How to Position a Snakebite
What do they always say about real estate?
LOCATION, LOCATION, LOCATION!
Well, the same applies when it comes to snakebites. Admittedly, it’s not the most important issue. However, proper positioning (location) can make a difference.
Because approximately 98% of all US native snakebites are from pit vipers (copperheads, cottonmouths, rattlesnakes), I will address them first and in greater detail.
More than 95% of all pit viper envenomations are associated with tissue damage. For many patients, local tissue injury is the only manifestation. Hematologic and systemic toxicity are much less common. Healthcare professionals should do everything possible to minimize the amount of tissue damage because mismanagement can have long-term implications.
One of the best things we can do to minimize tissue injury is to elevate the affected extremity aggressively and properly. Ideally, the affected extremity should be at least 45° elevated and straight. We don’t want the arm bent at the elbow or the leg bent at the knee. This allows the fluids that have accumulated from the envenomation to drain and it reduces the hydrostatic pressures that can contribute to tissue damage.
I’ve seen so many people rapidly improve as soon as we elevated the affected extremity. This is so important that it’s one of the very first things mentioned in the unified treatment algorithm:
Some people fear that elevation will increase the systemic absorption of venom. First of all, it probably doesn’t make much of a difference. The volume of venom is so insignificant that positioning probably will not have any significant effect on absorption. Furthermore, if it did, that could be considered a good thing, because that would allow for the venom to mix with the antivenom more easily.
Of course, the unified treatment algorithm is intended for in-hospital care. Optimal positioning in the prehospital environment has been debated.
I almost always recommend aggressive elevation for the same reasons described above. Some people fear the development of systemic toxicity without the availability of antivenom. If that likelihood is high, e.g., following a large rattlesnake envenomation with the rapid onset of signs and symptoms, it is reasonable to keep the affected extremity at or just above heart level until they arrive at the hospital, and which time it should be elevated.
What we never want to do is keep the affected extremity below heart level with crotalid bites (e.g., rattlesnakes, moccasins). It will aggravate the local tissue injury, which, again, can have long-lasting consequences.
Because it cannot be said enough, remember that the definitive treatment for snakebite is antivenom. There are no home remedies for an envenomation, so please seek qualified medical treatment as soon as possible.
A note regarding coralsnakes…
For bites from snakes that are exclusively neurotoxic, keeping the affected extremity below heart level is reasonable. In the United States, only coral snakes are exclusively neurotoxic. However, serious systemic toxicity is observed less frequently than significant pain. Therefore, I tell the patients to keep the affected extremity in whatever position is most comfortable for them. And, remember, coral snakes only account for about 2% of U.S. snake envenomations.
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