Challenges in the Management of an Echis coloratus Adult Snakebite Victim at a Tertiary Care Hospital: A Case Report

Patient: Male, 18-year-old Final Diagnosis: Snakebite envenomation Symptoms: Coagulopathy Medication:— Clinical Procedure: Anti snake venom Specialty: General and Internal Medicine • Toxicology • Tropical Medicine OBJECTIVE: Unusual clinical course BACKGROUND: The World Health Organization has set clear guidelines for the management of snakebite envenomation. However, challenges have been reported in the clinical application of guidelines, such as identification of the biting snake, hypersensitivity reactions to the antivenom, and influence of repeated antivenom administration during hospital stay. This report aims to discuss how these challenges can affect patient management and to highlight improvement opportunities. CASE REPORT: An 18-year-old man presented to the Emergency Department without remarkable signs of envenomation following a snakebite. An initial dose of antivenom was given despite the misidentification of snake species. An allergic reaction developed and was successfully managed. Following admission, the coagulation profile and local tissue reaction worsened. Upon consulting the Drug and Poison Information Center, it was discovered that a subtherapeutic dose of antivenom was administered. The patient was rechallenged after the administration of premedication. Coagulation profile could not be maintained; therefore, 2 extra doses of antivenom were administered, resulting in sustained improvement in local tissue reaction and coagulation profile. CONCLUSIONS: First, victims presenting without signs and symptoms of envenomation may benefit from close monitoring for late presentation of envenomation signs. Second, dosing guidelines are suggested to consider Institute of Safe Medication Practices recommendations for order sets to reduce the possibility of medication errors. Third, premedication may be an effective alternative in patients who develop allergic reaction to the locally produced equine antivenom in the setting of absent goat-derived antivenom. Lastly, antivenom administration should be titrated to patient response even if it occurs over several days.