Dr. Bob on Snakebites in TEOTWAWKI

This article was requested by a reader from SurvivalBlog and therefore is published here before it even appears on my own web site next week.  In reviewing the snake-related material in the history, no review of snakebites was found.  There was some reference to people that have been bitten by rattlers, and the July 2006 run in that the fine editor of this blog had with a 3-footer, but no review of risk and advise for treatment.  We will change all that in one swoop here, and the review will be as thorough as my capabilities allow, but hopefully will also generate many responses that will also help fill in some of the gaps or correct some of the information.  Sometimes more can be learned reading the comments that come after some of the articles than the article itself, as savvy readers are already very aware.  So, my advice is hopefully helpful, but keep checking back over the next 10 days while JWR sorts through the comments from other readers and posts some of their knowledge in the coming days.

Snakebites kill 125,000 people worldwide every year.  Here in the US deaths are much less common as our snakes are relatively lame in the deadly venom category, and something does need to be said here about risk.  Roughly 8000 people on average are bitten by venomous snakes each year in the US and about 5-10 per year die, making the risk >0.1% after being bitten!  That number would surely be higher with no treatment, but even being 100 times higher post-collapse would still put your risk of dying at >10%.  For comparison, bee stings kill an average of 120 people a year and lightning kills 150 per year.  That doesn’t really help our mental health when tromping around in the grassland though on a sunny Fall day.  Similar to the idea of shark attacks, the risk is not the same as our fear when floating in the Gulf 30 feet out.  Hopefully these stats will help put things in perspective for the serious prepper, as having Benadryl and Epipens for bee stings is better prepping than snake worries.  But, even more important from a risk category:  get inside if it’s storming out!

Anyone in snake country knows that snake risk is also regionally very different.  And even within that region the snakes are usually fairly predictable about where they hang out at.  Risk along Montana riversides is about one billion times higher than a northern Minnesota open field (mostly because there are no venomous snakes in northern Minnesota).  We saw more Prairie Rattlesnakes in Montana than any other type of snake there.  One of my tough-as-nails Vietnam Veteran friends had many hunting trips ruined blasting birdshot into rattlesnakes, sending him home early with shaky hands as he was deathly afraid of snakes.  He once got struck by a bigger rattler on the ankle of his boot, didn’t get bit, but related that it felt like Pujols took a full swing and landed the bat on his ankle.  After unloading and then reloading, 12 shells of dove-killing birdshot rendered the snake unrecognizable (he really doesn’t like snakes).

With venomous snakes here in America the general rule for worry is this: Person size relative to snake size predicts risk of death.  In other words, big dude vs small snake:  very little risk of death; big snake vs small child:  trouble.  Snake size does not mean relative to the person, it means relative to the type of snake it is.  However, the problem with that general rule is that bigger snakes are usually smarter about not wasting their venom and will often give you a “dry bite” warning first and then inject you with the venom if you don’t get the message they are trying to send.  Younger, smaller snakes often will inject more venom because they are not veteran biters, so they may inject more venom the first time than the older, bigger snake.

But, snakes often do weird things too.  In our area here in Missouri, the most common venomous snake is the Copperhead.  Time and time again, little kids will pick one up and carry it into their house or put it in a bucket, and the snake is cool with it.  How does that work?  Does the snake know that the kids are just stupid and give them a break?  Patients/friends of mine have a posse of hillbilly children that gathered up a couple buckets of about 40 snakes this year by pulling up rocks and grabbing them (a two-child operation).  In the buckets [among the other snakes] were two Copperheads!  They did take a teaching moment and tried the “this is a no-touchy snake” lecture, but no one really believes they won’t do it again next year.  One of the kids was a 3 year old, certainly at high risk for trouble if he had been bitten by even a middle-sized Copperhead.  Life in the Ozarks, gotta love it!

