Research In Action

As the Medical Director of the Poison Control Center at Children’s Hospital of Philadelphia (CHOP), I am often asked to provide injury prevention advocacy on various topics, including snakebite care, to our service area. This may mean visiting the Philadelphia Zoo in the middle of the night to pick up antivenom for a patient or providing expert testimony to lawmakers in the Delaware Valley.

Globally, snakebites and snake envenomation (the process by which venom is injected by the snake) are major causes of injury and death, even to children. According to the World Health Organization (WHO), 4 million people are bitten by snakes every year, many of them venomous, and as many as 138,000 die from their injury. WHO wants to reduce deaths from snakebites by half over the next decade and has developed its first-ever strategy to address this growing public health problem.

Many parts of the world lack adequate antivenom medications, and some snakes are migrating to places where they are typically not seen due to climate change. The WHO's strategy includes plans to increase access to antivenom medicines, as well as educating communities on the benefits of seeking treatment early. 

Effects of Snakebites

Bites by venomous snakes can cause acute medical emergencies involving severe paralysis that may prevent breathing, cause bleeding disorders that can lead to fatal hemorrhage, cause irreversible kidney failure, and cause severe local tissue destruction that can lead to permanent disability and limb amputation. Children may suffer more severe effects and can experience the effects more quickly than adults due to their smaller body mass. Even a bite from a nonvenomous snake can cause infection or allergic reaction in some children.

There are approximately 300 species of snakes native to the US, and about 10 percent of them are venomous. The most common venomous snakebites are caused by pit vipers (rattlesnakes, copperheads and cottonmouth [water moccasin] snakes); coral snakebites are uncommon in a few southern states. Pennsylvania is home to three native venomous snakes: the copperhead, the timber rattlesnake, and the eastern Massasauga rattlesnake. More people than we realize also keep exotic non-native snakes, like vipers and cobras, as pets. Occasionally, children will get bitten by these dangerous reptiles.

It’s very important for families to be aware of the potential seriousness of any venomous snakebite. They should get to a hospital emergency room as quickly as possible, especially if unsure of the exact type of snake responsible for the bite. With the correct antivenin (an antitoxin specific to the venom of a particular animal or insect) and other treatment, which may include lab work, pain or sedation medications, a tetanus booster, antibiotics, and supportive care, severe illness and/or death can be prevented.

I regularly help families and healthcare providers assess and care for snakebites in Pennsylvania and throughout Delaware; ED doctors and pediatricians are encouraged to get expert help, available by calling the CHOP Poison Control Center at 1-800-222-1222. Although clinical pathways are available for various types of snakebites, it is advantageous to have experience in the assessment of snakebite injuries.

High Cost of Treatment

Is a less swollen limb worth the economic cost associated with antivenom administration? Just last summer, emergency treatment for a copperhead bite to a 9-year-old girl in Indiana cost $142,938, according to a report by Kaiser Health News. And these types of charges are not uncommon and not new. In 2014 a team led by CHOP colleague, Evan S. Fieldston, MD, MBA, MSHP, published a study in Hospital Pediatrics that helps to illuminate some of these issues:

• The analysis suggests that it may be prudent to reevaluate a commonly used “Observation Status” billing system that often doesn’t reflect the resources committed to treating these patients.
• The resource-utilization study examined 2,755 children treated for the toxic effects of venom at 33 U.S. children’s hospitals, of whom 211 were hospitalized as inpatients and 124 under observation status. The mean costs attributed to children receiving antivenom under observation status were $17,665 as compared to $3,001 for children in observation status for other diagnoses.
• Given the clinical resources necessary and the financial consequences for both patients and hospitals when antivenom treatment is provided, it’s possible that snake envenomation care does not meet the spirit of criteria that the federal Centers for Medicare & Medicaid Services (CMS) intended for observation status.

Antivenom is a precious commodity that may save limb or life, but more health services research is needed to help define the best practices with respect to utilization of this resource. We also need to empower and engage communities and strengthen health systems to ensure safe and effective treatment.

The Poison Control Center at CHOP is staffed with professionals, who are available 24/7 free of charge, to help families and healthcare professionals manage snake bite care. Call 1-800-222-1222 or visit the center's website.