Impact of Anatomical Location on Snakebite Severity and Clinical Outcomes: A Retrospective Cohort Study
DOI:
https://doi.org/10.58600/eurjther3021Keywords:
anatomical location, antivenom, emergency medicine, envenomation severity, prognosis, snakebite, toxicologyAbstract
Objective: The impact of anatomical bite location on snakebite envenomation severity and clinical outcomes remains unclear. This study aimed to compare the clinical characteristics, treatment requirements, and outcomes of upper and lower extremity snakebites.
Methods: This retrospective study included adult patients presenting to a tertiary emergency department and toxicology unit in southeastern Türkiye between January 2018 and December 2023. Patients were categorized according to bite location (upper vs. lower extremity). Outcomes included envenomation severity, antivenom administration, antibiotic and blood product use, surgical interventions, length of hospital stay (LOS), and mortality. Multivariable logistic regression analysis was performed to identify independent predictors of clinically significant envenomation.
Results: A total of 149 patients were included (92 upper extremity bites, 57 lower extremity bites). Upper extremity bites were associated with higher envenomation severity in univariate analysis (p = 0.031); however, this association did not persist after adjustment for confounding variables. There were no significant differences between groups in antivenom use (77.2% vs. 63.2%; p = 0.065), total antivenom dose (median 2.0 vials; p = 0.873), blood product use, or LOS (p = 0.168). Surgical interventions occurred only in the upper extremity group (n = 5), but this was not statistically significant (p = 0.073). No mortality was observed.
Conclusion: Although upper extremity bites were associated with greater initial envenomation severity, anatomical location was not independently associated with clinically significant envenomation or clinical outcomes. Timely antivenom administration may mitigate differences in morbidity. These findings suggest that anatomical location alone may have limited prognostic value in snakebite management.
References
[1] Jamali A, Yousif M, Kareem S, Ali S, Salman B, Imtiaz S (2022) Epidemiology and complications of snakebite in rural area of Badin and Thar Sind, Pakistan. J Pak Med Assoc. 72:1591–1597. https://doi.org/10.47391/jpma.4547
[2] Gutiérrez JM, Calvete JJ, Habib AG, Harrison RA, Williams DJ, Warrell DA (2017) Snakebite envenoming. Nat Rev Dis Primers. 3:17063. https://doi.org/10.1038/nrdp.2017.63
[3] The Lancet (2017) Snake-bite envenoming: a priority neglected tropical disease. Lancet. 390:2. https://doi.org/10.1016/S0140-6736(17)31751-8
[4] Minghui R, Malecela MN, Cooke E, Abela-Ridder B (2019) WHO’s snakebite envenoming strategy for prevention and control. Lancet Glob Health. 7:e837–e838. https://doi.org/10.1016/S2214-109X(19)30225-6
[5] World Health Organization (2018) Addressing the burden of snakebite envenoming. Available at: https://iris.who.int/handle/10665/279476
[6] Williams DJ, Gutiérrez JM, Calvete JJ, Wüster W, Ratanabanangkoon K, Paiva O, Brown NI, Casewell NR, Harrison RA, Rowley PD, O’Shea M, Jensen SD, Winkel KD, Warrell DA (2011) Ending the drought: new strategies for improving the flow of affordable antivenoms. J Proteomics. 74:1735–1767. https://doi.org/10.1016/j.jprot.2011.05.027
[7] Fox S, Rathuwithana AC, Kasturiratne A, Lalloo DG, de Silva HJ (2006) Underestimation of snakebite mortality. Trans R Soc Trop Med Hyg. 100:693–695. https://doi.org/10.1016/j.trstmh.2005.09.003
[8] Al B, Orak M, Aldemir M, Güloğlu C (2010) Snakebites in adults from southeast Turkey. Ulus Travma Acil Cerrahi Derg. 16:210–214.
[9] Yaşar Ç, Çiçek K, Mulder J, Tok CV (2021) Distribution of reptiles in Turkey. North-West J Zool. 17:e201512.
