Management of Crotalinae (rattlesnake, water moccasin [cottonmouth], or copperhead) bites in the United States
- Allen C Cheng, MB, BS, FRACP
Allen C Cheng, MB, BS, FRACP
- Infectious Diseases Physician
- Menzies School of Health Research
- Steven A Seifert, MD, FAACT, FACMT
Steven A Seifert, MD, FAACT, FACMT
- University of New Mexico School of Medicine
- Section Editors
- Daniel F Danzl, MD
Daniel F Danzl, MD
- Section Editor — Environmental Emergencies
- Professor of Emergency Medicine
- University of Louisville School of Medicine
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Michele M Burns, MD, MPH
Michele M Burns, MD, MPH
- Section Editor — Pediatric Toxicology
- Assistant Professor of Pediatrics
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Snake bites are a significant problem in the United States. Successful treatment requires prompt definitive medical evaluation, careful clinical assessment, and timely administration of antivenom in selected patients. Consultation with a medical toxicologist or other clinician with experience in managing poisonous snake bites is recommended prior to antivenom administration. Phone consultation with a medical toxicologist is available through a United States regional poison control center by calling 1-800-222-1222.
The clinical evaluation and management of poisonous Crotalinae (rattlesnake, water moccasin [cottonmouth] or copperhead) snake bites is reviewed here. The principles of management of coral snake bites and snake bites outside the United States are discussed separately. (See "Evaluation and management of coral snakebites" and "Snakebites worldwide: Clinical manifestations and diagnosis".)
Rattlesnakes, water moccasins (cottonmouths), and copperheads are members of the family Viperidae, subfamily Crotalinae (formerly Crotalidae). They are also commonly called pit vipers, a name that refers to the heat sensing pit located behind the nostrils.
Rattlesnakes, water moccasins (cottonmouths), and copperheads are the most numerous and cause the most snake bites in the United States. Elapids (coral snakes) and imported exotic snakes cause a smaller number .
Estimates from the 1960s suggest that there were approximately 8000 bites annually from poisonous snake species in the United States, with 10 to 12 deaths annually . Additional studies of rattlesnake bites suggest that there is an increasing number of significant bites, but mortality has remained at low levels since the 1980s [3,4].
- Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med 2002; 347:347.
- Parrish HM. Incidence of treated snakebites in the United States. Public Health Rep 1966; 81:269.
- Walter FG, Stolz U, Shirazi F, McNally J. Epidemiology of severe and fatal rattlesnake bites published in the American Association of Poison Control Centers' Annual Reports. Clin Toxicol (Phila) 2009; 47:663.
- Seifert SA, Boyer LV, Benson BE, Rogers JJ. AAPCC database characterization of native U.S. venomous snake exposures, 2001-2005. Clin Toxicol (Phila) 2009; 47:327.
- Walter FG, Chase PB, Fernandez MC, McNally J. Venomous snakes. In: Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose, 4th, Shannon MW, Borron SW, Burns MJ (Eds), Saunders, Philadelphia 2007. p.399.
- Seifert S, White J, Currie BJ. Pressure bandaging for North American snake bite? No! Clin Toxicol (Phila) 2011; 49:883.
- McKinney PE. Out-of-hospital and interhospital management of crotaline snakebite. Ann Emerg Med 2001; 37:168.
- Corbett SW, Anderson B, Nelson B, et al. Most lay people can correctly identify indigenous venomous snakes. Am J Emerg Med 2005; 23:759.
- Hall EL. Role of surgical intervention in the management of crotaline snake envenomation. Ann Emerg Med 2001; 37:175.
- Stewart ME, Greenland S, Hoffman JR. First-aid treatment of poisonous snakebite: are currently recommended procedures justified? Ann Emerg Med 1981; 10:331.
- Alberts MB, Shalit M, LoGalbo F. Suction for venomous snakebite: a study of "mock venom" extraction in a human model. Ann Emerg Med 2004; 43:181.
