Re: Pit viper bites: rational management in locales in which copperheads and cottonmouths predominate.

The management of pitviper bites remains controversial. In order to better assess the efficacy of different treatment modalities, charts of 107 patients hospitalized for pitviper bites at University of North Carolina Hospitals between 1952 and 1992 were retrospectively reviewed. The series included 68 copperhead bites (64%), 8 cottonmouth bites (7%), 3 rattlesnake bites (3%), and 28 bites (26%) in which the snake could not be identified. First aid measures taken prior to hospitalization included cryotherapy (21%), incision and suction (22%), tight or loose tourniquets (32%), and moist heat (2%). After hospitalization, 29 patients (27%) underwent wound excision and 4 patients (4%) required fasciotomy. Antivenin was administered to 34 patients (32%) and 9 patients (26%) developed serum sickness. No patients died as a result of a bite injury and 84 patients (79%) recovered uneventfully. Complications of the injuries included coagulopathies (4%), infections (13%), tissue loss (12%), and permanent physical deformities (8%). No first aid measure significantly affected the outcome, although there was a trend toward increased complication rates in bites with moderate (grade II) or greater envenomation if cryotherapy or tourniquets were utilized. Wound excision after hospitalization was associated with a decreased complication rate in these significantly envenomated bites. Antivenin utilization did not improve outcome and there was a significantly higher incidence of tissue loss associated with its use. Therefore, no first aid measures are recommended for pitviper bites due to copperheads and cottonmouths except immobilization and elevation. Excision is efficacious for patients seen within 1 to 2 hours of bite injury. The risk of complications and questionable efficacy of antivenin outweigh any potential benefit for these patients. Data from the current series were insufficient to make definitive recommendations regarding rattlesnake bites.