Snake Bite Management

Initial Response and First Aid

• Rest and immobilize the bitten extremity to minimize venom spread, and remove constricting jewelry from the affected limb to prevent complications from swelling, as recommended by the American Heart Association 1
• Keep the victim calm to reduce heart rate and slow venom circulation, and position the bite site at or below heart level, as suggested by the American Heart Association 1
• Avoid the application of ice, suction devices, electric shock, and tourniquets, as they may cause tissue injury or worsen local tissue injury, according to the American Heart Association 1
• Do not use pressure immobilization bandaging for North American pit vipers, as it may worsen tissue injury, as recommended by the American Heart Association 1

Medical Treatment

• Antivenom is the cornerstone of treatment for venomous snake bites, according to the American College of Cardiology, and should be administered in a hospital setting with an initial dose of 4-6 vials as soon as possible after envenomation, followed by additional doses until initial control is achieved, as supported by evidence from the Annals of Emergency Medicine 2, 1
• Pit viper venom can cause tissue injury, low blood pressure, bleeding, and muscle fasciculations leading to paralysis, and can present with fang marks, local pain and swelling, progressive tissue injury, systemic symptoms, coagulopathy, neurotoxicity, and potential renal failure, according to the American Heart Association 1
• Perform complete blood count, coagulation studies, renal function tests, electrolytes, and cardiac monitoring to assess for hemolysis, anemia, coagulopathy, and acute kidney injury, as recommended by the American College of Emergency Physicians 3, 4
• Clean the wound with sterile normal saline, remove superficial debris if present, and avoid deep debridement unless absolutely necessary, according to the Infectious Diseases Society of America 5
• Leave infected wounds open and consider referral to plastic surgery for facial wounds, as recommended by the Infectious Diseases Society of America 5
• Continue elevation of the affected limb if swelling persists, using passive elevation methods such as a sling for outpatients, as suggested by the Infectious Diseases Society of America 5

Fluid Management and Renal Care

• Initiate aggressive fluid resuscitation with normal saline at an initial rate of 1000 ml/h, then taper by at least 50% after 2 hours, while avoiding potassium-containing balanced salt fluids due to the risk of hyperkalemia, as recommended by the American Society of Nephrology 6, 7
• Obtain immediate electrolytes, acid-base status, creatinine, and blood urea nitrogen in patients with nephrology emergencies, and use point-of-care devices when standard laboratory infrastructure is unavailable, as recommended by the Kidney International 7
• Monitor for hyperkalemia, which requires urgent treatment, according to the Kidney International guidelines 7
• Treat severe hyperkalemia (>6.5 mmol/L or ECG changes) with IV calcium gluconate, insulin, and glucose, and consider emergency dialysis if refractory, as emphasized by the Kidney International 7

Long-term Follow-up and Emergency Planning

• Have an emergency plan in place that includes fluid management protocols, contact information for specialists, and clear instructions for emergency medical personnel, as recommended by the American College of Nephrology 8, 7
• Each patient should have an emergency plan, including a medical alert bracelet, and should be treated in specialized centers with experience or under consultation with expert centers, as recommended by the Nature Reviews Nephrology and Kidney International 8, 7
• Long-term follow-up is essential, as up to 41% of patients may show persistent renal involvement, and there is a risk of progression to chronic kidney disease in approximately 5-20% of cases, as emphasized by the Kidney International 7