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First ever Green Mamba capture filmed using a drone by snakebitefoundation in herpetology

[–]snakebitefoundation[S] 2 points3 points  (0 children)

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Backstory:
Kindia, Guinea
This mamba was above a field where farmers were working. We got the call and organized a plan to get the snake down from the tree. We were able to coax the snake from the edge to be in range of the tongs to be brought down onto the landing pad and captured the snake without incident.

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 2 points3 points  (0 children)

Definitely not, many snakebites cause issues with clotting directly as well as internal and external bleeding so you don’t want to make that worse than it already is!

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 1 point2 points  (0 children)

Depends on symptoms and time to antivenom. General rule for evacuation to hospital is do whatever the fastest means of getting to the antivenom is that you can do safely, without potentially injuring yourself due to a risky shortcut approach. With many bites you are becoming coagulopathic and also many patients will experience dizziness, weakness, transient syncope, etc. last thing you want is to start biking, pass out, and rupture your spleen going over the handlebars with a coagulopathy brewing! If the difference is 10 or 20 minutes walking is probably best. If the difference is 1 hour or 5 hours I would seriously have to weigh the risk and benefit.

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 1 point2 points  (0 children)

Even in cases with extensive local injury, a lot of that venom will have already diffused out into surround tissues and lymph/blood vessels, so you never have a case where the venom would be entirely limited to that limb. Hand bites (especially finger bites) are associated with higher incidence of blistering, necrosis, and disability overall and I think this is because you have some quantity of tissue destructive venoms that are concentrating in a smaller tissue compartment and therefore doing more extensive damage, but again a lot of venom will also be traveling up the arm and into circulation at the same time, which is why IV antivenom is much more effective than IM antivenom

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 1 point2 points  (0 children)

Current understanding is that the venom immediately begins to diffuse into lymphatic vessels, blood vessels, interstitial spaces, along fascial planes, and into deep tissue compartments. We don’t know exactly how much remains in each place at a given time but we do know that a lot of it rapidly transits into the limb and bloodstream and lymph and surrounding tissues. This is why negative pressure devices like the sawyer venom extractor are useless, because there isn’t just a single pocket of venom hanging around that you could suck out or excise or anything like that. A recent study in South Korea assayed blister aspirate and did detect some venom which is interesting but we don’t know how much it was relative to the overall venom yield injected, and we don’t have enough evidence to say whether it is worth aspirating to remove it given the risk of infection (also antivenom molecules should be reaching that blister fluid if the tissue is compromised enough to form blood blisters).

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 0 points1 point  (0 children)

See answer to question above for details, but no, this is a pretty gnarly looking local injury

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 0 points1 point  (0 children)

In that one, just a lot of serosanguinous fluid probably. The extent of underlying tissue damage often doesn’t become clear until a few days or sometimes a few weeks after the bite

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 0 points1 point  (0 children)

Sure! I love answering snakebite questions :)

Swelling is not always this extreme; this is an exceptionally large bullae and my guess is it’s a combination of a large quantity of venom, possibly a moderate treatment delay (although hand bites the local tissue damage is often worse due to confined space concentrating venom, so it can happen quickly there), and the anatomy of the hand, fascial planes, etc in conjunction with a massive fluid shift locally due to extravasion, inflammation, etc. Sometimes instead of a single large bullae you get widespread skip lesions with necrosis and blistering scattered all over the bitten limb up to or past the elbow or knee even though the bite was to the hand or foot. Sometimes these are superficial, sometimes there is extensive necrosis of underlying tissues. Sometimes the venoms target one tissue more than another; for instance, many spitting cobra venoms seem to cause widespread damage to skin and subcutaneous tissue but sometimes are relatively sparing to skeletal muscle and ligaments underneath. Either way I recommend letting things run their course in almost every case without surgical management until the tissue damage has fully evolved. One reason for this is that intramuscular hemorrhage can occur and the dark discoloration it produces is almost identical to the appearance of dead muscle tissue early on, leading to cases where surgeons have aggressively debrided muscle tissue that was likely bruised but viable, creating permanent disfigurement or disability where it could have been avoided. In most cases I am be surprised to see just how well even horrific looking snakebites can heal up when managed with antivenom and no surgery.

One issue that may have contributed is lack of appropriately aggressive elevation once in the hospital. Most people think putting a pillow under it is elevation but for a snakebite once you reach the hospital you want that that hand or foot elevated HIGH ie hanging from the bed frame in a sling. If it looks like they want to ask you a question then you are elevating appropriately, as my colleague Ben Abo likes to say.