The other major problem in patient risk assessment is misidentifying the perpetrating snake and therefore the venom risk.  Here in Missouri, if someone is bitten by what they think is a small timber rattler and is a normal 200 pound guy, we watch him and away he goes with little in the way of symptoms and very little risk of death.  But, if he was wrong and it was a Eastern Massasauga rattler instead, which has very toxic venom, we watch him get very sick and his risk of death is certainly real.  So, in your retreat area, know your snakes.  Again, in the Ozarks, the Copperhead is by far and away the most common venomous snake that we see.  The good news for us:  there has never been a recorded death from a Copperhead bite in Missouri.  This would very likely change without medical support, but the risk of death is still very low from a Copperhead bite in our area, which is good peace of mind when your 3 year old is flipping rocks for fun.

Great, Dr. Bob, most snake fears are out of proportion to risk so we should all just walk around barefoot in Texas rock piles, eh?  Don’t do that please.  The first plan for snakes, no matter which area you live in is:  

PREVENTION
.  Imaging a doctor saying that; shocker.  Know your area, know your snakes, know your risk and then protect yourself.  Personally, the “1/2 Mile Rule” is one that we followed in Montana when we lived there.  [“Kill any rattlesnake within 1/2 mile of your habitation.”] It is generally a good one in my book.  As many previous readers have mentioned, have the correct firearms and ammo for snake-blasting when working fences or other high-risk areas for snake contact.  A .410 shotgun works well, but the weapon choice is personal and there are better articles available on this blog and others.  Boots.  End of story.  Type, style, etc., can be found here and the choice is yours.  Wear them though, and wear gloves when certain high-risk activities are necessary.  Rocks and woodpiles are dangerous snake areas, wear heavy gloves when reaching into these areas to reduce risk of bites.  We rolled hay bales down in a stack and knocked a section of wood over before pulling each bale or piece out to put in the wheelbarrows.  Knocking them over would scare or crush any potential snakes away was our thought, and it seemed to work as we didn’t see any close to us during that time.  Figure out your own plan and practice consistently so you build the good habit now.

Also needing mention is animals.  Horses in Montana often got their noses bitten, which can be life-threatening for a horse as they can’t breath out of their mouths.  When Docswife ran a boarding stable for a year, we had more than a couple horses that stayed for stable observation after a Rattlesnake bite.  We also had some neighboring ranchers that actually lost a horse to multiple rattler bites after collapsing a den while dust rolling.  Freak accident, but still, a loss of a valuable horse that may have been able to be prevented if that den had been identified and could have been fenced off.  A couple patients had been bitten by snakes when in Montana, but the only family member bitten in our Montana years was Aine, my wife’s border collie.  The poor dog still has a spot on that elbow where the hair won’t grow.  She laid around panting for a day before we found the bite, and then laid around sleeping a lot for another day while we worried–but she recovered just fine.  We assume it was a Rattler, not too big from the fang separation, but only she knows.  If we had lost her, my wife would have been devastated and we would have probably gone on a snake roundup for revenge and then one of us would surely have been bitten.  Moral of this story, animals are at much higher risk of contact and therefore illness and death due to snakebites.  Cats, dogs, and horses all were killed by Rattlesnake venom in our Montana neighborhood, while we did not know of any humans bitten during that same time period within the same area.

So let’s talk a bit about what you actually can do if bitten to reduce your risk of death or tissue loss.  You will not be able to count on any medical support necessarily, and without the support of your local ER after TEOTWAWKI, it might be worthwhile to know a little bit about treatment options.  The first and foremost thing about snakebite management is field management done correctly.  The following should be done for a snakebite victim:

