Like most physicians, I dread when a patient or family member comes into the emergency department (ED) or my clinic and tells me what s/he thinks is the diagnosis and/or proper management based on a cursory internet search. These people are generally wrong and often base their opinions on unreliable or inaccurate websites. Even when they use trustworthy sources, most people lack the requisite medical knowledge to correctly interpret the information. I end up spending more time explaining why we are not going to proceed with a specific treatment than I do coordinating the proper care.
That said, there are times when patients or their representatives are exceptionally knowledgeable and can contribute to the plan. For example, parents of children with uncommon metabolic syndromes are often much more familiar with the conditions than non-specialist physicians.
For many healthcare professionals, snakebites are also relatively obscure. There are many physicians who do not see many – or any – in their careers. It is undoubtedly frustrating and frightening for knowledgeable snakebite victims when they suspect their treating physician is not experienced with envenomations. So how can a snakebite patient self-advocate?
First, it is reasonable to politely ask the treating physician if s/he is experienced in snakebite management. If the doctor says s/he is not, you can request they consult the regional poison control center, medical toxicologist, or other snakebite expert.
If the physician states that s/he is knowledgeable about bites but his or her actions suggest otherwise, the best step is to politely advocate for yourself by using readily available peer-reviewed medical literature. The unified treatment algorithm (UTA) and the American Academy of Emergency Medicine clinical practice guidelines are both available online and provide clear instructions on how to assess and manage a native crotalid envenomation. Discuss the guidelines with your doctor; if he or she plans to deviate from them, find out if there is a good rationale for it.
There are several ways snakebites are managed poorly. You should specifically watch out for the following:
Insufficient monitoring: Even presumed “dry bites” from venomous snakes should be monitored for at least 8 hours. If there is any evidence of envenomation, patients should be observed for at least 12 – 24 hours. Snakebites are dynamic, and what appears insignificant at first can worsen over several hours.
Not recognizing the indication(s) for antivenom: Antivenom is warranted for systemic toxicity, hematologic toxicity, and/or significant or progressive local tissue findings. Antivenom indications, and a whole lot more, can be found in this summary of Emergency Department snakebite management.
Refusing to treat because the species is unknown: If the physician is reluctant to treat with antivenom because the snake species has not been determined, you can remind him or her that there are two currently available antivenoms are indicated for all North American crotalid envenomations, so exact species identification is unnecessary. Crotalid envenomation is a clinical diagnosis.
Minimizing copperhead envenomations: If the physician tells you that copperhead envenomations do not require treatment, show them my previous blog addressing this subject.
Exaggerating the risks of antivenom: If the treating physician says that the risks of antivenom greatly outweigh the benefits, show them this nice summary of antivenom safety.
Prophylactic antibiotics: We know that infections are uncommon following native pit viper envenomation, and that there are risks associated with indiscriminate antibiotic use. Antibiotics should only be administered when there is an obvious infection. My in-hospital management blog goes into greater detail. I also address how corticosteroids should not be administered routinely.
Surgical consultation: snakebites are a medical, not surgical, emergency. If the ED provider is requesting surgical evaluation, arm yourself – and everybody else – with this nice summary.
Some physicians are ambivalent about antivenom treatment and take a “wait-and-see” approach. However, we know that antivenom is most effective when given in the first six hours. Encourage your doctor to review the UTA and these articles by Anderson and Gerardo.
Finally, some providers will argue that treatment is not “worth the cost.” Make sure they have your interests at heart. There is no cost to the individual physician. The cost to the hospital is not your concern. People who are under- or uninsured may take the cost of treatment including antivenom, into consideration. But remember this: antivenom is not cheap, but neither is a prolonged or permanent disability. Antivenom accelerates recovery in a clinically significant way and minimizes the possibility of a prolonged or permanent disability. Early treatment often makes more financial sense than going without treatment.
If you feel that your needs are not being addressed, you can request a transfer to a different facility. As a last resort, you can choose to leave against medical advice, but this is potentially dangerous. You should only do this if it is clear you will not receive appropriate treatment at the original hospital. The best thing to do is research your local hospitals BEFOREHAND, so that you know where you will get the best care in the unfortunate event of getting bitten.
Dr. Greene is a paid consultant for BTG International Inc.
Spencer Greene, MD, MS, FACEP, FACMT, FAACT, FAAEM is a board-certified medical toxicologist and emergency physician. He currently serves as the Director of Toxicology and an attending emergency physician at HCA Houston Healthcare-Kingwood. He is a Clinical Professor at the University of Houston College of Medicine. Dr. Greene is a recognized expert in the management of snake envenomation in the US. He has treated more than 1000 snakebites at the bedside and has authored more than 50 scholarly articles and book chapters. He has also served as the course director for the Houston Venom Conference since 2013.
INDICATION
CroFab® Crotalidae Polyvalent Immune Fab (Ovine) is a sheep-derived antivenin indicated for the management of adult and pediatric patients with North American crotalid envenomation. The term crotalid is used to describe the Crotalinae subfamily (formerly known as Crotalidae) of venomous snakes which includes rattlesnakes, copperheads and cottonmouths/water moccasins.
IMPORTANT SAFETY INFORMATION
CONTRAINDICATIONS
Do not administer CroFab® to patients with a known history of hypersensitivity to any of its components, or to papaya or papain unless the benefits outweigh the risks and appropriate management for anaphylactic reactions is readily available.
WARNINGS AND PRECAUTIONS
Coagulopathy: In clinical trials, recurrent coagulopathy (the return of a coagulation abnormality after it has been successfully treated with antivenin), characterized by decreased fibrinogen, decreased platelets, and elevated prothrombin time, occurred in approximately half of the patients studied; one patient required re-hospitalization and additional antivenin administration. Recurrent coagulopathy may persist for 1 to 2 weeks or more. Patients who experience coagulopathy due to snakebite should be monitored for recurrent coagulopathy for up to 1 week or longer. During this period, the physician should carefully assess the need for re-treatment with CroFab® and use of any type of anticoagulant or anti-platelet drug.
Hypersensitivity Reactions: Severe hypersensitivity reactions may occur with CroFab®. In case of acute hypersensitivity reactions, including anaphylaxis and anaphylactoid reactions, discontinue infusion and institute appropriate emergency treatment. Patients allergic to papain, chymopapain, other papaya extracts, or the pineapple enzyme bromelain may also have an allergic reaction to CroFab®. Follow-up all patients for signs and symptoms of delayed allergic reactions or serum sickness (e.g., rash, fever, myalgia, arthralgia).
ADVERSE REACTIONS
The most common adverse reactions (incidence ≥ 5% of subjects) reported in the clinical studies were urticaria, rash, nausea, pruritus and back pain. Adverse reactions involving the skin and appendages (primarily rash, urticaria, and pruritus) were reported in 12 of the 42 patients. Two patients had a severe allergic reaction (severe hives and a severe rash and pruritus) following treatment and one patient discontinued CroFab® due to an allergic reaction. Recurrent coagulopathy due to envenomation and requiring additional treatment may occur.
