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Coral Snake Envenomation Medication

  • Author: Robert L Norris, MD; Chief Editor: Joe Alcock, MD, MS  more...
 
Updated: Oct 21, 2015
 

Medication Summary

Definitive therapy for coral snake envenomation is antivenom administration. Antivenom (usually derived from horses or sheep) is generally specific for closely related species of snakes, and no advantage exists to giving antivenom developed for unrelated snakes. Administering antivenom made from the venoms of unrelated snakes may add complications of acute or delayed adverse reactions (eg, nonallergic anaphylaxis [anaphylactoid reaction], delayed serum sickness) to an already serious situation. If specific antivenom is unavailable, compression and immobilization should be maintained and the airway and respiratory status supported as necessary. An appropriately applied compression/immobilization device should be removed only after supportive measures are in place and antivenom, if available, is obtained.

In the United States, the product used to treat Micrurus bites for the last several decades, Wyeth's North American Coral Snake (Micrurus fulvius) Antivenin, is no longer in production and current stock is due to expire in April 2016. Other antivenoms are produced in other countries (eg, Brazil, Costa Rica) for non-North American coral snakes. Mexico produces an antivenom that is likely effective for coral snake bites in the United States. One of these foreign antivenoms may prove useful for treatment of coral snake bites in the United States, and research in this area continues. Assistance in locating and securing an appropriate antivenom can be obtained by contacting a regional poison control center.

In the absence of such an antivenom, care will be entirely supportive.

Care for persons bitten by Sonoran coral snakes is entirely supportive because no specific antivenom is available for this species.

Any appropriate, available antivenom should be administered according to the manufacturer's instructions.

As with any form of bite, tetanus status should be updated as necessary.

Antibiotic prophylaxis is not indicated. Because of the relative paucity of enzymatic necrotic components in their venoms, coral snake bites tend to cause little local tissue damage, and secondary infections are rare.

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Antivenom

Class Summary

These agenst impart passive immunity to the patient against the venom components of the snake(s) for which it is manufactured. The heterologous antibodies administered bind with venom antigens and block their deleterious effects.

Antivenin, eastern & Texas coral snakes (Antivenin (Micrurus fulvius))

 

This historically is the drug of choice for significant bites by M fulvius (eastern coral snake) and M tener (Texas coral snake); however, it is no longer being produced. Unless another known effective antivenom is available, care for victims bitten by coral snakes in the United States will have to rely entirely on supportive care (as per the text above), though the outcome should still be good.

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Antihistamines

Class Summary

H1 and H2 blockers may blunt or prevent acute allergic reaction when given before the administration of antivenom. If an anaphylactoid reaction occurs despite pretreatment, further antihistamine dosing may be required. They are also useful in managing pruritus in cases of delayed serum sickness, which may appear days to weeks following antivenom treatment.

Diphenhydramine (Benadryl)

 

Diphenhydramine is administered parenterally and often is the H1 blocker of choice in treating or preventing anaphylactic/anaphylactoid reactions. It is also effective in oral forms for treating itching associated with serum sickness.

Cimetidine (Tagamet)

 

Cimetidine is administered parenterally and often is the H2 blocker of choice in treating or preventing anaphylactoid reactions. Use this medication in addition to H1 antihistamines.

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Cardiovascular agents

Class Summary

These agents are useful in treating acute allergic reactions that may occur with antivenom administration and in supporting the blood pressure and tissue perfusion of hypotensive patients with shock unresponsive to IV fluids and antivenom.

Epinephrine (EpiPen, Adrenaline)

 

Epinephrine is the drug of choice for treating anaphylactoid reactions. It has alpha-agonist effects that increase peripheral vascular resistance and reverse peripheral vasodilatation, systemic hypotension, and vascular permeability. Conversely, the beta-agonist activity of epinephrine produces bronchodilatation, chronotropic cardiac activity, and positive inotropic effects.

Dopamine (Intropin)

 

Dopamine may be required to support blood pressure with hypotension caused by an anaphylactoid reaction that is unresponsive to fluids and epinephrine or by direct coral snake venom effects that are unresponsive to fluids and antivenom.

Norepinephrine (Levophed)

 

Norepinephrine may be used as an alternative to dopamine to support blood pressure in the face of hypotension caused by an anaphylactoid reaction that is unresponsive to fluids and epinephrine.