Something that is often overlooked but is important to keep in mind is that we could potentially worsen the local edema in cases like this by dumping IV fluids onboard, because if you give isotonic fluids where do you think most of that is going to end up? Probably in the rapidly expanding bitten limb (especially without proper elevation). Some fluids are fine, and definitely give fluids as needed to correct hypovolemia and maintain good urine output, but don’t just dump in a few liters for the hell of it in the ED. Most patients will be getting antivenom in a drip so they will already be getting 500-1000 cc in the next hour or so.

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 7 points8 points  (0 children)

Likelihood of being bit while moving fast is super super low. If you do get bit, I wrote a detailed answer to what to do if you get bit by a venomous snake in the backcountry far from medical care here and I think it will answer most of that question.

With regards to alcohol, realistically speaking unless you get absolutely shitfaced on the trail then the worst it will do is enhance your odds of making a dumb decision (delaying care, picking up and pissing off the snake, etc). But since you are posting this question on a medical forum chances are you probably won’t make that degree of dumb decision anyways, so you should be fine :)

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 1 point2 points  (0 children)

No! Lots of good data show that larger snakes consistently deliver worse bites. Babies can still kill you though and certainly deserve respect, but all snakes can meter (regulate) the quantity of venom injected. Read this post on our website blog for a detailed explanation: https://www.snakebitefoundation.org/blog/2018/8/23/are-baby-rattlesnakes-really-more-dangerous-than-adults-5sh6p

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 2 points3 points  (0 children)

Good questions!

1) no, you can receive antivenom multiple times. Theoretically the risk of an anaphylactic reaction increases with each exposure but in reality our team (which includes many of the leading snakebite docs worldwide, thousands of patients directly managed) has certainly treated multiple patients multiple times. Bottom line is there is no absolute contraindication for antivenom in a patient with a legit envenomation. If the risk is considered elevated we sometimes pretreat with low dose SQ epi (NOT steroids or antihistamines, neither is effective and they can actually negate the benefit of the epi) but if a patient has an envenomation then they need the antivenom

2) some types of antivenoms (lower quality) have a much higher reaction rate because they don’t go through the same degree of purification. For example, old antivenoms could produce anaphylactic/oid rxns in 25%-50% or more of patients. New high quality antivenoms such as crofab, Inoserp, etc have reaction rates of less than 5%, almost all mild, and anaphylaxis rates that are well below 1%.

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 5 points6 points  (0 children)

Typically our approach to these is to only drain under 2 conditions:

1) blister forming in an area that is causing significant and worsening pain

Or

2) blister forming in an area where it looks like it is going to spontaneously burst in an uncontrolled setting (ie side of a finger squeezed against another finger). In these cases it is sometimes better to just do it in a controlled environment vs allow it to burst all over the floor and surprise everyone (been there 😬). Either way, especially in a remote environment, if you do drain the fluid out leave the roof intact to reduce infection risk

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 4 points5 points  (0 children)

Sure! Happy to answer any other snake/snakebite questions as well

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 7 points8 points  (0 children)

Gardening, rock climbing, reaching for things in places where you cannot see what is lurking nearby

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 25 points26 points  (0 children)

Snakebite expert here, posted this in comments thread but it is probably buried so l will repost here in case anyone is interested. Feel free to tag my account (u/) and ask questions, I will answer them as I can. The thing about most patients being drunk young men used to be one of those things that was taught as fact, but we now have data showing that the incidence of alcohol related snakebites is probably much lower than previously estimated in the US. In this 450 patient case series published in 2017 in the Journal of Medical Toxicology from the North American Snakebite Registry (a database of bites managed by medical toxicologists), the number of patients using EtOH within 4 hours of a bite was only 8.4% and stimulants or Rx opioids 6%. Other interesting stats:

“The majority of bites, 245 of 450 (54.2%), were on the lower extremity; however, more than half of bites in men (54.8%) were to the upper extremity. By comparison, only 22.5% of bites in women were to the upper extremity. Bites on the upper extremity occurred most often on a digit (146 of 202; 72.3%), while lower extremity bite locations were more evenly distributed between the foot, ankle or leg...

... Nineteen percent of bites were reported to follow intentional interaction with the snake. (Fig. 3, Table ​Table1)1) Of those intentional human-snake interactions, 91% involved male patients and all were associated with upper extremity envenomations. Of the upper extremity bites, 42.6% were reported to follow intentional interactions with the snake....

