Snakebite Questions & Answers

1. Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, Premaratna R, et al. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med. 2008 Nov 4. 5 (11):e218. [QxMD MEDLINE Link].

2. Mowry JB, Spyker DA, Cantilena LR Jr, Bailey JE, Ford M. 2012 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 30th Annual Report. Clin Toxicol (Phila). 2013 Dec. 51 (10):949-1229. [QxMD MEDLINE Link].

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4. Mowry JB, Spyker DA, Brooks DE, McMillan N, Schauben JL. 2014 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd Annual Report. Clin Toxicol (Phila). 2015. 53 (10):962-1147. [QxMD MEDLINE Link].

5. Mowry JB, Spyker DA, Brooks DE, Zimmerman A, Schauben JL. 2015 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 33rd Annual Report. Clin Toxicol (Phila). 2016 Dec. 54 (10):924-1109. [QxMD MEDLINE Link].

6. Gutiérrez JM, Lomonte B, León G, Rucavado A, Chaves F, Angulo Y. Trends in snakebite envenomation therapy: scientific, technological and public health considerations. Curr Pharm Des. 2007. 13 (28):2935-50. [QxMD MEDLINE Link].

7. Lu Q, Clemetson JM, Clemetson KJ. Snake venoms and hemostasis. J Thromb Haemost. 2005 Aug. 3 (8):1791-9. [QxMD MEDLINE Link].

8. Odeleye AA, Presley AE, Passwater ME, Mintz PD. Report of two cases: Rattlesnake venom-induced thrombocytopenia. Ann Clin Lab Sci. 2004 Autumn. 34 (4):467-70. [QxMD MEDLINE Link].

9. Ho CL, Lee CY. Presynaptic actions of Mojave toxin isolated from Mojave rattlesnake (crotalus scutulatus) venom. Toxicon. 1981. 19 (6):889-92. [QxMD MEDLINE Link].

10. Lameu C, Neiva M, Hayashi MA. Venom Bradykinin-related peptides (BRPs) and its multiple biological roles. Radis-Baptista G, ed. An Integrated View of the Molecular Recognition and Toxinology-From Analytical Procedures to Biomedical Applications. BoD - Books on Demand; 2013. 119-52.

11. Barros AC, Fernandes DP, Ferreira LC, Dos Santos MC. Local effects induced by venoms from five species of genus Micrurus sp. (coral snakes). Toxicon. 1994 Apr. 32 (4):445-52. [QxMD MEDLINE Link].

12. Corrêa-Netto C, Junqueira-de-Azevedo Ide L, Silva DA, Ho PL, Leitão-de-Araújo M, Alves ML, et al. Snake venomics and venom gland transcriptomic analysis of Brazilian coral snakes, Micrurus altirostris and M. corallinus. J Proteomics. 2011 Aug 24. 74 (9):1795-809. [QxMD MEDLINE Link].

13. de Roodt AR, Lago NR, Stock RP. Myotoxicity and nephrotoxicity by Micrurus venoms in experimental envenomation. Toxicon. 2012 Feb. 59 (2):356-64. [QxMD MEDLINE Link].

14. Tanaka GD, Pidde-Queiroz G, de Fátima D Furtado M, van den Berg C, Tambourgi DV. Micrurus snake venoms activate human complement system and generate anaphylatoxins. BMC Immunol. 2012 Jan 16. 13:4. [QxMD MEDLINE Link].

15. Janes DN Jr, Bush SP, Kolluru GR. Large snake size suggests increased snakebite severity in patients bitten by rattlesnakes in Southern california. Wilderness Environ Med. 2010 Jun. 21 (2):120-6. [QxMD MEDLINE Link].

16. Ruha AM, Kleinschmidt KC, Greene S, Spyres MB, Brent J, Wax P, et al. The Epidemiology, Clinical Course, and Management of Snakebites in the North American Snakebite Registry. J Med Toxicol. 2017 Dec. 13 (4):309-320. [QxMD MEDLINE Link].

17. Schulte J, Kleinschmidt KC, Domanski K, Smith EA, Haynes A, Roth B. Differences Between Snakebites with Concomitant Use of Alcohol or Drugs and Single Snakebites. South Med J. 2018 Feb. 111 (2):113-117. [QxMD MEDLINE Link].

