Treatment of snakebites at a regional burn center: report of a case series Gie N. Yu, M.D., Stephen D. Helmer, Ph.D., Anjay K. Khandelwal, M.D. Via Christi Regional Burn Center University of Kansas School of Medicine- Wichita

Background 3000-8000 venomous snakebites each year in the United States 5-6 deaths Although a rare occurrence, they can be life threatening Crotaline (rattlesnake, cottonmouth, copperhead)

Background Envenomation syndromes Local tissue damage Non-specific systemic effects Coagulopathy Rhabdomyolysis Increased vascular permeability, tachycardia, tachypnea, hypotension neurotoxicity Symptoms can be delayed so it is recommended that patients with crotaline snake bites be observed in the ER for at least 8 hours

Objective Review the characteristics, treatment, and outcome of patients with snakebites treated at a regional burn center

Methods Retrospective chart review American Burn Association verified regional burn center All patients admitted for treatment of a snakebite January 2000 – May 2009 All snake bit patients are to be admitted to the burn center

Results 12 patients 1 patient was excluded Admitted for wound debridement and skin graft 3 weeks after treatment at another facility

Results 10/11 snakebites occurred between April and September

Results Male Caucasian Age Rattlesnakes N=10 (90.9%) N= 8 (72.2%) 33.5 years average age Rattlesnakes Cause in 7 of 11 envenomations Type of snake unknown in other three

Results Transport by air Received antivenom One patient’s family refused One patient had a local reaction to a test dose No anaphylactoid reactions to the antivenom were recorded

Results Surgical intervention Average hospital stay N=3 3.5 days Fasciotomy for clinically diagnosed compartment syndrome (9.1%) Debridement and full thickness skin graft Incision and drainage of abscess Average hospital stay 3.5 days

Results One patient No mortalities All discharged home Readmitted secondary to upper GI bleed coagulopathy 11 days after snakebite injury No mortalities All discharged home

Discussion Characteristics of patients similar to other studies Majority male patients Occurred during the warmer months Majority of patients treated with Antivenom No mortality

Conclusions Patients who sustain snakebites can be effectively monitored and managed at a burn center In this case series, no anaphylactic reactions resulted from antivenin use.

Thank you

References   Parrish HM. Incidence of treated snakebites in the United States. Public Health Rep 1966; 81:269-76 ONeil ME, et al. Snakebite Injuries Treated in United States Emergency Departments, 2001-2004. Wilderness and Environmental Medicine. 2007; vol 18, 281-287 Langley RL, Morrow WE. Deaths resulting from animal attacks in the United States. Wild Env Med 1997;8:8-16 Gold BS et al. North American snake envenomation: diagnosis, treatment, and management. Emerg Med Clin N Am 2004; 22:423-443 Tokish JT et al. Crotalid envenomation: the southern Arizona experience. J of Orthopaedic Trauma. 2001; vol 15; no 1: 5-9. Bradley J, Lichtenhan JB. Venomous Snake Bites in Kansas. Kans Med. 1989 May: 90(5): 137-40.

Snakebite treatments FabAV therapy Give 4-6 grams (vials) initially Crotalinae bites and moderate to severe toxicity Confirmed rattlesnake or cottonmouth bites and minimal toxicity Give 4-6 grams (vials) initially Repeat if patient has not responded after one hour