New Treatment for Snakebites

Dr. Brandon Woods, Saint Francis Pediatric Critical Care, answers important questions about treating snakebites, including a new treatment option.

TK: Let’s start with the prevalence of snakebites. Do you see a lot of snake bites in the Pediatric ICU?

Dr. Woods: Thankfully, no. It’s always good to be ready and available when kids need us, but it’s great whenever they don’t need intensive care. So, looking at some statistics, Oklahoma-wide, we see about 350-400 snakebites on average per year. Most of them do get hospitalized for a short period of time, and they’re generally cared for in pediatric inpatient service. Only a handful go to the ICU each year. Thankfully, we’re able to treat snakebites without needing a lot of intensive care, but we do have the capacity, and we’re readily available whenever a child needs us.

TK: How does Oklahoma rank in terms of snakebites?

Dr. Woods: Oklahoma is ranked 4^th in the U.S., and our neighboring state, Arkansas, is 3^rd. So, we’re among the top.

TK: What is the most prevalent time of year that you see snakebites?

Dr. Woods: Snakes like a temperature of 80 degrees. Typically, you’ll see snakes come out of hibernation in April, and the snakebite season lasts all the way through October, before the temperature falls below 80 again.

TK: Are there any prevention steps that you would recommend that parents take to protect their children from snakebites?

Dr. Woods: The main thing is to stay vigilant. Vigilant with your eyes, vigilant with your ears. Don’t step anywhere that you can’t see what you’re stepping on. Don’t put your hand down and grab things that you can’t see. And if you hear things that sound concerning, like a rattle, then back up. Stay at least five feet away from a snake. That provides enough buffer in case they do decide that you are a predator to them. Remember that snakes are afraid of us, just as we’re afraid of them, so they generally only attack if they feel threatened or feel as if we are going to harm them.

Wear closed-toed shoes or boots if you’re going to an area with snakes. A walking stick is great; it provides a barrier for you to have a little more time to move away.

TK: Which snakes are the most dangerous in terms of venom?

Dr. Woods:  In the U.S. we have two families of snakes that are venomous, the pit vipers and the coral snakes. Within the pit viper family are the rattlesnakes, copperheads, cottonmouths and water moccasins. We commonly see those in Oklahoma. These snakes have a venom that can affect our muscles and our ability to form clots and our coagulation cascade. There are some reports of coral snakes in the U.S. They emit a neurotoxin, but coral snakes are rare in Oklahoma.

TK: We hear about antivenom. What is it, and how effective is it?

Dr. Woods: We’ve been able to develop immunoglobulins, or antibodies, against toxins and venoms through a variety of research techniques and have been able to develop it both for pediatric and adult use. We take this immunoglobulin and the four most common types of snakes and develop an antivenom against them. That allows us to circulate these antibodies and neutralize the toxin that is in the body that is released from the venom. With this anti-venom, we’re able to treat the patient, usually in a couple of doses, and we see a mitigation of the systemic effects of the venom. It does require an IV and some observation, and it’s only available in emergency departments and emergency facilities.

TK: I understand that Saint Francis is using a new treatment for snakebites. Could you tell us about that?

Dr. Woods: Generally, kids will present to the emergency department, and they’ll get the antivenom started there. That does a great job of mitigating the effects of the toxin. Sometimes the systemic effects of muscle breakdown, tissue breakdown, those kinds of toxins, can affect our kidneys and our ability to form clots. If a child is systemically ill with this, we are able to do what’s called therapeutic apheresis in our pediatric ICU. That allows us to both remove some of the toxin and dilute the effects of it. So, you hear that sometimes “the solution to pollution is dilution.” We’re able to decrease the overall effect of the toxin by diluting it throughout the body.

Additionally, we’re able to remove it as best we can through this therapeutic apheresis, or plasmapheresis. The best way to describe this is like we’re giving the body an oil change. We are able to, with the placement of a catheter, take out blood and run it through a centrifuge, and separate components of the blood into plasma, and then pull off the plasma that likely has all the toxin from the snake. We then discard that plasma and return either plasma or an albumen substitute back into the patient. With time, the venom or toxin effect is mitigated, and their kidney function can improve, as well as their muscle breakdown, and their clotting cascade is restored to normal. We’re able rid the body of the toxin by doing this kind of oil change technique that restores their body to normal function.

TK: To understand, if you’re using this new treatment, is the patient less likely to have long-term effects from the venom?

Dr. Woods: Yes. That’s our goal. Once we start to see systemic effects that are not being treated by the antivenom alone, we’ll place the patient in our ICU and do this therapeutic apheresis technique. This technique is used for other toxins and other indications for kids who have difficulty with their clotting cascade or have been exposed to other toxins, too.

And again, we reserve it for those that are having multiple core things and are severely ill. It’s nice to have the capability to do it whenever they need it. It’s all done within our pediatric ICU, and the patient is monitored the entire time for vital signs and any other abnormalities they might develop. The whole procedure takes a couple, maybe three to four hours. Sometimes we have to repeat the apheresis technique for two or three rounds before we start to see beneficial effects, but we can do that multiple times with the different techniques we have available here.

TK: What steps should parents take if their child is bitten by a snake?

Dr. Woods: Kids should be evaluated as soon as possible. The hard part is that often these bites take place in remote areas, and help is not readily available. The nearest emergency department is far away. We recommend getting to an emergency department as soon as possible. Also, just let it bleed naturally; don’t apply a tourniquet or any sort of restrictive device. Oftentimes, kids are bitten on their hands or feet or extremities. Let it bleed, don’t use a lancet or a knife to poke at any blisters or swelling that happens. Just cover it with gauze and then seek care.

You can call 911. There’s also a great number to memorize for help with any type of poison or toxin – our Poison Control Center. That number is 1.800.222.1222. So, any time your kid has ingested a substance they shouldn’t have or a toxin or have gotten a bite, that is a good number to call. It’s managed by a regional toxicologist, so they know exactly what advice to give you. These are things you can do while you’re in the car on your way to the emergency department.

The number one thing is to stay calm. We often hear when we fly, “Put on your oxygen mask before helping others.” Kids feed off of that, so if their parents are calm, they will also be calm. Help them stay calm, tell them that they will be OK, and that you’re seeking help. Get them the appropriate care in a quick, calm, timely manner.

If the snake is killed, and you have an ability to take a picture of it, that is great, because it can be beneficial to identify the snake. But we wouldn’t recommend getting close to a live snake in order to get a picture.

It’s also helpful to remove anything restrictive that your child is wearing on the hand or extremities such as a watch, wristband or kids bracelets, if they are on the hand that has been bitten. We do expect further swelling to develop as the toxin takes effect. Get that article of clothing or wristband off while you’re driving to emergency care.

TK: So, no tourniquets, no cutting. Those are the TV things that you see…none of that?

Dr. Woods: No. Just let it bleed and cover it with what you have available. You’re also welcome to irrigate it with water or a little gentle soap to try to dilute the effects of the toxin, but mainly just cover it and seek emergency care.

TK: Call a professional. Don’t do it yourself.

Dr. Woods: Don’t do it yourself. The child may get an IV formulation of the antiserum, and if that doesn’t work, we have therapeutic techniques in our pediatric ICU to further help them.