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Myths About Treatment

Myths About Treatments for North American Pit Viper Envenomation

Time Is Tissue.


In the event of a venomous snakebite, it can be just as important to know what NOT to do.

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Avoid the following actions in the event of a pit viper envenomation:

  • Tourniquets 
  • Extraction devices (cutting or applying suction to the bite site) 
  • NSAIDs 
  • Steroids (except for allergic phenomena) 
  • Electric shock (e.g., tasers/electricity) 
  • Routine use of blood products 
  • Debridement and fasciotomy 
  • Ice/cold packs on the affected area 
  • Prophylactic antibiotics 

When It Comes to Snake Envenomation, It Helps to Know Fact From Fiction

Expand each myth below to reveal more accurate facts about envenomation.

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Myths

    Fact: 98% of venomous snakebites in the United States are from North American pit vipers, including copperheads, cottonmouths, and rattlesnakes.  CroFab is specifically designed to contain a spectrum of venom-specific protein (Fab) fragments targeting the range of complex toxins found in North American pit viper venoms.  Therefore, treatment should not be delayed in an attempt to identify the species of snake that caused the envenomation. 

    You must identify the species of snake that bit the patient.

      Fact: Although copperhead envenomation is rarely fatal, it can result in substantial pain and impaired function lasting several weeks. In some cases limb dysfunction may last up to a year or more. 

      Copperhead bites are not dangerous.

        Fact: Because of the potential harm associated with platelet dysfunction caused by NSAIDs, the use of NSAIDs as part of treating snakebites is generally not recommended. 

        Using nonsteroidal anti-inflammatory drugs (NSAIDs) is part of treatment for snakebites.

          Fact: With the widespread availability of safe antivenom, any form of debridement or fasciotomy is rarely needed and not beneficial to the patient. 

          Debridement and fasciotomy are appropriate treatment options for the snakebite patient.

            Fact: Applying ice to a venomous snakebite appears to be ineffective. Aggressive cryotherapies (such as ice water immersion) are ineffective, as well, and have been associated with severe tissue injury.  The use of tourniquets is also ineffective and potentially harmful when used to treat snakebite envenomations. 

            Applying ice or tourniquet will slow the venom progression.

              Fact: The potential risk of antibiotics (i.e., allergic reactions, formation of drug-resistant bacteria) outweigh the benefit in the snakebite patient; therefore, use of antibiotics is not recommended. 

              Due to the puncture wound by the snakebite, antibiotics must be given.

              To learn how experts recommend treating pit viper envenomation, view the Unified Treatment Algorithm.

              Watch Dr. Arnold discuss why he considers surgical intervention a last resort.

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              Recommendations for the management of North American pit viper envenomation

              Launch Treatment Algorithm
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              Appropriate dosing achieves initial and sustained control of envenomation 

              Learn How to Dose CroFab
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              Real-world use supports improved outcomes with CroFab 

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              References

              1. Lavonas EJ, Ruha A-M, Banner W, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med. 2011;11:2.

              2. Amaral CF, Campolina D, Dias MB, Bueno CM, Rezende NA. Tourniquet ineffectiveness to reduce the severity of envenoming after Crotalus durissus snake bite in Belo Horizonte, Minas Gerais, Brazil. Toxicon. 1998;36(5):805-808

              3. Corbett B, Clark RF. North American Snake Envenomation. Emerg Med Clin North Am. 2017;35(2):339-354.

              4. Domanski K, Kleinschmidt KC, Greene S, et al. Cottonmouth snake bites reported to the ToxIC North American snakebite registry 2013-2017. Clin Toxicol (Phila). 2020;58(3):178-182.

              5. Toschlog EA, Bauer CR, Hall EL, Dart RC, Khatri V, Lavonas EJ. Surgical considerations in the management of pit viper snake envenomation. J Am Coll Surg. 2013;217(4):726-735.

              6. Frank HA. Snakebite or frostbite: what are we doing? An evaluation of cryotherapy for envenomation. Calif Med. 1971;114(5):25-27.

              7. Ruha AM, Kleinschmidt KC, Greene S, et al. The epidemiology, clinical course, and management of snakebites in the North American Snakebite Registry. J Med Toxicol. 2017;13(4):309-320.

              8. LoVecchio F, Klemens J, Welch S, Rodriquez R. Antibiotics after rattlesnake envenomation. J Emerg Med. 2002;23(4):327-328.

              9. Gummin DD, Mowry JB, Beuhler MC, et al. 2019 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 37th Annual Report. Clin Toxicol (Phila). 2020;58(12):1360-1541.

              10. CroFab®. Prescribing information. BTG International Inc.; August 2018.

              11. Lavonas EJ Gerardo CJ; Copperhead Snakebite Recovery Outcome Group. Prospective study of recovery from copperhead snake envenomation: an observational study. BMC Emerg Med. 2015;15:9.

              Indication and Important Safety Information
              Indication

              CroFab® Crotalidae Polyvalent Immune Fab (Ovine) is a sheep-derived antivenin indicated for the management of adult and pediatric patients with North American crotalid envenomation. The term crotalid is used to describe the Crotalinae subfamily (formerly known as Crotalidae) of venomous snakes which includes rattlesnakes, copperheads and cottonmouths/water moccasins.

              Important Safety Information
              Contraindications

              Do not administer CroFab® to patients with a known history of hypersensitivity to any of its components, or to papaya or papain unless the benefits outweigh the risks and appropriate management for anaphylactic reactions is readily available.

              Warnings and Precautions

              Coagulopathy: In clinical trials, recurrent coagulopathy (the return of a coagulation abnormality after it has been successfully treated with antivenin), characterized by decreased fibrinogen, decreased platelets, and elevated prothrombin time, occurred in approximately half of the patients studied; one patient required re-hospitalization and additional antivenin administration. Recurrent coagulopathy may persist for 1 to 2 weeks or more. Patients who experience coagulopathy due to snakebite should be monitored for recurrent coagulopathy for up to 1 week or longer. During this period, the physician should carefully assess the need for re-treatment with CroFab® and use of any type of anticoagulant or anti-platelet drug.

              Hypersensitivity Reactions: Severe hypersensitivity reactions may occur with CroFab®. In case of acute hypersensitivity reactions, including anaphylaxis and anaphylactoid reactions, discontinue infusion and institute appropriate emergency treatment. Patients allergic to papain, chymopapain, other papaya extracts, or the pineapple enzyme bromelain may also have an allergic reaction to CroFab®. Follow-up all patients for signs and symptoms of delayed allergic reactions or serum sickness (e.g., rash, fever, myalgia, arthralgia).

              Adverse Reactions

              The most common adverse reactions (incidence ≥ 5% of subjects) reported in the clinical studies were urticaria, rash, nausea, pruritus and back pain. Adverse reactions involving the skin and appendages (primarily rash, urticaria, and pruritus) were reported in 12 of the 42 patients. Two patients had a severe allergic reaction (severe hives and a severe rash and pruritus) following treatment and one patient discontinued CroFab® due to an allergic reaction. Recurrent coagulopathy due to envenomation and requiring additional treatment may occur.

              Please see full Prescribing Information.