Rattle Snake Envenomation 

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

Background

Rattlesnakes are pit vipers and include the genera Crotalus and Sistrurus. Pit vipers may be identified by a heat-sensing pit anteroinferior to the eye. Rattlesnakes may be identified in all but one species by a rattle at the tip of the tail. Rattlesnakes are indigenous from North America to South America.

Juvenile southern Pacific rattlesnake (Crotalus orJuvenile southern Pacific rattlesnake (Crotalus oreganus helleri). Photo by Sean Bush, MD.
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Pathophysiology

Venom is usually injected into subcutaneous tissue via hollow movable fangs located in the anterior mouth. Occasionally, intramuscular or (probably rarely) intravenous injection occurs. Rattlesnake venom is generally composed of several digestive enzymes and spreading factors, which result in local and systemic injury.

Clinically, local effects most commonly predominate, progressing from pain and edema to ecchymosis and bullae. Hematologic abnormalities, including defibrination with or without thrombocytopenia, may result, but serious bleeding is uncommon. Local or diffuse myotoxicity may result in complications such as compartment syndrome or rhabdomyolysis. Other general effects include shock, myokymia/fasciculations, taste changes, and vomiting. Rarely, direct cardiotoxicity or allergy to venom may occur. Some rattlesnakes may exhibit neurotoxicity with minimal local tissue effects (see Snake Envenomation, Mohave Rattle).

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Epidemiology

Frequency

United States

Approximately 7,000-8,000 reptile bites are reported to the American Association of Poison Control Centers (AAPCC) each year.[1, 2] However, this figure is probably conservative because of underreporting. Rattlesnakes cause the majority of all bites by identified venomous snakes in the United States.[3] Dry bite (ie, no clinical evidence of envenomation) occurs in between 10 and 50% of strikes.

International

An estimated 300,000-400,000 venomous snakebites occur per year. Although rattlesnakes are not found naturally outside of North America, Central America, and South America, they are imported into zoos, museums, and private collections in other regions of the world.

Mortality/Morbidity

Fewer than half a dozen deaths occur per year as a result of snakebite in the United States; most are caused by rattlesnake bites. Estimates of deaths each year from snakebite range from 30,000-110,000 worldwide. Up to 5 times as many individuals experience permanent morbidity.[4, 5]

US mortality with administration of antivenin is approximately 0.28%. Without antivenin being administered, mortality is approximately 2.6%.

Sex

Males are bitten more commonly than females.

Age

Young adults are bitten most commonly.

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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

  1. Watson WA, Litovitz TL, Klein-Schwartz W, Rodgers GC Jr, Youniss J, Reid N, et al. 2003 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2004;22(5):335-404. [Medline].

  2. Bronstein AC, Spyker DA, Cantilena LR Jr, Green J, Rumack BH, Heard SE. 2006 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS). Clin Toxicol (Phila). Dec 2007;45(8):815-917. [Medline].

  3. Wingert WA, Chan L. Rattlesnake bites in southern California and rationale for recommended treatment. West J Med. Jan 1988;148(1):37-44. [Medline].

  4. Langley RL, Morrow WE. Deaths resulting from animal attacks in the United States. Wilderness Environ Med. 1997;8:8-16.

  5. Norris RL Jr. Snake Venom Poisoning in the United States: Assessment and Management. Emerg Med Rep. 1995;16:87-94.

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

  7. Bush SP, Jansen PW. Severe rattlesnake envenomation with anaphylaxis and rhabdomyolysis. Ann Emerg Med. Jun 1995;25(6):845-8. [Medline].

  8. Bond RG, Burkhart KK. Thrombocytopenia following timber rattlesnake envenomation. Ann Emerg Med. Jul 1997;30(1):40-4. [Medline].

  9. Hurlbut KM, Dart RC, et al. Reliability of clinical presentation for predicting significant pit viper envenomation. Ann Emerg Med. 1988;438-9.

  10. Bogdan GM, Dart RC. Prolonged and recurrent coagulopathy after North American pit viper envenomation (abstract). Ann Emerg Med. 1996;27:820.

  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].

  12. Burgess JL, Dart RC. Snake venom coagulopathy: use and abuse of blood products in the treatment of pit viper envenomation. Ann Emerg Med. Jul 1991;20(7):795-801. [Medline].

  13. Riffer E, Curry SC, Gerkin R. Successful treatment with antivenin of marked thrombocytopenia without significant coagulopathy following rattlesnake bite. Ann Emerg Med. Nov 1987;16(11):1297-9. [Medline].

  14. Carroll RR, Hall EL, Kitchens CS. Canebrake rattlesnake envenomation. Ann Emerg Med. Jul 1997;30(1):45-8. [Medline].

  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].

  25. Jurkovich GJ, Luterman A, McCullar K, Ramenofsky ML, Curreri PW. Complications of Crotalidae antivenin therapy. J Trauma. Jul 1988;28(7):1032-7. [Medline].

  26. Offerman SR, Bush SP, Moynihan JA, Clark RF. Crotaline Fab antivenom for the treatment of children with rattlesnake envenomation. Pediatrics. Nov 2002;110(5):968-71. [Medline].

  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].

  28. Guisto JA. Severe toxicity from crotalid envenomation after early resolution of symptoms. Ann Emerg Med. Sep 1995;26(3):387-9. [Medline].

  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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