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Snakebites are very rare incidents in central parts of Europe (Austria, Germany, and Switzerland), and mortality has been reported to be 0% for adults.
The experience of medical personnel with treating snakebites may not be substantial, which at times may lead to an unnecessary time delay in treatment or difficulties in decision making, especially where children are concerned. Viper venoms contain more than 100 components and may cause local symptoms and signs, such as pain and swelling, but also systemic findings, such as gastrointestinal and circulatory disturbances and coagulation disorders. Children and elderly people are more likely to develop severe symptoms.
We would like to report a 12-year-old boy who was bitten on his right index finger by an adder (Vipera berus) in the outskirts of Innsbruck. Almost immediately after the bite, the patient developed signs of shock and complained of gastrointestinal pain and difficulty breathing. Upon arrival of the emergency medical system personnel 10 minutes after the bite, the patient was somnolent, hypotensive (blood pressure: 75/55 mm Hg), and tachycardic (heart rate: 145 beats/min). He had tachypnea with inspiratory stridor and a peripheral oxygen saturation (SpO2) of 90%. The patient was immediately supported with oxygen and rapid infusion of 1000 mL of a 0.9% NaCl solution. He was given 0.1 mg epinephrine, 4 mg dimethpyrindene, and 125 mg prednisolone hemisuccinate intravenously. He appeared to stabilize and was transported to the clinic. Upon arrival at the clinic, 45 minutes after the bite, neither gastrointestinal symptoms nor breathing difficulties were present. Apart from local pain, the patient was free of symptoms. His blood pressure was 90/60 mm Hg.
The local swelling, already present upon arrival, was affecting the right index finger and part of the hand. Local symptoms turned out to be the major problem in this case, as the swelling increased massively during the next 3 days, with a maximum extension to the right thorax with development of a subcutaneous hematoma. The patient developed no evidence of compartment syndrome, however. The patient received symptomatic treatment under continuous monitoring of electrocardiography, SpO2, and blood pressure. Laboratory findings at admission are noted in the Table. The patient's coagulation studies remained normal.
TableLaboratory parameters on admission in a 12-year-old boy bitten by Vipera berus. All values are within normal limits
TableLaboratory parameters on admission in a 12-year-old boy bitten by Vipera berus. All values are within normal limits
On the third day after the bite, the patient complained of heart palpitations, and the electrocardiogram showed ventricular extrasystoles. These were monitored and resolved without treatment.
The patient was treated as an inpatient for 6 days, until the swelling and hematoma finally began to resolve. At that time, a superficial area of necrosis (5 mm2) at the bite site had formed. This healed well, leaving only a small scar.
Since the incidence of snakebites is far higher in Sweden than in many other European countries, this country has a long tradition and much experience in the treatment of snakebites.
Dr Karlsson-Stiber and Dr Persson from the Swedish Poison Centre published the Stockholm criteria with indications for the use of antivenom after snakebites in Sweden.
Persson H, Karlsson-Stiber C. Clinical features and principles of treatment of envenoming by European vipers. In: Institute Pasteur, ed. Envenomings and their Treatments. Paris, France: Institute Pasteur, Fondation Marcel Me‘rieux; 1996:281–292.
To date, however, these criteria have been recommended for adults only. Even though the incidence of adder bites in children seems to be higher than in adults, there are no specific recommendations for antivenom treatment after adder bites in children.
Allergic reactions are uncommon following snakebites, particularly if the patient has never before been envenomated. Such reactions can, however, be life threatening.
Initial management of anaphylaxis includes the use of epinephrine, airway management, and administration of intravenous fluids, antihistamines, and steroids. We could not find any studies related to the effectiveness of such treatment for bites from Vipera berus.
Such concerns could certainly lead to a late or insufficient treatment of patients with significant snakebites. Specific recommendations for antivenom use in children suffering from bites by European vipers could help reduce time delay in treatment or difficulties in decision making.
Acknowledgments
The authors acknowledge the kind support of the Austrian Poisons Information Centre, the Natural History Museum in Vienna (Mag Johannes Hill), and especially the Swedish Poison Centre (Dr Christine Karlson-Stiber).
References
Petite J.
Viper bites: treat or ignore? Review of a series of 99 patients bitten by Vipera aspis in an alpine Swiss area.
Persson H, Karlsson-Stiber C. Clinical features and principles of treatment of envenoming by European vipers. In: Institute Pasteur, ed. Envenomings and their Treatments. Paris, France: Institute Pasteur, Fondation Marcel Me‘rieux; 1996:281–292.
