Review Arch Dis Child: first published as 10.1136/archdischild-2020-319428 on 28 October 2020. Downloaded from Paediatric snakebite envenoming: recognition and management of cases Jacqueline Le Geyt ,1 Sophie Pach,2 José María Gutiérrez,3 Abdulrazaq Garba Habib,4 Kalana Prasad Maduwage,5 Timothy Craig Hardcastle,6,7 Roger Hernández Diaz,8 María Luisa Avila- Aguero ,9,10 Kyaw Thu Ya,11,12 David Williams,13 Jay Halbert 14 For numbered affiliations see ABSTRACT What is already known? end of article. Snakebite in children can often be severe or potentially fatal, owing to the lower volume of distribution relative Snakebite in children disproportionately affects Correspondence to to the amount of venom injected, and there is potential ► Dr Jay Halbert, Department in low- income settings. for long- term sequelae. In the second of a two paper of Paediatrics, Royal London Most healthcare settings manage cases of series, we describe the pathophysiology of snakebite ► Hospital, London, UK; snakebite envenoming using a syndromic j. halbert@ nhs. net envenoming including the local and systemic effects. approach. We also describe the diagnosis and management of JLG and SP are joint first Antivenom is the mainstay of effective snakebite envenoming including prehospital first aid and ► authors. treatment. definitive medical and surgical care. Received 22 April 2020 Revised 27 August 2020 Accepted 27 August 2020 INTRODUCTION What this study adds? The global burden of snakebite is large, dispropor- tionately affecting children who live in low-income ► An updated review of the clinical presentation settings, and often leads to permanent physical and and management of snakebites in children. 1–5 psychological sequelae. Due to their smaller size, ► When and how to give antivenom in the children often present with more severe effects of paediatric population. snakebite, owing to their lower volume of distribu- ► An approach to management of snakebite in tion relative to the mass of injected venom. This children, including what to do and what not to higher ratio of venom to body mass can result in do. more rapid and severe neurotoxicity, coagulop- athy and severe local tissue damage.6 This review describes the clinical presentation of snakebite http://adc.bmj.com/ envenoming in children, and its management, espe- such as C- type lectin- like proteins, disintegrins and cially the challenges faced by clinicians in the low- dendrotoxins.3 income settings where snakebite is most common. Traditionally, antivenoms are preparations of immunoglobulins or immunoglobulin fragments Snake venoms and antivenoms prepared by immunising large animals, usually Venoms are injected by the snake either subcuta- horses but sometimes sheep, with snake venom. neously or intramuscularly, or rarely intravenously. After collection of blood and separation of plasma, on September 25, 2021 by guest. Protected copyright. Many venoms inflict local tissue damage at the antibodies are purified and preparations formulated anatomical site of injection. Rare cases result in to have a standard neutralising potency against the 8 areas of necrosis that occur away from the bite site, venoms used in the immunisation. such as by some species of spitting cobras. Venom toxins are absorbed via lymphatic and blood vessels Local effects to reach the circulation, causing systemic effects.3 Local effects at the bite site occur in bites inflicted An estimated quarter of bites from venomous by the majority of species of the family Viperidae snakes are ‘dry’ bites (this proportion varies with and by some species of the family Elapidae, such as snake species), meaning that venom is not injected the spitting cobras. These local effects are usually © Author(s) (or their and envenoming does not occur;7 it is important to pain, swelling, ecchymosis and blisters, sometimes employer(s)) 2020. No differentiate the autonomic manifestations of fear causing significant local tissue necrosis, including commercial re- use. See rights 9 and permissions. Published from actual systemic envenoming. myonecrosis and cutaneous necrosis (see figure 1). by BMJ. Snake venoms are complex mixtures of proteins. Swelling is often more severe and widespread in Viperid snake venoms are particularly rich in metal- children, although does tend to recover faster To cite: Le Geyt J, Pach S, loproteinases, serine proteinases and phospholi- than in adults, with most completely recovered in Gutiérrez JM, et al. 10 Arch Dis Child Epub ahead of pases A2. Elapid venoms contain high amounts of 1 month. There is, therefore, a risk of developing print: [please include Day proteins of the three- finger toxin family and phos- compartment syndrome, depending on the site of Month Year]. doi:10.1136/ pholipases A2. Many other protein