ReviewArticle

Sherman A. Minton, Department oi M crobiologyand mmunology

nd ana Un versitySchoo of Medicine
nd anapo s lndiana46223

PoisonousSnakesand Snakebitein the U.S.:

A Brief Review

Abstract
T h i s a r t i c l eb r i e f l y . e v i e w ss o m cc u r r c n t i d c a sr e g B r d i n gs n a k e t r i t ien t h e U n i l e d S t a t e sT
. w e n t ys p e c i e so f n a r i v ev n o n o u s
s n a l e so c c u r a n d i n c l u d e l 5 s p e c i e so f r a t t l e s n a k e st h, e c o p p e r h e a da n d c o t o n m o u r b ,r w o s p e c i e so f c o r a l s n a k c sa, n d o n e
s e a s n a k eS. n a k ev e n o m s . o n t a i na v a r i e t yo f e n z y m e sa n d n o n - e n z y m a t itco x i n s .C o m p o s i t i o nm a y v a r y g e o g r a p h i c a l j yo,n ,
togenetically,and indiridually. As dererminedby nouse loxicity, nost lethal venons are thoseofrhe Mohaveraltlesnske(Crotalus
s.ltrlatrs), tiger ratlesnake (C. t;grn), and pelagic seasnake(Peldn;s pldrrrz.r). Venonous snales mey bite {irhour injecring
venom and rarely inject more than half their available venom. Some colubr;d snakesgenerallr presumednonrenomous,such
a s g a r t e r s n a k e sc, a n i n r a r e i n s t a n c e si n f l i c t y c n o m o u sb i ! c s .
M o s t s n a k e b i t eisn t h e U n i t e dS t a t e sa r e s u s t a i n e d c l o s ct o t h e v i c l i m ' sh o m ea n d u s u a l l yr e a c hm e d i c a a l i d w i t h i na n h o u r .
Fishermen,hunters, and l,ackpackersdo nol seen lo be a high risk group. Almost half the biles result fron delibcrate conlact
with a venonous snale. Srmptoms of pit viper envenomationa.e.eviewed. A persistentdrop ;n blood pressureis rhe single
m o s t r e l i a b l ei . d i c a t ; o . o f d a n g e r o u se n y e n o m a t i o nA. b o u t h a l f t h e c o r a l s n a k eb i l e s d o n o l r e s u hi n e n v e n o m a t i o nb,u t i t
i s s e r i o u sw h e n i t o c c u r s .
Snakebitefirst aid neasures and principles of t.eatmenl are reyie$ed. Two relatively ncw procedures,elastic bandaging
of s bitten Iimb and use of a powerful small suction derice are discussed.Proceduresunder developnent include ELISA tests
to improve diagnosisand eyaluatc therBpy,anlivenomsof higher polency and lower allergenicity,and imnunizadon for hieh
risk indiriduah. Becauseof the complexily of evaluaiing snakebireand the chancethat a laynan might altempr a naiye treat-
rnent more harmful lhan helpful, the enphasis in first aid for snakbitis to get the stri.ken individual pronptly to a hospiral.

lntaoduction The Snakesand Their Venoms

Although venomoussnakebitesare uncommon ln Thereare 20 speciesof unquestionably venomous
the United States (6000.7000casesannually), they snakesknownfrom the United States-15 species
generate a disporportionate amount of interest, of rattlesnakes, the copperheadand cottonrnouth,
anxiety, and controversy. There are several two other pit vipersthat are closelyrelatedto
r e a s o n sf o r t h i s . F i r s t , s n a l , e b i t ei " a s i t u a t i o n eachother,and two speciesof coralsnakes.The
where a complex organism (a snake) injects a pelagicseasnake (Pelamisplaturuslis ocr"asion-
complex secretion(venom)into another complex ally reportedin Hawaiianwatersand has been
organism (a human). This generates a stagger- recordedonceon the coastof extremesouthern
ing number of variables and allows for outcomes California.Additionallythere are severalsnake
thal can range from death in less than an hour speciesthat are essentially harmlessbut can,on
rare occasions, inflict a mildly venomousbite.
to a totally trivial injury. Second, the composi
Rattlesnakes occur in at least 45 of the con-
l i o n a n d a m o u n l o f v e n o ma s n a k ei n j e c t sv a r i e .
tiguousstatesand four Canadianprovinces,al-
with geographic locality, season, and the age,
thoughthey are usuallyquite local in distribu-
size, and health of the reptile. Third, there are
tion, and their numbershavebeengreatlyreduced
no good animal models (aside from monkeys) for in the last half century.Speciesthat presentthe
evaluating the action of snake venoms on man greatestdanger to man are the easternand
and the effectivenessof treatments. The mouse westerndiamondbacks (Crotalusad,amanteus
ar,d
is widely used, but it is not a very small human C otro.t),timber rattlesnake(C horridusl,prairie
being. Finally, the unpredictable course of snake- rattlesnake(Co. oiridis), northern and southern
bite and the limited knowledge that most physi' Pacific rattlesnakes (C.r:. oreganus and C.t.
cians have of venomous snakes and their bites helleri), aladMohaverattlesnake(C. scutulatus).
may cause uncritical acceptance of treatment The pigmy rattlesnake (Sislrurus miliarius)
plans. causesmany bites in the southernstates,but

