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ACMT Toxicology Visual Pearls: Exotic Viper Envenomation


exotic snake envenomation

A man was bitten twice on the dorsal radial aspect of his right hand while feeding his pet West African Bush Viper. The patient immediately tied multiple tourniquets around his right arm before presenting to the emergency department. During examination he is complaining of swelling and severe pain in his right upper extremity, but has no other complaints. What are the appropriate next steps in managing this patient?

  1. Apply ice to the bites
  2. Measure compartment pressures in the right arm and forearm
  3. Perform a fasciotomy
  4. Remove the tourniquets and order hematologic studies
  5. Use a venom extractor to reduce venom burden

Reveal the Answer
The American College of Medical Toxicology (ACMT) hosts this Toxicology Visual Pearls series
Top L, Tulleken J, Ligtenberg J, Meertens J, van der, Zijlstra J. Serious envenomation after a snakebite by a Western bush viper (Atheris chlorechis) in the Netherlands: a case report. Neth J Med. 2006;64(5):153-156. [PubMed]
American C. Abstracts from the 2017 American College of Medical Toxicology (ACMT) Annual Scientific Meeting. J Med Toxicol. 2017;13(1):3-46. [PubMed]
Gold B, Dart R, Barish R. Bites of venomous snakes. N Engl J Med. 2002;347(5):347-356. [PubMed]
Hall E. Role of surgical intervention in the management of crotaline snake envenomation. Ann Emerg Med. 2001;37(2):175-180. [PubMed]
Tanen D, Danish D, Grice G, Riffenburgh R, Clark R. Fasciotomy worsens the amount of myonecrosis in a porcine model of crotaline envenomation. Ann Emerg Med. 2004;44(2):99-104. [PubMed]
Alberts M, Shalit M, LoGalbo F. Suction for venomous snakebite: a study of “mock venom” extraction in a human model. Ann Emerg Med. 2004;43(2):181-186. [PubMed]
Bryan Judge, MD, FACMT

Bryan Judge, MD, FACMT

Associate Professor of Emergency Medicine
Michigan State University College of Human Medicine
Bryan Judge, MD, FACMT

Latest posts by Bryan Judge, MD, FACMT (see all)

  • Meghan Spyres

    Great to highlight a snakebite case as we enter the season for native envenomations. As a caveat my experience is primarily in native pit viper (rattlesnake) envenomations.

    A few additions:
    -With regards to initial management, immobilization and elevation of the extremity should be first steps in the ED. If the limb is left in a depended position, venom will pool and worsen local tissue toxicity. This management of course doesn’t apply to exotic neurotoxic snake species.
    -I love that the rarity of compartment syndrome is emphasized here. Just know that although rare, a true compartment syndrome can occur. If suspected, first steps would be elevation of extremity, measurement of compartment pressures, and administration of antivenom (Crofab for native pit vipers). Antivenom alone may be effective, but surgical fasciotomy may be required in extreme cases.
    -And please remember, although antivenom may not be available for this exotic case, in native pit viper envenomations, antivenom is available and indicated for signs of local toxicity or thrombocytopenia or coagulopathy.

  • Bryan Judge

    Thank you for your salient treatment tips below, especially the important first steps of immobilization and elevating an affected limb after envenomation, with the exception of exotic neurotoxic snakes.