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Pit viper envenomation

Key sources
The following summarized guidelines for the evaluation and management of pit viper envenomation are prepared by our editorial team based on guidelines from the Wilderness Medical Society (WMS 2015).


1.Classification and risk stratification

Risk stratification: do not use prediction of the amount of envenomation from a snakebite or potential sequelae for risk stratification, because even a knowledgeable caregiver may not be able to predict it.
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2.Diagnostic investigations

Physical examination in the field
Observe local tissue effects which are the most common physical manifestations of pitviper envenomations and occur in > 90% of patients with medically significant envenomations.
Consider patients without local or systemic symptoms 8 hours after the bite as having a dry bite, if evacuation is difficult or prolonged.

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  • Assessment in the emergency department

  • Laboratory studies

  • Abdominal imaging

3.Medical management

Setting of care: hospitalize patients with moderate-to-severe envenomations.

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  • Antibiotic prophylaxis

  • Pain management

  • Tetanus prophylaxis

  • Antivenom

  • Management of secondary infection

4.Nonpharmacologic interventions

First aid: remove or cut jewelry or constrictive clothing near the bite to avoid constriction with subsequent swelling.
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  • Evacuation

5.Therapeutic procedures

Interventions to avoid: avoid interventions that are harmful or without benefit:
oral suction
mechanical suction
laceration or bleeding the bite site
electrotherapy or electrical currents
cryotherapy or cooling
tourniquet placement
pressure bandaging

6.Surgical interventions

Fasciotomy: consider fasciotomy in rare patients who fail to respond. Perform fasciotomy according to the decision made by a surgeon within 6 hours of signs of neurovascular compromise and elevated intracompartmental pressure despite appropriate administration of antivenom.

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  • Digital dermotomy

  • Wound care

7.Specific circumstances

Pregnant patients: administer antivenom in pregnant patients with snakebite, as indicated, and provide fetal assessment or monitoring as the fetus is at higher risk to coagulopathy-related complications, such as placental abruption.

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  • Pediatric patients

  • Critically ill patients

  • Allergic reactions

8.Follow-up and surveillance

Clinical deterioration: administer repeat doses of antivenom and arrange timely toxinologist or poison control center consultation if the clinical condition deteriorates.

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  • Monitoring before discharge

  • Discharge from hospital

  • Follow-up after discharge