18. Emswiler MP, Griffith FP Th, Cumpston KL. Clinically Significant Envenomation From Postmortem Copperhead (Agkistrodon contortrix). Wilderness Environ Med. 2017 Mar. 28 (1):43-45. [QxMD MEDLINE Link].

19. Willhite LA, Willenbring BA, Orozco BS, Cole JB. Death after bite from severed snake head. Clin Toxicol (Phila). 2018 Sep. 56 (9):864-865. [QxMD MEDLINE Link].

20. Tanen DA, Ruha AM, Graeme KA, Curry SC, Fischione MA. Rattlesnake envenomations: unusual case presentations. Arch Intern Med. 2001 Feb 12. 161 (3):474-9. [QxMD MEDLINE Link].

21. Hogan DE, Dire DJ. Anaphylactic shock secondary to rattlesnake bite. Ann Emerg Med. 1990 Jul. 19 (7):814-6. [QxMD MEDLINE Link].

22. Camilleri C, Offerman S. Anaphylaxis after Rattlesnake bite. Ann Emerg Med. 2004 Jun. 43 (6):784-5. [QxMD MEDLINE Link].

23. Hinze JD, Barker JA, Jones TR, Winn RE. Life-threatening upper airway edema caused by a distal rattlesnake bite. Ann Emerg Med. 2001 Jul. 38 (1):79-82. [QxMD MEDLINE Link].

24. 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. 1999 Apr 12. 159 (7):706-10. [QxMD MEDLINE Link].

25. Lavonas EJ, Khatri V, Daugherty C, Bucher-Bartelson B, King T, Dart RC. Medically significant late bleeding after treated crotaline envenomation: a systematic review. Ann Emerg Med. 2014 Jan. 63 (1):71-78.e1. [QxMD MEDLINE Link].

26. Kopec KT, Yen M, Bitner M, Evans CS, Gerardo CJ. Marked Hypofibrinogenemia and Gastrointestinal Bleeding After Copperhead (Agkistrodon contortrix) Envenomation. Wilderness Environ Med. 2015 Dec. 26 (4):488-90. [QxMD MEDLINE Link].

27. Bond RG, Burkhart KK. Thrombocytopenia following timber rattlesnake envenomation. Ann Emerg Med. 1997 Jul. 30 (1):40-4. [QxMD MEDLINE Link].

28. Ho CL, Lee CY. Presynaptic actions of Mojave toxin isolated from Mojave rattlesnake (crotalus scutulatus) venom. Toxicon. 1981. 19 (6):889-92. [QxMD MEDLINE Link].

29. Bush SP, Siedenburg E. Neurotoxicity associated with suspected southern Pacific rattlesnake (Crotalus viridis helleri) envenomation. Wilderness Environ Med. 1999 Winter. 10 (4):247-9. [QxMD MEDLINE Link].

30. Farstad D, Thomas T, Chow T, Bush S, Stiegler P. Mojave rattlesnake envenomation in southern California: a review of suspected cases. Wilderness Environ Med. 1997 May. 8 (2):89-93. [QxMD MEDLINE Link].

31. Jansen PW, Perkin RM, Van Stralen D. Mojave rattlesnake envenomation: prolonged neurotoxicity and rhabdomyolysis. Ann Emerg Med. 1992 Mar. 21 (3):322-5. [QxMD MEDLINE Link].

32. Morgan DL, Borys DJ, Stanford R, Kjar D, Tobleman W. Texas coral snake (Micrurus tener) bites. South Med J. 2007 Feb. 100 (2):152-6. [QxMD MEDLINE Link].

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

34. Kerrigan KR, Mertz BL, Nelson SJ, Dye JD. Antibiotic prophylaxis for pit viper envenomation: prospective, controlled trial. World J Surg. 1997 May. 21 (4):369-72; discussion 372-3. [QxMD MEDLINE Link].

35. Ruha AM, Kang AM, Onisko NS, Greene S, Rohra R. Antibiotic use in the management of snake envenomation [abstract]. J Med Toxicol. 2015. 11(1):36-7.

