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<< Diagnosis And Management Of North American Snake And Scorpion Envenomations


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the
reference, where available.

  1. Watson WA, Litovitz TL, Klein-Schwartz W, et al. 2003 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2004;22(5):335-404. (Prospective; 2,395,582 patients)
  2. Watson WA, Litovitz TL, Rodgers GC, et al. 2004 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2005;23(5):589-666. (Prospective; 2,438,644 patients)
  3. Langley RL, Morrow WE. Deaths resulting from animal attacks in the United States. Wilderness Environ Med 1997;8:8-16. (Expert opinion)
  4. Gold BS, Barish RA, Dart RC. North American Snake Envenomation: diagnosis, treatment and management. Emerg Med Clin North Am 2004;22(2):423-43. (Review)
  5. Gold BS, Dart RC, Barish RA. Current Concepts: Bites of Venomous Snakes. N Engl J Med 2002;347: 347-356. (Review)
  6. Dart RC, Waeckerle JF. Introduction: "Advances in the Management of Snakebite" Symposium. Ann Emerg Med 2001;37:166-167. (Expert opinion)
  7. Kitchens CS, Van Mierop LH. Envenomation by the Eastern Coral Snake (Micrurus fulvius fulvius). A study of 39 victims. JAMA. 1987;258(12):1615-1618
  8. German BT, Hack JB, Brewer K, et al. Pressure-immobilization bandages may delay toxicity in a porcine model of eastern coral snake (Micrurus fulvius fulvius) envenomation. Ann Emerg Med 2005;45(6):603-608. (Animal study, randomized, controlled)
  9. Abroug F, El Atrous S, Nouira S, et al. Serotherapy in scorpion envenomation: a randomized controlled trial. The Lancet 1999;354:906-909. (Prospective, randomized, controlled; 825 patients)
  10. Foex B. BestBETs: Scorpion envenomation: Does administration of antivenom alter outcome? Accessed 25 May 2006 at http://www.bestbets.org/cgibin/ bets.pl?record=00567 . (Systematic review)
  11. ECC Committee, Subcommittees and Task Forces of the American Heart Association. First aid: 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2005;112(22 Suppl):15- 25. (Consensus conference report)
  12. Parrish HM. Incidence of treated snakebites in the United States. Public Health Rep 1966;81:269-276. (Survey)
  13. Russell FE, Banner W. Snake venom poisoning. Conn's Current Therapy. Rakel RE (ed). Philadelphia, WB Saunders Co, 1988, p 1002.
  14. Juckett G, Hancox JG. Venomous Snakebites in the United States: Management Review and Update. Am Fam Phys 2002;65(7):1367-1374. (Review)
  15. Johnson CA. Management of Snakebite. Am Fam Phys 1991;44(1):174-180. (Review)
  16. Liebelt EL, Kazzi ZN. Timing and Toxicology Criticalfor Treating Snakebite Victims. UAB Insight 2006; Spring: 9-10. (Expert Opinion)
  17. McKinney PE. Out-of-hospital and Interhospital Management of Crotaline Snakebite. Ann Emerg Med 2001;37(2)168-174 (Review)
  18. Otten EJ. Venomous Animal Injuries. In: Marx JA, editor- in-chief. Rosen's Emergency Medicine:  oncepts and Clinical Practice, 6th ed. Philadelphia: Mosby Elsevier; 2006. 894-913 (Textbook  hapter)
  19. Messmore HL, Jeske WP, Wehrmacher W, el al. Antiplatelet Agents: Current drugs and future trends. Hematol Oncol Clin N Am 2005;19:87-117. (Review)
  20. Suncoast Herpetological Society. Venom1 Antivenom Bank. May 2006. Accessed 12 September 2006 at http://www.kingsnake.com/suncoastherpsociety/SH Sven.htm.
  21. Cheng D. Scorpion Sting. Accessed 25 May 2006 at http://www.emedicine.com. (Review)
  22. Rodriguez de la Vega RC, Possani LD. Current views on scorpion toxins specific for K+ channels. Toxicon 2004;43(8):865-875. (Basic science)
  23. Zuo XP, Ji YH. Molecular mechanism of scorpion neurotoxins acting on sodium channels: insight into their diverse selectivity. Mol Neurobiol 2004;30(3):265-278. (Basic science)
  24. Conant R, Collins JT. Reptiles and Amphibians: Eastern and Central North America 3rd ed. New York: Houghton Mifflin; 1998. Peterson Field Guide Series. (Reference book)
  25. Stebbins RC. A Field Guide to Western Reptiles and Amphibians 3rd ed. New York: Houghton Mifflin; 2003. Peterson Field Guide Series. (Reference book) 
  26. Venomous Snakes of North America. Accessed 12 September 2006 at http://www.geocities.com/RainForest/2221/snakeid.html.
