Copperhead bite

[LittleLebowski]

We have a guy at work on crutches due to a copperhead bite on his foot. He was walking his dog at night (it's been warm here this week) and got hit. He called the paramedics and the paramedic assured him that he didn't need antivenom due to it being a "dry bite." Well, it wasn't a dry bite the next day and it was too late for antivenom. It sucks, but he seems alright and won't have any permanent effects.

[Tensaw]

Copperheads suck.

So, understanding that many bites from snakes are dry, how in the world is someone supposed to tell a dry bite, from envenomated (if that is a word)? Mr. Paramedic was, I suspect, pretty far out of his lane.

[Mjolnir]

Copperheads suck.

So, understanding that many bites from snakes are dry, how in the world is someone supposed to tell a dry bite, from envenomated (if that is a word)? Mr. Paramedic was, I suspect, pretty far out of his lane.

There is no way in Hades I would have listened to the paramedic.

He definitely was far out of his lane.


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[Josh Runkle]

Mr. Paramedic was, I suspect, pretty far out of his lane.

Maybe, maybe not. A handful of states regularly require EMS to get training on various types of snake bites. If particular snakes are problematic in certain areas, they probably get more training on those specific types of snakes. When I did SAR, I got a lot more training on copperhead bites than I ever did in EMS. It going to depend on what their protocols are as well. Most EMS agencies used to focus on transporting everyone because of legal liabilities. Today, since everyone goes to the emergency department when they have a cold, some places are specifically trying to avoid taking people to the emergency department.

Unfortunately, what happens a lot in EMS is:
-people with little training recognize it is over their head.
-people with lots of training feel they are equipped to handle it.
-people with even more training recognize it is still over their head.

The paramedic in question may have had significant training and been given the impression that reducing the amount of patients to the ED was important.

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[blues]

I dispatched one the other day...more out of fear of it biting the dog than anything else.

[nalesq]

When doing yard work with my snub in my pocket, I load the fifth chamber with snake shot, just in case Mr Copperhead shows up. Hopefully I’ll have time to draw, pop the cylinder, rotate the snake shot round into the number one position, and blast him before he slithers away.


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[scjbash]

There's a good chance he wouldn't have received antivenom anyway. Until very recently care for a copperhead bite virtually never included it. It wasn't until a couple of years ago that a study showed that the current antivenoms were even worth giving at all. It's also expensive as hell and can run well over $50K just for a starter dose.

We're infested with copperheads in this area but as a healthy adult I would most likely turn down antivenom for a single bite on the foot.

[mtnbkr]

I live in the same region as LL. We are lousy with copperheads. I see them all the damn time. Luckily they're not very aggressive.

From April until Oct, when I'm in the woods, I carry a revolver and the first shot is snake shot. I know from experience it'll dispatch a large snake with ease.

Chris

[TGS]

There's a good chance he wouldn't have received antivenom anyway. Until very recently care for a copperhead bite virtually never included it. It wasn't until a couple of years ago that a study showed that the current antivenoms were even worth giving at all. It's also expensive as hell and can run well over $50K just for a starter dose.

We're infested with copperheads in this area but as a healthy adult I would most likely turn down antivenom for a single bite on the foot.

Why is it so expensive? Shkreli run the company that makes it?

[txdpd]

There is no way in Hades I would have listened to the paramedic.

He definitely was far out of his lane.


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Agreed. When my friend got bit by a rattlesnake at the police range, she went to the hospital and was told she would be there 6 hours minimum. After an hour the swelling set in and there was s nurse in the room every 15 minutes with a sharpie marking the spread.

[Gadfly]

It may not be a “deadly” bite, but it looks like it sucks. That has got to be painful... I am surprised I don’t see them more often. My cats bring in lizards and little garter snakes all the time. I am afraid they would go after a baby copper head.

(From google image of “copperhead bite”)

https://uploads.tapatalk-cdn.com/20190912/5667b191fd0f5942266cbdb6fb54bc1f.jpg


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[mtnbkr]

Agreed. When my friend got bit by a rattlesnake at the police range, she went to the hospital and was told she would be there 6 hours minimum. After an hour the swelling set in and there was s nurse in the room every 15 minutes with a sharpie marking the spread.

I've known people who were bit by Copperheads. I have not directly known anyone bitten by rattlesnake, but I know people who have known those who were bit.

