The venom of poisonous snakes and lizards may be predominantly neurotoxic (coral snake) or predominantly cytolytic (rattlesnakes, other pit vipers). Neurotoxins cause respiratory paralysis; cytolytic venoms cause tissue destruction by digestion and hemorrhage due to hemolysis and destruction of the endothelial lining of the blood vessels. The manifestations of rattlesnake envenomation are mostly local pain, redness, swelling, and extravasation of blood. Perioral tingling, metallic taste, nausea and vomiting, hypotension, and coagulopathy may also occur. Thrombocytopenia can persist for several days after a rattlesnake bite. Neurotoxic envenomation may cause ptosis, dysphagia, diplopia, and respiratory arrest.
Immobilize the patient and the bitten part in a neutral position. Avoid manipulation of the bitten area. Transport the patient to a medical facility for definitive treatment. Do not give alcoholic beverages or stimulants; do not apply ice; do not apply a tourniquet. The potential trauma to underlying tissues resulting from incision and suction performed by unskilled people is probably not justified in view of the small amount of venom that can be recovered.
B. Specific Antidote and General Measures
1. Pit viper (eg, rattlesnake) envenomation
There are two commercially available antivenins for rattlesnake envenomation (CroFab and Anavip). Depending on the severity of symptoms CroFab is administered in increments of 4–6 vials by slow intravenous drip in 250–500 mL saline. For more serious envenomation with marked local effects and systemic toxicity (eg, hypotension, coagulopathy), higher doses and additional vials may be required. The dosing of Anavip is 10 vials by slow intravenous infusion over 60 minutes initially followed by additional 10-vial increments as needed for more serious envenomations or for progression of symptoms. Monitor vital signs and the blood coagulation profile. Type and cross-match blood. The adequacy of venom neutralization is indicated by improvement in symptoms and signs, and the rate that swelling slows. Prophylactic antibiotics are not indicated after a rattlesnake bite.
2. Elapid (coral snake) envenomation
Give 1–2 vials of specific antivenom as soon as possible. Note: Pfizer/Wyeth no longer makes coral snake antivenom in the United States and remaining supplies are dwindling. To locate antisera for this or exotic snakes, call a regional poison control center (1-800-222-1222).
et al. Prophylactic antibiotics are not needed following rattlesnake bites. Am J Med. 2018 Nov 131(11):1367–71.
et al. North American snake envenomation. Emerg Med Clin North Am. 2017 May;35(2):339–54.
et al. Clinically significant envenomation from postmortem copperhead (Agkistrodon contortrix
). Wilderness Environ Med. 2017 Mar;28(1):43–5.
et al. Unresolved issues in the understanding of the pathogenesis of local tissue damage induced by snake venoms. Toxicon. 2018 Jun 15;148:123–31.