What is in a “Protocol” for venomous snake emergencies?

(NOTE: THIS ARTICLE IS FOR FUTURE PLANNING, NOT FOR EMERGENCY USE. IF YOU HAVE A SNAKEBITE RIGHT NOW, DO NOT WASTE TIME HERE! CALL YOUR POISON CENTER OR LOCAL EMERGENCY SERVICES / 911 SYSTEM.)

I'm a medical toxinologist. About once a month, somebody who works with venomous snakes asks me this: how can I prepare a Protocol, for rescuers to use in case of a bite?

The answer is complicated, because a genuinely helpful protocol has to be tailored to your particular needs. It helps if you stop for a moment and imagine the worst-case scenario: the most knowledgeable and experienced member of your team has been bitten and is incapacitated. The snake is loose on the floor. The doctor you know best is on vacation. The first rescuer on the scene is the new trainee.

How will people know what to do, as fast as possible? Do a practice walk-through, imagining each step: where is that phone number? Would an EMT spot the proper documents right away? You need a written policy and procedure, for training purposes, and all necessary materials must always be clearly labeled and in easy reach.

Here is one example. Let’s start with a well-prepared facility:
• a second person (trained in CPR and in use of any emergency materials such as oxygen or epinephrine) is on duty;
• there is a system for containment of the loose animal;
• emergency numbers are posted next to a working wall phone;
• a color-coded ID card is affixed to the empty enclosure, indicating which antivenom to use and which snake information sheet to bring;
• antivenoms are separated into clearly-labeled bins in an accessible refrigerator;
• personal medical information (allergies, medications, medical risk factors, signed/dated consent to treat with antivenom) is recorded in advance and stored in individual envelopes with each person’s name clearly visible;
• knowledgeable medical consultants have agreed in advance to the emergency plan; and
• species-specific information and medical emergency protocols are prepared and coded to match the enclosure cards.

Two separate protocols are actually needed in this situation: one for personnel at the scene, and a totally different one for the medical team.

The Facility Emergency Protocol should be posted on the wall, by the phone. It might be a one-page list, titled “IN CASE OF SNAKEBITE” and listing steps to be taken by the bitten person, such as:
• Call for help / 911 / emergency transport
• If you can do it safely, secure the snake
• Sit or lie down, in a safe place
• Remove rings and other constricting items
• Attend to allergic symptoms, if applicable

Then, steps to be taken by the second person might include:
• Call 911 / emergency transport
• Help secure the snake, if necessary; or secure the room and post a warning
• Attend to the bitten person’s immediate needs if necessary (allergy treatment, CPR)
• Using a sharpie, draw around the edge of the bite and mark the time
• If applicable, apply a pressure dressing
• Prepare the Snakebite Emergency Transport Kit to provide to transport team (Cover sheet, personal medical history, species datasheet, Medical Emergency Protocol, all in or on the bin with the proper antivenom)
• Notify emergency contacts (local physician, toxinology consultant, family); make sure the local physician and tox consultant know each other’s and the hospital’s contact information
• Put your own contact information on the cover sheet, in case a witness is needed for the hospital to consult later
• Shut down/lock up the facility before leaving

The Facility Emergency Protocol (above) does not need to be sent with the bitten person, because everything the medical team needs to see should be in the Snakebite Emergency Transport Kit. Let’s consider what goes into that kit, more closely:

Cover Sheet: This should state prominently that this is a snakebite emergency transport kit, the name of the facility, the fact that a venomous reptile keeper has been exposed to snake venom antigens and is at risk for both anaphylaxis and envenomation. It should include the name and phone number of the physician who has signed off on the medical emergency protocol, and of the primary consulting toxinologist, if there is one. It should also list the other components of the kit:
• personal medical history and signed consent for antivenom treatment
• snake species datasheet
• medical emergency protocol
• antivenom

(Note: unfortunately, things tend to get separated in emergency rooms. If you affix the list on top of a closed container, and if everything has matching colors or logos or laminated coating, it’s more likely to stay together.)