- Markenson D, Ferguson JD, Chameides L, et al. Part 13: First aid: 2010 American Heart Association and American Red Cross International Consensus on First Aid Science With Treatment Recommendations. Circulation 2010; 122:S582.
- Lavonas EJ, Ruha AM, Banner W, 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; 11:2.
- American College of Medical Toxicology, American Academy of Clinical Toxicology, American Association of Poison Control Centers, et al. Pressure immobilization after North American Crotalinae snake envenomation. J Med Toxicol 2011; 7:322.
- American College of Medical Toxicology, American Academy of Clinical Toxicology, American Association of Poison Control Centers, et al. Pressure immobilization after North American Crotalinae snake envenomation. Clin Toxicol (Phila) 2011; 49:881.
- RUSSELL FE, EVENTOV R. LETHALITY OF CRUDE AND LYOPHILIZED CROTALUS VENOM. Toxicon 1964; 15:81.
- LoVecchio F, Klemens J, Welch S, Rodriguez R. Antibiotics after rattlesnake envenomation. J Emerg Med 2002; 23:327.
- Tun Pe. Heparin therapy in Russell's viper bite victims with disseminated intravascular coagulation: a controlled trial. Southeast Asian J Trop Med Public Health 1992; 23:282.
- Shaw BA, Hosalkar HS. Rattlesnake bites in children: antivenin treatment and surgical indications. J Bone Joint Surg Am 2002; 84-A:1624.
- Hardy DL Sr, Zamudio KR. Compartment syndrome, fasciotomy, and neuropathy after a rattlesnake envenomation: aspects of monitoring and diagnosis. Wilderness Environ Med 2006; 17:36.
- Gold BS, Barish RA, Dart RC, et al. Resolution of compartment syndrome after rattlesnake envenomation utilizing non-invasive measures. J Emerg Med 2003; 24:285.
- Tanen DA, Danish DC, Grice GA, et al. Fasciotomy worsens the amount of myonecrosis in a porcine model of crotaline envenomation. Ann Emerg Med 2004; 44:99.
- Bush SP, Ruha AM, Seifert SA, 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; 53:37.
- Weinstein SA. The pharmacotherapy for pit viper envenoming in the United States: a brief retrospective on roots, recurrence, and risk. Clin Toxicol (Phila) 2015; 53:1.
- Goto CS, Feng SY. Crotalidae polyvalent immune Fab for the treatment of pediatric crotaline envenomation. Pediatr Emerg Care 2009; 25:273.
- Yip L. Rational use of crotalidae polyvalent immune Fab (ovine) in the management of crotaline bite. Ann Emerg Med 2002; 39:648.
- Lavonas EJ, Gerardo CJ, O'Malley G, et al. Initial experience with Crotalidae polyvalent immune Fab (ovine) antivenom in the treatment of copperhead snakebite. Ann Emerg Med 2004; 43:200.
- Whitley RE. Conservative treatment of copperhead snakebites without antivenin. J Trauma 1996; 41:219.
- Caravati EM. Copperhead bites and Crotalidae polyvalent immune Fab (ovine): routine use requires evidence of improved outcomes. Ann Emerg Med 2004; 43:207.
- Walker JP, Morrison RL. Current management of copperhead snakebite. J Am Coll Surg 2011; 212:470.
- Dart RC, McNally J. Efficacy, safety, and use of snake antivenoms in the United States. Ann Emerg Med 2001; 37:181.
- Hutchinson, RH. On the incidence of snakebite poisoning in the United States and the results of newer methods of treatment. Bull Antivenom Institute of America 1929; III:43.
- do Amaral, A. The anti-snakebite campaign in Texas and in the subtropical United States. Bull Antivenom Institute of America 1927;I:77.
- Dart RC, Goldner AP, Lindsey D. Efficacy of delayed administration of crotalid antivenom and crystalloid fluids. Toxicon 1988; 26:1218.
