The most recent and up-to-date summary of snakebite treatment is that by McCollough and Gennaro (1963). Following is a brief summary of their suggestions:
1. Immobilization—Systemic immobilization is effected by body rest and locally by splinting the bitten area.
2. Tourniquet—A lightly occlusive tourniquet during a 30- to 60-minute period of incision and suction would seem to possess some advantages. In severe cases where medical attention is hours away, a completely occlusive tourniquet may be necessary to prevent death. Sacrifice of the extremity may be necessary for the preservation of life.
3. Incision and suction—Suction should begin three to five minutes after injection of venom if symptoms of poisoning are present. Incisions one-fourth inch to an inch long across each fang mark should be made in order to open the wound for more efficient suction. Multiple incisions are not useful for the removal of venom but may be employed under hospital conditions to reduce subcutaneous tensions and ischemia.
4. Cryotherapy—An ice cap over the site of the bite for relief of pain would seem to be permissible, especially prior to the administration of antivenin. It must be remembered that cooling during the administration of the antivenin radically reduces the access of the antiserum to the bite area.
5. Antivenin—Antiserum is the keystone to the therapy of snakebite. Careful evaluation of the severity of the bite and the patient's sensitivity should be made before the use of antivenin. In Grade II (moderate) bites, the intramuscular injection on the side of the bite may suffice. In Grades III (severe) and IV (very severe), shock and systemic effects require intravenous injection. In bites producing symptoms of this severity, antivenin must be given in amounts large enough to produce clinical improvement. Ten to 20 units may be necessary to prevent the relapse that sometimes occurs after small doses of antivenin. Permanent remission of swelling and interruption of necrosis are the therapeutic end point in the clinical use of the antiserum.
In all cases of snakebite where there is any doubt as to the snake's identity, it should be killed if possible and taken to the hospital for positive identification. In many instances of actual bites by poisonous snakes the only treatment needed was an injection of tetanus antitoxin or toxoid and sedation, because physical examination revealed no indication of poisoning (Stimson and Engelhardt, loc. cit.).
Case History of a Bite
On July 29, 1963, at 8:20 a.m., I was treating a nine-month-old cottonmouth for mites. As I dropped the snake into a sink, it twisted its head and bit the tip of my right middle finger with one fang. The fang entered just under the fingernail and was directed downward, the venom being injected about five millimeters below the site of fang penetration. After placing the snake back in its cage, I squeezed the finger once to promote bleeding, wrapped a string around the base of the finger, and drove to Watkins Memorial Hospital on the University of Kansas campus. I began to feel a burning sensation in the tip of the finger almost immediately. Upon my arrival at the hospital, an additional ligature was placed around my wrist. At 8:30 a.m. a small incision was made in the end of the finger, which by this time was beginning to darken at the point of venom deposition. I sucked on the finger until 8:35 a.m., when a pan of ice water that I had requested was brought to me. No pain was felt except that caused by the ice. Fresh ice was added as needed to keep the temperature low. By 9:30 a.m. the finger had swollen and stiffened. At 10:00 a.m. the swelling had progressed to the index finger and back of the hand. I experienced difficulty in opening and closing the hand. Blood oozed slowly from the incision. A dull ache persisted and about every two to four minutes a sharp throb could be felt until nearly 11:00 a.m., when the pain diminished. The rate and intensity of throbbing increased whenever the hand was removed from the ice bath for more than a few seconds. Although only the hand was immersed, the entire forearm was cold. Pain was felt along the lymphatics on top of the arm when it was touched, and by 1:00 p.m. a slight pain could be felt in the armpit. Since swelling and pain were almost nonexistent by 2:00 p.m., I was permitted to leave. After walking to a nearby building, I again felt a burning sensation as the hand warmed. I made another ice bath and again immersed the hand in it until 4:10 p.m., at which time it was removed from the water. The pain and swelling began anew, and the hand was placed back in an ice bath from 5:30 p.m. until about 7:30 p.m. At this time cryotherapy was discontinued. From 10:00 p.m. to 12:00 midnight my legs twitched periodically, and pain could be felt in both armpits. A slight difficulty in breathing also was experienced for a short time. The acute pain and burning sensation remained in the finger until the following morning, but swelling progressed only as far as the wrist. The only discomfort that day was in the finger. The tip was darkened, the entire first digit red and feverish, and the lymphatics still painful when touched. By the third day the swelling had regressed. The incision itself was the main cause of discomfort, and the soreness at the site of the bite persisted for at least four days.
Although the L-C method of snakebite treatment has been vigorously attacked by many, there is still need of much more data before it can be unequivocally condemned or praised. It was preferred in the treatment of this bite because: I knew that envenomation was minimal and that there would be no need for antivenin; only one fang of a snake less than one foot long had entered the tip of the finger; the snake had bitten three frogs in the previous two days and had possibly used up a considerable amount of its venom; the venom was deposited at such a shallow depth that at least a portion of it could be removed by suction; and the wound bled freely even before suction was applied. The ice water was uncomfortably cold but was not cold enough to cause frostbite, a major objection to the L-C method. Ideally, fresh ice should be added little by little to replace that which is melting, and the immersed area should be protected from the water by a plastic bag. Pain and swelling can be minimized by cryotherapy, but I would recommend its use only in cases of mild poisoning such as the one described herein.