t30 NorthwestScience,Vol. 61, No. 2, 1987

fatalitiesare unknown.The other species(see and prefers swampsand sluggishwaterways.
T a b l el ) , ' i t h e ra r eu n c o m m oonr o c c u ri n r e g i o n s Nevertheless it accountsfor a significantnumber
wherethey havelittle contactwith man.The cop- of snakebitesin the southeasternstatesand
perhead(Agkistrodorxcontortr;x), with a wide fatalitiesare on record.Coralsnakesare highly
rangein the easternUnitedStatesand abilityto . he eastern
s e c r e t i t ea n d s e l d o ms c e n T "peci""
survivein well populatedareas,probablycauses (Micrurus fuhius), which may reach 1.2 m in
more bitesthan any one speciesof rattlesnake, length,is potentiallylethal;the smallerArizona
but fatalitiesare virtuallyunknown.The cotton- species (Micruroid.es eurytanthus) has never
mo[th (A. piscioorus)has a more lirnited range causeda human fatality.

TABLE 1. \'enomous snakesof the United States and Canada and their geographic distribution

Scientific Name comnon NameG) Distribution

Crotolus adananteus E a s t r nD i a m o n d b a c kR a t l t e s n a k e Coastal plain, from se. Nonh Carolina to Lounrana

Western Diamondback Rattlesnake Weslern Arkansas& s. Oklahoma thru mosl of Texas to
se. California'
Sidewinder Southern Arizona & s. California deserts'
'linber New England to .. Florida, sesl to central Texas, norlh
Rattlesnake
C a n e b r a k eR a t t l e s n a k e to se. Nebraska,s. Wisconsin & s. Minnesola
( s o u r h e r np o p u l a t ; o n s )
RockRattlesnake Mountains and canyonsfrom s. central Texas lo se.

Speckled Rattlesnake Western Arizona, s. Utah, !. Ne'ada, s. California-

Pananint Rattlesnak
B l a c k t a i lR a t t l e s n a k e South central Texas lo w. Arizona'
Tsin-spotted Rattlesnake M o u n t a i n so f s e . A r i z o n a '
Red Dianond Rattlesnake South1{este.nCali{ornia'
Crota[usvutulatus Mohave Rattlesnak Trans-PecosTexas to s. Nevada & adjacent Cali{ornia.
Crotalus tigris Tiger Rattlesnake S o u t h c e n t r a lA r i z o n a '
Prairie Rattlesnake Vest Texas and New Mexico norlh to {. North Dakota,
M o n t a n a ,s e . S a s k a t c h e w a&n a d j a c e n A
t lbetta'
Pac;f;c Rattlesnake Most of Cslifornia north ro s. centrnl Bfitisb Colunbia'

Crotalus t. tutosus Creat Basin Rattlesnake N e v a d a ,w . U t a h & o r e g o n ,s . I d a h o . '

Sistturus catenLtus
Agkistrodon contontir
ABkistro.Ionpiscirotus
Micruroides curyxanthus
R i d g e - n o s eR
d atllesnake Mountains o{ s. Arizona & adjacent New Mexico.
M a s s a s a u gR aaltlesnake Southern Onrrrio, i{. New York & nw. Pennsylvania
southsest to se. Arizona & s. Texas"
Plgny Rattlesnake Eastern Norlh Carolina to e. Texas & Oll:rhoma, s.
Missouri, sv. Kentuck)
Copperhead Sourhern Ne* Engiand to Florida penhandle, we* ro
Trans'PecosTexas, north to se. Nebraska,cenlral Indiana
& 0hio
SoutheasternVirginia to cenrral Texas rnostly at low
Water Moccasin elevations,north to cenlral Missouri & sw. Indiana
Coasial plain from se. North Carolina to sN. Texas, north
CoralSnake
A r i z o n ao r S o n o r aC o t a l S n a k e S o u r h e r nA r i , o n a & s w . N e w M e x i c o "
Pelagic Sca Snake Hawaii, extreme sr. California coast. Fe{ rccords, prob
Y e l l o wb e l l i e ds e a s n a k e a b l y b a s e do n s t r a l s . '