36. Angel MF, Zhang F, Jones M, Henderson J, Chapman SW. Necrotizing fasciitis of the upper extremity resulting from a water moccasin bite. South Med J. 2002 Sep. 95 (9):1090-4. [QxMD MEDLINE Link].

37. Spiller HA, Bosse GM. Prospective study of morbidity associated with snakebite envenomation. J Toxicol Clin Toxicol. 2003. 41 (2):125-30. [QxMD MEDLINE Link].

38. Thorson A, Lavonas EJ, Rouse AM, Kerns WP 2nd. Copperhead envenomations in the Carolinas. J Toxicol Clin Toxicol. 2003. 41 (1):29-35. [QxMD MEDLINE Link].

39. Wills BK, Billet M, Rose SR, Cumpston KL, Counselman F, Shaw KJ, et al. Prevalence of hematologic toxicity from copperhead envenomation: an observational study. Clin Toxicol (Phila). 2020 Apr. 58 (4):262-265. [QxMD MEDLINE Link].

40. Domanski K, Kleinschmidt KC, Greene S, Ruha AM, Bebarta VS, Onisko N, et al. Cottonmouth snake bites reported to the ToxIC North American snakebite registry 2013-2017. Clin Toxicol (Phila). 2020 Mar. 58 (3):178-182. [QxMD MEDLINE Link].

41. Ruha AM, Curry SC, Albrecht C, Riley B, Pizon A. Late hematologic toxicity following treatment of rattlesnake envenomation with crotalidae polyvalent immune Fab antivenom. Toxicon. 2011 Jan. 57 (1):53-9. [QxMD MEDLINE Link].

42. Lavonas EJ, Ruha AM, Banner W, Bebarta V, Bernstein JN, Bush SP, et al. Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop. BMC Emerg Med. 2011 Feb 3. 11:2. [QxMD MEDLINE Link].

43. German BT, Hack JB, Brewer K, Meggs WJ. 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. [QxMD MEDLINE Link].

44. American College of Medical Toxicology, American Academy of Clinical Toxicology, American Association of Poison Control Center, et al. Pressure immobilization after North American Crotalinae snake envenomation. Clin Toxicol (Phila). 2011 Dec. 49 (10):881-2. [QxMD MEDLINE Link].

45. Sutherland SK, Coulter AR, Harris RD. Rationalisation of first-aid measures for elapid snakebite. Lancet. 1979 Jan 27. 1 (8109):183-5. [QxMD MEDLINE Link].

46. Dart RC, Gustafson RA. Failure of electric shock treatment for rattlesnake envenomation. Ann Emerg Med. 1991 Jun. 20 (6):659-61. [QxMD MEDLINE Link].

47. Ben Welch E, Gales BJ. Use of stun guns for venomous bites and stings: a review. Wilderness Environ Med. 2001 Summer. 12 (2):111-7. [QxMD MEDLINE Link].

48. Cohen WR, Wetzel W, Kadish A. Local heat and cold application after eastern cottonmouth moccasin (Agkistrodon piscivorus) envenomation in the rat: effect on tissue injury. Toxicon. 1992 Nov. 30 (11):1383-6. [QxMD MEDLINE Link].

49. Frank HA. Snakebite or frostbite: what are we doing? An evaluation of cryotherapy for envenomation. Calif Med. 1971 May. 114 (5):25-7. [QxMD MEDLINE Link].

50. Toschlog EA, Bauer CR, Hall EL, Dart RC, Khatri V, Lavonas EJ. Surgical considerations in the management of pit viper snake envenomation. J Am Coll Surg. 2013 Oct. 217 (4):726-35. [QxMD MEDLINE Link].

51. Alberts MB, Shalit M, LoGalbo F. Suction for venomous snakebite: a study of "mock venom" extraction in a human model. Ann Emerg Med. 2004 Feb. 43 (2):181-6. [QxMD MEDLINE Link].

52. 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. 2000 Fall. 11 (3):180-8. [QxMD MEDLINE Link].

53. Bush SP. Snakebite suction devices don't remove venom: they just suck. Ann Emerg Med. 2004 Feb. 43 (2):187-8. [QxMD MEDLINE Link].

