Evaluation and management of coral snakebites
- Steven A Seifert, MD, FAACT, FACMT
Steven A Seifert, MD, FAACT, FACMT
- Professor of Emergency Medicine
- 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 and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Coral snakebites are rare. Successful treatment requires prompt transfer of the snakebite victim to definitive medical care, careful clinical assessment, and timely administration of antivenom in selected patients. Consultation with a medical toxicologist or other physician with experience in managing poisonous snakebites 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. For clinicians outside of the United States, the World Health Organization (WHO) provides a listing of international poison centers on its website.
The clinical evaluation and management of coral snakebites is reviewed here. The principles of management of Crotalinae (eg, “pit vipers”, including rattlesnakes, water moccasin [cottonmouth], or copperhead) snakebites and snakebites outside the United States are discussed separately. (See "Snakebites worldwide: Clinical manifestations and diagnosis" and "Snakebites worldwide: Management" and "Evaluation and management of Crotalinae (rattlesnake, water moccasin [cottonmouth], or copperhead) bites in the United States".)
Coral snakes are native to a large portion of the Americas from the southern United States through Mexico, Central America, and South America to southern Argentina (figure 1) . Throughout the Americas, coral snakebites are uncommon, ranging from 2 bites per year in Argentina to less than 100 bites per year in the southern United States [1,2]. In Central American, Colombia, and Brazil, <1 to 2 percent of all snakebites are attributed to coral snakes [1,3]. Most bites involve Micrurus species [1,3,4]. As an example, Micrurus fulvius fulvius (eastern coral snake) (picture 1) and Micrurus fulvius tenere (Texas coral snake) account for almost all bites reported in the United States . Envenomation is most notable for causing neurologic symptoms. Fatalities from coral snake envenomation are rare but have been described .
Coral snakes are also found outside of the Americas, including Asia and southern Africa. Neurotoxicity with bites by these snakes is possible but rarely described .
CORAL SNAKE CHARACTERISTICS
Appearance, venom apparatus, and venom actions for coral snakes are as follows:
- 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; 55:13.
- Mowry JB, Spyker DA, Cantilena LR Jr, et al. 2012 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 30th Annual Report. Clin Toxicol (Phila) 2013; 51:949.
- Pardal PP, Pardal JS, Gadelha MA, et al. Envenomation by Micrurus coral snakes in the Brazilian Amazon region: report of two cases. Rev Inst Med Trop Sao Paulo 2010; 52:333.
- Gold BS, Barish RA, Dart RC. North American snake envenomation: diagnosis, treatment, and management. Emerg Med Clin North Am 2004; 22:423.
- 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; 53:693.
- White J. Elapid snakes. In: Medical Toxicology, 3rd edition, Dart RC. (Ed), Lippincott, Williams & Wilkins, Philadelphia 2004. p.1566.
- Norris RL, Bush SP, Cohen Smith J. Bites by venomous reptiles in Canada, the United States, and Mexico. In: Wilderness Medicine, 6th edition, Auerbach PS. (Ed), Elsevier Mosby, Philadelphia 2012. p.1011.
- Manock SR, Suarez G, Graham D, et al. Neurotoxic envenoming by South American coral snake (Micrurus lemniscatus helleri): case report from eastern Ecuador and review. Trans R Soc Trop Med Hyg 2008; 102:1127.
- Sasaki J, Khalil PA, Chegondi M, et al. Coral snake bites and envenomation in children: a case series. Pediatr Emerg Care 2014; 30:262.
- Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med 2002; 347:347.
- Kitchens CS, Van Mierop LH. Envenomation by the Eastern coral snake (Micrurus fulvius fulvius). A study of 39 victims. JAMA 1987; 258:1615.
- Wood A, Schauben J, Thundiyil J, 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; 51:783.
- RUSSELL FE, EVENTOV R. LETHALITY OF CRUDE AND LYOPHILIZED CROTALUS VENOM. Toxicon 1964; 15:81.
- 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; 38:61.
- Tanaka GD, Furtado Mde F, Portaro FC, et al. Diversity of Micrurus snake species related to their venom toxic effects and the prospective of antivenom neutralization. PLoS Negl Trop Dis 2010; 4:e622.
- Bucaretchi F, Hyslop S, Vieira RJ, et al. Bites by coral snakes (Micrurus spp.) in Campinas, State of São Paulo, Southeastern Brazil. Rev Inst Med Trop Sao Paulo 2006; 48:141.
- Lewis-Younger C. Update on the coral snake antivenom shortage. Clin Toxicol 2012; 50:652.
- Walter FG, Chase PB, Fernandez MC, McNally J. Venomous snakes. In: Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose, 4th, Shannow MW, Borron SW, Burns MJ. (Eds), Saunders, Philadelphia 2007. p.422.
- Expiration date extension for North American Coral Snake Antivenin (Micrurus fulvius) (Equine origin) Lot 4030024 through April 30, 2017. US Food and Drug Administration. http://www.fda.gov/biologicsbloodvaccines/safetyavailability/ucm445083.htm (Accessed on February 07, 2017).
- Expiration date extension for North American Coral Snake Antivenin (Mircrurus fulvius) (Equine origin) Lot L67530 through January 31, 2018. US Food and Drug Administration. http://www.fda.gov/biologicsbloodvaccines/safetyavailability/ucm538841.htm (Accessed on February 07, 2017).
- Theakston RDG, Lalloo DG. Venomous bites and stings. In: Principles and Practice of Travel Medicine, Zuckerman JN. (Ed), John Wiley & Sons, West Sussex 2001. p.321.
- Wisniewski MS, Hill RE, Havey JM, et al. Australian tiger snake (Notechis scutatus) and mexican coral snake (Micruris species) antivenoms prevent death from United States coral snake (Micrurus fulvius fulvius) venom in a mouse model. J Toxicol Clin Toxicol 2003; 41:7.
- Sánchez EE, Lopez-Johnston JC, Rodríguez-Acosta A, Pérez JC. Neutralization of two North American coral snake venoms with United States and Mexican antivenoms. Toxicon 2008; 51:297.
- Arce V, Rojas E, Ownby CL, et al. Preclinical assessment of the ability of polyvalent (Crotalinae) and anticoral (Elapidae) antivenoms produced in Costa Rica to neutralize the venoms of North American snakes. Toxicon 2003; 41:851.
- Ramos HR, Vassão RC, de Roodt AR, et al. Cross neutralization of coral snake venoms by commercial Australian snake antivenoms. Clin Toxicol (Phila) 2017; 55:33.
- 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.
- CORAL SNAKE CHARACTERISTICS
- CLINICAL MANIFESTATIONS
- Physical examination
- Ancillary studies
- - Respiratory function
- DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
- FIRST AID
- General principles
- Pressure immobilization
- Techniques to avoid
- INITIAL MANAGEMENT
- Respiratory support
- Wound management
- Acute hypersensitivity reactions
- - Expired or alternative antivenoms
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS