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SSSSNAKESNAKESNAKESNAKES & S& S& S& SPIDERPIDERPIDERPIDER BBBBITESITESITESITES

Theresa Matoushek, PharmD, CSPIMissouri Poison CenterSSM Health Cardinal Glennon Children’s Hospitaltheresa.matoushek@ssmhealth.com

ObjectivesObjectivesObjectivesObjectives

1. Identify the clinical presentation of pit viper envenomation and describe the appropriate use of antivenin.

2. List the most common venomous spider bites, describe associated symptoms, and identify the appropriate treatment.

The Missouri Poison CenterThe Missouri Poison CenterThe Missouri Poison CenterThe Missouri Poison Center

• Cost effective “center of excellence” of specialized personnel and data systems.

• Multiple access routes make Poison Center services available to virtually everyone in MO 24/7/365. (toll-free phone; 800800800800----222222222222----1222122212221222, text, web chat, TTY)

• Public, 911 Dispatchers, Police, EMS, Nurses, Physicians, Pharmacists, Veterinarians, and more.(888888888888----268268268268----4195419541954195:314-268268268268----4195419541954195)

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Population ServedPopulation ServedPopulation ServedPopulation Served

• The Missouri Poison Center served all 114 Counties in 2015

• Total population ∼5 million

• 2.7 million cases handled since 1974

Who is Serving Missouri?Who is Serving Missouri?Who is Serving Missouri?Who is Serving Missouri?

Registered Pharmacists & Nurses who are certified as Specialists in Poison

Information, clinically supervised by a board certified physician toxicologist

Poison Center Patient Care PathsPoison Center Patient Care PathsPoison Center Patient Care PathsPoison Center Patient Care Paths

• Reassure

• Provide home care and follow-up

• Provide detailed consultation to doctors on hospitalized

cases

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QUESTIONQUESTIONQUESTIONQUESTION

HOW MANY EXPOSURES DOES MPC HOW MANY EXPOSURES DOES MPC HOW MANY EXPOSURES DOES MPC HOW MANY EXPOSURES DOES MPC HANDLE PER YEAR?HANDLE PER YEAR?HANDLE PER YEAR?HANDLE PER YEAR?

Facts At A GlanceFacts At A GlanceFacts At A GlanceFacts At A Glance

Envenomation is approximately Envenomation is approximately Envenomation is approximately Envenomation is approximately

1% of our exposure calls1% of our exposure calls1% of our exposure calls1% of our exposure calls

SNAKE BITESSNAKE BITESSNAKE BITESSNAKE BITES

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Snake Bite General FactsSnake Bite General FactsSnake Bite General FactsSnake Bite General Facts

2,700 species 450 venomous

NOT a major cause of death in US

< 20 deaths in last 20 years in US

7,000-8,000 venomous bites per year

OPHIDIOPHOBIA THE FEAR OF SNAKES

20-25% of fanged

bites are DRY BITESDRY BITESDRY BITESDRY BITES

(no venom injected)

Venomous or NonVenomous or NonVenomous or NonVenomous or Non----Venomous?Venomous?Venomous?Venomous?

NonNonNonNon----Venomous SnakesVenomous SnakesVenomous SnakesVenomous Snakes

• Examples:

• Colubridae: king, black rat, garter

• NO fangs

• Upper and lower row of tiny teeth

• Painful but not serious

• Looks similar to a human bite

DispositionWound

careTetanus update

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CrotalineCrotalineCrotalineCrotaline Pit Viper FamilyPit Viper FamilyPit Viper FamilyPit Viper Family

• Massasauga Rattlesnake “Swamp rattler”

• Timber Rattlesnake

• Western Pygmy Rattlesnake “Ground rattler”

RATTLESNAKESRATTLESNAKESRATTLESNAKESRATTLESNAKES

• Water Moccasin

COTTONMOUTHCOTTONMOUTHCOTTONMOUTHCOTTONMOUTH

• Osage

• Southern

• Northern

• Broadbanded

COPPERHEADCOPPERHEADCOPPERHEADCOPPERHEAD

Pit Viper CharacteristicsPit Viper CharacteristicsPit Viper CharacteristicsPit Viper Characteristics

• Copper-colored triangulartriangulartriangulartriangular----shapedshapedshapedshaped heads

• Elliptical slitslitslitslit----like pupilslike pupilslike pupilslike pupils

• Heat sensing “pitpitpitpit” proximal to nostril

• A singlesinglesinglesingle row of subcaudalscales distal to the anal plate

Pit Viper (Pit Viper (Pit Viper (Pit Viper (CrotalidCrotalidCrotalidCrotalid) Venom) Venom) Venom) Venom

• Aqueous solution of high molecular weight enzymesenzymesenzymesenzymes that spread slowly via the lymphatic system

• Cytotoxic Cytotoxic Cytotoxic Cytotoxic and hemotoxic hemotoxic hemotoxic hemotoxic components

• CytotoxicCytotoxicCytotoxicCytotoxic: damage tissue

• HemotoxicHemotoxicHemotoxicHemotoxic: harms blood clotting system

• No neurotoxic neurotoxic neurotoxic neurotoxic snakes in Missouri

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Clinical PresentationClinical PresentationClinical PresentationClinical Presentation

• Local effects:Local effects:Local effects:Local effects:

• Fang punctures (1-4 usually)

• Typically in 5 minutes: sharp, burning pain at site

• 30 min to 6-8 hours: edema, erythema & possible ecchymosis

• Proximal edema may progress for 24-48 hours

QUESTIONQUESTIONQUESTIONQUESTION

T/F: Putting ice on a snake bite reduces T/F: Putting ice on a snake bite reduces T/F: Putting ice on a snake bite reduces T/F: Putting ice on a snake bite reduces swelling and improves outcomes.swelling and improves outcomes.swelling and improves outcomes.swelling and improves outcomes.

Initial ManagementInitial ManagementInitial ManagementInitial Management

• Anticipate swelling

• Immobilize and elevate slightly above the heart

• Mark and measure swelling every 15 to 30 minutes

Do NOT Use

IceIceIceIce TourniquetsTourniquetsTourniquetsTourniquetsPressurePressurePressurePressure

ImmobilizationImmobilizationImmobilizationImmobilization

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Medical ManagementMedical ManagementMedical ManagementMedical Management

Determine the severity on Determine the severity on Determine the severity on Determine the severity on presentationpresentationpresentationpresentation

• History; location of bite; pre-hospital treatment

• Current symptoms

1Baseline labsBaseline labsBaseline labsBaseline labs

• CBC, PT/PTT, INR, fibrinogen

• Electrolytes, BUN, SCr2

Restricted mobilizationRestricted mobilizationRestricted mobilizationRestricted mobilization

• Elevate slightly above heart

• Activity enhances venom spread3Pain controlPain controlPain controlPain control

• Parenteral opiates such as morphine or fentanyl

• NSAIDs only if low risk of bleeding4

AnxietyAnxietyAnxietyAnxiety

• Benzodiazepines

• Calming environment5OtherOtherOtherOther

• Tetanus booster as needed

• IV Fluids6

Labs & MonitoringLabs & MonitoringLabs & MonitoringLabs & Monitoring

• Baseline CBC, PT/PTT, INR, fibrinogen, electrolytes, BUN and creatinine

• Repeat in 6 hours; if within normal limits, no further labs indicated

Conservative Use of AntiveninConservative Use of AntiveninConservative Use of AntiveninConservative Use of Antivenin

• CrotalidaeCrotalidaeCrotalidaeCrotalidae polyvalent immune fab fragments polyvalent immune fab fragments polyvalent immune fab fragments polyvalent immune fab fragments ((((CroFabCroFabCroFabCroFab))))

• Antivenin is recommended if bite is classified as mmmmoderateoderateoderateoderate----severesevereseveresevere

based on any of the 3 domainsbased on any of the 3 domainsbased on any of the 3 domainsbased on any of the 3 domains or may become so in next 6666----12 12 12 12 hourshourshourshours

Binds & neutralizes

Pulls toxins away from tissue

Eliminated from the body

1

Local

2

Systemic

3

Hematologic

CroFabCroFabCroFabCroFab does not reverse does not reverse does not reverse does not reverse

tissue damage; it halts or tissue damage; it halts or tissue damage; it halts or tissue damage; it halts or

slows its progression. slows its progression. slows its progression. slows its progression.

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Conservative Use of AntiveninConservative Use of AntiveninConservative Use of AntiveninConservative Use of Antivenin

Do NOT automatically

give Crofab!

It is expensive and not

necessary in all patients.

Swelling beyond (or is

anticipated to cross)

elbow or knee at 6-12 hrs

���� recommend to give it

1

2

3

Another Another Another Another whwhwhwh

• Dry bite (venom was not injected)

• History of hypersensitivity reaction to CroFabCroFabCroFabCroFab

• History of hypersensitivity to sheep serumsheep serumsheep serumsheep serum

• Skin irritation from wool is not an allergic reaction

• History of hypersensitivity to papaya or papainpapaya or papainpapaya or papainpapaya or papain

• Unless benefits outweigh the potential risk & anaphylaxis treatment is available

CroFabCroFabCroFabCroFab ContraindicationsContraindicationsContraindicationsContraindications

• Dry bite (venom was not injected)

• History of hypersensitivity reaction to CroFabCroFabCroFabCroFab

• History of hypersensitivity to sheep serumsheep serumsheep serumsheep serum

• Skin irritation from wool is not an allergic reaction

• History of hypersensitivity to papaya or papainpapaya or papainpapaya or papainpapaya or papain

• Unless benefits outweigh the potential risk & anaphylaxis treatment is available

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Proper Proper Proper Proper Dosing of Dosing of Dosing of Dosing of CroFabCroFabCroFabCroFab

• Pediatric and adult dosing is identicalidenticalidenticalidentical because it is based on severity of envenomation, not on size or age.

• Reduce infusion volume of reconstituted antivenin in small children.

• Establish initial control initial control initial control initial control of envenomation with 4 to 6 vials 4 to 6 vials 4 to 6 vials 4 to 6 vials of CroFab.

• In adults, start the 250 mL infusion at a rate of 25 to 50 mL/hour for the first 10 minutes and observe for hypersensitivity reaction.

• If no reaction occurs, complete the infusion over the next 50 to 60 minutes. Faster infusion may be indicated in critically ill patients with hemorrhage or shock.

• 5%; consider risk vs benefit before giving againIncidence of acute hypersensitivityIncidence of acute hypersensitivityIncidence of acute hypersensitivityIncidence of acute hypersensitivity

• Resolve spontaneously or with steroids and antihistaminesMost cases are mildMost cases are mildMost cases are mildMost cases are mild

How many vials?How many vials?How many vials?How many vials?

Most copperhead copperhead copperhead copperhead

bites

Single 4444---- vialvialvialvial initial dose

Most cottonmouth cottonmouth cottonmouth cottonmouth

bites

1 or 2 initial doses of 4 to 6 vials 4 to 6 vials 4 to 6 vials 4 to 6 vials each

Most rattlesnake rattlesnake rattlesnake rattlesnake

bites

1 or 2 initial doses of 4 to 6 vials 4 to 6 vials 4 to 6 vials 4 to 6 vials each

In life-threatening envenomation administer 8 to 128 to 128 to 128 to 12 vials initially.

How to assess “control”How to assess “control”How to assess “control”How to assess “control”

• Assess Assess Assess Assess control of the envenomation by repeat clinical exam and laboratory coagulation tests control of the envenomation by repeat clinical exam and laboratory coagulation tests control of the envenomation by repeat clinical exam and laboratory coagulation tests control of the envenomation by repeat clinical exam and laboratory coagulation tests at any time within an hour of completion of the initial CroFab dose.

• Recurrence Recurrence Recurrence Recurrence of venom effects of venom effects of venom effects of venom effects or delayed onset of venom effects occurs in 50% of those treated with CroFab. Scheduled maintenance dosing is controversial. Scheduled maintenance dosing is controversial. Scheduled maintenance dosing is controversial. Scheduled maintenance dosing is controversial. For this reason, additional 2-vial CroFab doses should be considered only on an “as needed” basis.

• Consultation Consultation Consultation Consultation with the poison center is recommended before giving any “maintenance” dose. with the poison center is recommended before giving any “maintenance” dose. with the poison center is recommended before giving any “maintenance” dose. with the poison center is recommended before giving any “maintenance” dose.

Control Control Control Control is defined as…

• No or limited progression of local tissue effects, improved systemic symptoms, and all coagulation studies and platelet counts are clearly trending toward normal.

If control is notnotnotnot achieved…

• A second 4 to 6 vial dose may be beneficial.

• Consultation with the poison center Consultation with the poison center Consultation with the poison center Consultation with the poison center is recommended before giving any is recommended before giving any is recommended before giving any is recommended before giving any repeat doses. repeat doses. repeat doses. repeat doses.

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Surgical InterventionSurgical InterventionSurgical InterventionSurgical Intervention

• AVOID cutting, suctioning, excising the bite area, or exploration of the wound

• CONTRAINDICATED: Prophylactic Fasciotomy Prophylactic Fasciotomy Prophylactic Fasciotomy Prophylactic Fasciotomy

• Compartment syndrome is rare following pit viper pit viper pit viper pit viper bites because subfascial injection of venom is rare.

• FASCIOTOMY FASCIOTOMY FASCIOTOMY FASCIOTOMY IS VERY RARELY INDICATED IS VERY RARELY INDICATED IS VERY RARELY INDICATED IS VERY RARELY INDICATED and can be avoided with early and adequate administration of CroFab which prevents progression of tissue injury and swelling.

Compartment syndrome = RARERARERARERARE in pit viper bites

Venom deposited in the dermal or SQ tissue

Edema is usually subcutaneous NOT sub-fascial

DispositionDispositionDispositionDisposition

• Discharge after wound care and anti-tetanus

update

• Return if signs of envenomation develop over

the next 8 to 12 hours.

Asymptomatic Asymptomatic Asymptomatic Asymptomatic patients with a dry bite dry bite dry bite dry bite

OR nonvenomousnonvenomousnonvenomousnonvenomoussnakebite:

• Observe for a minimum of 8 to 12 hours after

the bite, until stable.

• Admit if necessary for management of pain,

systemic symptoms, or to administer CroFab.

Envenomated Envenomated Envenomated Envenomated snakebite:

Educate about good

wound care, monitoring,

and management at

home after discharge

Wound Care & Other TreatmentsWound Care & Other TreatmentsWound Care & Other TreatmentsWound Care & Other Treatments

Cleanse, cover wound with sterile dressing. Apply antibiotic ointment.

Surgical wound debridement at 3-10 days, if necessary.

Resume activity at 3-4 days post bite.

Steroids should be avoided except for true allergic phenomena or serum sickness related to CroFab.

Prophylactic antibiotics should be avoided. Snake bites have a very low incidence of infection.

Electric shock therapy of the wound should be avoided.

Elevate the limb as often as possible. Recurrent edema may occur for several MONTHS.

Do not wear anything constricting until healed.

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SPIDER BITESSPIDER BITESSPIDER BITESSPIDER BITES

Spider Bites…In GeneralSpider Bites…In GeneralSpider Bites…In GeneralSpider Bites…In General

• 20,000 species of native spiders!20,000 species of native spiders!20,000 species of native spiders!20,000 species of native spiders!

• Local EffectsLocal EffectsLocal EffectsLocal Effects

• Effects vary from unnoticed to mild-moderate symptoms

• A blister may develop

• Risk for secondary infection

• Most fangs are too small too small too small too small to penetrate skin and envenomate

• Stinging

• Burning

• Painful

• Swollen

• Itching

• Redness

• Blanching

CCCCOMMONOMMONOMMONOMMON SSSSYMPTOMSYMPTOMSYMPTOMSYMPTOMS

General Spider Bite ManagementGeneral Spider Bite ManagementGeneral Spider Bite ManagementGeneral Spider Bite Management

• Therapeutic InterventionTherapeutic InterventionTherapeutic InterventionTherapeutic Intervention

• Wash area thoroughly with soap and water

• Keep clean and dry

• Do NOT apply ice

• Apply a topical antibiotic or hydrocortisone 1%

• Monitor for symptoms of a venomous bite

ICE

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QUESTIONQUESTIONQUESTIONQUESTION

WHAT ARE THE VENOMOUS WHAT ARE THE VENOMOUS WHAT ARE THE VENOMOUS WHAT ARE THE VENOMOUS SPIDERS IN MISSOURI?SPIDERS IN MISSOURI?SPIDERS IN MISSOURI?SPIDERS IN MISSOURI?

Venomous SpidersVenomous SpidersVenomous SpidersVenomous Spiders

BLACK WIDOWBLACK WIDOWBLACK WIDOWBLACK WIDOWBROWN RECLUSEBROWN RECLUSEBROWN RECLUSEBROWN RECLUSEloxoseles latrodectus

BROWN RECLUSEBROWN RECLUSEBROWN RECLUSEBROWN RECLUSE

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Is it always a brown recluse?Is it always a brown recluse?Is it always a brown recluse?Is it always a brown recluse?

AAAALLLLLLLL OFOFOFOF THESETHESETHESETHESE MUSTMUSTMUSTMUST BEBEBEBE PRESENTPRESENTPRESENTPRESENT TOTOTOTO IDENTIFYIDENTIFYIDENTIFYIDENTIFY ITITITIT ASASASAS AAAA BROWNBROWNBROWNBROWN RECLUSERECLUSERECLUSERECLUSE::::

1. Six eyes arranged in pairs.

2. A dark violinviolinviolinviolin shape on the cephalothorax

3. Uniformly lightlightlightlight----colored legscolored legscolored legscolored legs: no stripes, no bands.

4. Uniformly colored abdomenabdomenabdomenabdomen (cream to dark brown)

5. Only fine hairs fine hairs fine hairs fine hairs on the legs – NO spines.

6. Body length is about 3/8 inch3/8 inch3/8 inch3/8 inch. If > ½ inch, it is NOT a recluse.

7. Web is hiddenhiddenhiddenhidden from sight; never out where it can be seen.

Brown Recluse VenomBrown Recluse VenomBrown Recluse VenomBrown Recluse Venom

• Cytotoxic venomCytotoxic venomCytotoxic venomCytotoxic venom

• L. reclusa: Most prevalent species in the US (found in Missouri, among other states); the Chilean recluse (L. laeta) is more potent (found in LA, Florida, and Massachusetts)

Tissue Necrosis

Red Cell Lysis (uncommon)

CYTOTOXIC

VENOM

Local Effects Local Effects Local Effects Local Effects

Painless initiallyPainless initiallyPainless initiallyPainless initially

Early blister and Early blister and Early blister and Early blister and surrounding surrounding surrounding surrounding

inflammation inflammation inflammation inflammation with significant with significant with significant with significant

painpainpainpain

Bite site is Bite site is Bite site is Bite site is usually flat or usually flat or usually flat or usually flat or

depresseddepresseddepresseddepressed

Center becomes Center becomes Center becomes Center becomes sunken and sunken and sunken and sunken and

dull/gray dull/gray dull/gray dull/gray

Necrotic Necrotic Necrotic Necrotic ulceration once ulceration once ulceration once ulceration once center sloughs center sloughs center sloughs center sloughs off; ulcerationoff; ulcerationoff; ulcerationoff; ulceration

Ulcer can takes weeks to heal Secondary infection can occurNecrosis is worse if bite was in a fatty area

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Systemic EffectsSystemic EffectsSystemic EffectsSystemic Effects

SSSSYSTEMICYSTEMICYSTEMICYSTEMIC EEEEFFECTSFFECTSFFECTSFFECTS

AAAARERERERE RARERARERARERARE

Develop within 24-72

hours

Head-to-toe pruritic rash

General inflammatory

symptoms

Hemolysis; dark urine

Rarely DIC

TreatmentTreatmentTreatmentTreatment

Recommended Recommended Recommended Recommended Medical Medical Medical Medical ManagementManagementManagementManagement

General wound care

Tetanus prophylaxis

Antibiotics if needed

NOT NOT NOT NOT RecommendedRecommendedRecommendedRecommended

Dapsone is NOT a routine recommendation

NO benefit: injected steroids, vasodilators, electric shock

Early excision of wound is NOT recommended and may prolong healing

Delay surgical Delay surgical Delay surgical Delay surgical intervention for intervention for intervention for intervention for

8 weeks8 weeks8 weeks8 weeks

BLACK WIDOWBLACK WIDOWBLACK WIDOWBLACK WIDOW

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Overview Overview Overview Overview ---- Black WidowBlack WidowBlack WidowBlack Widow

• Most bites are in the Southwest US during warm months

• HabitatHabitatHabitatHabitat: woodpiles, garages, rock piles

• Characteristic hourglasshourglasshourglasshourglass

• May or may NOTNOTNOTNOT be visible

• Juvenile and male black widows are smaller and brown

Black Widow VenomBlack Widow VenomBlack Widow VenomBlack Widow Venom

• Neurotoxic venomNeurotoxic venomNeurotoxic venomNeurotoxic venom

• Latrodectus species (latro-toxin)

