Coral Snake Envenomation Treatment & Management

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 the images below. 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. 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. 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. 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. 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.

• 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.

• Consult a toxicologist or expert in snakebite management.