Rattle Snake Envenomation Clinical Presentation

  • Author: Sean P Bush, MD, FACEP; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Nov 2, 2010
 

History

All or none of the following may be present. Note that symptoms are subject to change, and this change can be very rapid or very insidious. In addition, severity is generally guided by the most severely affected parameter.[6, 5, 7, 8, 9]

  • Pain around the bite site
  • Swelling
  • Taste changes (eg, a metallic taste)
  • Difficulty breathing
  • Chest pain
  • Nausea, vomiting, or diarrhea
  • Hematemesis, hematochezia
  • Neurologic symptoms
    • Weakness
    • Paresthesias
  • Syncope, near syncope
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Physical

Physical examination findings may include the following:

  • Fang marks - May be 1, 2, or more, or may be unable to discernModerate rattlesnake envenomation in a toddler aftModerate rattlesnake envenomation in a toddler after treatment with antivenom. Photo by Sean Bush, MD.
  • Tenderness surrounding the bite site
  • Local edema
    • Use a pen to mark and time the border of advancing edema every 15-20 minutes initially. Once stabilization with antivenom has occurred, repeat measurements every 1-2 hours.
    • Rapidly progressive swelling is usually indicative of a severe envenomation.
  • Erythema
  • Ecchymosis
  • Bullae
  • Bleeding
  • Hypotension/hypertension
  • Tachycardia
  • Myokymia (muscle fasciculations)
  • Neurologic effects
  • Lethargy
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Causes

A large percentage of bites occur when a snake is handled, kept as a pet, or abused. These are considered intentionally interactive bites. Many bites are associated with ethanol use.

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Contributor Information and Disclosures
Author

Sean P Bush, MD, FACEP  Professor of Emergency Medicine, Loma Linda University School of Medicine; Consulting Staff, Envenomation Specialist, Department of Emergency Medicine, Loma Linda University Medical Center

Sean P Bush, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, International Society on Toxicology, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Protherics Consulting fee Consulting; Nycomed (formerly Fougera) Grant/research funds Speaking and teaching; Rare Disease Therapeutics Grant/research funds Research; Bioclon Grant/research funds Research

Specialty Editor Board

Robert L Norris, MD  Professor, Department of Surgery, Chief, Division of Emergency Medicine, Stanford University Medical Center

Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, California Medical Association, International Society of Toxinology, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

James Steven Walker, DO, MS  Clinical Professor of Surgery, Department of Surgery, University of Oklahoma College of Medicine

James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

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. Norris Jr RL, Bush SP. North American venomous reptile bites. In: Auerbach PS, ed. Wilderness Medicine. 5th ed. 2006.

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  11. Boyer LV, Seifert SA, Clark RF, McNally JT, Williams SR, Nordt SP, et al. Recurrent and persistent coagulopathy following pit viper envenomation. Arch Intern Med. Apr 12 1999;159(7):706-10. [Medline].

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  15. French WJ, Hayes WK, Bush SP, Cardwell MD, Bader JO, Rael ED. Mojave toxin in venom of Crotalus helleri (Southern Pacific Rattlesnake): molecular and geographic characterization. Toxicon. Dec 1 2004;44(7):781-91. [Medline].

  16. Spaite D, Dart R, Sullivan JB. Skin testing in cases of possible crotalid envenomation. Ann Emerg Med. Jan 1988;17(1):105-6. [Medline].

  17. Bush SP. Snakebite suction devices don't remove venom: they just suck. Ann Emerg Med. Feb 2004;43(2):187-8. [Medline].

  18. Bush SP, Hegewald KG, Green SM, Cardwell MD, Hayes WK. Effects of a negative pressure venom extraction device (Extractor) on local tissue injury after artificial rattlesnake envenomation in a porcine model. Wilderness Environ Med. Fall 2000;11(3):180-8. [Medline].

  19. Bush SP, Green SM, Laack TA, Hayes WK, Cardwell MD, Tanen DA. Pressure immobilization delays mortality and increases intracompartmental pressure after artificial intramuscular rattlesnake envenomation in a porcine model. Ann Emerg Med. Dec 2004;44(6):599-604. [Medline].

  20. Hardy DL, Bush SP. Pressure/immobilization as first aid for venomous snakebite in the United States. Herpetol Rev. 1998;29:204-8.

  21. Consroe P, Egen NB, Russell FE, Gerrish K, Smith DC, Sidki A, et al. Comparison of a new ovine antigen binding fragment (Fab) antivenin for United States Crotalidae with the commercial antivenin for protection against venom-induced lethality in mice. Am J Trop Med Hyg. Nov 1995;53(5):507-10. [Medline].

  22. Bush SP, Wu VH, Corbett SW. Rattlesnake venom-induced thrombocytopenia response to Antivenin (Crotalidae) Polyvalent: a case series. Acad Emerg Med. Feb 2000;7(2):181-5. [Medline].

  23. Bush SP, Green SM, Moynihan JA, Hayes WK, Cardwell MD. Crotalidae polyvalent immune Fab (ovine) antivenom is efficacious for envenomations by Southern Pacific rattlesnakes (Crotalus helleri). Ann Emerg Med. Dec 2002;40(6):619-24. [Medline].

  24. Dart RC, Seifert SA, Carroll L, Clark RF, Hall E, Boyer-Hassen LV, et al. Affinity-purified, mixed monospecific crotalid antivenom ovine Fab for the treatment of crotalid venom poisoning. Ann Emerg Med. Jul 1997;30(1):33-9. [Medline].

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  27. Premawardhena AP, de Silva CE, Fonseka MM, Gunatilake SB, de Silva HJ. Low dose subcutaneous adrenaline to prevent acute adverse reactions to antivenom serum in people bitten by snakes: randomised, placebo controlled trial. BMJ. Apr 17 1999;318(7190):1041-3. [Medline].

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  29. Clark RF, Selden BS, Furbee B. The incidence of wound infection following crotalid envenomation. J Emerg Med. Sep-Oct 1993;11(5):583-6. [Medline].

 
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Juvenile southern Pacific rattlesnake (Crotalus oreganus helleri). Photo by Sean Bush, MD.
A recent study suggests that the Extractor (Sawyer Products) does not reduce swelling after rattlesnake envenomation and may be associated with skin necrosis beneath the suction cup. Photo by Sean Bush, MD.
Moderate rattlesnake envenomation in a toddler after treatment with antivenom. Photo by Sean Bush, MD.
 
 
 
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