• Remove yourself and patient from the snake’s territory, or the snake from the territory (via hot lead injection from of safe distance)
• Try to immobilize the area bitten below the level of the heart
• Clean the wound as well as you are able in the field
• Do not allow the patient to drink alcohol or take medication that may cause sedation
• Transport the patient to any available medical facility (will there be one?)
So, one of your members gets tagged “it” by a local venomous villain, now what.  Let’s say it was an “oops” moment reaching into a storage area and a snake had holed up there unexpectedly.  Remove that snake safely, in 12 gauge fashion to prevent return.   The back of the bitten hand is painful, swollen, and there are 2 little holes present.  Calm the person!  Lay them down and keep that hand below the cot, bed, or litter the “patient” is now on.  Wash it with clean, soapy water and if not available use peroxide.  If neither is available, alcohol is the last resort; either medical or social.  Don’t let the patient have any of the social type, and move them to your main housing area (it is assumed that is the available medical facility).  For the first 12 hours, the person needs to be encouraged to drink fluids and stay still and calm.  That hand needs to stay below the heart if possible the entire time.  Elevate the patient with blankets or cushions and leave the arm lower, but try not to “hang” it below as that can sometimes cut off circulation at the armpit and cause nerve damage, especially if the patient is unconscious.

Antibiotics are not necessary unless the wound is heavily contaminated.  In a study of 53 snakebites here in the US, none developed infection following the bite.  If the wound is contaminated, then use generic Augmentin (amoxicillin/clavulanate) if available, and generic Omnicef (Cefdinir) as a second choice.  On the other hand, Tetanus contamination of a snakebite can occur, and keeping up to date on your Tdap vaccination is essential prevention while the grid is up.  If the patient is conscious and becomes nauseous, use any anti-nausea medication that you may have to help the person keep fluids down.  Fluids are vitally important to help the body “thin” down the toxicity of the venom over the next 24 hours after being bitten.  So, you have the person calmly resting with the bitten area below the heart, the wound was cleaned, fluids are flowing, now what?  Pray and wait.  We will discuss severe symptoms and signs of trouble later in the article.  The large majority of the time the person may feel a little ill and nauseated, with sweats and a rapid heartbeat, but will stay conscious and recover with a nasty scar.

What should you NOT do?  Well, that is where the heated debate comes in.  Using the latest medical information available, these are the things that are largely believed out there that DO NOT have any proven medical benefit:
• Incision
• Oral suction
• Suction devices
• Freezing
• Electric shocking
• Tourniquets

A large study using mock venom showed that suction of venom reduced the toxin in the system by 2%, meaning 98% of the venom still made it into the tissues.  Not enough to make a difference in life or death, and certainly not worth the risk of increased infection from some of the methods used (like putting your nasty, bacteria-filled mouth on an open wound).  Tourniquets can damage nerves, tendons, blood vessels and cause infections themselves.  Therefore, they are medically not recommended.  This is constantly a topic of debate, as well as all of these recommendations above, because people just want to be able to do something.  Medically speaking, from the research available and the results from that research, these things will not help and will likely cause more harm than good.

Now, snakes are generally good survival eating, so it would be best to kill the snake and get some extra protein for a meal if possible.  An amazing fact: dead snakes can still bite!  Snakes are muscle and reflex, that’s about it.  Even a dead one can reflexively latch on to the unsuspecting doofus’ arm and even inject venom.  Amazing but true, so watch out.  Most snake-savvy folks cut the head right off and then the problem is solved. [JWR Adds: Reader Dan J. notes: “A decapitated snake head can skill inject venom. The head must be buried, put in a bucket with a lid, or otherwise made safe and not available to dogs, cats, curious children or foolish adults for a long time.”