' S p e c i e sa l s o o c c u r si n M e x i c o .
.'Orher subspeciesof C/ordlus,l/td;s occur in parts ofArizona, Urah, Coloradoand Wvoning. Theseare Ct. cozcolor(Midget
Faded Rattlesnake),C.. nunli&s (Hopi Ra lesnake),Cr. cerDerus(Arizona Black Rartlesnake),and er. c6yszs {Grand Can-
yon Rattlesnake).

PoisonousSnakesand Snakebitein the U.S. l3l

 Snakevenomsare the mostcomplexof animal T A B L E 2 . V e n o m) i e l d s i . o m a d u l t s n a k e so t a r e r a g es i z e
toxins,containingup to twentyor so biologically and mouselethaldoscs.B.rsedchieflyon daralrom
tbe aothor'slaborrtor_y and from Clenn & Straight
active proteins and polypeptides.Many are en-
(1982).
zymes.Thosethat are most important and wide-
spreadincludephospholipase A and proteases (en- Averase Mouse LD/50 mgrkg
dopeptidases) that accountfor someof the hemor- Species Venom Yield intra sub'
rhagic and necrotizing activity, arginine ester (md renous cutaneous
hydrolases that contributeto hypotensive and anti-
CrctaLusadamanteus 250-500 1.68 14.55
coagulant activity, and hyaluronidasethat
Crotalus atot INE) 200,400 3.15 t9.52
facilitatesthe spreadof venom in tissues.There Crctalus atrc, (SW) 100250 2.O7 14.16
are also non-enzymaticmyotoxinsand neurotox- Crotalus cerates 30-60 2.25 12.35
ins.It mustbe emphasized, however,that the ef- Crctatus horridus 100-200 2.63 9.15
fects of snake envenomationresult from many Croralus tepi.d.us 5-30 I1.55'
venomcomponentsacting in concert.The classi- CrotaLusnitcheLli 75-150 r0.90,
ficationofvenomsasneurotoxic,hemorrhagic,or Crotalus nolossus 150-300 t6.42
Crctalus pr;.cei 2l2 0.95 I t.39
m y o l o r i ci s u s u a l l )a n o r e r s i m p J i f i c a t i o n .
Crotalus ruber 200-400 3.72 21.25
As judgedby mousetoxicity,the mostlethal Crotalus s<:utulatus 40-100 0.16 0.31r
Crotalus tigri 5'15 0.06 0.21
rattlesnakevenomis that of the tiger rattlesnake
Crotalus t riridis 50-100 l.61 16.15
(Crotalustigrts)lollowedby that of the Brazilian 1.29
Crotalus L helleti 75-150 3.56
rattlesnake(C. durissus terrificus), Mohave rat- Crotalut t. concolor 10-25 0.28
tlesnake,and midget fadedrattlesnake(C. t iridis Crotalus uillard.i 2-15 L6l
concolor). All these venomscontain a powerful Sisturus catenatus 15-40 0.25 5.25.
neurotoxin.In SouthAmericanrattlesnakes, it Sistrutus nilidrius 7.25 3.65 24.25
is knownas crotoxin;in North Americanrattle- contortrit 40-70 t0.92 25.60
snakesas Mohavetoxin. Recentwork showsthe
two are immunologicallyvery similar (Weinstein piscircrus 100150 5.1t 25.80
et al, l9B5\, Mouse lethal dosesfor some rat- Micrurus fuh,ius 4-16 0.38 r.30
tlesnakeand other snakevenornsare shownin
euqxanthus 0.5 3 0.90
Table2. Venomsof manysnakespeciesshowin- Pelamisplaturus 0.25'l 0.705
d i v i d u a lo. n t o g e n i ca.n dg e o g r a p h irca r i a t i o ni n
lethality and other prope ies. Venomsof two 'Based on specimensfrom the Big Bend resion of Terias.
gravid tirnberrattlesnakescollectedthe sameday Eyidenceindicatesmuch variation in loxicit) anone popula-
on the samehilltop showeda five-folddifference tions o{ this species.
lBased on specimensfron San Diego Co., Caiifornia. A
in lethaltoxicity(Minton 1953).In at leastthree
subspecies{ith much nore toric renom occu6 in Baja
rattlesnake species, venomsof youngsnakesdif-
California.
fer markedlyfrom thoseof adultsin protein com- rBasedon specinensfrom populationsshos vnomcontains
position(Minton1967,Fieroet al. 1972,Minton Mohale toxifl.
& Weinstein1986).In all, lethality seemsto peak 'Based on Indiana specinens.Venon ofwesternpopularions
in snakes6-9monthsof age,then declineto adult a p p e a r st o b e l e s st o x i c .
levels.Reportsof unexpectedly severereactions sBasedon specirnensfron the Coral Sea.
to bites of young rattlesnakesindicate this varia-
tion may be of clinical significance(Reid & Who GetsBittenand Why
Theakstonl97B).Overa largepart of its Arizona
range,venomof the Mohaverattlesnake doesnot Thosewhosework or recreationtakesthem
containMohavetoxin and is much like venon outdoorsand into remoteareasoften consider
of the western diamondbackrattlesnakein themselvesat specialrisk from snakebite.Unless
l e t h a l i tayn dp r o t e o l y tai cn dh e m o r r h a gai cc t i v i t y their activitiesincludehuntingsnakes, thisis not
(Glenn el rrt 1983). Venom from western the case.Snakebitethroughoutthe world is
diamondback rattlesnakes from westTexasand largely a matter of contacthours.The snakethat
Arizonahasgreaterlethalitybut lowerproteolytic b i t e s1 o u i s m o s tl i k e l yo n e l h a t l i v e si n y o u r
activitythan that of snakesfrom north Texasand gardenor underyour house.Most snakebites in
Oklahoma(Minton & Weinstein1986). the UnitedStates,unlessthey involvedeliberate