Based on that, I would say the two are not the same and not even close. The last guy I knew who got bit by a copperhead didn't seek treatment and the bit healed on its own after a lot of swelling and pain with no permanent damage. I've heard of folks with rattlenake bites and immediate medical care suffering permanent and disfiguring damage.

That's not to say I would ignore a copperhead bite, but they're certainly a different level of risk compared to a rattlesnake.

Chris

[scjbash]

Why is it so expensive? Shkreli run the company that makes it?

There are two companies making copperhead antivenom and both are stupid expensive. This is the breakdown someone came up with for one of them.

"After examining cost data from every step of the process, from the factory floor to hospital billings, Boyer developed a pricing model that shows how much each part contributed to the ultimate expense. Fees and costs for licensing, regulation and hospital profits amounted to 27.7 percent of the overall cost and clinical trials made up just 2.1 percent. The cost of making the antivenom, including research, development, animal care and plasma harvesting? A mere 0.1 percent. As for the remaining 70.1 percent, Boyer found that the cost was due to hospital markups used in negotiations with insurance companies."

https://www.smithsonianmag.com/smart-news/why-single-vial-antivenom-can-cost-14000-180956564/

[TGS]

Ah, so it "costs" $50k, but you won't actually pay that much.

Kind of like my appendectomy being priced at $60k but the actual amount paid to the hospital being a small fraction of that.

[JHC]

There's a good chance he wouldn't have received antivenom anyway. Until very recently care for a copperhead bite virtually never included it. It wasn't until a couple of years ago that a study showed that the current antivenoms were even worth giving at all. It's also expensive as hell and can run well over $50K just for a starter dose.

We're infested with copperheads in this area but as a healthy adult I would most likely turn down antivenom for a single bite on the foot.

I read that the avoidance of administering antivenom for what is believed to be a dry bite is the risk of allergic reaction to the antivenom. That risk was alleged to be not insignificant. Does that sound legit?

[Sensei]

Maybe, maybe not. A handful of states regularly require EMS to get training on various types of snake bites. If particular snakes are problematic in certain areas, they probably get more training on those specific types of snakes. When I did SAR, I got a lot more training on copperhead bites than I ever did in EMS. It going to depend on what their protocols are as well. Most EMS agencies used to focus on transporting everyone because of legal liabilities. Today, since everyone goes to the emergency department when they have a cold, some places are specifically trying to avoid taking people to the emergency department.

Unfortunately, what happens a lot in EMS is:
-people with little training recognize it is over their head.
-people with lots of training feel they are equipped to handle it.
-people with even more training recognize it is still over their head.

The paramedic in question may have had significant training and been given the impression that reducing the amount of patients to the ED was important.

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There is no reliable way to determine if someone had a significant envenomation in the first few hours of many domestic US snake bites. Many people will have some pain at the site, but swelling and even hematologic effects can be delayed by hours. We have an envenomation protocol in our ED which involves observation for 12 hours with serial measurement of limb circumference. I’ve never seen an EMS protocol for envenomation that allows a paramedic to look at a bite to determine if transport to a hospital is needed. I have seen plenty of people with initially benign looking hand / foot bites in the first couple of hours develop into moderate envenomations with swelling up to the knee or elbow within 12 hours.


There's a good chance he wouldn't have received antivenom anyway. Until very recently care for a copperhead bite virtually never included it. It wasn't until a couple of years ago that a study showed that the current antivenoms were even worth giving at all. It's also expensive as hell and can run well over $50K just for a starter dose.

We're infested with copperheads in this area but as a healthy adult I would most likely turn down antivenom for a single bite on the foot.

CroFab was given to moderate to severe (defined by Snake Bite Severity Score) Copperhead envenomations for the 14 years that I practiced emergency medicine in NC. Use in mild to moderate bites was hit or miss depending on the provider and poison control recommendations. There has been some debate about the cost effectiveness of CroFab for all but severe Copperhead envenomations. However, the recent study by Gerardo el al in Annals of EM pretty much guaranteed that it will at least be offered in mild to moderate envenomations although I still do not feel that this trial adequately addressed the issue cost-effectiveness. https://www.annemergmed.com/article/S0196-0644(17)30510-3/fulltext#/article/S0196-0644(17)30510-3/fulltext

[txdpd]

I've known people who were bit by Copperheads. I have not directly known anyone bitten by rattlesnake, but I know people who have known those who were bit.