US snakes we really need to worry about are in the subfamily of Crotalinae.  This includes rattlesnakes, water moccasins, copperheads.  99% of all US venomous snakebites are from these snakes.  The only other snake outside that family that causes significant risk is the Elapidae family which includes the coral snake.  Coral snake bites are rare due to the limited distribution and are primarily found in Texas and Florida.  The most venomous snake from a venom potency standpoint aside from the Coral snake is the Mojave Rattler.  This nasty crawler’s venom can cause neuromuscular weakness and respiratory depression and should be taken as a serious risk if it is in your area; which includes the south western United States in southern California, southern Nevada, extreme south western Utah, most of Arizona, southern New Mexico and western Texas.  From the risk standpoint though, even this deadly enemy is no match to the more populous snakes that we encounter more often.  The following is stolen directly from www.snakesandspiders.com:

With this in mind, the two snakes that jump out at me are the Western Diamondback the Eastern Diamondback Rattlesnakes. The Mojave Rattlesnake would likely be right there with these two if it were a bit more common, and more widespread. They are found in a pretty focused area that is often not inhabited by human beings. This leads to fewer bites, and therefore precludes their being included as one of the deadliest.

The Western Diamondback has no such qualms. They are around plenty of humans and do plenty of biting when compared to the majority of venomous snakes. Their venom is powerful, and they deliver the bite with large fangs that can give a large dose of that deadly venom. Many consider the Western Diamondback to be the deadliest snake in the United States.

For my money, the Eastern Diamondback is about as deadly as they come. This is not only the deadliest snake in America in my opinion, it is also the largest venomous snake as well. They grown big, fat, and can have a nasty disposition when they are bothered. The venom glands are huge on the eastern diamondback rattlesnake, and they are not shy about injecting that venom.

Of all the snakes in America, I call the Eastern Diamondback the deadliest overall. The Western diamondback is a close second, with the Mojave close behind them.

Unfortunately for us, the Western Diamondback is commonly encountered by those in its territory, which ranges from California to Arkansas.  These powerful, dangerous snakes can reach 7 feet long.  As noted above, the Eastern Diamondback is even nastier and can be bigger, reaching 8 feet long.  The recent popular email of a 15 foot Eastern Diamondback in Florida was a camera trick and the snake was actually 7 feet 3 inches, which was still a monster and did weigh over thirty pounds.  Their range is from North Carolina to Louisiana and all points south.  95% of all deaths from snakebites are from Diamondbacks, so they are to be feared if you live where they do.  Children, small females, and pets are at the highest risk for death due to the size ratio mentioned earlier.  Usually, these snakes do lie in wait and are not aggressive hunters, so avoiding them and sealing up your housing and storage areas is the best protection from their wrath.

Now, for some of the more technical medical information for those that would be in charge of the medical aspects of their group, it is recommended that the non-medical folks proceed with caution as there is lots of bad news in the following paragraphs.  Again, keep in mind that most snakebites are not severe and that 25% of all venomous snakebites have no envenomation.  For those 75%, there are two types of venom problems medically:  hemotoxic and neurotoxic.  Hemotoxic symptoms are far more common as the neurotoxic snakes are the Mojave Rattlesnake and the Coral snake, along with any exotics that may escape and survive as short time.  Hemotoxic and neurotoxic symptoms:

Hemotoxic symptoms Neurotoxic symptoms
Intense pain Minimal pain
Edema Ptosis
Weakness Weakness
Swelling Paresthesia (often numb at bite site)
Rapid pulse Numbness or tingling
Ecchymoses Diplopia
Muscle fasciculation Dysphagia
Paresthesia (oral) Sweating
Unusual metallic taste Salivation
Vomiting Diaphoresis
Confusion Hyporeflexia
Bleeding disorders Respiratory depression
  Paralysis

The usual Rattlers can cause death with severe envenomation by profound hemotoxic effects, mostly through clotting problems.  The unusual snakes that cause neurotoxic symptoms cause death much more often by percentage, due to respiratory depression and paralysis of breathing muscles.  If there is any doubt as to the type of envenomation, this chart can help sort it out as the patient deteriorates, not that it will be of much consolation.  The risk of death is also increased by the distance to the heart.  A chest or back bite by a decent sized Rattler is very likely to be fatal.  The meaty part of the thigh, shoulder or buttocks is also risky due to the blood flow present and closeness to the heart.  Any bite to the face is nearly always fatal due to airway swelling and plentiful blood flow.  Use this information to allocate resources and effort, as it may save others that suffer a survivable bite in the future.