[10] Seifert SA, Armitage JO, Sanchez EE (2022) Snake envenomation. N Engl J Med. 386:68–78. https://doi.org/10.1056/NEJMra2105228
[11] Ruha AM, Kleinschmidt KC, Greene S, Spyres MB, Brent J, Wax P, Padilla-Jones A, Campleman S (2017) Epidemiology of snakebites. J Med Toxicol. 13:309–320. https://doi.org/10.1007/s13181-017-0633-5
[12] Gaus DP, Herrera DF, Troya CJ, Guevara AH (2013) Management of snakebite in Ecuador. Wilderness Environ Med. 24:345–350. https://doi.org/10.1016/j.wem.2013.08.001
[13] Açıkalın A, Gökel Y, Kuvandık G, Duru M, Köseoğlu Z, Satar S (2008) Low-dose antivenom therapy. Am J Emerg Med. 26:402–407. https://doi.org/10.1016/j.ajem.2007.06.017
[14] Gold BS, Dart RC, Barish RA (2002) Bites of venomous snakes. N Engl J Med. 347:347–356. https://doi.org/10.1056/NEJMra013477
[15] Paolino G, Di Nicola MR, Pontara A, Didona D, Moliterni E, Mercuri SR, Grano M, Borgianni N, Kumar R, Pampena R (2020) Vipera snakebite in Europe. J Eur Acad Dermatol Venereol. 34:2247–2260. https://doi.org/10.1111/jdv.16722
[16] Janes DN, Bush SP, Kolluru GR (2010) Snake size and severity. Wilderness Environ Med. 21:120–126. https://doi.org/10.1016/j.wem.2010.01.010
[17] Stephen S, Mohanty CR, Radhakrishnan RV, Issac A, Jacob J, Krishnan N, VR V, Guru S, Muhammed Shaji I, Aggarwal A (2024) Snakebite outcomes. Wilderness Environ Med. 35:155–165. https://doi.org/10.1177/10806032241239628
[18] Myo-Khin, Theingi-Nyunt, Nyan-Tun-Oo, Ye-Hla (2012) Prognostic indicators in snakebite. WHO South East Asia J Public Health. 1:144. https://doi.org/10.4103/2224-3151.206927
[19] Frangides CY, Koulouras V, Kouni SN, Tzortzatos GV, Nikolaou A, Pneumaticos J, Pierrakeas C, Niarchos C, Kounis NG, Koutsojannis CM (2006) Snake venom poisoning in Greece. Eur J Intern Med. 17:24–27. https://doi.org/10.1016/j.ejim.2005.10.001
[20] Elbey B, Baykal B, Yazgan ÜC, Zengin Y (2017) Prognostic value of NLR. Saudi J Biol Sci. 24:362–366. https://doi.org/10.1016/j.sjbs.2015.10.002
[21] Eslamian L, Mobaiyen H, Bayat-Makoo Z, Piri R, Benisi R, Behzad MN (2016) Snake bite in Northwest Iran: a retrospective study. J Res Clin Med. 4:133–138. https://doi.org/10.15171/jarcm.2016.022
[22] Currie BJ, Sutherland SK, Hudson BJ, Smith MA (1991) Epidemiology of snakebite envenomation in Papua New Guinea. Med J Aust. 154:266–268. https://doi.org/10.5694/j.1326-5377.1991.tb121088.x
[23] Feitosa EL, Sampaio VS, Salinas JL, Queiroz AM, Da Silva IM, Gomes AA, Sachett J, Siqueira AM, Ferreira LCL, Dos Santos MC, Lacerda M, Monteiro W, Gutiérrez JM (2015) Older age and time to medical assistance are associated with severity and mortality of snakebites in the Brazilian Amazon: a case-control study. PLoS One. 10:e0132237. https://doi.org/10.1371/journal.pone.0132237
[24] Kang S, Moon J, Chun B (2016) Does the traditional snakebite severity score correctly classify envenomated patients? Clin Exp Emerg Med. 3:34–40. https://doi.org/10.15441/ceem.16.123