  27. Alberts M, Shalit M, LoGalbo F. Suction for Venomous Snakebite: A Study of "Mock Venom" Extraction in a Human Model. Ann Emerg Med 2004; 43(2) 181-186. (Prospective;8 human volunteers)
  28. Dart RC, Daly FS. Reptile Bites. In: Tintinalli J, editor. Emergency Medicine: A Comprehensive Study Guide, 6th ed. Chicago: McGraw Hill; 2004. p1200-1205. (Textbook Chapter)
  29. Bronstein AC, Russell FE, Sullivan JB. Negative pressure suction in the field treatment of rattlesnake bite. Vet Hum Toxicol 1985;28:297 (Abstract)
  30. Bronstein AC, Russell FE, Sullivan JB. Negative pressure suction in the field treatment of rattlesnake bite victims. Vet Hum Toxicol 1986; (Abstract)
  31. Burgess JL, Dart RC, Egen NB, et al. Effects of constriction bands on rattlesnake venom absorption: a pharmacokinetic study. Ann Emerg Med 1992;21:1086- 1093.
  32. Hall EL. Role of surgical intervention in the management of crotaline snake envenomation. Ann Emerg Med 2001;37(2):175-180. (Review)
  33. Singletary EM, Rochman AS, Bodmer JC, et al. Envenomations. Med Clin N Am 2005; 1195-1224. (Systematic review)
  34. Clark R.F, Selden BS, Furbee B, The incidence of wound infection following crotalid envenomation. J Emerg Med 1993;11:583-586. (Prospective, observational; 54 patients)
  35. Weed HG, Nonvenomous snakebite in Massachusetts: prophylactic antibiotics are unnecessary. Ann Emerg Med 1993; 22:220-224. (Prospective observational; 72 patients)
  36. Talan DA, Citron D.M, Overturf G.D, et al. Antibacterial activity of crotalid venoms against oral snake flora and other clinical bacteria. J Infect Dis 1991;164:195-198. (Basic Science) 
  37. Protherics. "CROFAB® CROTALIDAE POLYVALENT IMMUNE FAB (OVINE)" Package Insert. 2006. (Package Insert)
  38. Quarre JP, Lecomte J, Lauwers D, et al. Allergy to latex and papain. J Allergy Clin Immunol 1995; 95(4):922. (Case Report)
  39. Baur X, Chen Z, Rozynek P, Düser D, et al. Cross-reacting IgE antibodies recognizing latex allergens, including Hev b 1, as well as papain. Allergy 1995;50(7):604- 609. (Clinical Trial, 58 patients)
  40. Caravati EM, Copperhead bites and Crotalidae polyvalent immune Fab (ovine): Routine use requires evidence of improved outcomes. Ann Emerg Med 2004;43(2): 207-208. (Expert opinion) 
  41. Lavonas EJ, Gerardo CJ, O'Malley G, et al. Initial experience with Crotalidae polyvalent immune Fab (ovine) antivenom in the treatment of copperhead snakebite. Ann Emerg Med  004;43:200-206. (Retrospective chart review;32 patients)
  42. Jurkovich GJ, Luterman A, McCullar K, et al. Complications of Crotalidae antivenin therapy. J Trauma 1988;28(7):1032-1037. (Prospective, Cohort; 40 patients)
  43. Schmidt JM. Antivenom therapy for snakebites in children: is there evidence? Curr Opin Pediatrics 2005;17(2):234-238. (Review)
  44. Offerman SR, Bush SP, Moynihan JA, et al. Crotaline Fab antivenom for the treatment of children with rattlesnake envenomation. Pediatrics 2002;110: 968–971. (Prospective/Retrospective, pediatric cohort; 12 patients)
  45. Dart RC, McNally J. Efficacy, safety, and use of snake antivenoms in the United States. Ann Emerg Med 2001;37(2):181-188. (Review)
  46. Holstege CP, Wu J, Baer AB. Immediate hypersensitivity reaction associated with the rapid infusion of Crotalidae polyvalent immune Fab (ovine). Ann Emerg Med 2002; 39(6):677-679. (Case report)
  47. Clark RF, McKinney PE, Chase PB. et al. Immediate and delayed allergic reactions to Crotalidae polyvalent immune Fab (ovine) antivenom. Ann Emerg Med 2002;39(6):671-676.
