eMedicine Specialties > Emergency Medicine > Environmental

Snake Envenomation, Coral

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

Updated: Dec 17, 2008

Introduction

Background

Approximately 40-50 species of venomous coral snakes exist in North America and South America, with the greatest variety from Mexico to northern South America. A number of African and Asian coral snake species also exist. All coral snakes belong to the family Elapidae; Micrurus fulvius (eastern coral snake) and Micrurus tener (Texas coral snake) are the most important species in the United States.

Another US coral snake is Micruroides euryxanthus (Sonoran or Arizona coral snake); this is a relatively innocuous snake, and no deaths have been attributed to its bite.

Coral snakes tend to be relatively shy creatures, and bites are uncommon. Coral snakes account for fewer than 1% of venomous snakebites in the United States. Most people bitten by coral snakes are handling them intentionally. Most bites occur in the spring or fall.

Pathophysiology

The coral snake venom apparatus is composed of a pair of small, fixed, hollow fangs in the anterior aspect of the upper jaw through which the snake conducts venom via a chewing motion (see Media file 2). Unlike pit vipers, such as rattlesnakes, copperheads, and cottonmouths, which strike quickly, coral snakes must hang on for a brief period to achieve significant envenomation in humans.

Coral snake skull.

Frequency

United States

Probably fewer than 20 bites per year (though 99 alleged bites were reported to the American Association of Poison Control Centers in 2004).¹

International

No accurate information on international incidence is available.

Mortality/Morbidity

No deaths related to coral snake bites have been reported in the United States since coral snake antivenom became available. Before that time, the estimated case-fatality rate was 10%, and the cause of death was respiratory or cardiovascular failure. Patients who survive the bite may require respiratory support for up to a week and may suffer persistent weakness for weeks to months.

Clinical

History

The vast majority of patients bitten by coral snakes report that a brightly colored snake bit them.

North of Mexico City, including the United States, the color pattern of the snake can be helpful in differentiating a coral snake from a harmless mimic (eg, nonvenomous milk snake). In this region, all coral snakes have a red, yellow, black, yellow, red banding pattern (red and yellow touching, see Media file 1); most harmless mimics have a red, black, yellow, black, red pattern (red and yellow separated by black). The mnemonic "Red on yellow, kill a fellow; red on black, venom lack," may be helpful in this region. South of Mexico City, the banding patterns are much less helpful, and bicolor (red and black) species are also present.

Snake envenomations, coral. Comparison of the harmless Lampropeltis triangulum annulata (Mexican milksnake) (top) with Micrurus tener (Texas coral snake) (bottom). Photo by Charles Alfaro.

• Onset of symptoms may be delayed up to 10-12 hours but may then be rapidly progressive.
• Paucity of local complaints
• Local paresthesias (may be painful)
• Soft tissue swelling (usually mild)
• Alteration of mental status
• Complaints related to cranial nerve dysfunction (eg, diplopia, ptosis, difficulty swallowing)

Physical

Physical findings of snake bite may include the following:

• Impending respiratory failure
  • Respiratory distress
  • Pharyngeal spasm
  • Hypersalivation
  • Cyanosis
  • Trismus
• Neurologic dysfunction
  • Altered mental status
  • Ptosis
  • Generalized weakness
  • Muscle fasciculations
• Cardiovascular collapse
  • Hypotension
  • Tachycardia

Differential Diagnoses

Snake Envenomations, Brown
Snake Envenomations, Cobra
Snake Envenomations, Moccasins
Snake Envenomations, Mohave Rattle
Snake Envenomations, Rattle
Snake Envenomations, Sea

Workup

Laboratory Studies

• No laboratory studies are of diagnostic benefit. Baseline laboratory studies (eg, complete blood count [CBC], electrolyte tests, renal function studies) may be obtained in severe bite cases or if the patient has significant underlying medical problems. Coagulation studies are not indicated.
• An arterial blood gas (ABG) determination may be helpful if the patient's respiratory status is of concern.

Imaging Studies

• A chest radiograph is beneficial in patients who have severe envenomation, who require intubation, or who show evidence of cardiopulmonary failure.

Treatment

Prehospital Care

Of utmost importance is prompt movement of the victim to a medical facility capable of rendering advanced care, including possible antivenom administration and airway support.

• Briefly attempt to identify the snake (especially, note the color pattern). If possible, take a digital photo of the snake from a safe distance. Efforts to catch or kill the animal can result in wasted time and further bites.
• Rapidly apply a compressive bandage (eg, elastic bandage, crepe bandage, torn clothing) to the bitten extremity, starting distally and progressing to encompass the entire limb. Wrap it as tightly as one would wrap a severe sprained ankle. Then, splint the extremity and, if possible, keep it at approximately heart level. This technique may significantly delay systemic absorption of elapid venoms, including coral snake venom. Research suggests that, in a simulated snakebite scenario, even after focused, intensive hands-on training, people tend to underestimate the application tension required for the technique to be effective. See Media file 3.