[25] Grace TG, Omer GE (1980) The management of upper extremity pit viper wounds. J Hand Surg Am. 5:168–177. https://doi.org/10.1016/S0363-5023(80)80149-3
[26] Seğmen MS, Acehan S, Avci A, Gülen M, Satar S (2020) Acil servise yılan ısırması nedeniyle başvuran hastaların demografik ve klinik özellikleri. Phoenix Med J. 2:72–78. https://doi.org/10.38175/phnx.623049
[27] Tansuwannarat P, Tongpoo A, Phongsawad S, Sriapha C, Wananukul W, Trakulsrichai S (2023) Clinical characteristics, treatments, and outcomes of cobra envenomation. Toxins (Basel). 15:468. https://doi.org/10.3390/toxins15070468
[28] Aköz A, Yildiz V, Orun S, Turkdogan KA, Duman A (2018) Management of poisonous snake bites: analysis of 29 cases. J Clin Exp Investig. 9:140–144. https://doi.org/10.5799/jcei/3998
[29] Das RR, Sankar J, Dev N (2015) High-dose versus low-dose antivenom in snakebite: a systematic review. Indian J Crit Care Med. 19:340–349. https://doi.org/10.4103/0972-5229.158275
[30] Isbister GK, Jayamanne S, Mohamed F, Dawson AH, Maduwage K, Gawarammana I, Lalloo DG, de Silva HJ, Scorgie FE, Lincz LF, Buckley NA (2017) Fresh frozen plasma for coagulopathy in Russell’s viper envenoming: a randomized controlled trial. J Thromb Haemost. 15:645–654. https://doi.org/10.1111/jth.13628
[31] Jayaraman T, Dhanasinghu R, Kuppusamy S, Gaur A, Sakthivadivel V (2022) Bite-to-needle time as an indicator of outcomes in snakebite. Indian J Crit Care Med. 26. https://doi.org/10.5005/jp-journals-10071-24344
[32] Anderson VE, Gerardo CJ, Rapp-Olsson M, Bush SP, Mullins ME, Greene S, Toschlog EA, Quackenbush E, Rose SR, Schwartz RB, Charlton NP, Lewis B, Kleinschmidt KC, Sharma K, Lavonas EJ (2019) Early administration of antivenom and limb recovery in snakebite. Clin Toxicol (Phila). 57:25–30. https://doi.org/10.1080/15563650.2018.1491982
[33] Hung DZ, Yu YJ, Hsu CL, Lin TJ (2006) Antivenom treatment and renal dysfunction in Russell’s viper snakebite. Trans R Soc Trop Med Hyg. 100:489–494. https://doi.org/10.1016/j.trstmh.2005.07.020
[34] Ahmed SM, Ahmed M, Nadeem A, Mahajan J, Choudhary A, Pal J (2008) Emergency treatment of snakebite: pearls from literature. J Emerg Trauma Shock. 1:97–105. https://doi.org/10.4103/0974-2700.43190
[35] Ralph R, Faiz MA, Sharma SK, Ribeiro I, Chappuis F (2022) Managing snakebite. BMJ. 376:e057926. https://doi.org/10.1136/bmj-2020-057926
[36] August JA, Boesen KJ, Hurst NB, Shirazi FM, Klotz SA (2018) Prophylactic antibiotics are not needed following rattlesnake bites. Am J Med. 131:1367–1371. https://doi.org/10.1016/j.amjmed.2018.06.006
[37] Brenes-Chacon H, Gutiérrez JM, Avila-Aguero ML (2024) Use of antibiotics following snakebite in the era of antimicrobial stewardship. Toxins (Basel). 16:37. https://doi.org/10.3390/toxins16010037
[38] Houcke S, Pujo JM, Vauquelin S, Ngoula GRL, Matheus S, Cho FN, Pierre-Demar M, Gutiérrez JM, Resiere D, Hommel D, Kallel H (2023) Effect of time to antivenom administration on recovery from snakebite envenoming-related coagulopathy in French Guiana. PLoS Negl Trop Dis. 17:e0011242. https://doi.org/10.1371/journal.pntd.0011242
