Prehospital Care
In the prehospital setting, the primary goal 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. [8, 9] 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. [10] See the images below.
The Australian pressure immobilization technique: Step 1. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally, around as much of the extremity as possible. 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, 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: Step 2. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally, around as much of the extremity as possible. 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, 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: Step 3. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally, around as much of the extremity as possible. 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, 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: Step 4. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally, around as much of the extremity as possible. 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, 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: Step 5. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally, around as much of the extremity as possible. 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, 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.
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. However, recent data suggests that there adminstration of antivenom to asymptomatic patients is of no benefit. [6]
In the United States, the Food and Drug Administration (FDA) approved antivenom for coral snake envenomation is the North American Coral Snake Antivenin (Micrurus fulvius) (Equine Origin). However, production of this coral snake antivenom has ceased. The FDAhas extended the expiration date for the remaining of North American Coral Snake Antivenin through June 30, 2024. [11] 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 studies have demonstrated that some non-native elapid antivenom can neutralize North American coral snake venom. [12, 13] 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.
Further 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 acute reaction, continue to administer systemic antihistamines and steroids as needed.
Patients should be monitored for 12-24 hours after the last dose of antivenom.
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).
-
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: Step 1. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally, around as much of the extremity as possible. 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, 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: Step 2. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally, around as much of the extremity as possible. 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, 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: Step 3. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally, around as much of the extremity as possible. 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, 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: Step 4. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally, around as much of the extremity as possible. 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, 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: Step 5. This technique has been shown to be helpful in delaying systemic absorption of elapid venoms. A broad pressure bandage is immediately wrapped, beginning distally, around as much of the extremity as possible. 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, 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.
