Venomous snake bites are rarely encountered, yet they are a frequently tested topic in Emergency Medicine. Luckily, in North America, there are only two broad categories of venomous snake bites that we need to know how to manage.
In the United States, 98% of reported venomous snake bites come from snakes in the crotalid family, otherwise known as pit vipers. We reviewed these bites in a prior article you can find here. The other 2% of venomous snake bites reported in the U.S. come from elapids, otherwise known as coral snakes. Coral snakes deliver their venom by chewing rather than biting, and they have shorter fangs that are less effective at piercing through human skin. Even if bitten, symptoms may not manifest immediately and delay presentation. Remember the pneumonic for coral snake envenomations: Red on yellow, kill a fellow. Red on black, venom lack.
This article aims to review prehospital care of coral snake bites, possible clinical manifestations in the ED, management of symptoms, indications and dosing for antivenom, and disposition.
EPIDEMIOLOGY
From: Peterson ME. Chapter 76 – Snake Bite: Coral Snakes. Small Animal Toxicology. 3rd Ed. 2013. 799-805. Print.
PREHOSPITAL MANAGEMENT
Prehospital management is essentially the same for all venomous snake bites and is focused on preventing the spread of venom.
DO:
- Stay calm
- Immobilize the bitten body part
- Splint the affected limbs/joints in extension
- Remove constricting clothing and accessories
- Mark the bite site and any swelling/erythema
- Immediately transport to the closest hospital that stocks antivenom
DO NOT:
- Attempt to suck the venom out
- Attempt to catch or kill the snake
- Apply pressure dressings or tourniquets.
**Caveat**: If you are CERTAIN this was a coral snake bite, and it will NOT delay transport, you can place a pressure dressing around and proximal to the bite area to impede lymphatic flow (NOT BLOOD FLOW) of the bitten extremity
EMERGENCY DEPARTMENT MANAGEMENT
Once in the hospital, a thorough history and physical should be conducted to guide management. The Poison Control Center should be contacted for all suspected snake bites.
| Clinical Effect | Treatment | Antivenom |
| Respiratory Failure | Early intubation | Not helpful |
| Descending Paralysis | Antivenom | Yes |
| Local Wound | Update tetanus
No antibiotics |
Not helpful |
Lab Studies are not useful
Antivenom: (NACSA) – Initial dose: 3-5 vials (repeat if no response)
DISPOSITION
- Admit all patients to ICU
- Minimum 12-24 hrs observation
- q1hr neuro checks
Here is a clinical pathway from EM Practice that may be helpful:
From: Sheikh S, Lefferts P. Emergency Department Management of North American Snake Envenomations. EM Practice. 2018;20(9)
Resources:
- Ahmed SM, Ahmed M, Nadeem A, et al. Emergency treatment of a snake bite: Pearls from literature. J Emerg Trauma Shock 2008;1:97.
- Brown SA, Seifert SA, Rayburn WF. Management of envenomations during pregnancy. Clin Toxicol (Phila). 2013;51(1):3-15.
- Morgan DL, Borys DJ, Stanford R, et al. Texas coral snake (Micrurus tener) bites. South Med J. 2007;100(2):152-156.
- Mowry JB, Spyker DA, Brooks DE, et al. 2015 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 33rd annual report. Clin Toxicol (Phila). 2016;54(10):924-1109.
- Ruha et al. Epidemiology, Clinical Course, and Management of Snakebites in the North American Snake Bite Registry. J Med Toxicol. 2017;13(4):309-320.
- Seifert SA. Evaluation and management of coral snakebites. UpToDate.
- Sheikh S, Lefferts P. Emergency Department Management of North American Snake Envenomations. EM Practice. 2018;20(9)
- Spiller HA, Bosse GM, Ryan ML. Use of antivenom for snakebites reported to United States poison centers. Am J Emerg Med. 2010;28(7):780-785.
- 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.
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