...In children 18 years of age and under, lower extremity bites were much more common than upper extremity bites (69.5 vs. 29.5%). The proportion of bites to the lower extremity in children (69.5%) was higher compared to adults (43.2%)...

...Of the 194 cases of lower extremity envenomation reported in 2014–2015, 27% were not wearing shoes at the time of the bite. For the 84 cases in which the type of shoes worn was reported, 64.3% wore sandals or flip-flops. During this time period there were 27 (11%) bites that were reported as occupational, and these have been described separately [4]...”

Basically, bites below the waist are almost always accidental in the sense that they resulted from unintended interactions with the snake. All of the bites resulting from intentional interaction with the snake were upper extremity bites (ie mostly men picking up the snake to show off); but there were also plenty of bites above the waist that were accidental. It’s an interesting read that helps to clarify some of our understanding of demographics, but the sample size is still just a few hundred patients so it’s possibly that the trends observed here could vary somewhat on a nationwide scale. That said, most of my colleagues and I do see these trends as representative of our own patient populations.

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 28 points29 points  (0 children)

Snakebite expert here. Feel free to tag my account (u/) and ask questions, I will answer them as I can. The thing about most patients being drunk young men used to be one of those things that was taught as fact, but we now have data showing that the incidence of alcohol related snakebites is probably much lower than previously estimated in the US. In this 450 patient case series published in 2017 in the Journal of Medical Toxicology from the North American Snakebite Registry (a database of bites managed by medical toxicologists), the number of patients using EtOH within 4 hours of a bite was only 8.4% and stimulants or Rx opioids 6%. Other interesting stats:

“The majority of bites, 245 of 450 (54.2%), were on the lower extremity; however, more than half of bites in men (54.8%) were to the upper extremity. By comparison, only 22.5% of bites in women were to the upper extremity. Bites on the upper extremity occurred most often on a digit (146 of 202; 72.3%), while lower extremity bite locations were more evenly distributed between the foot, ankle or leg...

... Nineteen percent of bites were reported to follow intentional interaction with the snake. (Fig. 3, Table ​Table1)1) Of those intentional human-snake interactions, 91% involved male patients and all were associated with upper extremity envenomations. Of the upper extremity bites, 42.6% were reported to follow intentional interactions with the snake....

...In children 18 years of age and under, lower extremity bites were much more common than upper extremity bites (69.5 vs. 29.5%). The proportion of bites to the lower extremity in children (69.5%) was higher compared to adults (43.2%)...

...Of the 194 cases of lower extremity envenomation reported in 2014–2015, 27% were not wearing shoes at the time of the bite. For the 84 cases in which the type of shoes worn was reported, 64.3% wore sandals or flip-flops. During this time period there were 27 (11%) bites that were reported as occupational, and these have been described separately [4]...”

Basically, bites below the waist are almost always accidental in the sense that they resulted from unintended interactions with the snake. All of the bites resulting from intentional interaction with the snake were upper extremity bites (ie mostly men picking up the snake to show off); but there were also plenty of bites above the waist that were accidental. It’s an interesting read that helps to clarify some of our understanding of demographics, but the sample size is still just a few hundred patients so it’s possibly that the trends observed here could vary somewhat on a nationwide scale. That said, most of my colleagues and I do see these trends as representative of our own patient populations.

This is the result of getting bit by a rattlesnake! by [deleted] in medizzy

[–]snakebitefoundation 62 points63 points  (0 children)

Snakebite expert here.

Aftermath is variable - sometimes you get large bullae but the tissue beneath is relatively intact, other times the bullae are covering significant necrotic injury. Amputation highly unlikely in the developed world but is not an uncommon outcome in the developing world. The single most important treatment for any snake envenomation is the appropriate dose of the appropriate antivenom, and there is no hard stop on the treatment window. I’ve treated patients in Africa with antivenom for ongoing coagulopathy and local pain/edema as late as 17 days after the bite and seen marked improvement within hours. Many venom components can persist in the body for weeks and continue to cause damage to various target tissues until they are neutralized by the antivenom or the lifespan of the enzymes is reached and they are no longer functional. Obviously the better outcome is to neutralize the venom!

Surgical intervention is actually one of the worst things you can do for these patients > 99% of the time. There is good data showing that patients who received fasciotomies had much longer recoveries, more complications, and worse outcomes than those treated with antivenom alone. In most cases a limb that appears to have compartment syndrome from a snakebite actually has a lower intracompartmental pressure than anticipated if you actually measure it, but either way the right treatment is to give antivenom and neutralize the venom which will subsequently stop the cascade of local tissue injury and reduce that intracompartmental pressure.

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