The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms, but its use in cobra bites remains controversial. 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. Used with permission from Commonwealth Serum Laboratories.

• No incisions are indicated.
• Suction is of no benefit and may be harmful.
• Avoid applying ice or initiating any other cooling measures.

Emergency Department Care

• Aggressively manage any signs of impending respiratory failure with endotracheal intubation to prevent aspiration.
• Immediately institute cardiac and pulse oximetry monitoring.
• Monitor vital signs closely.
• Start at least one large-bore intravenous line of normal saline or Ringer's lactate at a maintenance rate. If evidence of hypotension or hypoperfusion is present, select an appropriate, faster rate.
• Although numerous recommended grading scales are available for judging the severity of pit viper bites, these scales rely heavily on local findings, which are often minimal in coral snake bites.
  • Do not use such scales for coral snake bites.
  • Because of the lack of early signs and symptoms, the severity of coral snake bites may be underestimated at presentation. Maintain a high index of concern.
• Historically, if the snake was positively identified as an eastern or Texas coral snake and the victim was asymptomatic, or if signs and symptoms of envenomation were already present, the recommendation was to obtain and immediately administer appropriate antivenom. In the United States, however, as of October 2008, all available stocks of Wyeth's North American Coral Snake Antivenin will have expired, and this country will find itself without a commercially available antivenom.
  • Some research centers may have access to other Micrurus antivenoms that may be useful on a research or compassionate care basis in cases of severe bites.
  • Absent an available antivenom, victims can be managed with sound supportive care (as outlined above) with an expectation of excellent outcome as long as airway management and respiratory support are adequate, though ventilator dependence could persist for many days following serious bites.
  • Bites by Sonoran coral snakes tend to be very mild (there has never been a documented fatality) and are treated with supportive measures alone.

Consultations

• Consult a toxicologist or expert in snakebite management.

Medication

In the United States, the product used to treat Micrurus bites for the last several decades, Wyeth's Micrurus fulvius Antivenin, is no longer in production. 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. It may prove that one of these exotic antivenoms will be required to be imported into the United States for use in serious bites here. In the absence of such an antivenom, care must 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.

Antivenom

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

Micrurus fulvius Antivenin

Historically the DOC 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.

Dosing

Adult

As per the manufacturer's package insert for the appropriate, available product

Pediatric

Pediatric doses of snake antivenoms are the same as for adults

Interactions

None reported

Contraindications

Documented hypersensitivity; may still be indicated for significant envenomation despite allergy if the reaction is easily reversed with appropriate medications (eg, epinephrine, antihistamines, steroids)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Anaphylactic/anaphylactoid reactions and delayed serum sickness are a concern; appropriate therapeutic agents for anaphylaxis treatment should be ready for immediate use; while use in pregnancy has not been well studied, it is generally felt that the benefits of antivenom administration outweigh the risks

Antihistamines

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)

Administered parenterally and often is the H1 blocker of choice in treating or preventing anaphylactic/anaphylactoid reactions. Also effective in oral form for treating itching associated with serum sickness.

Dosing

Adult

Pretreatment for antivenom: 1 mg/kg/dose IV; not to exceed 100 mg/dose; if acute allergic reaction subsequently occurs, additional doses may be required; not to exceed 300 mg/d
Serum sickness: 1 mg/kg PO q6h prn itching; not to exceed 400 mg/d

Pediatric

Pretreatment for antivenom: Administer as in adults
Serum sickness: 1 mg/kg PO q6h prn itching; not to exceed 300 mg/d

Interactions

Potentiates effect of CNS depressants; because of alcohol content, do not give syrup dosage form to patient taking medications that can cause disulfiramlike reactions

Contraindications

Documented hypersensitivity; MAOIs

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction

Cimetidine (Tagamet)

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

Dosing

Adult

300 mg IV q6h prn

Pediatric

5-10 mg/kg IV q6h prn; not to exceed 300 mg/dose

Interactions

Can increase blood levels of theophylline, warfarin, tricyclic antidepressants, triamterene, phenytoin, quinidine, propranolol, metronidazole, procainamide, and lidocaine

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Elderly persons may experience confusional states; may cause impotence and gynecomastia in young males; may increase levels of many drugs; adjust dose or discontinue treatment if changes in renal function occur

Cardiovascular agents

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)

DOC for treating anaphylactoid reactions. Has alpha-agonist effects that increase peripheral vascular resistance and reverse peripheral vasodilatation, systemic hypotension, and vascular permeability. Conversely, beta-agonist activity of epinephrine produces bronchodilatation, chronotropic cardiac activity, and positive inotropic effects.

