Introduction
Snakebite envenomation is a common medical emergency in several regions of the United States. North central Florida is home to several indigenous pit vipers including the eastern diamondback rattlesnake (Crotalus adamanteus ), the water moccasin (Agkistrodon piscivorus ), timber rattlesnake (Crotalus horridus ), and the pygmy rattlesnake (Sistrurus miliarius ).1 Most of the canine veterinary literature describes snakebite envenomation adults, excluding its effect or outcome on pediatrics.
Many dogs free roam leading to several unwitnessed bites. Therefore, the attending clinician often needs to make the diagnosis based on physical examination and supporting characteristic effects of envenomation including coagulopathy, hemolysis, neurological signs, hypotension, pain, and soft tissue damage. Clinical signs vary according to the snake involved, amount of venom delivered, venom components in the particular snake, and previous comorbidities of the victim. Except for the pygmy rattlesnake that causes severe pain at the bite site and occasional thrombocytopenia, the remaining pit vipers have venom causing various combinations of hemolysis, vasculotoxicity, tissue toxicity, coagulopathy, and rhabdomyolysis. Cardiotoxicity and neurotoxicity are additional features of eastern diamondback rattlesnake venom while some timber rattlesnakes have potent neurotoxicity.2
Limited evidence-based data exists to guide medical management of pit viper envenomation in children, and no pediatric guidelines exist in veterinary medicine. Pit viper envenomation in children was historically accompanied by an increased concern for grave consequences due to smaller patient size, thus theoretically exposing the victim to a higher concentration of venom per kilogram and potentially more severe consequences from the venom compared to adults.3Recent literature in human medicine advocates for judicious use of antivenom based on systemic involvement (coagulopathy, shock, neurological signs, gastrointestinal signs, etc.) with infrequent fasciotomies reserved for management of compartment syndrome.4,5 Although variable, antivenom protocols in children recommend initial control of systemic signs with 4 to 18 (mean 7.7) vials of F(ab) antivenom with subsequent maintenance therapy of 2 vials every 6 hours.6 Hospitalization ranges from one to eight days (average 2 days), use of empirical antimicrobial therapy is discouraged, and outcome is often favorable.5,7,8
The objectives of this case series are to describe pit viper envenomation in five pediatric dogs, which has not been previously reported, and to show that treatment conforms to standard treatment recommended for mature dogs.