- Davidson TM. Intravenous rattlesnake envenomation. West J Med 1988; 148:45.
- Consroe P, Egen NB, Russell FE, et al. Comparison of a new ovine antigen binding fragment (Fab) antivenin for United States Crotalidae with the commercial antivenin for protection against venom-induced lethality in mice. Am J Trop Med Hyg 1995; 53:507.
- Lavonas EJ, Kokko J, Schaeffer TH, et al. Short-term outcomes after Fab antivenom therapy for severe crotaline snakebite. Ann Emerg Med 2011; 57:128.
- Burch JM, Agarwal R, Mattox KL, et al. The treatment of crotalid envenomation without antivenin. J Trauma 1988; 28:35.
- Dart RC, Seifert SA, Boyer LV, 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; 161:2030.
- Johnson PN, McGoodwin L, Banner W Jr. Utilisation of Crotalidae polyvalent immune fab (ovine) for Viperidae envenomations in children. Emerg Med J 2008; 25:793.
- Lavonas EJ, Schaeffer TH, Kokko J, et al. Crotaline Fab antivenom appears to be effective in cases of severe North American pit viper envenomation: an integrative review. BMC Emerg Med 2009; 9:13.
- Ruha AM, Curry SC, Beuhler M, et al. Initial postmarketing experience with crotalidae polyvalent immune Fab for treatment of rattlesnake envenomation. Ann Emerg Med 2002; 39:609.
- Pizon AF, Riley BD, LoVecchio F, Gill R. Safety and efficacy of Crotalidae Polyvalent Immune Fab in pediatric crotaline envenomations. Acad Emerg Med 2007; 14:373.
- Yin S, Kokko J, Lavonas E, et al. Factors associated with difficulty achieving initial control with crotalidae polyvalent immune fab antivenom in snakebite patients. Acad Emerg Med 2011; 18:46.
- 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; 19:121.
- Protherics. CroFab: Crotalidae polyvalent immune Fab (ovine) product information. In: Nashville TN; 2000.
- Clark RF, McKinney PE, Chase PB, Walter FG. Immediate and delayed allergic reactions to Crotalidae polyvalent immune Fab (ovine) antivenom. Ann Emerg Med 2002; 39:671.
- Cannon R, Ruha AM, Kashani J. Acute hypersensitivity reactions associated with administration of crotalidae polyvalent immune Fab antivenom. Ann Emerg Med 2008; 51:407.
- Gold BS, Barish RA, Rudman MS. Refractory thrombocytopenia despite treatment for rattlesnake envenomation. N Engl J Med 2004; 350:1912.
- Boyer LV, Seifert SA, Cain JS. Recurrence phenomena after immunoglobulin therapy for snake envenomations: Part 2. Guidelines for clinical management with crotaline Fab antivenom. Ann Emerg Med 2001; 37:196.
- Seifert SA, I Kirschner R, Martin N. Recurrent, persistent, or late, new-onset hematologic abnormalities in Crotaline snakebite. Clin Toxicol (Phila) 2011; 49:324.
- GEOGRAPHICAL DISTRIBUTION
- CLINICAL MANIFESTATIONS
- FIRST AID APPROACH
- Venomous or nonvenomous?
- Techniques to avoid
- - Pressure immobilization
- INITIAL EVALUATION AND MANAGEMENT
- Clinical assessment
- Ancillary studies
- Wound management
- Supportive care
- - Coagulopathy
- - Rhabdomyolysis
- - Elevated tissue pressures and compartment syndrome
- CROTALINAE (PIT VIPER) ANTIVENOM
- Fab antivenom
- - Indications
- - Efficacy
- - Contraindications
- - Assessment of response
- - Initial regimen based upon severity
- - Treatment of acute hypersensitivity
- - Treatment of recurrent toxicity
- F(ab')2 antivenom
- Discharge instructions
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS