Snakebite Clinical Presentation

  • Author: Brian James Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 14, 2010
 

History

History usually can be obtained from the patient. Most cases result from attempting to handle snakes, so the genus usually is known. Knowledge of indigenous fauna also is important.

The time elapsed since the bite is a necessary component of the history. This allows assessment of the temporal effects of the bite to determine if the process is confined locally or if systemic signs have developed.

  • Obtain a description of the snake or capture it, if possible, to determine its color, pattern, or the existence of a rattle.
  • Most snakes remain within 20 feet after biting.
  • Assess the timing of events and onset of symptoms. Inquire about the time the bite occurred and details about the onset of pain. Early and intense pain implies significant envenomation.
  • Local swelling, pain, and paresthesias may be present.
  • Systemic symptoms include nausea, syncope, and difficulty swallowing or breathing.
  • Determine history of prior exposure to antivenin or snakebite.
  • Determine history of allergies to medicines because antibiotics may be required.
  • Determine history of comorbid conditions (eg, cardiac, pulmonary, and renal disease) or medications (eg, aspirin, anticoagulants such as warfarin [Coumadin] or GPIIb/IIIa inhibitors, beta-blockers).
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Physical

Follow the established routine for a complete comprehensive examination.

  • Vital signs, airway, breathing, circulation
  • Fang marks or scratches (determine coral snakebite pattern by expressing blood from the suspected wound)
  • Local tissue destruction
    • Soft pitting edema that generally develops over 6-12 hours but may start within 5 minutes
    • Bullae
    • Streaking
    • Erythema or discoloration
    • Contusions
  • Systemic toxicity
    • Hypotension
    • Petechiae, epistaxis, hemoptysis
    • Paresthesias and dysesthesias - Forewarn neuromuscular blockade and respiratory distress (more common with coral snakes)
  • Effects from a copperhead bite are shown in the images below. Snakebite. Copperhead bite day 3; initial wounds tSnakebite. Copperhead bite day 3; initial wounds to finger. Snakebite. Copperhead bite day 3; initial wounds tSnakebite. Copperhead bite day 3; initial wounds to finger. Snakebite. Copperhead bite day 3; initial wounds tSnakebite. Copperhead bite day 3; initial wounds to finger.
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Causes

  • In the United States, more than 40% of victims put themselves in danger by either handling pets or attempting to capture reptiles in the wild. The popularity of keeping exotic species has increased the number of envenomations by nonnative species.
  • UTMCK data support this by reporting that 15 of 25 patients were bitten handling snakes; 2 of these were involved in religious ceremonies.
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Contributor Information and Disclosures
Author

Brian James Daley, MD, MBA, FACS, FCCP, CNSC  Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

A Mariah Alexander, MD  Resident Physician, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville

A Mariah Alexander, MD is a member of the following medical societies: American College of Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Lisa Kirkland, MD, FACP, CNSP, MSHA  Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, CNSP, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, and Society of Hospital Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Daniel R Ouellette, MD, FCCP  Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

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  6. Dart RC, Seifert SA, Boyer LV, et al. A randomized multicenter trial of crotalinae polyvalent immune Fab (ovine) antivenom for the treatment for crotaline snakebite in the United States. Arch Intern Med. Sep 10 2001;161(16):2030-6. [Medline].

  7. 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. Feb 2004;43(2):200-6. [Medline].

  8. Vohra R, Cantrell FL, Williams SR. Fasciculations after rattlesnake envenomations: a retrospective statewide poison control system study. Clin Toxicol (Phila). Feb 2008;46(2):117-21. [Medline].

  9. Richardson WH, Goto CS, Gutglass DJ, Williams SR, Clark RF. Rattlesnake envenomation with neurotoxicity refractory to treatment with crotaline Fab antivenom. Clin Toxicol (Phila). Jun-Aug 2007;45(5):472-5. [Medline].

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  12. Holstege CP, Singletary EM. Images in emergency medicine. Skin damage following application of suction device for snakebite. Ann Emerg Med. Jul 2006;48(1):105, 113. [Medline].

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  16. Kularatne SA, Kumarasiri PV, Pushpakumara SK, et al. Routine antibiotic therapy in the management of the local inflammatory swelling in venomous snakebites: results of a placebo-controlled study. Ceylon Med J. Dec 2005;50(4):151-5. [Medline].

  17. 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. Feb 2004;43(2):200-6. [Medline].

  18. Schmidt JM. Antivenom therapy for snakebites in children: is there evidence?. Curr Opin Pediatr. Apr 2005;17(2):234-8. [Medline].

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  22. Whitley RE. Conservative treatment of copperhead snakebites without antivenin. J Trauma. Aug 1996;41(2):219-21. [Medline].

 
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Snakebite. Western diamondback rattlesnake.
Snakebite. Western coral snake.
Snakebite. Southern Copperhead snake, from snakesandfrogs.com
Snakebite. Copperhead bite day 3; initial wounds to finger.
Snakebite. Copperhead bite day 3; initial wounds to finger.
Snakebite. Copperhead bite day 3; initial wounds to finger.
Snakebite. Comparison of the harmless Lampropeltis triangulum annulata (Mexican milksnake) (top) with Micrurus tener (Texas coral snake) (bottom). Photo by Charles Alfaro.
Snakebite. Juvenile southern Pacific rattlesnake (Crotalus oreganus helleri). Photo by Sean Bush, MD.
Snakebite. Moderate rattlesnake envenomation in a toddler after treatment with antivenom. Photo by Sean Bush, MD.
 
 
 
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