182
SNAKE BITES
Tanen et al. • RATTLESNAKE ENVENOMATIONS IN ARIZONA
ing the diagnosis of a compartment syndrome in
one patient.
Hemorrhagic skin bullae occurred more fre-
quently after envenomations of the upper extrem-
Hemorrhagic skin bullae formation was not un- ities as compared with the lower extremities. The
common and in our study occurred at a signifi- need for operative procedures such as digital der-
cantly higher frequency in upper-extremity enven- motomy and fasciotomy was infrequent. The av-
omations. Bullae were usually unroofed at the erage length of hospital stay was less than 3 days.
bedside with subsequent pain relief after decom-
When children were compared with adults
pression of fluid. Bullae decompression was per- there was no clinical or statistically significant dif-
formed without regard to any underlying hemato- ference detected in the amount of antivenin in-
logic abnormalities.
fused, hematologic parameters, need for operative
It has been previously suggested that children procedures, or skin bullae formation.
may suffer greater morbidity than adults from rat-
References
tlesnake envenomations because of their smaller
mass, and that they would require higher doses of
antivenin.8,18–20 In dosing antivenin based on clin-
ical response, children and adults received similar
amounts of antivenin in our series, and we could
detect no difference in the frequency of hemato-
logic abnormalities or the frequency of local wound
complications when children were compared with
adults.
1. Litovitz TL, Klein-Schwartz W, Caravati EM, Youniss J,
Crouch B, Lee S: 1998 annual report of the American Associ-
ation of Poison Control Centers Toxic Exposure Surveillance
System. Am J Emerg Med. 1999; 17:435–87.
2. Kunkel DB, Curry SC, Vance MV, Ryan PJ. Reptile enven-
omations J Toxicol Clin Toxicol. 1984; 21:503–26.
3. Russell FE, Carlson RW, Wainschel J, Osborne AH. Snake
venom poisoning in the United States. Experience with 550
cases. JAMA. 1975; 233:341–4.
4. Hardy DL. Fatal rattlesnake envenomation in Arizona:
1969–1984. J Toxicol Clin Toxicol. 1986; 24:1–10.
5. Holstege CP, Miller MB, Wermuth M, Furbee B, Curry SC.
Crotalid snake envenomation. Crit Care Clin. 1997; 13:889–
921.
LIMITATIONS AND FUTURE QUESTIONS
6. Russell FE. Snake Venom Poisoning, 2nd ed. Great Neck,
NY: Scholium International, 1983.
7. Watt CH. Treatment of poisonous snakebite with emphasis
on digit dermotomy. South Med J. 1985; 78:694–9.
8. Wingert WA, Chan L. Rattlesnake bites in southern Cali-
fornia and rationale for recommended treatment. West J Med.
1988; 148:37–44.
9. Curry SC, Horning D, Brady P, Requa R, Kunkel DB, Vance
MV. The legitimacy of rattlesnake bites in central Arizona. Ann
Emerg Med. 1989; 18:658–63.
10. Downey DJ, Omer GE, Moneim MS. New Mexico rattle-
snake bites: demographic review and guidelines for treatment.
J Trauma. 1991; 31:1380–6.
11. Plowman DM, Reynolds TL, Joyce SM. Poisonous snake-
bite in Utah. West J Med. 1995; 163:547–51.
12. Bajwa SS, Markland FS, Russell FE. Fibrinolytic en-
zyme(s) in western diamondback rattlesnake (Crotalus atrox)
venom. Toxicon. 1980; 18:285–90.
13. Kitchens CS. Hemostatic aspects of envenomation by
North American snakes. Hematol Oncol Clin North Am. 1992;
6:1189–95.
Potential limitations of this report include our ret-
rospective collection of data by chart reviews. For
example, hematology studies were not always
drawn at the same time following envenomation in
all patients. Furthermore, our experience may not
apply to the bites of some rattlesnake species
found in other parts of the United States. For ex-
ample, thrombocytopenia by the timber rattle-
snake (not found in Arizona) frequently is refrac-
tory to treatment with Crotalidae Polyvalent
Antivenin. Finally, referral bias certainly explains
why almost all of our patients were envenomated,
and might have resulted in the transfer of more
seriously ill patients to our facility. Future similar
studies may clarify these issues.
14. La Grange RG, Russell FE. Blood platelet studies in man
and rabbits following Crotalus envenomation. Proc West Phar-
macol Soc. 1970; 13:99–105.
CONCLUSIONS
15. Russell FE. Snake venom poisoning in the United States.
Ann Rev Med. 1980; 31:247–59.
16. Lang DM. Anaphylactoid and anaphylactic reactions. Haz-
ards of beta-blockers. Drug Saf. 1995; 12:299–304.
17. Burgess JL, Dart RC. Snake venom coagulopathy: use and
abuse of blood products in the treatment of pit viper enven-
omation. Ann Emerg Med. 1991; 20:795–801.
18. Jurkovich GJ, Luterman A, McCullar K, Ramenofsky ML,
Curreri PW. Complications of Crotalidae antivenin therapy. J
Trauma. 1988; 28:1032–37.
19. Weber RA, White RR. Crotalidae envenomation in chil-
dren. Ann Plast Surg. 1993; 31:141–5.
The rattlesnake envenomations in Arizona typi-
cally involved adult males who were bitten on ex-
tremities. Most envenomations occurred between
April and September. There was no fatality, but
hematologic abnormalities and the administration
of antivenin were common. Antivenin administra-
tion was associated with anaphylactoid or imme-
diate hypersensitivity reactions in a third of our
patients, but these reactions were mild and easily
controlled.
20. Cruz NS, Alvarez RG. Rattlesnake bite complications in 19
children. Pediatr Emerg Care. 1994; 10:30–3.