Based on that, I would say the two are not the same and not even close. The last guy I knew who got bit by a copperhead didn't seek treatment and the bit healed on its own after a lot of swelling and pain with no permanent damage. I've heard of folks with rattlenake bites and immediate medical care suffering permanent and disfiguring damage.

That's not to say I would ignore a copperhead bite, but they're certainly a different level of risk compared to a rattlesnake.

Chris

My point being that there’s no way an EMT can accurately assess a snake bite in the field, without an observation period. She didn’t need antivenom and ended up with a hole hole in her skin that looked like a MRSA infection and a quarter size scar.

Anecdotally the only thing I’ve heard about copperhead bites was a neighbor that disturbed a copperhead nest, clearing out a brush pile on his farm, and was bit death. Now that I have better understanding of white trash lingo and the synonymous use of “drug overdose” and “snake bite”, the lack of fire, I have some doubts about that story.

[TGS]

We have a guy at work on crutches due to a copperhead bite on his foot. He was walking his dog at night (it's been warm here this week) and got hit. He called the paramedics and the paramedic assured him that he didn't need antivenom due to it being a "dry bite." Well, it wasn't a dry bite the next day and it was too late for antivenom. It sucks, but he seems alright and won't have any permanent effects.

I'm not the kind of person that advocates people sue for anything possible, but speaking as a former EMS chief I'd say that at the very least your coworker should bring this to the attention of that EMS agency's management for quality assurance.....in particular the Clinical Coordinator. The Clinical Coordinator is usually a senior medic that doesn't have operational duties, but rather QAs medical care administered by the agency and has oversight of clinical competencies and training.

Even if he doesn't want to sue and isn't looking to get someone fired, there's some learning/correction that needs to occur. I would not assume that the hospital is conveying anything to the EMS agency.

[Mjolnir]

My point being that there’s no way to accurately assess a snake bite in the field. She didn’t need antivenom and ended up with a hole hole in her skin that looked like a MRSA infection and a quarter size scar.

Anecdotally the only thing I’ve heard about copperhead bites was a neighbor that disturbed a copperhead nest, clearing out a brush pile on his farm, and was bit death. Now that I have better understanding of white trash lingo and the synonymous use of “drug overdose” and “snake bite”, the lack of fire, I have some doubts about that story.

Four or five bites could possibly do that to a human being.

I dunno.

I’m in southeastern Louisiana and we have a metric shit ton of venomous snakes here.

Snake Boots are mandatory. Just north of me we have timber rattlers (St. Francisville, LA). In the Greater Baton Rouge Metro Area we have cotton mouth water moccasins. I believe we have copperheads wherever there are rattlers but copperhead venom is less dangerous. We even have coral snakes (which the nation has little anti-venom for; so keep that in mind if you choose to try to handle one).


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[ST911]

No experience with copperhead bites, but have seen bunches of folks bit by (prairie) rattlers. Adult bites tend to be dry bites to extremities. Many rural patients don't seek medical attention for extremity bites. Treatment for healthy patients is wound cleaning and monitoring. Some docs may do antibiotics and a tetanus. Vulnerable patients or bites elsewhere on the body are more likely to seek care and get more attention. In an EMS response, patients either refuse or no transport is indicated. EMS protocol is Benadryl p.o. and prepare for anaphylaxis. Last fatality I know of was an elderly patient with health issues, who got a dry bite and panicked into cardiac arrest.

[scjbash]

I read that the avoidance of administering antivenom for what is believed to be a dry bite is the risk of allergic reaction to the antivenom. That risk was alleged to be not insignificant. Does that sound legit?


Sensei would know better than me but I think allergic reaction was a problem with earlier antivenoms but isn't much of an issue with CroFab or Anavip.

[Sensei]

I read that the avoidance of administering antivenom for what is believed to be a dry bite is the risk of allergic reaction to the antivenom. That risk was alleged to be not insignificant. Does that sound legit?

There is a big difference between equine-derived whole antibody antivenom and newer Fab fragment antivenom (CroFab) that is now used for domestic crotalidae envenomations. Both whole antibodies and Fab fragments can cause two types of hypersensitivity reactions - early Type I anaphylaxis and a late reaction known as serum sickness (aka Type III or immune complex mediated hypersensitivity reaction). About 20% of people getting whole antibodies will have either anaphylaxis or serum sickness and it can be severe. Interestingly, about the same percentage getting Fab fragments report some reaction with a rash being the most common. Severe reactions with Crofab are rare and were seen in 1 out of 45 people get it in the most recent study. You are still likely to get whole antibody antivenin if you get bitten by an exotic snake or are traveling out of the US.

