I was wondering if patients being intoxicated complicates their treatment?
Patients are rarely so intoxicated that you can’t get an exam. Most of them sober up by the time they get to us. Occasionally it might limit the amount of opioid pain medication you can give them. NSAIDS are generally contraindicated because of their affect on platelets. Where it really makes a difference is when someone comes in and claims they’ve been bitten by a coral snake and they are too drunk to adequately describe the snake. Same thing happens with young children (who are basically like little drunks).
What about scenarios where the identity of the snake is unknown? How do you proceed?
There are really only two different types of snakes in the US, the pit vipers/Crotaline, which are the rattlesnakes, Cottonmouth, copperhead and the coral snakes. The clinical picture is very similar for the pit vipers with local tissue distraction, thrombocytopenia, systemic or neurologic symptoms and the antivenom is actually the same for all of them.
For the coral snakes you have to have a good history. Most toxicologist know which snakes are in their geographic area.
Whether it’s a pygmy rattlesnake or a cottonmouth doesn’t really matter. We use the same antivenom for either of those for example. If the snake is completely unknown and maybe an exotic snake, then we examine the patient and treat target organ injury. If the patient has neurologic symptoms then that’s what we treat.
Do you have an anti-venom that acts on more than one snake venom type?
There is a lot of overlap in the binding of antivenom to different species of snakes. Even though some antivenoms are made with specific snakes that may not even be indigenous to where you live, either of the two Crotaline antivenoms would work for almost any US pit viper. For coral snake you have to use coral snake Antivenom. Sometimes we get exotic bites like cobra or mamba. Usually those come from zoos or herpetologist who usually know which snake bit them. In Miami we have an Antivenom team run by Miami Dade fire rescue. Poison centers also keep an index of zoos and aquariums that act as repositories for the antivenoms that correspond to the animals they keep.
If the bite is from an unknown snake is there a risk associated with elevating the limb potentially increasing the extremity.
Yes, good point. If the snake is a neurotoxic snake we would generally keep the extremity at the level of the heart until we have antivenom at the ready.
What's the weirdest case you've had?
I get asked this question a lot and I can never think of one when I need to: We had two guys partying out in the Everglades they got so high that one of them didn’t realize his finger was being chewed on by a coral snake. His friend pulled it off and got bitten himself. They both ended up getting antivenom. We also had a patient unloading crates at the port of Miami from the Middle East. He was bitten by a monocled cobra. I had a patient feeding his pet Python a mouse and holding the mouse in front of his face. The python struck and hit him in the eye and split his upper eyelid in half and punctured the globe. He went to the OR that night. I’ve had several patients bitten on the face from trying to kiss a snake.
How do you project envenomation injuries to change with climate change? Recommendations for providers working in areas not historically concerned with snakes but may see more with incr. warming?
We are generally seeing less snakebites over time because we are paving over their habitat. With over development we are taking away their home and so I think there are a lot less of them. We have seen the effect of global warming in other toxicities, however. Manchineel trees were once located exclusively in the keys, and now have been seen as high as Palm Beach. Irukandji syndrome was once exclusive to Australia and now has been reported off the coast of Florida in the Caribbean and in Hawaii. Red tide and various allergies have flourished in the warmer waters off the West Coast of Florida.
Do people who have been bitten/stung multiple times build up a long-term tolerance to the venom?
Many snake handler‘s have become sensitized to their snakes and develop allergic symptoms when they go near them. This is particularly true for cobra handler‘s. People do develop some antibodies but generally not enough to protect them from a real bite. I know of several cases where someone who thought they were protected from multiple bites have died and others who have almost died.