54. Cox RD, Parker CS, Cox ECE, Marlin MB, Galli RL. Misidentification of copperhead and cottonmouth snakes following snakebites^.. Clin Toxicol (Phila). 2018 Dec. 56 (12):1195-1199. [QxMD MEDLINE Link].

55. CroFab® (crotalidae polyvalent immune Fab [ovine]) [package insert] [package insert]. West Conshohocken, Pa: BTG International Inc. 2018. Available at [Full Text].

56. Dart RC, Seifert SA, Boyer LV, Clark RF, Hall E, McKinney P, et al. A randomized multicenter trial of crotalinae polyvalent immune Fab (ovine) antivenom for the treatment for crotaline snakebite in the United States. Arch Intern Med. 2001 Sep 10. 161 (16):2030-6. [QxMD MEDLINE Link].

57. 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. 1997 Jul. 30 (1):33-9. [QxMD MEDLINE Link].

58. Anavip® (crotalidae polyvalent immune F(ab’)2 [equine]) [package insert]. Accessed online on March 24, 2020 [package insert]. Franklin, Tenn: Rare Disease Therapeutics, Inc. 2015. Available at [Full Text].

59. Gerardo CJ, Quackenbush E, Lewis B, Rose SR, Greene S, Toschlog EA, et al. The Efficacy of Crotalidae Polyvalent Immune Fab (Ovine) Antivenom Versus Placebo Plus Optional Rescue Therapy on Recovery From Copperhead Snake Envenomation: A Randomized, Double-Blind, Placebo-Controlled, Clinical Trial. Ann Emerg Med. 2017 Aug. 70 (2):233-244.e3. [QxMD MEDLINE Link].

60. Anderson VE, Gerardo CJ, Rapp-Olsson M, Bush SP, Mullins ME, Greene S, et al. Early administration of Fab antivenom resulted in faster limb recovery in copperhead snake envenomation patients. Clin Toxicol (Phila). 2019 Jan. 57 (1):25-30. [QxMD MEDLINE Link].

61. Freiermuth CE, Lavonas EJ, Anderson VE, Kleinschmidt KC, Sharma K, Rapp-Olsson M, et al. Antivenom Treatment Is Associated with Fewer Patients using Opioids after Copperhead Envenomation. West J Emerg Med. 2019 May. 20 (3):497-505. [QxMD MEDLINE Link].

62. Wyeth® Antivenin (Micrurus fulvius) (Equine Origin) North American Coral Snake Antivenin [package insert] [package insert]. Marietta, Pa: Wyeth Laboratories Inc. August 31, 2001. Available at [Full Text].

63. Yang DC, Dobson J, Cochran C, Dashevsky D, Arbuckle K, Benard M, et al. The Bold and the Beautiful: a Neurotoxicity Comparison of New World Coral Snakes in the Micruroides and Micrurus Genera and Relative Neutralization by Antivenom. Neurotox Res. 2017 Oct. 32 (3):487-495. [QxMD MEDLINE Link].

64. Prieto da Silva AR, Yamagushi IK, Morais JF, Higashi HG, Raw I, Ho PL, et al. Cross reactivity of different specific Micrurus antivenom sera with homologous and heterologous snake venoms. Toxicon. 2001 Jul. 39 (7):949-53. [QxMD MEDLINE Link].

65. de Roodt AR, Paniagua-Solis JF, Dolab JA, Estévez-Ramiréz J, Ramos-Cerrillo B, Litwin S, et al. Effectiveness of two common antivenoms for North, Central, and South American Micrurus envenomations. J Toxicol Clin Toxicol. 2004. 42 (2):171-8. [QxMD MEDLINE Link].

66. Vital Brazil O, Vieira RJ. Neostigmine in the treatment of snake accidents caused by Micrurus frontalis: report of two cases (1). Rev Inst Med Trop Sao Paulo. 1996 Jan-Feb. 38 (1):61-7. [QxMD MEDLINE Link].

67. Gold BS. Neostigmine for the treatment of neurotoxicity following envenomation by the Asiatic cobra. Ann Emerg Med. 1996 Jul. 28 (1):87-9. [QxMD MEDLINE Link].

