Snake Bite in Children: Approach & Management Learning Tool

Clinical History Assessment

Systematic approach to history taking for a child presenting with suspected snakebite

Physical Examination Guide

Systematic approach to examining a child with suspected snakebite

Diagnostic Approach

Initial Assessment

For a child presenting with suspected snakebite, the initial assessment should include:

• Detailed history of the bite circumstances, time elapsed, and symptoms progression
• Complete physical examination focusing on the bite site and systemic manifestations
• Assessment of vital signs and level of consciousness
• Evaluation of bite site for local envenomation signs

Classification of Snakebite Envenomation

Different classifications of envenomation severity help guide management:

Severity	Local Manifestations	Systemic Manifestations
No Envenomation (Dry bite)	Fang marks only, minimal pain, minimal swelling	No systemic symptoms, normal laboratory values
Mild Envenomation	Swelling around bite site (1-5 cm), local pain, no ecchymosis	Minimal or no systemic symptoms, mild laboratory abnormalities
Moderate Envenomation	Progressive swelling (5-15 cm), ecchymosis, moderate pain	Systemic symptoms present but not life-threatening, moderate laboratory abnormalities
Severe Envenomation	Rapidly spreading swelling (>15 cm), severe pain, tissue necrosis	Life-threatening systemic symptoms, severe coagulopathy, neurotoxicity, or rhabdomyolysis

Toxidrome Recognition by Snake Type

Snake Family	Common Examples	Characteristic Features
Viperidae (Pit Vipers)	- Rattlesnakes - Copperheads - Cottonmouths	- Prominent local tissue effects (edema, ecchymosis) - Coagulopathy (prolonged PT/PTT, decreased fibrinogen) - Thrombocytopenia - Hypotension in severe cases - Rhabdomyolysis possible
Elapidae (Coral Snakes, Cobras)	- Coral snakes - Cobras - Mambas - Kraits	- Minimal local tissue effects - Prominent neurotoxicity (ptosis, diplopia) - Bulbar involvement (dysphagia, dysarthria) - Respiratory paralysis - Descending flaccid paralysis
Atractaspididae (Burrowing Asps)	- Burrowing asps - Stiletto snakes	- Local pain and swelling - Local necrosis - Cardiac conduction abnormalities - Rarely systemic effects
Hydrophiidae (Sea Snakes)	- Sea snakes - Marine cobras	- Minimal local reaction - Myotoxicity/rhabdomyolysis - Myoglobinuria - Neurotoxicity - Acute kidney injury

Differential Diagnosis

Condition	Features	Distinguishing Factors
Other Venomous Bites/Stings	- Spider bites - Scorpion stings - Marine envenomations	- Different bite/sting pattern - Different progression of symptoms - Different geographic distribution
Non-venomous Snake Bite	- Puncture marks may be present - Local pain - Minimal swelling	- No progression of symptoms - No systemic manifestations - Normal laboratory values
Cellulitis/Soft Tissue Infection	- Local inflammation - Erythema and swelling - Tenderness	- No history of bite - Slower onset - No coagulopathy or neurotoxicity
Allergic Reaction	- Urticaria - Angioedema - Respiratory distress	- More rapid onset - Often history of allergen exposure - Different distribution of symptoms
Trauma or Puncture Wound	- Local pain - Potential bleeding - Wound edges visible	- Clear trauma history - No progression beyond local area - No systemic effects

Laboratory Studies

Initial and follow-up laboratory studies for suspected envenomation:

Investigation	Clinical Utility	When to Consider
Complete Blood Count	Assess for thrombocytopenia, hemolysis, leukocytosis	All suspected envenomations; repeat q6h in moderate to severe cases
Coagulation Studies (PT/PTT, INR, Fibrinogen)	Detect coagulopathy and monitor response to antivenom	All viper bites; repeat q6h until stable then q24h
Basic Metabolic Panel	Assess electrolytes, renal function	All moderate to severe envenomations
Urinalysis	Check for hematuria, myoglobinuria, proteinuria	All moderate to severe envenomations
Creatine Kinase	Assess for rhabdomyolysis	Sea snake bites, severe viper bites

Advanced Studies

Reserve for specific scenarios or severe presentations:

Investigation	Clinical Utility	When to Consider
Electrocardiogram	Detect cardiac conduction abnormalities	Patients with chest pain, palpitations, or hypotension
Venom-Specific ELISA	Identify snake species, confirm envenomation	When available and species identification is unclear
Ultrasound of Bite Site	Evaluate for compartment syndrome, abscess	Severe local swelling, concern for compartment syndrome
Chest X-ray	Assess for pulmonary edema, aspiration	Respiratory symptoms, suspected aspiration
Type and Cross	Prepare for potential transfusion	Severe coagulopathy, active bleeding, anemia

Diagnostic Algorithm

A stepwise approach to diagnosing and assessing snakebite severity:

1. Confirm snakebite through history and physical examination of the bite site
2. Identify snake species if possible (photo, description, geographic location)
3. Mark the leading edge of swelling/erythema and reassess every 15-30 minutes
4. Obtain baseline laboratory studies appropriate for suspected snake type
5. Monitor for systemic manifestations including vital sign changes, bleeding, neurotoxicity
6. Classify severity of envenomation based on local and systemic findings
7. Reassess frequently as envenomation may progress over hours
8. Consider consultation with toxicology or regional poison center for complex cases

Management Strategies

General Approach to Management

Key principles in managing pediatric snakebite:

• Rapid assessment and stabilization: Prioritize ABCs (Airway, Breathing, Circulation)
• Early consultation: Contact regional poison center or toxicologist
• Timely antivenom administration: For moderate to severe envenomation
• Frequent reassessment: Envenomation may progress rapidly in children
• Age-appropriate support: Consider the psychological impact on children
• Weight-based dosing: Adjust all medications including antivenom for pediatric patients

Initial Measures and First Aid

Intervention	Description	Evidence Level
Remove Constrictive Items	- Remove rings, watches, tight clothing - Anticipate swelling progression	Strong recommendation; good clinical practice
Immobilization	- Splint bitten extremity - Keep extremity at level of heart - Limit patient movement	Moderate; reduces venom spread via lymphatics
Wound Care	- Clean bite site with soap and water - Apply sterile dressing - Mark edge of swelling/erythema	Moderate; reduces infection risk and helps monitor progression
Recommended Transport Method	- Carry child rather than allowing walking - Rapid transport to medical facility - Keep child calm	Moderate; limits venom spread and minimizes complications
Harmful Practices to Avoid	- NO cutting or incising wound - NO suction or extraction devices - NO tourniquets - NO ice or heat application - NO application of electric shocks	Strong; evidence of harm from these interventions

Pressure Immobilization Technique

Snake Type	Technique	Evidence and Considerations
Elapids (Neurotoxic Venoms)	- Apply elastic bandage over bite site - Wrap entire limb at lymphatic pressure (40-70 mmHg) - Apply splint - Keep patient still	- Moderate evidence supporting use - Delays systemic absorption of neurotoxins - Most beneficial for elapid bites - Apply promptly after bite
Viperids (Cytotoxic Venoms)	- NOT recommended - May increase local tissue damage	- May worsen local tissue injury - Can increase compartment pressure - Potential to increase necrosis - Contraindicated in cytotoxic envenomation

Antivenom Therapy

Consideration	Approach	Pediatric Considerations
Indications	- Progressive local effects - Systemic symptoms - Laboratory abnormalities (coagulopathy, thrombocytopenia) - Moderate to severe envenomation	- Same indications as adults - Lower threshold due to smaller body mass - Consider more rapid progression in children - Early intervention often beneficial
Dosing	- Based on severity, not weight or age - Initial dose: typically 4-6 vials for moderate envenomation - Severe cases may require 10+ vials initially - Additional vials based on clinical response	- Same vial dose as adults regardless of size - Venom amount, not patient size, determines dose - May need higher dose per kg than adults - Careful monitoring during administration
Administration	- Premedication considerations - Initial doses intravenously - Infusion over 1 hour if no reaction - Continuous monitoring during infusion	- Ensure appropriate IV access - Monitor closely for reactions - Age-appropriate monitoring equipment - Prepare for potential reactions
Monitoring Response	- Assess cessation of progression - Monitor coagulation studies - Follow neurological status - Additional dosing if progression continues	- Reassess every 15-30 minutes - Serial laboratory studies - Document limb circumference - Age-appropriate neurological assessment

Managing Acute Complications

Complication	Management Approach	Pediatric Considerations
Coagulopathy/Bleeding	- Antivenom as primary treatment - Blood products only for significant bleeding - Avoid invasive procedures if possible - Serial coagulation studies	- Lower blood volume increases risk - Age-specific normal values - Monitor hemoglobin closely - Weight-based blood product dosing
Neurotoxicity	- Antivenom administration - Respiratory support as needed - Frequent neurological assessment - Anticipate need for ventilation	- Respiratory deterioration may be rapid - Lower threshold for intubation - Size-appropriate equipment - Careful monitoring of respiratory effort
Compartment Syndrome	- Elevate limb - Antivenom as primary treatment - Measurement of compartment pressures - Surgical consultation if confirmed	- Difficult to assess in anxious children - Lower threshold for objective measurements - Antivenom usually more effective than fasciotomy - Consider sedation for evaluation
Rhabdomyolysis/AKI	- IV hydration (1.5-2x maintenance) - Urinary alkalinization if severe - Monitor renal function and electrolytes - Consider renal replacement if severe	- Calculate fluid needs by weight - Monitor intake/output closely - Check for signs of fluid overload - Age-appropriate electrolyte management

Adverse Reactions to Antivenom

Reaction Type	Management	Pediatric Dose Considerations
Acute Hypersensitivity (Type I)	- Stop antivenom infusion - Epinephrine for anaphylaxis - Antihistamines - Corticosteroids - Resumption of antivenom at slower rate after stabilization	- Epinephrine: 0.01 mg/kg (1:1000) IM (max 0.3mg) - Diphenhydramine: 1-2 mg/kg IV/IM (max 50mg) - Methylprednisolone: 1-2 mg/kg IV - Age-appropriate resuscitation equipment
Serum Sickness (Delayed)	- Antihistamines - NSAIDs for mild symptoms - Corticosteroids for moderate to severe - Supportive care	- Prednisolone: 1-2 mg/kg/day PO (max 60mg) - Ibuprofen: 5-10 mg/kg/dose PO q6-8h - Monitoring for delayed presentation - Parent education on symptoms

Wound Management and Supportive Care

• Pain management: Weight-appropriate analgesics (avoid NSAIDs if coagulopathy present)
• Tetanus prophylaxis: Update as needed per standard guidelines
• Antibiotic therapy: Not routinely recommended unless signs of infection develop
• Wound care: Regular cleaning, elevation, and assessment
• Psychological support: Age-appropriate explanation and comfort measures

Discharge Criteria and Follow-up

• Observe minimum 8 hours: For suspected dry bites or minimal envenomation
• Observe minimum 24 hours: After antivenom administration and resolution of symptoms
• Laboratory parameters: Normalization or stable coagulation studies before discharge
• Local effects: Stable or improving local wound with no signs of progression
• Follow-up: Arrange 1-3 day follow-up for wound check and laboratory testing if indicated
• Education: Signs requiring return to hospital, wound care instructions, activity limitations
• Special considerations: Serum sickness risk (~7-10 days post-antivenom)

When to Refer or Transfer

• Higher level of care: Severe envenomation or complications requiring ICU support
• Specialist consultation: Access to pediatric critical care, toxicology, or surgical expertise
• Antivenom availability: Transfer if appropriate antivenom not available
• Specific complications: Respiratory compromise, severe coagulopathy, compartment syndrome
• Exotic snakes: Bites from non-native species requiring specialized antivenom