By Matt Windsor
If you’re a gardener or an outdoorsy type, you probably know the dangers snakes can present. But do you know a first-of-its-kind Comprehensive Snakebite Program is available at the University of Alabama at Birmingham in case you do get bitten?
The program includes one of the nation’s first dedicated snakebite follow-up clinics, which treats patients in the hospital, provides long-term follow-up and studies new approaches and protocols in venomous snakebite care, according to a press release from UAB. The team also is pioneering new methods and is working toward a better understanding of the medical consequences of snakebites.
Death from venomous snakebites is rare; only five people on average in America die from snakebites each year. But snakebites can have serious long-term effects.
“So many people – in the Southeastern United States, especially – have persistent wounds, bad swelling and morbidity issues after snake envenomation, and there was no good place to send them for follow-up,” said Dr. William Rushton, associate professor in the UAB Department of Emergency Medicine and co-director of the snakebite program.
He also is a medical toxicologist and medical director of the Alabama Poison Information Center, based at Children’s of Alabama. In the heart of snakebite season, Rushton and fellow medical toxicologist Dr. Sukhshant Atti average one or two snakebite consults every day with providers throughout the state.
Rushton and wound-care expert Dr. Dag Shapshak, associate professor in the Department of Emergency Medicine, launched the snakebite program last year.
Shapshak, of Mountain Brook, also runs the UAB Comprehensive Wound Care Clinic and specializes in treating persistent wounds and swelling. Most of his patients in the wound care clinic are about 80 years old and dealing with complications from diabetes or cancer.
“Our snakebite patients are much younger, from 5 to 30 or so, but the same techniques apply,” Shapshak said in the press release, “and they can make the difference between lifelong complications and a full recovery.”
The snakebite clinic is staffed by toxicologists, wound-care experts, pharmacists and physical therapists to give patients full-spectrum care.
Snakebites are rare enough that any given doctor may not see many patients who have complications, said Dr. Matthew Kelly, co-medical director for Wound Care and Hyperbaric Medicine at UAB.
As a result, clinics don’t stock a lot of antivenom and may not have what patients need when they need it.
“Snakebites can be intimidating to treat given all of the various scenarios in which patients can present,” Atti said. “This can create a lot of uncertainty for a community physician in trying to decide whether a patient needs to be transferred to another hospital for further care. We’re able to guide physicians in such scenarios, allowing them to make sound decisions.”
Kelly, who lives in Homewood, reiterated that thought.
“With the snakebite clinic, we are able to see patients from throughout the state and, as with many things, experience is key in understanding the nuances of clinical care.”
The clinic provided follow-up treatment after snake envenomation to 17 patients in 2021. That includes a teenage cheerleader with lingering complications and a truck driver with severe envenomation and necrosis that threatened his job and his ability to play guitar, according to the press release.
The snakebite program uses lower doses of antivenom and has shorter patient stays than many other hospitals, typically discharging patients in less than 24 hours.
It’s the follow-up care and multidisciplinary treatment plans that set UAB’s clinic apart.
“We will keep seeing people as long as they have persistent wounds and swelling,” Rushton said. “What we’re doing is cutting-edge. No one else is thinking this deeply about snakebites and follow-up.”
While patients are in the hospital, physical therapists emphasize early range-of-motion exercises and getting patients out of bed. Rushton said UAB pharmacy expertise has been crucial with the timing of the antivenom. Patients then get follow-up in the snakebite clinic.
“Leaving the hospital after a snake envenomation experience can create a sense of ‘now what?’” Atti said. “Many patients find their questions unanswered, including ‘Do I elevate my limb? Do I do physical therapy? How long will the swelling last?’ and ‘When can I get back to work?’ I believe that having a place to follow up with snake envenomation experts provides comfort to patients that they are not on their own when they leave the hospital.”
Dangers of Snakebites
Snakebite season in Alabama and the Southeast runs from roughly mid-March to mid-November, and most bites occur in the evening.
About 10% of envenomations in Alabama are from rattlesnakes. The rest are from other pit vipers, including copperheads, cottonmouths and water moccasins. Doctors are quick to distinguish envenomation from the more all-encompassing term snakebite, because up to 50% of bites are dry, with no venom injected.
The most common complications from envenomation are local wound damage, swelling of extremities and severely painful blood blisters. When a snake envenomates a person, often on the foot, the tissues fill up with blood.
“For someone with little experience of snakebite, that swollen leg can look like dead, necrotic tissue that needs to be removed to avoid wider damage,” Rushton said. “That’s a hallmark of our program, to keep people away from unnecessary or harmful procedures.
“These large blood blisters are cared for by a wound-care specialist who has specific training of the mechanisms of envenomation. What we don’t want is someone trying to cut away that tissue, at least early on during active envenomation.”
The Comprehensive Snakebite Program is an innovator in the use of thromboelastography, or TEG, a method of precisely studying blood coagulation, clot strength and clot stability.
TEG can provide a more rapid answer than traditional tests, such as prothrombin time and partial thromboplastin time tests. Because the Department of Emergency Medicine is a national leader in research, access to TEG is widespread enough that every snakebite patient admitted to UAB can benefit from the technology and have their antivenom titrated appropriately, Rushton noted in the press release.
Even though rattlesnakes make up less than 10 percent of envenomation in the Southeast, rattlesnake bites can cause life-threatening coagulopathy.
“We don’t want to miss those,” Rushton said. “The reason we get TEGs on every snakebite patient is to screen for rattlesnake bites that may have been erroneously reported as copperhead bites. If that is the case, we will be more aggressive about giving antivenom, and we use the TEG to titrate the antivenom dose as well.”
Although the evidence is still out on whether TEGs are better than traditional labs, Rushton says the team can predict rattlesnake bites on the thromboelastogram earlier than from traditional coagulation markers.