Dosing

Adult

0.01 mL/kg of 1:1000 (1 mg/mL) IM/SC; not to exceed 0.5 mL

Pediatric

0.01 mL/kg of 1:1000 (1 mg/mL) IM/SC; not to exceed 0.3 mL; may be repeated q10-20min prn
For severe hypotension: 0.05 mcg/kg/min IV initially (ie, 1 mg in 500 mL isotonic saline, starting at 0.025 mL/kg/min); titrate to effect

Interactions

Concurrent use with alpha- or beta-blockers is not recommended; nonselective beta-blockade allows alpha-receptor effects to predominate; increasing vascular resistance leads to increased BP and reflex bradycardia; closely monitor vital signs if the patient is taking a beta-blocker; pressor action is increased when coadministered with alpha-agonists; increases toxicity of halogenated inhalational anesthetics

Contraindications

Documented hypersensitivity; cardiac dysrhythmias or angle-closure glaucoma; do not use during labor (may delay second stage of labor)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in elderly persons, prostatic hypertrophy, hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac dysrhythmias

Dopamine (Intropin)

May be required to support BP with hypotension caused by anaphylactoid reaction that is unresponsive to fluids and epinephrine or by direct coral snake venom effects that are unresponsive to fluids and antivenom.

Dosing

Adult

5-20 mcg/kg/min IV; titrate to effect

Pediatric

Administer as in adults

Interactions

Phenytoin, alpha-adrenergic and beta-adrenergic blockers, general anesthesia, and MAOIs increase and prolong the effects

Contraindications

Documented hypersensitivity; pheochromocytoma; ventricular fibrillation

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Closely monitor urine flow, cardiac output, pulmonary wedge pressure, and BP during infusion; prior to infusion, correct hypovolemia as indicated; monitoring central venous pressure or left ventricular filling pressure may be helpful in detecting and treating hypovolemia

Norepinephrine (Levophed)

May be used as alternative to dopamine to support BP in the face of hypotension caused by anaphylactoid reaction unresponsive to fluids and epinephrine.

Dosing

Adult

0.5-1 mcg/min IV; titrate to effect

Pediatric

0.1 mcg/kg/min IV; titrate to effect

Interactions

Atropine may enhance pressor response by blocking reflex bradycardia

Contraindications

Documented hypersensitivity; peripheral or mesenteric vascular thrombosis because ischemia may be increased and area of infarct extended

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

If possible, correct intravascular volume depletion before therapy; extravasation may cause severe tissue necrosis and, thus, should be administered into a large vein; caution in occlusive vascular disease

Corticosteroids

Essential for 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)

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

Dosing

Adult

125 mg IV q6-8h

Pediatric

1-2 mg/kg IV q6-8h

Interactions

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels; phenobarbital, phenytoin, and rifampin may decrease levels (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics

Contraindications

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use

Prednisone (Deltasone)

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

Dosing

Adult

1 mg/kg PO qd until symptoms resolve; taper over 1-2 wk

Pediatric

Administer as in adults

Interactions

Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Contraindications

Documented hypersensitivity; viral, connective tissue, fungal, or tubercular skin infections; peptic ulcer disease; hepatic dysfunction

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids after long-term therapy may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

Immune globulins

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

Tetanus immune globulin (Hyper-Tet)

Used for passive immunization if wound might be contaminated with tetanus spores when the patient has no history of completing a primary tetanus immunization series.

Dosing

Adult

Prophylaxis: 250-500 U IM in different anatomical site than tetanus toxoid administration
Clinical tetanus: 3000-10,000 U IM

Pediatric

Prophylaxis: 250 U IM in different anatomical site than tetanus toxoid administration
Clinical tetanus: Administer as in adults

Interactions

None reported

Contraindications

Since antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live-virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live-virus vaccination

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Persons with isolated immunoglobulin A (IgA) deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing since intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing the medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not admix with other medications since usually incompatible

Tetanus toxoid

Used to induce active immunity against tetanus.

Tetanus toxoid

The immunizing agent of choice for most adults and children >7 y is tetanus and diphtheria toxoids. 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, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is the mid-thigh laterally.

Dosing

Adult

Suggested dosing:
Primary immunization: 0.5 mL IM, give 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y

Pediatric

Administer as in adults

Interactions

Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)

Contraindications

Documented hypersensitivity; a history of any type of neurological symptoms or signs following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Do not use to treat actual tetanus infections, or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin), diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended

Follow-up

Further Inpatient Care

• Admit all persons bitten by a coral snake to a closely monitored facility, whether or not antivenom is given.
• Observe asymptomatic patients for at least 24 hours because delayed signs and symptoms may occur.
• If an appropriate antivenom was available and administered, but resulted in an anaphylactoid reaction, continue to administer systemic antihistamines and steroids as needed.
• Generally, little or no risk of tissue necrosis is present following coral snake bites.
• Inform patients who have received antivenom of the signs and symptoms of delayed serum sickness. If symptoms of serum sickness develop after discharge, promptly evaluate the patient for initiation of systemic steroids and diphenhydramine (see Medications).

