Buyer Beware: Bitten By A Devenomated Snake

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The following case was seen in the Jacobi ED and recently published by Drs. S.Ayala and M.Touger in conjunction with Drs. C.Birmingham and L.Nelson of the NYC Poison Control Center.  Some case features have been altered to fit this format.

A 25-year-old man with a history of depression and bipolar disorder purchased a snake which, he was told, was “devenomated.”  The next day, the man was bitten on his right hand, and within 3 hours he was discovered “shaking” and nearly apneic.  His wife attempted rescue breathing, and when EMS arrived he was intubated due to severe respiratory distress.  He was initially brought to a local hospital but was quickly transferred to the regional snakebite center for further management.  Upon arrival, he was unresponsive and flaccid, with initial vital signs as follows:

Blood pressure, 156/103 mm Hg; heart rate, 112 beats/min; respiratory rate, 17 breaths/min; temperature, 35.9°C; Spo2, 100% on a ventilator.

The remainder of the physical examination was unremarkable except for the area of the bite: Two pinpoint puncture marks were visible on the dorsolateral portion of the patient’s right fifth digit, and his right upper extremity had mild to moderate edema.

EMS brings the snake, which looks like this:

Why did this patient become symptomatic if the snake was “devenomated”?  How is the correct antivenom chosen?

Leave your thoughts below and check back in a week (or hit the subscribe button to get auto-emails) to see what happened…

4 Comments

  • Ismael

    The devenomation process for snakes acquired by questionable means can be a problem. To do this they attempt to either surgically remove the venom glands or ligate the canal that connects the venom gland to the fangs. Both procedures can fail. When surgically removing the glands you may not get all of the tissue out and over time venom may be produced again. Similarly, over time, the canal that was supposedly ligated may simply recanalize. Plus, who is even performing this procedure? Prob not a vet or herpetologist

  • sannman

    Well the guy’s bipolar and has depression….what meds is he supposed to be on and could he have overdosed?

    The snake is a cobra/elapidae (specifically an albino monocled cobra/Naja kaouthia)…its venom is a postsynaptic neurotoxin that causes flaccid paralysis, eventually hitting the diaphragm thus causing respiratory failure. I doubt anyone would just say, “sure, the snakes devenomated, let’s stop there.” The appropriate cobra antivenin would be needed. Gota treat other findings as they come (atropine, fluids, pressors, etc).

    Tetanus booster would be good too.

  • Sammy

    #1: Don’t trust buying a snake when you go over state line to buy an exotic animal that is supposedly “devenomated”
    #2: in choosing antivenon, species identification is key!

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