Out-of-hospital and interhospital management of crotaline snakebite

Despite insufficient data for the development of evidence-based guidelines for the out-of-hospital treatment of crotaline snake envenomation, practical concerns dictate a rational approach based on existing information. Out-of-hospital care should focus on stabilization and rapid transport of the victim to a health care facility with the capability of antivenom administration. However, the out-of-hospital interval provides for the evaluation and management of the patients with snakebite. Out-of-hospital providers must be familiar with common first-aid techniques and be aware of their potential complications. Proven measures to slow systemic absorption are limited but should include immobilization of the bitten extremity in a neutral position in every case, and the patient should maintain strict bed rest. Constriction bands or pressure wraps placed on the wound at the scene and without vascular compromise should be left in place until arrival at a health care facility. Placement of a constriction band or pressure wrap (to delay systemic absorption of venom) can be considered for prolonged transport times or when the patient's condition is deteriorating. A suction device, if applied and functioning, should be left in place. Vital signs should be closely monitored to assess for hypotension as a sign of systemic toxicity. The extent of local swelling should be documented, and information regarding extent and progression of the envenomation syndrome should be relayed to the receiving hospital to expedite antivenom administration, if indicated. During interhospital transport of patients who have received or continue to receive antivenom, the patient should be monitored for allergic reactions to treatment and treated appropriately. Routine stocking of the existing horse serum antivenom product on ambulances is not recommended because of the extended length of time required to prepare the infusion and potential allergic complications. Antivenoms with improved side effect profiles may be better suited to use in the out-of-hospital setting in well-defined cases.