Tissue damage is very common with Rattler bites.  Sometimes dramatic and impressive, it is rarely infected and not usually life-threatening.  Some pictures of dramatic cases are found here [Warning: Graphic!]

Many more dramatic and impressive examples can be found with a simple web search if you need more grossing out.  This tissue damage can be extremely painful, and medication available will be used to help bring down swelling and control pain.  Caution will have to be used with NSAIDs as the risk of bleeding from the venom will have to be considered against the benefit of the medication, especially in the first 12 hours.  For someone without tachycardia and systemic symptoms on a distal hand or ankle bite, it will likely be fine to start NSAID therapy and then discontinue if there are any signs of bleeding that develop. 

There are five degrees of envenomation that are predictive of death in a TEOTWAWKI situation:

Degree of Envenomation
Presentation
Treatment
0. None Punctures or abrasions; some pain or tenderness at the bit Local wound care
I. Mild Pain, tenderness, edema at the bite; perioral paresthesias may be present. Aggressive hydration, Benadryl, NSAIDS
II. Moderate Pain, tenderness, erythema, edema beyond the area adjacent to the bite; often, systemic manifestations and mild coagulopathy Aggressive hydration, Benadryl, caution with NSAIDS, consider IV fluids if available, death possible but unlikely if the patient continues to be conscious and able to take po fluids
III. Severe Intense pain and swelling of entire extremity, often with severe systemic signs and symptoms; Coagulopathy IV fluids, Benadryl, consider Epipen use if available, avoid NSAIDS due to bleeding risk, death will be very likely
IV. Life-threatening Marked abnormal signs and symptoms; severe coagulopathy Death even with all efforts, are up to God

This will not be a happy time to be in charge of the medical care for your group if you are tasked with caring for a patient with grades III and IV envenomation.  Again, information may help allocate resources in the future if you live in an area where snakebites will be likely within your group in the future.  Notice that these gradings are done on an extremity, as the trunk, chest and face wounds will almost always be grade IV.  The photos at my web site all show bites that are grades I and II, although the third photo may have been grade III at its peak.  In caring for the more severe snakebite patient, urine output is a helpful sign of stability.  If urine output falls, kidney failure is likely and death will likely result.  Bleeding can occur, and intercranial hemorrhages can even occur with severe cases.  Monitoring the gums, eyelids, and fingernails can indicate hemorrhage.  Unfortunately, if coagulopathy does occur, it can only be corrected by antivenom, which in TEOTWAWKI will surely not be available.

Most severe cases of envenomation will show signs within 6 hours, but with neurotoxic venoms there can be a delay.  Be sure to monitor any patient suspected to have the possibility of neurotoxic venom for a minimum of 24 hours, even if they show no symptoms.  For hemotoxic envenomation, the 24 hour mark is critical for those cases of grades II and above.  All grade II patients showing improvement at 24 hours will very likely recover completely, and even those that are touchy but conscious will also likely recover.  Grade III patients showing improvement or at least stability at 24 hours have a good hope of survival, and efforts towards recovery will usually not be in vain for grade III patients that are improving.  Grade IV patients will very rarely survive to a 24 hour assessment.  Without antivenom available, these patients will not survive outside Divine intervention at TEOTWAWKI.

For those of you that are still with me after almost 4,000 words and a lot of information, hopefully this was a helpful review and will perhaps save lives someday.  It needs to be repeated that the best possible treatment for poisonous snakebites is prevention.  Please feel free to comment to me directly at survivinghealthy@hotmail.com and updates will be made to this article on my site as information that is helpful or useful becomes available.  Stay strong and wear your boots! 

JWR Adds: Dr. Bob is is one of the few consulting physicians in the U.S. who prescribes antibiotics for disaster preparedness as part of his normal scope of practice. His web site is: SurvivingHealthy.com.

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