Poitonoui Snake% of iho VVor/c/ 



iiulit'ul ii>ii. l''(illi>\\ in;; liiU's liy tlit> Austniliiin 

 t'liipuls it mi^jlil li»' of viiliio ('V(Mi wlioii fjivi'ii ln' 

 yoiiil t'J hours foUowiii^j tlio hilo. 



Administnitioii of !iiiti\'i>iiiii is iiol a proccdtiic 

 willioiit ilaii^M'. Ill sonsitivp iiorsoiis i(s injec- 

 tion call 1)0 fatal. In pofsons witli a liistoiy <ir 

 oxtiMisivo alliM^jies it must bo injected uitli cx- 

 trenio caution. ovt>n in tlio pi'psonco of ;i lu-f^alivc 

 skin test. .\.|)proxiinately SO pcrccnl of one l;ii;;c 

 ujioup of Americans tested for horse serum sensi- 

 livity follo\\in<r rattlesnake hites had nejrative or 

 only slightly positive reactions. Twenty percent 

 of this ijrovi]) were subse((uently Irealed for de 

 laved sonim reactions; reactions were most 

 marked in tliose patients receiviiif]: '■'> vials or more 

 of antivenm. 



In patients sensitive to horse serum, desensitiza- 

 tion slioidd he carried out as indicated in the hro- 

 chure accompanyinir the antivenin, or according 

 to standard medical proce(hires for desensitiza- 

 tion. In liiose patients liavin^ a history of sensi- 

 tivity and a strone;ly ])f)sitive skin or conjunctival 

 test ('^ or 4+), antivenin should he withheld. 

 However, the physician will need to weigh the 

 risk of withholding the antivenin, against the 

 risk of death, when poisoning has occurred by 

 hirge mambas, kraits, cobras, or certain of the 

 Australian elapids. (See p. 23 regarding use of 

 corticosteroids.) .Vntivenin has lieen given to 

 very sensitive patients in a slow drip of physio- 

 logic saline, but oidy in a hospital where systemic 

 arterial and venous pressures and respirations 

 could be continuously monitored, and where an 

 electrocardiogram conld be watched. 



Blood Transfusions and Parenteral Fluids 



All severe cases of snake venom poisoning give 

 rise, early or late in the course of the disease, to 

 a decrease in blood flow. The shock seen im- 

 mediately following the severe bite by <i rattle- 

 snake is due to the pooling of blood in the pul- 

 monary circulation, and to a lesser extent in the 

 larger vessels of the thorax. In such cases, the 

 availability of blood to the heart and brain is 

 markedly reduced, and unless circulating blood 

 volume is restored, the patient may develop ir- 

 reversible tis.sue changes. "Wlien shock develops 

 late (12 to 72 hours) in the cour.se of the disease, 

 it is usually due to blood loss through liemorrhage. 

 The hemorrhage may be evident in the injured 



part, or it may 1h^ nuisked inl raperiloneally or 

 let roperiloncidly, or it may ()c<iir into the gas- 

 I roinleslinal, urinary, or ic^piraloiv tracts. 

 Pooling of blond in some organs imiy also lake 

 place and add l<i llie decI•eas(^ in circulating 

 \olume. ( '(ini'uniil ani wilh llioe rhanges, the 

 red blood cells may undergo lysis and fuilher 

 embarrass the cii'culat if)n. Tf) comliat these. 

 ell'ects, blood \oliinie and blood llnw must bo 

 maini ained. 



Parenteial (luid should always be given follow- 

 ing a se\ere envenomat ion. It may be necessary 

 to add a vasopressor drug to the soint ion. .V void 

 using corticosteroids, part icidarly if antivenin 

 has or is being administered. While plasma or 

 plasma expanders can be given, whole blood 

 should be administered if it is available. In cases 

 of crotalid and viperid venom poisoning, fresh 

 Mood is preferred, as the patient may be unable to 

 produce or circulate i)latelets. If. and when, 

 bleeding begins, the hematocrit may fall rapidly 

 necessitating a nund)er of transfusions. Ex- 

 change transfusions should be considered when 

 the clotting time is at infinity and the blood 

 picture displays no evidence nl' inipid\enient. 

 .Vs many as 25 pints of blood may need to be 

 C'i\-en to tin' \ictim of a severe I'attlesnal'.'e bit(>. 



Antibiotics 



A broad-s])ectrum antibiotic should be given 

 if the reaction to envenomation is severe. Since 

 the nature of the injury predisposes to infection, 

 and since pathogenic bacteria are likely to be 

 introduced into the wound, the use of an anti- 

 biotic seems justified. Should infection develop, 

 cultures and organism sensitivity tests will guide 

 subsequent antibiotic therapy. If there is exten- 

 sive skin damage, large doses of an antibiotic may 

 be needed. In such cases, repeated wound cul- 

 tures and blood counts are advisable. 



Tetanus Prophylaxis 



Since the members of the armed services have 

 been routinely immunized against tetanus, a 

 "booster shot" of tetanus toxoid shotild be given 

 upon admission. The use of gas gangrene anti- 

 toxin is not warranted. 



22 



