Rattlesnake envenomation to the face of an infant

Mortality from rattlesnake envenomation in the United States is rare. Despite approximately 8000 crotaline (pit vipers) bites annually, it is estimated that only 10 to 15 deaths occur. Besides direct intravascular envenomation and anaphylaxis, bites to the head and neck may account for some of these rare fatalities. We report a pediatric case of severe facial envenomation requiring emergent intubation and antivenom administration.

A 14-month-old female toddler was envenomated by a Southern Pacific rattlesnake (Crotalus viridis helleri) above the right upper lip while playing in her backyard. Rapid swelling and ecchymosis developed, and the patient was airlifted to a pediatric tertiary care hospital. Within 3 hours, stridorous respirations complicated by significant facial and oropharyngeal edema necessitated emergent orotracheal intubation. A total of 16 vials of FabAV [Crotalidae Polyvalent Immune Fab (ovine) antivenom] were administered over the next 24 hours. The child gradually improved and was successfully extubated 5 days later. A 3-month follow-up demonstrated no significant cosmetic facial abnormalities.

Crotaline bites to the head and neck have the potential for significant swelling and airway compromise. Facial bites, anaphylaxis, and rare intravascular envenomation may account for many of the fatalities from rattlesnake envenomation. Early intubation may be required to maintain airway patency.