[39] Al-Lawati A, Al-Abri SS, Lalloo DG (2009) Epidemiology and outcome of snake bite cases in Oman. J Infect Public Health. 2:167–170. https://doi.org/10.1016/j.jiph.2009.09.001
[40] Sachett JAG, da Silva IM, Alves EC, Oliveira SS, Sampaio VS, do Vale FF, Romero GAS, dos Santos MC, Marques HO, Colombini M, da Silva AMM, Wen FH, Lacerda MVG, Monteiro WM, Ferreira LCL (2017) Poor efficacy of preemptive amoxicillin-clavulanate in Bothrops snakebites. PLoS Negl Trop Dis. 11:e0005745. https://doi.org/10.1371/journal.pntd.0005745
[41] Kim JS, Yang JW, Kim MS, Han ST, Kim BR, Shin MS, Lee JI, Han BG, Choi SO (2008) Coagulopathy in snakebite patients. Korean J Intern Med. 23:94–99. https://doi.org/10.3904/kjim.2008.23.2.94
[42] Berling I, Isbister GK (2015) Hematologic effects and complications of snake envenoming. Transfus Med Rev. 29:82–89. https://doi.org/10.1016/j.tmrv.2014.09.005
[43] White J (2005) Snake venoms and coagulopathy. Toxicon. 45:951–967. https://doi.org/10.1016/j.toxicon.2005.02.030
[44] Holla SK, Rao HA, Shenoy D, Boloor A, Boyanagari M (2018) Role of fresh frozen plasma in snakebite envenomation. Trop Doct. 48:89–93. https://doi.org/10.1177/0049475518756083
[45] Park EJ, Choi S, Kim HH, Jung YS (2020) Novel treatment strategy for venom-induced consumptive coagulopathy. Toxins (Basel). 12:295. https://doi.org/10.3390/toxins12050295
[46] Jeon YJ, Kim JW, Park S, Shin DW (2019) Risk factors and management of snakebite-induced coagulopathy. Acute Crit Care. 34:269–275. https://doi.org/10.4266/acc.2019.00591
[47] Menon JC, Joseph JK, Jose MP, Dhananjaya BL, Oommen OV (2016) Clinical profile of snakebite victims in Kerala. J Assoc Physicians India. 64:22–29.
[48] Hsu CP, Chuang JF, Hsu YP, Wang SY, Fu CY, Yuan KC, Chen CH, Kang SC, Liao CH (2015) Predictors of compartment syndrome after snakebite. Scand J Trauma Resusc Emerg Med. 23:97. https://doi.org/10.1186/s13049-015-0179-y
[49] Rha JH, Kwon SM, Oh JR, Han BK, Lee KH, Kim JH (2015) Surgical management of snakebite in Korea. Yonsei Med J. 56:1443–1448. https://doi.org/10.3349/ymj.2015.56.5.1443
[50] Türkmen A, Temel M (2016) Prevention of unnecessary fasciotomy in snakebite. Injury. 47:2822–2827. https://doi.org/10.1016/j.injury.2016.10.023
[51] Scop J, Little M, Jelinek GA, Daly EES (2009) Severe tiger snake envenoming in Australia. Anaesth Intensive Care .37:613–618. https://doi.org/10.1177/0310057X0903700414
[52] Sharma N, Chauhan S, Faruqi S, Bhat P, Varma S (2005) Snake envenomation in North India. Emerg Med J. 22:118–120. https://doi.org/10.1136/emj.2003.008458
[53] Mohammed R, van Griensven J, Ambaw AA, Yimer TY, Takarinda KC, Kamau EM, Zolfo M, Vanlerberghe V (2022) Snakebite case management in Ethiopia. J Infect Dev Ctries. 16:52S–59S. https://doi.org/10.3855/jidc.15971
Downloads
Published
How to Cite
License
Copyright (c) 2026 Mert Gültekin, Cuma Yıldırım, Ahmet Faruk Yıldız
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