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Corticosteroids

Class Summary

Corticosteroids are essential for the management of acute and delayed allergic phenomena following antivenom administration. Steroids have no primary role in the management of snake envenomation.

Methylprednisolone (Solu-Medrol, Adlone)

 

Methylprednisolone ameliorates the delayed effects of anaphylactoid reactions and may limit biphasic anaphylaxis. In severe cases of serum sickness, parenteral steroids may reduce the inflammatory effects of this immune-complex mediated disease.

Prednisone (Deltasone)

 

This or other oral forms of corticosteroids (eg, prednisolone) are useful in managing mild-to-moderate serum sickness on an outpatient basis.

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Immune globulins

Class Summary

Immune globulins bind toxoids, stimulate an immune response, and offer transient protection while the host immune system develops antibodies.

Tetanus immune globulin (TIG)

 

Tetanus immune globulin is used for passive immunization if the wound might be contaminated with tetanus spores when the patient has no history of completing a primary tetanus immunization series.

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Tetanus toxoid

Class Summary

This is used to induce active immunity against tetanus.

Tetanus toxoid adsorbed or fluid

 

The immunizing agent of choice for most adults and children older than 7 years is tetanus and diphtheria toxoids. It is necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. In children and adults, it may be administered into the deltoid or midlateral thigh muscles. In infants, the preferred site of administration is the mid thigh laterally.

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Contributor Information and Disclosures
Author

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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

David Eitel, MD, MBA Associate Professor, Department of Emergency Medicine, York Hospital; Physician Advisor for Case Management, Wellspan Health System, York

David Eitel, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, American Society of Pediatric Nephrology, Society for Academic Emergency Medicine, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Edmond A Hooker, II, MD, DrPH, FAAEM Associate Professor, Department of Health Services Administration, Xavier University, Cincinnati, Ohio; Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

Edmond A Hooker, II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, Southern Medical Association

Disclosure: Nothing to disclose.

References
  1. Mowry JB, Spyker DA, Cantilena LR Jr, McMillan N, Ford M. 2013 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st Annual Report. Clin Toxicol (Phila). 2014 Dec. 52 (10):1032-283. [Medline].

  2. de Roodt AR, De Titto E, Dolab JA, Chippaux JP. Envenoming by coral snakes (Micrurus) in Argentina, during the period between 1979-2003. Rev Inst Med Trop Sao Paulo. 2013 Jan-Feb. 55(1):13-8. [Medline].

  3. Pardal PP, Pardal JS, Gadelha MA, Rodrigues Lda S, Feitosa DT, Prudente AL. Envenomation by Micrurus coral snakes in the Brazilian Amazon region: report of two cases. Rev Inst Med Trop Sao Paulo. 2010 Nov-Dec. 52(6):333-7. [Medline].

  4. Cardwell MD. Recognizing dangerous snakes in the United States and Canada: a novel 3-step identification method. Wilderness Environ Med. 2011 Dec. 22 (4):304-8. [Medline].

  5. German BT, Hack JB, Brewer K, et al. Pressure-immobilization bandages delay toxicity in a porcine model of eastern coral snake (Micrurus fulvius fulvius) envenomation. Ann Emerg Med. 2005 Jun. 45(6):603-8. [Medline].

  6. Gray S. Pressure immobilization of snakebite. Wilderness Environ Med. 2003 Spring. 14(1):70-1. [Medline].

  7. Simpson ID, Tanwar PD, Andrade C, et al. The Ebbinghaus retention curve: training does not increase the ability to apply pressure immobilisation in simulated snake bite--implications for snake bite first aid in the developing world. Trans R Soc Trop Med Hyg. 2008 May. 102(5):451-9. [Medline].

  8. U.S. Food and Drug Administration. Expiration Date Extension for North American Coral Snake Antivenin (Micrurus fulvius) (Equine Origin) Lot 4030024 Through April 30, 2016. Available at http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/ucm445083.htm. May 1, 2015; Accessed: October 19, 2015.

  9. Wood A, Schauben J, Thundiyil J, Kunisaki T, Sollee D, Lewis-Younger C, 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 Sep-Oct. 51 (8):783-8. [Medline].

  10. Norris RL, Pfalzgraf RR, Laing G. Death following coral snake bite in the United States--first documented case (with ELISA confirmation of envenomation) in over 40 years. Toxicon. 2009 May. 53(6):693-7. [Medline].

