P3.140: Variability in EMS Management of Venomous Snake Bites in Pediatric Patients

Background: A combination of epinephrine, diphenhydramine, and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are frequently used by Emergency Medical Services (EMS) when treating venomous snake bites. However, the efficacy of diphenhydramine and NSAIDs in this context remains controversial. This study aims to assess the impact of diphenhydramine on the clinical acuity of venomous snake bite victims, hypothesizing that it does not contribute to clinical improvement.

Methods: This retrospective cohort study was conducted utilizing data from the National Emergency Medical Services Information System (NEMSIS) from 2017-2020. A descriptive analysis of the distribution of snakebite treatments among pediatric patients was completed. Chi-square and Wilcoxon rank sum analysis was conducted to evaluate the associations between patient characteristics, type of treatments received, and clinical outcomes.

Results: A total of 1,269 pediatric patients received EMS care for venomous snake bites. Median age was 9 (5-14, p< 0.001), without notable differences in gender distribution (p=0.62) or bite by snake species (p=0.99). The most common anatomic sites were upper extremity (37%) and lower extremity (17%). 57 (4.49%) patients were treated with diphenhydramine/NSAIDs, 102 (8.93%) with opioids alone, and 1100 (87.47%) with neither diphenhydramine/NSAIDs or opioids. On initial assessment, the following proportion of patients were considered critical; 17.99% (diphenhydramine/NSAIDs), 17.7% (opioids alone), and 6.94% (neither diphenhydramine/NSAIDs or opioids) (p < .0001). Upon arrival to the ED, critical status was reassessed; the diphenhydramine/NSAIDs treatment group had 31.2% improvement in acuity, opioids alone treatment group had 9.23% improvement in acuity, and neither diphenhydramine/NSAIDs or opioids treatment group had 9.33% improvement in acuity (p=.002). Notably, administration of epinephrine was higher in the diphenhydramine/NSAIDs treatment group (26%) vs. opioids alone treatment group (0%), and neither diphenhydramine/NSAIDs or opioids treatment group (0.26%) (p < .0001). The diphenhydramine/NSAIDs treatment group was also more likely to have enroute physician direction (45.6%) vs. opioids alone treatment group (33.3%), and neither diphenhydramine/NSAIDs or opioids treatment group (33.7%) (p=.03).

Conclusion: The study highlights variability in the treatment of venomous snake bites by EMS across the United States. Despite the lack of robust scientific evidence, we found that diphenhydramine and NSAIDs are frequently administered alongside epinephrine. It is difficult to assess if the improvement is due to diphenhydramine/NSAIDs use or the concurrent use of epinephrine in critically ill patients. Further research is needed to align clinical practices with established best practices, ensuring the efficacy and safety of treatments administered to venomous snake bite victims in the pre-hospital setting.