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Management of Pediatric Snake Bites: Are We Doing Too Much?

Saturday, October 26, 2013
Windermere Ballroom X (Hyatt Regency Orlando, formerly the Peabody)
Jesus A. Correa, BA1, Sara C. Fallon, MD1, Andrea T. Cruz, MD, MPH2, Glenda A. Grawe, M.D.3, Phong V. Vu, MD3, Brent Kaziny, MD3, Daniel M. Rubalcava, MD3, Bindi J. Naik-Mathuria, MD1 and Mary L. Brandt, MD, FAAP1, (1)Texas Children's Hospital Trauma Program, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, (2)Pediatrics, Section of Emergency Medicine & Infectious Disease, Baylor College of Medicine, Houston, TX, (3)Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medcine, Houston, TX

Purpose

Snake bite injuries are a common cause of presentation to a children's emergency department, particularly in the southwest region. Despite the incidence, the optimal management of children with snake bites is not well defined, particularly with regards to antivenom administration, diagnostic tests, and antibiotic use. The study aim was to review the utility of these interventions in children with exposure to venomous snakes in order to design an institutional management algorithm.

Methods

We performed a retrospective single-center review of all children (0-18 years old) injured by snake bite from 1/2006-6/2012. Patients were identified through their injury code in a prospectively maintained trauma database. Data collected included patient demographics, injury characteristics, and hospital interventions.  The severity of injury was scored using a novel 4-point scale based on initial physical examination at our hospital (Figure 1). 

Results

One hundred fifty-one children (mean age 8.4±4.3 years) were identified; there were no deaths. Lower (60%) and upper (38%) extremity injuries were the most common. Most bites were from copperheads (43%). The median hospital stay for admitted patients (79%) was 2 days (range 1-7). Four patients required surgery: two fasciotomies, one skin graft, and one debridement.  Fifty-two children (34%) received antivenom, with one allergic reaction; none had serum sickness. 46% of patients who received antivenom had wound scores <3. Outcomes related to wound score are given in Table 1. Eighteen of 135 (13%) tested patients were coagulopathic; none had wound class of 1 or 2. No patients had evidence of thrombocytopenia <100,000U/L. While antibiotic use increased according to the wound severity, antivenom administration was evenly distributed by wound score.

Conclusion

Despite a high rate of envenomated bites, significant morbidity and systemic illness are rare.  Children with a wound score of 1 or 2 are unlikely to be coagulopathic, suggesting that laboratory investigation should be reserved for patients with higher scores.  Antivenom use deserves further prospective study, as its administration may be the most beneficial when limited to patients with the most severe wounds or with early wounds with the potential for progression.

Figure 1:

Table 1—Resource Utilization by Wound Score

Interventions

Wound Score 1

(n=14)

Wound Score 2

(n=51)

Wound Score 3

(n=72)

Wound Score 4

(n=14)

Complete Blood Count

64%

83%

89%

85%

Platelets <100,000

0%

0%

0%

0%

PT/PTT/INR

71%

86%

93%

100%

INR>1.5, PT>15, PTT>40

0%

0%

17%

43%

Creatinine Kinase (CK)

14%

12%

28%

50%

Abnormal CK

0%

0%

5%

0%

IV antibiotics

14%

39%

54%

71%

Antivenom

36%

37%

32%

36%

All labs +  IV antibiotics  + Antivenom

7%

10%

22%

21%