Deterrence/Prevention

• Avoid handling venomous or unidentified snakes.

Complications

Complications of snake bite may include the following:

• Respiratory failure
• Cardiovascular collapse
• Prolonged neuromuscular weakness
• Antivenom-related complications  
  • Anaphylactoid reactions
  • Delayed serum sickness

Prognosis

• With sound supportive care (eg, prevention of aspiration) and appropriate antivenom administration, when available, prognosis following coral snake envenomation is excellent; expect a full recovery. This is generally true, even in the absence of an available, appropriate antivenom, but the overall clinical course (including the need for prolonged intubation and respiratory support) will be longer.

Patient Education

• For excellent patient education resources, visit eMedicine's Bites and Stings Center. Also, see eMedicine's patient education article Snakebite.

Miscellaneous

Medicolegal Pitfalls

• Considering the potential delay in onset of signs and symptoms, it is unwise to discharge asymptomatic patients with possible coral snake bite.
• Some risk of acute or delayed allergic reaction associated with antivenom use always exists. If possible, obtain patient consent before use and be immediately available throughout the administration to intervene if necessary.
• Be aware of the lack of efficacy of inappropriate antivenom as discussed above.
• Failure to aggressively manage a patient's airway in the face of impending respiratory failure may lead to aspiration, with its attendant complications.

Special Concerns

• The biggest current special concern related to coral snake bites in the United States is the lack of a commercially available antivenom in production at the time of this writing. It is hoped that an alternative, effective antivenom from another country in Latin America will be imported for US Micrurus bites or that a manufacturer will begin supplying a new, specific antivenom for Micrurus fulvius and M tener.
• Absent an available antivenom, care must rely on support of the airway and respirations as indicated—possibly for a period of many days in cases of serious envenoming.

Multimedia

Media file 1: Snake envenomations, coral. Comparison of the harmless Lampropeltis triangulum annulata (Mexican milksnake) (top) with Micrurus tener (Texas coral snake) (bottom). Photo by Charles Alfaro.

Media file 2: Coral snake skull.

Media file 3: The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms, but its use in cobra bites remains controversial. 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. Used with permission from Commonwealth Serum Laboratories.

Media file 4: The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms, but its use in cobra bites remains controversial. 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. Used with permission from Commonwealth Serum Laboratories.

Media file 5: The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms, but its use in cobra bites remains controversial. 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. Used with permission from Commonwealth Serum Laboratories.

Media file 6: The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms, but its use in cobra bites remains controversial. 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. Used with permission from Commonwealth Serum Laboratories.

Media file 7: The Australian pressure immobilization technique. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms, but its use in cobra bites remains controversial. 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. Used with permission from Commonwealth Serum Laboratories.

References

1. Watson WA, Litovitz TL, Rodgers GC Jr, et al. 2004 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 2005;23(5):589-666. [Medline].

2. Davidson TM, Eisner J. United States coral snakes. Wilderness Environ Med. 1996;1:38-45.

3. 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. Jun 2005;45(6):603-8. [Medline].

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

5. Kitchens CS, Van Mierop LH. Envenomation by the Eastern coral snake (Micrurus fulvius fulvius). A study of 39 victims. JAMA. Sep 25 1987;258(12):1615-8. [Medline].

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

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

8. 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].

9. Parrish HM, Khan MS. Bites by coral snakes: report of 11 representative cases. Am J Med Sci. May 1967;253(5):561-8. [Medline].

10. 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. May 2008;102(5):451-9. [Medline].

Keywords

snake envenomation, snakebite, snake bite, coral snake, Elapidae, Micrurus fulvius, eastern coral snake, Micrurus tener, Texas coral snake, coral snake envenomations, coral snake bite, Micruroides euryxanthus, Sonoran coral snake, Arizona coral snake

Contributor Information and Disclosures

Author

Robert L Norris, MD, Associate 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.

Medical Editor

Edmond A Hooker II, MD, DrPH, FAAEM, Assistant Professor, Department of Health Services Administration, Xavier University; Associate Clinical Professor, Department of Emergency Medicine, University of Louisville; Assistant Clinical Professor, Department of Emergency Medicine, Wright State University
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, and Southern Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & 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.

Managing Editor

David Eitel, MD, MBA, Associate Professor, Department of Emergency Medicine, York Hospital
David Eitel, MD, MBA is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

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

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
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