The best reason not to give CroFab is cost unless it’s a severe envenomation. Each vial is $2200 to the hospital and 3-10X that to the patient or insurer. I’ve seen severe rattlesnake envenomations get 20-30 vials. One kid in FL got 80 vials and a $1.6 million dollar hospital bill - all that to save a future “FL Man...”

Finally, there is an alternative to Crofab called Anavip but it is only FDA approved for rattlesnakes and is marginally less expensive.

[TCFD273]

Several things:

1-working and living in the south, I receive training on snake bites regularly

2-most bites are dry

3-any EMT-P worth a f*ck is going to recommend transport to an ED for evaluation by an ER Doc

4-having worked in a very large trauma hospital, Crofab is the antivenin. It covers Rattle snakes, Copperheads and water moccasins.

5-more than likely he wouldn’t have received the antivenin.


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[scjbash]

TOne kid in FL got 80 vials and a $1.6 million dollar hospital bill - all that to save a future “FL Man...”


That motherfucker better live up to his potential and get arrested for or killed by something that will give us one helluva laugh.

[willie]

Those walking/running at night are more at risk of snake bite because many snakes are nocturnal. In daytime snakes are more likely to be active during earlier and later times when temps are cooler. Regardless of time of day, avoid putting hands and feet where you can't see where they will go. In barns or old abandoned houses you can count on having a snake nearby. In my residence I found a shed copperhead skin behind my refrigerator. The serpent lived with me without my knowledge. At night I have found snakes in my carport, storage shed, under vehicles, and in flower beds. More than one person in my area has crawled under a car or truck and come face to face with a snake resting in the suspension. Others have left vehicle windows down and discovered a snake in the car the next day. A friend while piloting a small plane had a snake crawl into his lap. Waking up with a snake in my bed would give me the hebegeebees.

[LSP552]

My dad was bitten by a copperhead when he was a teenager, squirrel hunting miles from the truck. That was probably 65+ years ago. He jumped as the snake struck and only got stuck with one fang. He said it was definitely a sucky experience and it was a couple of weeks before he was walking normally.

I’ve come so close to being bitten by cottonmouths and rattle snakes several times. By the way, RI doesn’t have any poisonous snakes!

[drjaydvm]

For comparison, equine origin polyvalent crotalidae antivenin is around $220 per unit hospital cost for animals. Most dogs only get one unit for a copperhead bite and most bites don’t get any antivenin at all. In our area venom induced consumptive coagulopathy and dic are what usually cause deaths from
envenomations. As the cost has come down and quality has gone up I am more likely to give antivenin now versus a decade ago.

[0ddl0t]

The cost of making the antivenom, including research, development, animal care and plasma harvesting? A mere 0.1 percent.

Does this 0.1% include R&D for the 999 failed drugs that come with every treatment to make it all the way through FDA approval?

[JAD]

The cost of drugs includes the cost of running the drug company, including R&D and litigation. The fiscal libertarian in me gets a little tired of drug cost discussions.

When I was unassing Texas my gardener got bit on the thumb. One fang from a juvenile copperhead. I wrapped a rubber band around the base of his thumb and drove him to the hospital and sat with him for a few hours until his wife got off work. It sucked out loud for him; he lost a pretty good chunk out of his thumb and two week’s work. He got the hospital bill mitigated but I did wind up paying him as if he’d worked for me for a solid week.

I miss the barbecue but not the fucking snakes.

[Caballoflaco]

When I was unassing Texas my gardener got bit on the thumb. One fang from a juvenile copperhead. I wrapped a rubber band around the base of his thumb and drove him to the hospital and sat with him for a few hours until his wife got off work. It sucked out loud for him; he lost a pretty good chunk out of his thumb and two week’s work. He got the hospital bill mitigated but I did wind up paying him as if he’d worked for me for a solid week.
.

Applying tq’s to snake bites is not recommended because the majority of venom is highly cytotoxic and restricting the blood flow keeps the venom from diluting and increases the severity of tissue damage.

[JAD]

Damn it. The doctor told me otherwise but maybe he was just trying to make me feel better.

[Sensei]

Damn it. The doctor told me otherwise but maybe he was just trying to make me feel better.

Don’t forget to suck the venom out - it could be life saving in the right situation...Victoria Secret model bitten on the thigh. ;)