Complications
May occur following Crotalinae envenomation as a result of venom-induced activation of the coagulation cascade and resultant consumption coagulopathy. This may occur hours to days after envenomation. Cases of delayed coagulopathy have been reported in children who presented to an emergency department 5 to 7 days following envenomation and initial treatment and required further antivenom therapy.[50] In one study, medically significant delayed hemorrhage was reported in approximately 0.5% of North American crotaline snakebite victims treated with CroFab® antivenom.[49]
Treatment with antivenom will frequently reverse the coagulopathy and should be considered first-line therapy for this condition.
Transfusion of blood products such as packed red blood cells, platelets, and fresh frozen plasma may be necessary. Pulmonary, gastrointestinal, and soft-tissue hemorrhage should be treated in standard fashion.
May occur as a result of envenomation or antivenom administration.
If anaphylaxis develops as a result of antivenom administration, the infusion should be stopped immediately.
Anaphylactic reaction should be managed with epinephrine.
May occur as a result of envenomation or, more commonly, as a result of antivenom administration. Around 5% of patients develop serum sickness following Crotalidae polyvalent immune Fab (ovine) antivenom administration, characterized by fevers, arthralgias, malaise, and rash.[1]
Serum sickness should be treated with an oral corticosteroid taper.
Hypotension may occur as a result of cardiogenic shock, anaphylactic shock, or hypovolemic shock from third-spacing of intravascular volume.
Initial management includes intravascular hydration with normal saline or lactated Ringers solution.
Patients with hypotension despite vigorous hydration may require vasopressor administration. Central venous pressure, inferior vena cava collapsibility index, and/or arterial pressure transduction may be used to guide fluid resuscitation and vasopressor administration.
May occur following Crotalinae envenomation due to cardiac failure or increased pulmonary capillary permeability, and may lead to death in some cases.[25]
May require supplemental oxygen or, in some cases, intubation and positive pressure ventilation.
Elapidae envenomation may cause weakness or paralysis of the muscles of respiration. Crotalinae envenomation may result in life-threatening pulmonary edema.
Intubation and mechanical ventilation may be expeditiously performed if needed.
May happen following Elapidae envenomation.
Patients with an impaired ability to protect their airway or with inadequate minute ventilation/oxygenation require endotracheal intubation and mechanical ventilation. In some cases, prolonged mechanical ventilation may be necessary until the patient regains use of the muscles of respiration.
May occur following Crotalinae envenomations as a result of muscle necrosis and increased capillary permeability leading to increased compartmental pressures.
Antivenom administration is considered standard treatment for venom-induced compartment syndrome.
Several studies have shown no benefit from fasciotomy, although, due to the potential for poor outcome and the general acceptance of fasciotomy for compartment syndrome in the medical community, clinicians may still wish to consider the procedure.[51][52][53]
Crotalinae venom is directly myotoxic, although clinically important rhabdomyolysis is uncommon following North American pit viper envenomation.
Increased compartment pressures at the envenomation site may impair perfusion and lead to further muscle death.
Rhabdomyolysis following Crotalinae envenomation should be treated with standard measures such as aggressive hydration and urine alkalinization to minimize myoglobinuric renal damage.
Wound infections are rare but may occur.
The use of prophylactic antibiotics is not generally thought to be necessary.[40][41]
The risk of snakebite infection in immunocompromised patients is not well defined. The use of prophylactic antibiotics may be prudent.
If prophylactic antibiotics are indicated, wound cultures following snakebite infection predominantly grow gram-negative aerobic bacilli (primarily Enterobacteriaceae) and gram-positive aerobic cocci, so antibiotic therapy should be directed against these bacteria.
These are serious complications of Elapidae envenomation.
Crotalinae envenomation has been reported to cause myocardial infarction.
Crotalinae envenomation has been reported to cause arrhythmia and conduction delay.
May complicate Crotalinae envenomations with significant rhabdomyolysis.
Quadriplegia/locked-in syndrome has been rarely reported following nondomestic elapid envenomation.[21]
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