Advertisement

Upper Extremity Crotalid Envenomation: A Review of Incidence and Recent Trends in Management of Snakebites

      Purpose

      The goal of this study was to evaluate the recent trends in the management of upper extremity Crotalid envenomation in the state of Georgia, United States.

      Methods

      A retrospective review of the Georgia Poison Center database looking at the reported snakebites to the upper extremity between 2015 and 2020 was performed. Patient demographics, timing and location of injury, severity of envenomation, treatment, including use of antivenin and surgical intervention, and reported complications related to the use of antivenin was extracted.

      Results

      A retrospective review of snakebites between 2015 and 2020 showed 2408 snakebite cases with a mean patient age of 37.4 years. Males incurred 62.8% of all bites. The highest incidence was in summer 52.5%, and between the hours of 5 PM to midnight 57.2%. Overall, 1010 (41.9%) of all bites were categorized as venomous snakebites (55.6% copperhead, 20% rattlesnake, 2.4% cottonmouth, and 22% miscellaneous [including 3 Elapid envenomations] or unidentified. The total number of venomous bites to the upper extremity was 575 (56.9%) and 567 patients received antivenin. Envenomation severity was mild in 29%, moderate in 45%, severe in 10%, and undetermined in 16% of cases. Crotalidae polyvalent immune Fab (Ovine) was the main antivenin used, with overall mean initial therapy dose of 6.2 vials and 59% of patients receiving maintenance therapy. Three patients (0.5%) had a severe anaphylactic reaction to antivenin requiring cessation of therapy. Seven patients had acute compartment syndrome of the upper extremity requiring fasciotomy (3 copperhead, 2 rattlesnake, and 2 unidentified). There was no reported mortality during this period.

      Conclusions

      Hand surgeons should be familiar with the management of upper extremity Crotalid envenomation. Antivenin remains the main treatment for symptomatic patients. Crotalid snakebites rarely require operative intervention.

      Level of evidence

      Level IV, Prognostic

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Minghui R.
        • Malecela M.N.
        • Cooke E.
        • Abela-Ridder B.
        WHO’s Snakebite envenoming strategy for prevention and control.
        Lancet Glob Health. 2019; 7: e837-e838
        • Seifert S.A.
        • Boyer L.V.
        • Benson B.E.
        • Rogers J.J.
        AAPCC database characterization of native U.S. venomous snake exposures, 2001-2005.
        Clin Toxicol (Phila). 2009; 47: 327-335
        • Edgerton M.T.
        • Koepplinger M.E.
        Management of snakebites in the upper extremity.
        J Hand Surg Am. 2019; 44: 137-142
        • Abbey J.M.
        • Jaffar N.A.
        • Abugrara H.L.
        • Nazim M.
        • Smalligan R.D.
        • Khasawneh F.A.
        Epidemiological characteristics, hospital course and outcome of snakebite victims in West Texas.
        Hosp Pract (1995). 2015; 43: 217-220
        • Tanen D.
        • Ruha A.
        • Graeme K.
        • Curry S.
        Epidemiology and hospital course of rattlesnake envenomations cared for at a tertiary referral center in Central Arizona.
        Acad Emerg Med. 2001; 8: 177-182
        • Greene S.
        • Ruha A.M.
        • Campleman S.
        • Brent J.
        • Wax P.
        • Tox I.C.S.S.G.
        Epidemiology, clinical features, and management of Texas coral snake (Micrurus tener) envenomations reported to the North American Snakebite Registry.
        J Med Toxicol. 2021; 17: 51-56
        • Gold B.S.
        • Dart R.C.
        • Barish R.A.
        Bites of venomous snakes.
        N Engl J Med. 2002; 347: 347-356
        • Seiler III, J.G.
        Rattlesnake bite with associated compartment syndrome: what is the best treatment?.
        J Bone Joint Surg Am. 2003; 85 (author reply 1164): 1163-1164
        • Hall E.L.
        Role of surgical intervention in the management of crotaline snake envenomation.
        Ann Emerg Med. 2001; 37: 175-180
        • Garfin S.R.
        • Castilonia R.R.
        • Mubarak S.J.
        • Hargens A.R.
        • Akeson W.H.
        • Russell F.E.
        The effect of antivenin on intramuscular pressure elevations induced by rattlesnake venom.
        Toxicon. 1985; 23: 677-680
        • Mars M.
        • Hadley G.P.
        Raised compartmental pressure in children: a basis for management.
        Injury. 1998; 29: 183-185
        • Turkmen A.
        • Temel M.
        Algorithmic approach to the prevention of unnecessary fasciotomy in extremity snake bite.
        Injury. 2016; 47: 2822-2827
        • Grace T.G.
        • Omer G.E.
        The management of upper extremity pit viper wounds.
        J Hand Surg Am. 1980; 5: 168-177
      1. CroFab®. Prescribing information. Brentwood, tn 37027: Protherics Inc., 2012.

