Coral Snake Envenomation Treatment & Management
- Author: Robert L Norris, MD; Chief Editor: Joe Alcock, MD, MS more...
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 the Australian pressure immobilization technique in which a compressive bandage (eg, elastic bandage, crepe bandage, torn clothing) is wrapped around the bitten extremity, starting distally and progressing to encompass the entire limb.[5, 6] Wrap it as tightly as one would wrap a severely sprained joint. Then, splint the extremity and, if possible, keep it at approximately heart level. The victim must then be carried from the scene to the hospital (ie, without any ambulation, regardless of whether the bite is on an upper or lower extremity). This technique may significantly delay systemic absorption of elapid venoms, including coral snake venom. Research suggests, however, 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.
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.
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, production of coral snake antivenom has ceased. The Food and Drug Administration has extended the expiration date for Lot #4030024 of Wyeth's North American Coral Snake Antivenin through April 30, 2016. After this time, unless stock remains and the expiration date is further extended, this country may find itself without a commercially available coral snake antivenom. Research is ongoing to find a suitable new antivenom for the treatment of coral snake bite victims in the United States and Canada, and there is a possibility that coral snake antivenom production will resume in the United States at some point in the future. Until then, healthcare providers treating a coral snake bite victim should contact their regional poison control center for assistance.
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 or weeks 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.
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].
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].
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].
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].
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].
Gray S. Pressure immobilization of snakebite. Wilderness Environ Med. 2003 Spring. 14(1):70-1. [Medline].
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].
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.
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].
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].
Norris RL, Bush SP. North American venomous reptile bites. Auerbach PS, ed. Wilderness Medicine. 4th ed. St. Louis: Mosby; 2001. 896-926.
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].
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].