  11. Norris RL, Bush SP. North American venomous reptile bites. Auerbach PS, ed. Wilderness Medicine. 4th ed. St. Louis: Mosby; 2001. 896-926.

  12. Norris RL, Dart RC. Apparent coral snake envenomation in a patient without visible fang marks. Am J Emerg Med. 1989 Jul. 7(4):402-5. [Medline].

  13. Norris RL, Ngo J, Nolan K, et al. Physicians and lay people are unable to apply pressure immobilization properly in a simulated snakebite scenario. Wilderness Environ Med. 2005. 16(1):16-21. [Medline].

 
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Snake envenomations, coral. Comparison of the harmless Lampropeltis triangulum annulata(Mexican milksnake) (top) with Micrurus tener(Texas coral snake) (bottom). Photo by Charles Alfaro.
Coral snake skull.
The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally (Media file 3), around as much of the extremity as possible (see Media files 4 and 5). No effort should be spent removing clothing prior to bandage application. The bandage is wrapped snugly, as for a severely sprained ligament. A splint (or sling when applied to the upper extremity) is then placed (see Media files 6 and 7), and the victim is carried from the scene. The victim should expend no effort in getting to definitive care. Pressure immobilization should remain in place until the victim has reached medical care. The doctor will decide when to remove the bandages. If venom has been injected, it will move into the bloodstream quickly once the bandages are removed. The doctor should leave the bandages and splint in position until appropriate antivenom is available whenever possible. Used with permission from Commonwealth Serum Laboratories.
The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally (Media file 3), around as much of the extremity as possible (see Media files 4 and 5). No effort should be spent removing clothing prior to bandage application. The bandage is wrapped snugly, as for a severely sprained ligament. A splint (or sling when applied to the upper extremity) is then placed (see Media files 6 and 7), and the victim is carried from the scene. The victim should expend no effort in getting to definitive care. Pressure immobilization should remain in place until the victim has reached medical care. The doctor will decide when to remove the bandages. If venom has been injected, it will move into the bloodstream quickly once the bandages are removed. The doctor should leave the bandages and splint in position until appropriate antivenom is available whenever possible. Used with permission from Commonwealth Serum Laboratories.
The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally (Media file 3), around as much of the extremity as possible (see Media files 4 and 5). No effort should be spent removing clothing prior to bandage application. The bandage is wrapped snugly, as for a severely sprained ligament. A splint (or sling when applied to the upper extremity) is then placed (see Media files 6 and 7), and the victim is carried from the scene. The victim should expend no effort in getting to definitive care. Pressure immobilization should remain in place until the victim has reached medical care. The doctor will decide when to remove the bandages. If venom has been injected, it will move into the bloodstream quickly once the bandages are removed. The doctor should leave the bandages and splint in position until appropriate antivenom is available whenever possible. Used with permission from Commonwealth Serum Laboratories.
The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally (Media file 3), around as much of the extremity as possible (see Media files 4 and 5). No effort should be spent removing clothing prior to bandage application. The bandage is wrapped snugly, as for a severely sprained ligament. A splint (or sling when applied to the upper extremity) is then placed (see Media files 6 and 7), and the victim is carried from the scene. The victim should expend no effort in getting to definitive care. Pressure immobilization should remain in place until the victim has reached medical care. The doctor will decide when to remove the bandages. If venom has been injected, it will move into the bloodstream quickly once the bandages are removed. The doctor should leave the bandages and splint in position until appropriate antivenom is available whenever possible. Used with permission from Commonwealth Serum Laboratories.
The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally (Media file 3), around as much of the extremity as possible (see Media files 4 and 5). No effort should be spent removing clothing prior to bandage application. The bandage is wrapped snugly, as for a severely sprained ligament. A splint (or sling when applied to the upper extremity) is then placed (see Media files 6 and 7), and the victim is carried from the scene. The victim should expend no effort in getting to definitive care. Pressure immobilization should remain in place until the victim has reached medical care. The doctor will decide when to remove the bandages. If venom has been injected, it will move into the bloodstream quickly once the bandages are removed. The doctor should leave the bandages and splint in position until appropriate antivenom is available whenever possible. Used with permission from Commonwealth Serum Laboratories.
 
 
 
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