  48. Boyer LV, Seifert SA, Clark RF, et al. Recurrent and persistent coagulopathy following pit viper envenomation. Arch Intern Med 1999;159(7):706-710. (Retrospective chart review; 38 patients) 
  49. Boyer LV, Seifert SA, Cain JS. Recurrence phenomena after immunoglobulin therapy for snake envenomations: part 2. Guidelines for clinical management with Crotaline Fab antivenom. Ann Emerg Med 2001;37(2):196-201. (Review and clinical guidelines)
  50. Holstege CP, Miller MB, Wermuth M, et al. Crotalid snake envenomation. Crit Care Clin 1997;13(4):889-921. (Review Article)
  51. Stewart RM, Page CP, Schwesinger WH, et al. Antivenin and fasciotomy/debridement in the treatment of the severe rattlesnake bite. Am J Surg 1989;158:543-547. (Animal Study, randomized, controlled)
  52. Tanen DA, Danish DC, Grice GA, et al. Fasciotomy worsens the amount of myonecrosis in a porcine model of Crotaline envenomation. Ann Emerg Med 2004;44(2):99-104. (Randomized, blinded, controlled animal; 20 pigs)
  53. American College of Surgery, Commission on Trauma and American College of Emergency Physicians. Guidelines for treatment (poster publication). Chicago, IL: American College of Surgery; 1994. (Clinical Consensus Statement)
  54. Sutherland SK, Coulter AR, Harris RD. Rationalisation of first aid measures for elapid snakebite. Lancet 1979;1(8109):183-185. (Expert opinion)
  55. Howarth DM, Southee AE, Whyte IM. Lymphatic flow rates and first aid in simulated peripheral snake or spider envenomation. Med J Aust 1994;161:695-700. (Animal study, randomized, controlled)
  56. Bouaziz M, Bahloul M, Hergafi L, et al. Factors associated with pulmonary edema in severe scorpion sting patients—a multivariate analysis of 428 cases. Clin Toxicol (Phila) 2006;44(3):293-300. (Retrospective, cohort;428 patients)
  57. Bahloul M, Chaari A, Khlaf-Bouaziz N, et al. Gastrointestinal manifestations in severe scorpion envenomation. Gastroenterol Clin Biol 2005;29(10):1001- 1005. (Retrospective chart review; 951 patients)
  58. Moran NF, Newman WJ, Theakston RD, et al. High incidence of early anaphylactoid reaction to SAIMR polyvalent snake antivenom. Trans R Soc Trop Med Hyg. 1998;92(1):69-70. (Prospective case series; 17 patients)
  59. Isbister GK, Tankel AS, White J, et al. Med J Aus. 2006;184(8):419-20. (Prospective case series; 14 patients)
  60. LoVecchio F, Welch S, Klemens J, et al. Incidence of immediate and delayed hypersensitivity to Centruroides antivenom. Ann Emerg Med 1999;34(5):615-619. (Prospective, cohort;116 patients) 
  61. Lo Vecchio F, Klemens J, Roundy EB, et al. Serum sickness following administration of Antivenin (Crotalidae) Polyvalent in 181 cases of presumed rattlesnake envenomation. Wilderness Environ Med 2003;14(4)220-221. (Retrospective;181 patients)
  62. Premawardhena AP, deSilva CE, Fonseka MMD, et al. Low dose subcutaneous adrenaline to prevent acute adverse reactions to antivenom serum in people bitten by snakes: randomized, placebo controlled trial. BMJ 1999;318:1041-1043. (Prospective, randomized, controlled; 105 patients)
  63. Nuchpraryoon I, Garner P. Interventions for preventing reactions to snake antivenom. Cochrane Database Syst Rev 2000;(2):CD002153. (Systematic review)
  64. LoVecchio F, McBride C. Scorpion envenomations in young children in central Arizona. J Toxicol Clin Toxicol 2003;41(7):937-40. (Prospective case series; 483 patients)
  65. Riley BD, LoVecchio F, Pizon AF. Lack of Scorpion Antivenom Leads to Increased Pediatric ICU Admissions. Ann Emerg Med 2006;47(4):398-399. (Before-after cohort; about 35,000 patients) 
  66. Gupta V. Prazosin: a pharmacological antidote for scorpion envenomation. J Trop Pediatr 2006;52(2):150- 151. (Prospective, before-after, quasi-experimental;36 patients)
  67. McClain C. 2-year scorpion-antivenin trials successful; FDA scrutiny next. Accessed 6 July 2006 at http://www.azstarnet.com/allheadlines/124591. (Unpublished, prospective, randomized, controlled; 50 patients)
  68. Hughes A. Observation of snakebite victims: is twelve hours still necessary? Emerg Med (Freemantle) 2003;15(5-6):511-517. (Two phase case series; 360 patients)
  69. Norris R. "Snake Venom Poisoning In The United States: A Medical Emergency!" Accessed 11 September 2006 at http://www.emed.stanford.education/didactics/ snakebites.htm.
  70. Gibly R, Williams M, Walter FG et al. Continuous intravenous midazolam infusion for Centruroides exilicauda scorpion envenomation. Ann Emerg Med 1999;34(5): 669-670.

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