Evaluation and treatment of poisonous snakebites.

Snakebite victims should be transported immediately to the nearest emergency department. Incision and suction are contraindicated unless performed by experienced personnel within five minutes of the bite, or unless transport of the patient to definitive medical care will take more than 30 minutes. Cryotherapy is contraindicated. All bites should be graded for severity of envenomation. The wound should be cleaned and broad-spectrum antibiotics administered. Tetanus status should be determined and tetanus toxoid administered if necessary. Antivenin is indicated in certain mild cases and in all moderate and severe cases of envenomation. Patients with a mild case of envenomation may require up to five vials of antivenin; patients with moderate bites may require 10 to 15 vials, and patients with severe bites may require 15 to 20 vials. Antivenin is effective only when administered intravenously; skin testing to predict the possibility of anaphylactic reaction is mandatory before administration. Diphenhydramine and epinephrine should be readily available in case of anaphylaxis. Fasciotomy is only indicated in rare cases involving elevated intracompartment pressures.