Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, June 21, 2007

Not Something You See Every Day

A lady called to make an appointment for a hospital follow-up. Sure; what had she been in the hospital for?

She had been bitten by a snake.

A copperhead had apparently been lounging on her driveway at night as she walked her dogs. It was pitch black, which was why she hadn't seen it (although notice how incredibly well they blend in with their surroundings:)
In fact, she was grateful that it was she who was bitten and not one of her dogs, for whom the bite would surely have been fatal.

The pain was severe and almost immediate. At the hospital, she told me the ER doc said to her, "I have no idea how to treat you." He got on the phone to Poison Control and they basically talked the medical staff through her care for the entire three days she was in the hospital. (Nothing wrong with that, by the way.)

So as a semi-public service to others (like me) unfamiliar with the treatment of venomous snakebite, the basics of copperhead bite management can be found here.

It turns out that the risks of antivenin (anaphylaxis and serum sickness) are significant enough to render it useful only in "severe" envenomations, ie, edema and erythema reaching the trunk, or systemic symptoms or laboratory abnormalities (consumptive coagulopathy, etc.)

I saw her five days post-bite. Her entire lower leg was green and swollen, but not nearly as swollen as it had been, she told me. She was worried about the green. I explained hemolysis, so she was quick to pick up on the idea of "soft tissue bruising." There was still a fair amount of pain, especially when she let the leg hang down after it had been elevated. She described a "whoosh" of pain, as if the blood rushing to her leg were fire. It did not sound fun.

In addition to continuing elevation of the leg and offering pain medicine, I'd recommend adding outdoor illumination to the driveway. The moral of the story, as always, is "watch where you step." (edit: She told me she's getting a pair of knee-high snake boots just as soon as the swelling goes down enough to try them on. They're hideous, but she doesn't care. And she's not going anywhere near the driveway where she was bitten without them.)

9 Comments:

At Wed Jun 20, 11:28:00 PM, Blogger Ambulance Driver said...

Yeah, unless it's a severe envenomation, we usually don't bother. And a surprisingly high number of crotalid bites are dry bites, without envenomation. Of the thousands of people bitten every year in the US, usually less than a dozen die.

Around here, water moccasin bites are common. Those bites are NASTY. Lots more tissue loss than you see with rattlesnakes or copperheads.

 
At Thu Jun 21, 09:59:00 AM, Blogger Voter Mom said...

Scary!!!
Tell me that snake wasn't in my neighborhood ...please!

 
At Thu Jun 21, 02:07:00 PM, Blogger The MSILF said...

Holy crap! I wish you had a picture of the leg!

 
At Thu Jun 21, 04:38:00 PM, Blogger Cheesy Knit Wit said...

That is very scary. Thanks for the link as we have copperheads and timber rattlers where I live.

 
At Thu Jun 21, 06:52:00 PM, Blogger #1 Dinosaur said...

Voter Mom: Not in your neighborhood, but not all that far either. (Close to the park.)

 
At Fri Jun 22, 10:45:00 AM, Anonymous IS THIS 1960? said...

PEOPLE THIS IS THE YEAR 2007! With the newer antivenoms the side effects are almost non-existent. Milder bites and copperhead bites are very commonly treated with antivenom.

 
At Fri Jun 22, 07:46:00 PM, Blogger MedStudentWife said...

Ive had to deal with "swelling" in a numerous session for stuff I have had... just to get it out & moving.. fluid thats not being reabsorbed etc

would,could physio be a call here ?

 
At Fri Jun 22, 08:18:00 PM, Blogger #1 Dinosaur said...

Medstudentwife: Re: Physio, I assume you mean physical therapy, as in exercise, massage etc?

As I told the patient: NO!!

"Swelling" is usually caused by fluid leaking out of anatomically intact capillaries because of various physiological derangement (low protein levels, high return pressures, etc.) for which exercise and stuff makes sense.

This is tissue damage caused by toxins in the venom: muscle cells broken apart ("lysed"); blood vessels disrupted and blood cells burst; connective tissue dissolved.

This lady is still having a ton of pain whenever she hangs her leg down more than a few minutes because all the blood rushes down there (gravity, you know) and pools in damaged tissue, tearing apart the newly formed structures her body is trying to create ("healing.")

Although it's usually a reasonable suggestion, I don't believe exercise, mobilization, massage, etc. would be helpful here. I did suggest she work out the rest of her body to keep in shape while the leg heals, but I think "getting things moving" would do more harm than good in this specific instance.

 
At Wed Jul 04, 06:06:00 AM, Anonymous Mary Lu said...

Doc Dino--

You might want to file away contact info with Dr Sean Bush at Loma Linda Univ. Sean's a great guy and always works with other MD around the country on snakebite cases. We call him the Venom Doc around here. The funny but scarey thing was about a year ago his son Jude got bit by a small rattlesnake when he tried to move it out of the yard "just like Dad did." They chopped him into Loma Linda-- Jude was lucky, his Dad was working in ER that day... but he did get a "chewing out."

http://www.llu.edu/llumc/emergency/venom-er/

If you ever need to get the QT on treatment or an ER staff needs a little education Sean and LLU have made a 15 minute video (it's free if they still have any copies,) you can get by emailing him at ljones@ahs.llumc.edu.

 

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