groups each cause a characteristic clinical syndrome, which can be used in combination with local geographical distribution information to determine the probable snake involved and appropriate antivenom to use. The Snake Venom Detection Kit may assist in regions where the range of possible snakes is too broad to allow the use of monovalent antivenoms. When the snake identification remains unclear, two monovalent antivenoms (eg, brown snake and tiger snake antivenom) that cover possible snakes, or a polyvalent antivenom, can be used. One vial of the relevant antivenom is sufficient to bind all circulating venom. However, recovery may be delayed as many clinical and laboratory effects of venom are not immediately reversible. For expert advice on envenoming, contact the National Poisons Information Centre on 13 11 26.
Highlights
Haematological: evidence of abnormal coagulation.[2,17]
Box 2 provides a summary of major clinical effects of the clinically important groups of Australian snakes.[4]
Admission to an intensive care unit is only necessary for patients with major complications, including those with neurotoxic paralysis, thrombotic microangiopathy or severe myotoxicity requiring mechanical ventilation
Summary
VICC occurs in most patients who require antivenom and is usually present on arrival (86% of cases in one study), but may become evident later, within 6 hours of the bite.[1,14] VICC is complete or severe in most cases, but partial VICC occurs in some cases where there is only partial consumption of the clotting factors (Box 1). Neurotoxicity and myotoxicity are uncommon and evolve over hours, making the timing of decisions to use antivenom problematic.[2,5,6] Thrombotic microangiopathy is a more recently recognised condition that is always associated with VICC and is characterised by thrombocytopenia, microangiopathic haemolytic anaemia (with fragmented red blood cells) and acute renal impairment.[7] Anticoagulant “coagulopathy”, characterised by an elevated activated partial thromboplastin time (aPTT), occurs.
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