Personal Medical History and signed consent: At a bare minimum, this should tell the patient’s name, date of birth, known allergies, medications, major medical conditions, family contact information, and useful numbers associated with insurance or previous admission to hospitals. In case the patient has lost consciousness, this may be all that is known, for a while; so risk factors for things that interact with venom are important to record in advance (asthma, epilepsy, use of blood thinners, contact lenses, heart disease for example). In addition there should be a signed, dated permission form stating that it is okay to use antivenom, and that it is okay to share information with the doctor(s) named in the protocol. This form varies, depending on the circumstances – it is better to use a format approved in advance by the hospital and its ethics committee; but even a note written in advance by the patient is far better than nothing.

Species Datasheet: At a minimum, this should state (properly spelled) the genus and species of the responsible snake; because without this the medical team will be completely lost. Ideally, there will be 1-2 pages of additional information: where is the snake found in nature; what are the known consequences of its bite; which antivenoms are believed to be effective against it; and full citations of peer-reviewed medical reports describing its medical management. It is even better if you also attach a full copy (not just the abstract) of at least one good article, to save the medical team time searching.

Medical Emergency Protocol: At the top, this should include the title of the protocol, the name and 24-hour contact number of the medical doctor(s) who signed off on the protocol, and a statement of whether the accompanying antivenom is approved for routine use in your country or is provided under special-use rules. Specific details, depending on the snake, might include:
• A short overview of what to watch for (e.g. coagulopathy, paralytic neurotoxicity, shock, tissue necrosis)
• Blood testing to be conducted before and after use of antivenom (for example, depending on the snake it might include Complete Blood Count, platelets, fibrinogen, PT, aPTT and renal panel, at baseline, 4 hours, and as needed thereafter)
• How much extra serum should be frozen for later research analysis (for example, 1-5 ccs at the same time as each regular blood test)
• The risk of an infusion reaction should be explicitly described, so the medical team will be ready to treat.
• A recommended starting antivenom dose (what product, how many vials, added to what volume of saline, to be administered intravenous over what period of time)
• Criteria for when to give a second dose of antivenom
• The importance of medical specialty consultation should be very clear, with 24/7 phone numbers – if you don’t have it in writing, the doctors will depend on other consultants who may not be experienced with this situation.
• Follow-up considerations may be worth mentioning (debridement, serum sickness, physical therapy); but these are difficult to predict, so consultation is important before the hospitalization is over. Make it super-easy for the doctor to find the right name and number of the experts you trust, by including them in the protocol itself.
• If you are in the USA, explain how to deal with the FDA: If the antivenom is held under an Investigational New Drug Application (INDA), there are two routes for reporting its use:
- If there is an existing INDA, and an approved consent form, the INDA sponsor has a responsibility to report use of the antivenom.
- If an emergency INDA is needed, the doctor should call the FDA emergency phone number (240-402-7800 during business hours) or check the website for night/weekend numbers.

Antivenom: Vials should be in their original boxes, together with the original package inserts. There should be enough in the bin to give a first dose, and a second, and perhaps a third. If you are providing out of date stock, then include an authoritative statement about their use – a peer-reviewed paper may be best, unless this is a product where the expiry date has been officially extended, in which case keep that documentation right in the bin with the product. If you are providing an antivenom that cross-protects against a snake, but that does not mention the particular species in its package insert, then it is essential to provide evidence that this is the proper antivenom – or the doctors may suspect that it is the wrong kind, causing a dangerous delay in care.

Keep in mind: medical care will vary greatly, depending on circumstances (type of snake, individual health issues, distance travelled to the hospital); and the level of detail of a treatment protocol depends on whether an in-depth consultation is planned, or a research project, or a referral to a particular team such as a poison center or venom institute. Your very best advocate should be your own doctor, who can help navigate the hospital system while you are out of commission. Suggestions for finding physicians who can tackle these issues can be found in a previous article, Tips for Venomous Animal Enthusiasts Looking for the Right Doctor.

Best wishes, and stay safe.