• Stimulates neurotransmitter release (acetylcholine)

• Increased frequency and force of muscle contractions

• NOT dermato-necrotic

Neurological

Autonomic

BLACK

WIDOW

VENOM

Local EffectsLocal EffectsLocal EffectsLocal Effects

Painless, or possible pin-prick

sensation

Increasing pain at the bite site

quickly, over 15 min to several

hours

Pain may radiate up the limb to

lymph nodes or chest

CharacteristicCharacteristicCharacteristicCharacteristic: sweating around

the bite site

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Systemic EffectsSystemic EffectsSystemic EffectsSystemic Effects

• ““““LLLLatrodectismatrodectismatrodectismatrodectism””””

• Develop within 30 minutes – 2 hours

• Remote or generalized pain

• Headache, anxiety, “Pavor mortis”

• Muscle cramping and fasciculations; writhes in pain

• Board-like rigidity of the abdomen, shoulders, and back

• Nausea, vomiting, increased oral secretions, tachycardia, hypertension

• Irritability, agitation

• Malaise, lethargy, fever

Grade 1Grade 1Grade 1Grade 1: Mild Envenomation

Grade 2: Grade 2: Grade 2: Grade 2: Moderate

Envenomation

Grade 3: Grade 3: Grade 3: Grade 3: Severe Envenomation

TreatmentTreatmentTreatmentTreatment

• Spontaneous recover expected in 24-48 hours

• Death is very rare

• Administer benzodiazepines to relax muscles and reduce blood pressure; opiates for intense pain

• ANTIVENOMANTIVENOMANTIVENOMANTIVENOM:• IgG horse-serum by Merck = expired but extensions have been granted

by the FDA

• Administer only if patient has failed standard care

• Premedicate with antihistamines

• DO NOT GIVE:DO NOT GIVE:DO NOT GIVE:DO NOT GIVE: Calcium gluconate, dantrolene, muscle relaxers

• Antibiotics are not usually needed

Resources from MPCResources from MPCResources from MPCResources from MPC

MISSOURIPOISONCENTER.ORGMISSOURIPOISONCENTER.ORGMISSOURIPOISONCENTER.ORGMISSOURIPOISONCENTER.ORG

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CASE EXAMPLECASE EXAMPLECASE EXAMPLECASE EXAMPLE

Case Example Case Example Case Example Case Example –––– Snake BiteSnake BiteSnake BiteSnake Bite

• An 8 yo patient presented to the emergency department 40 minutes after being bitten on the left ankle by a copperheadcopperheadcopperheadcopperheadwhile walking barefoot to the car after spending the day at the river. Two puncture wounds Two puncture wounds Two puncture wounds Two puncture wounds are noted. There is redness but minimal swellingswellingswellingswelling.

• Vital signs: Temp: 97.8°F BP: 95/65 mmHg HR: 100 RR: 20

• HEENT: unremarkable

• Lungs: clear to auscultation

• CV: normal sinus rhythm

• Abd: normal bowel sounds

• Neuro: alert and oriented

Case Example Case Example Case Example Case Example –––– Snake BiteSnake BiteSnake BiteSnake Bite

1.1.1.1. Based Based Based Based on the patient’s presentation what would be the best on the patient’s presentation what would be the best on the patient’s presentation what would be the best on the patient’s presentation what would be the best initial initial initial initial management?management?management?management?A. Apply ice to reduce the swelling.

B. Allow the patient to ambulate and monitor the progression of symptoms.

C. Obtain a baseline CBC, PT/PTT, INR, fibrinogen, electrolytes, BUN and creatinine.

D. Begin a 4 vial regimen of Crofab.

2.2.2.2. When should labs be repeated?When should labs be repeated?When should labs be repeated?When should labs be repeated?

3.3.3.3. When would we recommend When would we recommend When would we recommend When would we recommend CrofabCrofabCrofabCrofab????

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SSSSNAKESNAKESNAKESNAKES & S& S& S& SPIDERPIDERPIDERPIDER BBBBITESITESITESITES

Theresa Matoushek, PharmD, CSPIMissouri Poison CenterSSM Health Cardinal Glennon Children’s Hospital