Management of Snakebite Poisoning in Children: Comprehensive Guide

Introduction

Snakebite poisoning in children is a medical emergency that requires prompt and precise management to prevent serious complications or death. Effective treatment hinges on early assessment, appropriate use of antivenom, and comprehensive supportive care, including cardiovascular and neuromuscular support.

Initial Assessment and Stabilization

1. Safety First: Ensure the child and bystanders are moved to a safe area away from the snake.

2. Calm and Reassure: Keep the child as still and calm as possible to slow the spread of venom.

3. ABCs of Resuscitation:

   • Airway: Ensure the airway is open and clear.
   • Breathing: Monitor respiratory rate and effort; provide oxygen if needed.
   • Circulation: Check heart rate, blood pressure, and perfusion.

4. Immobilization and Wound Care:

   • Immobilize the affected limb with a splint to reduce venom spread.
   • Clean the bite area with soap and water.

Hospital-Based Management

Antivenom Therapy

Indications: Antivenom is indicated for children showing systemic symptoms (e.g., neurotoxicity, coagulopathy), significant local symptoms (e.g., extensive swelling, tissue necrosis), or other signs of envenomation.

Types and Dosages:

• North America: CroFab (Crotalidae Polyvalent Immune Fab) is used for pit viper bites.
  • Dosage: Initial dose of 4-6 vials intravenously; may repeat with additional 2-vial doses every 6 hours as needed.
• India: Polyvalent anti-snake venom serum (ASVS) for bites by species such as the Indian cobra, Russell's viper, saw-scaled viper, and common krait.
  • Dosage: Initial dose of 10 vials intravenously; further doses based on clinical response.
• Australia: Specific antivenoms such as Tiger Snake Antivenom or Brown Snake Antivenom.
  • Dosage: Typically 1-2 vials initially, with further doses as required based on severity.

Administration:

• Administer antivenom intravenously over 60 minutes.
• Pre-medicate with antihistamines or corticosteroids to reduce the risk of allergic reactions.
• Monitor closely for anaphylaxis and treat promptly with epinephrine if it occurs.

Cardiovascular Support

Monitoring:

• Continuous monitoring of heart rate, blood pressure, and oxygen saturation.
• Electrocardiography (ECG) to detect arrhythmias.

Interventions:

• Fluid Resuscitation: Administer isotonic saline or Ringer’s lactate to maintain blood pressure and perfusion.
• Inotropes/Vasopressors: Use agents such as dopamine or norepinephrine if hypotension persists despite adequate fluid resuscitation.

Management of Complications:

• Coagulopathy: Monitor coagulation profile; administer fresh frozen plasma (FFP), cryoprecipitate, or platelets as needed.
• Shock: Early and aggressive management with fluids and inotropes.

Neuromuscular Support

Assessment:

• Monitor for signs of neurotoxicity, such as ptosis, diplopia, dysphagia, or respiratory distress.
• Perform regular neurological examinations.

Interventions:

• Respiratory Support: Provide supplemental oxygen; intubate and mechanically ventilate if respiratory failure is imminent or present.
• Anticholinesterase Agents: For neurotoxic bites (e.g., by cobras), use neostigmine and atropine to counteract paralysis.

Laboratory and Diagnostic Monitoring

1. Blood Tests: Complete blood count, electrolytes, renal function tests, liver function tests, and coagulation profile.
2. Urinalysis: Monitor for hematuria or myoglobinuria, which can indicate hemolysis or muscle damage.
3. Imaging: Ultrasound or MRI may be needed to assess for compartment syndrome or extent of tissue damage.

Long-Term Management and Follow-Up

1. Rehabilitation: Engage in physical therapy to restore function if there has been significant tissue damage or prolonged immobilization.
2. Psychological Support: Provide counseling to address trauma and anxiety resulting from the snakebite incident.
3. Education: Educate the family on snakebite prevention strategies and the importance of early medical intervention.

Conclusion

The management of snakebite poisoning in children is multifaceted, involving immediate stabilization, antivenom administration, and comprehensive supportive care. Effective treatment requires a multidisciplinary approach, including toxicologists, pediatricians, intensivists, and rehabilitation specialists, to ensure the best possible outcomes for the affected child.