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A 5-year-old boy with rattlesnake bite
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With all sorts of creatures waking up about now after their winter sleep, we will start to see the consequences of their activities when our patients get in their way. Therefore, this month and next, we will focus on summertime problems that begin with a bite and can end in loss of life or limb.
A 5-year-old boy was transferred from a regional hospital for evaluation and treatment of a rattlesnake bite to his right hand. He was bitten on the morning of admission and began receiving CroFab; a combination of four monovalent immunoglobulin Fab fragments (antibodies against three different rattlesnake types and the water moccasin antigens), obtained from immunized sheep.
His past medical history was that of a previously healthy boy with no other health problems. His immunizations were documented up to date.
Examination revealed normal vital signs and the swelling of his right hand and forearm. His swelling was well-controlled but appeared to have some areas of necrosis soon after admission as shown in figures 1 – 3 taken the next day. He required no decompression, but he did have significant problems with coagulation, with bleeding at the bite site, epistaxis, hematemasis, and petechiae (figure 4). You are consulted and asked:
What is the best prophylaxis?
- Clindamycin + Gentamicin
- Meropenem
- None
- Unasyn + Ceftriaxone
Case Discussion
Depending on where you look, all the choices have been recommended. However, because of the necrosis associated with this wound, my answer is A, clindamycin plus gentamicin. The choice of clindamycin and gentamicin is based on the mix of Gram-negative bacilli, such as Morganella species, E. coli and other Gram-negative bacilli, along with group D Streptococci and anaerobes often found in the mouth of snakes, as well as Staphylococcus aureus and other Gram-positive cocci that may be on the bite victims skin or clothes. The other antibiotics listed have been recommended as well.
If the patient happens to be colonized with MRSA, as many are today, then prophylaxis should probably include coverage for that as well. At our location, a high percentage of strains of MRSA are clindamycin sensitive.
The decision of whether to use prophylaxis at all is a bit controversial, but most experts are recommending antimicrobial prophylaxis only for those snakebite victims who present with or develop tissue necrosis. Some practitioners still recommend antimicrobial prophylaxis for all snakebite wounds because of the abundant oral flora of most snakes, related to the nature of their eating activity of small mammals. However, studies are emerging that favor only local wound care and management of the complications of envenomation, as long as there is no necrosis. In this era of increasing antimicrobial resistance, this advice is more pertinent than ever.
Sometimes you can anticipate tissue injury by knowing what type of snake bit the patient. Significant envenomation occurs in only about 25% of bite wounds. When this occurs, swelling and pain are noted immediately, particularly if due to Rattlesnakes or water moccasins. So, by the time patients present for care, they are usually experiencing marked pain and swelling with risk for compartment syndrome. In this setting, tissue necrosis might be predicted, and antimicrobial prophylaxis might be appropriate. On the other hand, copperhead bites (figure 5) typically do not require any antivenin and rarely have secondary infections, probably because of the unlikely possibility of necrosis. However, don’t take any snake bite lightly. Even copperheads can result in significant damage.
Pediatric Infectious Disease, Scott and White's Children's Health
Center and Associate Professor of Pediatrics,
Texas A&M University,
College of Medicine, Temple, Texas.
e-mail:
jhbrien@aol.com
There’s a ton of papers and book chapters on snake bite management. They don’t always agree. The most experienced are usually emergency medicine physicians and plastic surgeons. However, the local expert at your facility maybe anyone with a special interest.
Lastly, one should always review the patients’ immunization history, and if needed, give tetanus prophylaxis per the 2006 Red Book recommendations.
By the way, the patient recovered without any loss of tissue.
Columnist comments
Imagine that you have just been diagnosed with a life-threatening illness. Then picture yourself going through prolonged hospital therapy and radical surgery. How would you handle it knowing what you know, especially if you see mistakes being made? As a hospitalist with some idea of how things should be done, I’m pretty sure I would not handle it very well.
Well, this happened to my old friend, Itzhak Brook, MD. Many of you may know Dr. Brook from his many papers and excellent textbook on anaerobic infections (I keep it on my desk at work). In fact, I can remember my mentor, Jim Bass referring to Itzhak with great respect when I was a fellow in the early 1980s. Itzhak and I have shared many stories and cases over the years, and I have known him to always be an honorable and thoughtful person. However, as you know, bad things happen to good people, and Itzhak was diagnosed with hypopharyngeal cancer. You can probably see where this is going.
Experiencing the often impersonal practice of medicine and surgery from the patient’s perspective is nothing new, as was so accurately portrayed in the 1999 Pulitzer Prize-winning play, “Wit”, by Margaret Edson; which, by the way, should be required viewing by all entering the medical profession. On the other hand, we rarely hear what it’s like from the standpoint of a physician as the patient. Dr. Brook recently described the horror and fear associated with this experience from the perspective of being a physician in a recently published editorial in the Archives of Otolaryngology Head and Neck Surgery, volume 135 (2), February 2009. He was able to obtain permission to view a reprint of his thought-provoking experience, and can be found at the following Internet site: www.freewebs.com/dribrook/Cancer.Reflections.AOHNS.09.pdf.
You can also write Itzhak at his e-mail address: ib6@georgetown.edu with your personal experiences and thoughts. Just as I learned some of the things to do and not to do after seeing “Wit”, I think as a physician and a person, I am a little bit better after reading Itzhak’s story. I’ll bet you will be too.
What’s Your Diagnosis? is a monthly case study featured in Infectious Diseases in Children, with treatment information and discussion to follow.