68. Tanen DA, Danish DC, Grice GA, Riffenburgh RH, Clark RF. Fasciotomy worsens the amount of myonecrosis in a porcine model of crotaline envenomation. Ann Emerg Med. 2004 Aug. 44 (2):99-104. [QxMD MEDLINE Link].

69. Tanen DA, Danish DC, Clark RF. Crotalidae polyvalent immune Fab antivenom limits the decrease in perfusion pressure of the anterior leg compartment in a porcine crotaline envenomation model. Ann Emerg Med. 2003 Mar. 41 (3):384-90. [QxMD MEDLINE Link].

70. Stewart RM, Page CP, Schwesinger WH, McCarter R, Martinez J, Aust JB. Antivenin and fasciotomy/debridement in the treatment of the severe rattlesnake bite. Am J Surg. 1989 Dec. 158 (6):543-7. [QxMD MEDLINE Link].

71. Cumpston KL. Is there a role for fasciotomy in Crotalinae envenomations in North America?. Clin Toxicol (Phila). 2011 Jun. 49 (5):351-65. [QxMD MEDLINE Link].

72. Mazer-Amirshahi M, Boutsikaris A, Clancy C. Elevated compartment pressures from copperhead envenomation successfully treated with antivenin. J Emerg Med. 2014 Jan. 46 (1):34-7. [QxMD MEDLINE Link].

73. Schaeffer TH, Khatri V, Reifler LM, Lavonas EJ. Incidence of immediate hypersensitivity reaction and serum sickness following administration of Crotalidae polyvalent immune Fab antivenom: a meta-analysis. Acad Emerg Med. 2012 Feb. 19 (2):121-31. [QxMD MEDLINE Link].

74. Kleinschmidt K, Ruha AM, Campleman S, Brent J, Wax P, ToxIC North American Snakebite Registry Group. Acute adverse events associated with the administration of Crotalidae polyvalent immune Fab antivenom within the North American Snakebite Registry. Clin Toxicol (Phila). 2018 Nov. 56 (11):1115-1120. [QxMD MEDLINE Link].

75. Khobrani M, Huckleberry Y, Boesen KJ, Aljabri A, Alharthi M, Patanwala AE. Incidence of allergic reactions to Crotalidae polyvalent immune Fab. Clin Toxicol (Phila). 2019 Mar. 57 (3):164-167. [QxMD MEDLINE Link].

76. Bush SP, Ruha AM, Seifert SA, Morgan DL, Lewis BJ, Arnold TC, et al. Comparison of F(ab')2 versus Fab antivenom for pit viper envenomation: a prospective, blinded, multicenter, randomized clinical trial. Clin Toxicol (Phila). 2015 Jan. 53 (1):37-45. [QxMD MEDLINE Link].

77. Lavonas EJ, Benson BE, Seifert SA. Failure to develop sensitization despite repeated administration of ovine fab snake antivenom: update of a single-patient, multicenter case series. Ann Emerg Med. 2013 Mar. 61 (3):371-2. [QxMD MEDLINE Link].

Spencer Greene, MD, MS, FACEP, FACMT, FAAEM President, Bayou City Medical Toxicology and Emergency Medicine Consultants, PLLC

Spencer Greene, MD, MS, FACEP, FACMT, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, East Texas Herpetological Society, Texas College of Emergency Physicians

Disclosure: Nothing to disclose.

Sean P Bush, MD, FACEP Professor of Emergency Medicine, The Brody School of Medicine at East Carolina University

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, Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Medical Director, Pulmonary Medicine General Practice Unit (F2), Senior Staff and Attending Physician, Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Received research grant from: Sanofi Pharmaceutical.

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.

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association

Disclosure: Nothing to disclose.

Lisa Kirkland, MD, FACP, FCCM, MSHA Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; Chair, Department of Critical Care, ANW Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, FCCM, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Chandler Long, MD Resident Physician, Department of Surgery, University of Tennessee Medical Center-Knoxville

Disclosure: Nothing to disclose.

A Mariah Alexander, MD Resident Physician, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville

A Mariah Alexander, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Sneha Bhat, MD Resident Physician, Department of Surgery, University of Tennessee Health Science Center College of Medicine

Disclosure: Nothing to disclose.

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