families are also the bite, the volume and type of venom injected, archdischild-2020-319428 present in venoms and contribute to their toxicity, and the local reaction.11 Le Geyt J, et al. Arch Dis Child 2020;0:1–6. doi:10.1136/archdischild-2020-319428 1 Review Arch Dis Child: first published as 10.1136/archdischild-2020-319428 on 28 October 2020. Downloaded from cardiorespiratory arrest associated with snakebite envenoming, due to cardiovascular toxicity of venoms.18 A number of ‘colubrid’ species can cause life-threatening envenomation characterised by haemorrhage and coagulopathy, and some species (notably African boomslang Dispholidus typus and Japanese yamakagashi Rhabdophis tigrinus) have caused fatalities. In Africa and some parts of the Middle East burrowing asps in the genus Atractaspis are common causes of nocturnal snake- bites. Clinical signs include local pain, moderate to severe local and regional swelling, oedema, lymphadenopathy, blister and Figure 1 Scarring after cobra snakebite. Photograph by David J bleb formation and subsequent necrosis. Some species can cause Williams. cardiovascular effects, including direct cardiotoxicity induced by endothelin- like toxins (sarafotoxins).19 Table 1 summarises the most important systemic effects of snakebite envenoming. Systemic effects Envenoming can initially cause non- specific systemic symptoms of nausea, vomiting, back pain, headache, abdominal pain and Management of paediatric snake envenoming dizziness. Unilateral focal tender lymphadenopathy is commonly Community prehospital first aid reported as a non- specific sign of snake venom envenoming. The child should be kept calm and comfortable, as a hyperdy- Systemic envenoming by species of the family Elapidae are namic state can accelerate dissemination of venom. Immobili- mostly characterised by neurotoxic manifestations, that is, a sation of the bitten part of the body, in a functional position descending neuromuscular paralysis which may end in bulbar below the level of the heart, reduces lymphatic absorption of paralysis and respiratory arrest.9 This is a consequence of neuro- the venom.20 The immobilised child should be transferred to a muscular blockade through the action of presynaptically or medical facility as quickly as possible, with the focus on airway postsynaptically acting neurotoxins.12 13 Evidence of paralysis and breathing support, prevention of aspiration (of vomitus or typically first appears as bilateral ptosis with or without ophthal- other fluids), oxygen administration and gaining intravenous moplegia or diplopia. Some viperid species, such as the South 20 American rattlesnake, also induce neuromuscular paralysis.14 A access in an unaffected limb, if available. 15 Harmful practices such as incision, suction devices, snake number of Australian elapid venoms also cause coagulopathy. 21 22 Systemic manifestations of many viperid envenomings are stones, cryotherapy and tourniquets should not be used. typically associated with coagulopathy and bleeding, owing to Tourniquets, often still applied in rural settings, can increase local the disruption of microvessel wall integrity by venom protein- tissue destruction and cause gangrene and should be removed ases16 and to a consumption coagulopathy. Some viper bites slowly. Pressure immobilisation bandages are useful in bites by do not cause coagulopathy. In severe cases, hypovolaemia elapids (neurotoxic snakes that do not cause local swelling) to secondary to coagulopathy, capillary leakage and vasoactive reduce lymphatic flow. But they are not recommended in the and myocardial depressant toxins can precipitate cardiovascular case of viperid bites. If poorly applied, a pressure immobili- 9 shock. Some venoms, such as that of Russell’s viper, cause a sation bandage may cause increased local tissue damage. For http://adc.bmj.com/ systemic capillary leakage syndrome, which contributes to hypo- these reasons, pressure immobilisation bandages are not recom- volaemia and shock.17 A number of elapid and viper species can mended by the WHO in the majority of snake bites globally, cause acute kidney injury, owing to hypovolaemia, direct neph- although immobilisation of the affected limb is essential for all rotoxic effects, thrombotic microangiopathy or accumulation snakebites.23 of myoglobin in renal tubules as a consequence of rhabdomy- Remove objects such as rings, bangles or belts that can olysis.3 Recently, there have been increasing reports of sudden compress the bite site and increase oedema. Try to avoid the on September 25, 2021 by guest. Protected copyright. Table 1 Mechanism, signs and symptoms of predominant snakebite envenoming systemic effects Mechanism Typical symptoms and signs Typical snakes associated Neurotoxic effects Blockade