Snake Bite - Copperhead - Water Moccasin - Rattlesnake - Cottonmouth - Coral Snake - Trauma CME | Digest

Emergency Department Management of North American Snake Envenomations

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Points and Pearls Excerpt

  • Pit vipers—rattlesnakes, copperheads, and water moccasins/cottonmouths—produce a predominantly hemotoxic venom. Both local and systemic effects can occur. Systemic effects include tachycardia, tachypnea, hypotension, nausea, vomiting, weakness, and diaphoresis.
  • Patients with snakebite should be treated with supportive care, pain control, and specific antivenom, when indicated.
  • In general, venomous pit vipers have a triangular or spade-like head, elliptical pupils, and hollow, retractable fangs.
  • Usually, venomous coral snakes have adjacent red and yellow bands; if there is a black band between the red and yellow, the snake is usually nonpoisonous.
  • Coral snakes have teeth, not fangs, and tend to “chew,” rather than bite.

Most Important References

  • Lavonas EJ, Ruha AM, Banner W, et al. Unified treatment algorithm for the management of Crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med. 2011;11:2-227X-11-2. (Consensus panel) DOI:
  • Bush SP, Ruha AM, Seifert SA, et al. Comparison of F(ab’)2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial. Clin Toxicol (Phila). 2015;53(1):37-45. (Randomized controlled trial; 121 patients) DOI:
  • American College of Medical Toxicology, American Academy of Clinical Toxicology, American Association of Poison Control Centers, European Association of Poison Control Centres and Clinical Toxicologists, International Society on Toxicology, Asia Pacific Association of Medical Toxicology. Pressure immobilization after North American Crotalinae snake envenomation. Clin Toxicol (Phila). 2011;49(10):881-882. (Position statement) DOI:
  • Wood A, Schauben J, Thundiyil J, et al. Review of eastern coral snake (Micrurus fulvius fulvius) exposures managed by the Florida Poison Information Center Network: 1998- 2010. Clin Toxicol (Phila). 2013;51(8):783-788. (Retrospective; 387 patients) DOI:
  • Cumpston KL. Is there a role for fasciotomy in Crotalinae envenomations in North America? Clin Toxicol (Phila). 2011;49(5):351-365. (Review) DOI:
  • Walker JP, Morrison RL. Current management of copperhead snakebite. J Am Coll Surg. 2011;212(4):470-474. (Retrospective; 142 patients) DOI:
  • Hwang CW, Flach FE. Recurrent coagulopathy after rattlesnake bite requiring continuous intravenous dosing of antivenom. Case Rep Emerg Med. 2015;2015:719302. (Case report) DOI:
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Publication Information

Sophia Sheikh, MD; Patrick Leffers, PharmD

Peer Reviewed By

Daniel J. Sessions, MD; Andy Jagoda, MD, FACEP

Publication Date

September 1, 2018

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