        • Dart R.C.
        • McNally J.
        Efficacy, safety, and use of snake antivenoms in the United States.
        Ann Emerg Med. 2001; 37: 181-188
      2. Cocchio C, Johnson J, Clifton S. Review of North American pit viper antivenoms. Am J Health Syst Pharm. 24 2020;77(3):175–187.

        • Schaeffer T.H.
        • Khatri V.
        • Reifler L.M.
        • Lavonas E.J.
        Incidence of immediate hypersensitivity reaction and serum sickness following administration of Crotalidae polyvalent immune Fab antivenom: a meta-analysis.
        Acad Emerg Med. 2012; 19: 121-131
        • Bush S.P.
        • Ruha A.M.
        • Seifert S.A.
        • et al.
        Comparison of F(ab’)2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial.
        Clin Toxicol (Phila). 2015; 53: 37-45
      3. Georgia Poison Center.
        • McCollough N.C.
        • Gennaro Jr., J.F.
        Evaluation of venomous snakebite in Southern United States from parallel clinical and laboratory investigations.
        J Fla Med Assoc. 1963; XLIX: 959-967
        • Russell F.E.
        Snake venom poisoning in the United States.
        Annu Rev Med. 1980; 31: 247-259
        • Russell F.E.
        • Eventov R.
        Lethality of crude and lyophilized crotalus venom.
        Toxicon. 1964; 15: 81-82
        • Van Mierop L.H.
        Poisonous snakebite: a review. 2. Symptomatology and treatment.
        J Fla Med Assoc. 1976; 63: 201-210
      4. Anavip®. Prescribing information [pending FDA approval at the time of this writing]. Mexico D.F., Mexico: instituto Bioclon S.A. deCv.

        • World Health Organization
        Snake bite envenomation. World Health Organization.
        • Greene S.
        • Cheng D.
        • Vilke G.M.
        • Winkler G.
        How should native crotalid envenomation be managed in the emergency department?.
        J Emerg Med. 2021; 61: 41-48
        • Wade L.
        Drug industry. For Mexican antivenom maker, U.S. market is a snake pit.
        Science. 2014; 343: 16-17
      5. Drugs.com - Anavip prices.
        https://www.drugs.com/price-guide/anavip
        Date accessed: July 17, 2021
      6. ToxTidbits, June 2019.
        • Kleinschmidt K.
        • Ruha A.M.
        • Campleman S.
        • Brent J.
        • Wax P.
        • ToxIC North American Snakebite Registry Group
        Acute adverse events associated with the administration of Crotalidae polyvalent immune Fab antivenom within the North American Snakebite Registry.
        Clin Toxicol (Phila). 2018; 56: 1115-1120
        • Mahmoudi G.A.
        • Ahadi M.
        • Fouladvand A.
        • Rezaei B.
        • Bodagh Z.
        • Astaraki P.
        Evaluation of allergic reactions following intravenous infusion of polyvalent antivenom in snakebite patients.
        Antiinflamm Antiallergy Agents Med Chem. 2021; 20: 367-372
        • Gerardo C.J.
        • Vissoci J.R.N.
        • Evans C.S.
        • Simel D.L.
        • Lavonas E.J.
        Does this patient have a severe snake envenomation?: the Rational Clinical Examination Systematic Review.
        JAMA Surg. 2019; 154: 346-354
        • Gale S.C.
        • Peters J.A.
        • Allen L.
        • Creath R.
        • Dombrovskiy V.Y.
        FabAV antivenin use after copperhead snakebite: clinically indicated or knee-jerk reaction?.
        J Venom Anim Toxins Incl Trop Dis. 2016; 22: 2
        • Walker J.P.
        • Morrison R.L.
        Current management of copperhead snakebite.
        J Am Coll Surg. 2011; 212 (discussion 474–475): 470-474
        • Lavonas E.J.
        • Ruha A.M.
        • Banner W.
        • et al.
        Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop.
        BMC Emerg Med. 2011; 11: 2
        • LoVecchio F.
        • Klemens J.
        • Welch S.
        • Rodriguez R.
        Antibiotics after rattlesnake envenomation.
        J Emerg Med. 2002; 23: 327-328
        • Campbell B.T.
        • Corsi J.M.
        • Boneti C.
        • Jackson R.J.
        • Smith S.D.
        • Kokoska E.R.
        Pediatric snakebites: lessons learned from 114 cases.
        J Pediatr Surg. 2008; 43: 1338-1341