132 Minton
contactwith venomoussnakes,occur within a
half-mileof the vicrim'shome.Writing of his ex'
tensiveexperience in California,Russell(1980p.
2 6 9 ) . u 1 " " g o n , . r r y l o p o p u l a ro p i n i o n .m o s l
snakebites in the United Statesoccur within a
shortdistancefrom medicalcare.In California,
orpr g0 perceno l f t h e r a t t l e s n a kbei l e so c c u r
within city limits or within 2 milesof city limits
in foothill area.., Felr bites occur in
backpackers, serioushunters,or fishermen. . . In
the past 20 years, there has been only one
backpackerin the Sierras of California, who I
knowof, who has beenbitten by a rattlesnake,
a n d t h i sh a p p e n ew d h e nh e r n a sc h a n g i n ga t i r e
at the end of his hike."
Until about 1950,most snakebitesin the
United Stateswere associated with what could
broadlybe calledagriculturalactivities.When
I wasgrowingup in southernIndiana,the first
snakebiteof the seasonmight occurwith mush-
room hunting in late April but was more likely
to be associated with strawberryor blackberry
picking in late May or June.Other bitesweresus-
tainedwhilelifting rocks,clearingweedsor rub-
bish,or doing other choresaboutthe farm. To-
daythere are many fewersmallfarmswheremost
of the work is doneby hand,and therehasbeen
a great increasein large scale mechanized
agriculture.0n the other hand, there has also
beena decidedincreasein permanentor seasonal
rural living. Rural children ages5-12havealways
beena comparativelyhigh risk group if rhey live
where venomoussnakesare relatively plentiful.
Children of this age are more likely to go
barefootand be lessthan carefulwherethey step
or where they put their hands. Many small
childrenare insatiablycuriousaboutsnakesand
today are more likely to try to catchreptilestheir
grandparents at the sameagewouldhavekilled
forthright.Todaya much higherpercentageof
bites involvedeliberatecontactwith venomous
snakes. Snakecatching,snakehandling,and the
keepingof venomoussnakesin captivityattract
p e o p l ew h o s em o t i v e sv a r y f r o m s e r i o u "s c i e n .
tific interestto exhibitionismand religiousfer-
vor. With a few,abuseof alcoholand drugsmay
contributeto the risk.
The Bite and lts Effects
An important fact not always appreciated by
physicians or laymen is that venomous snakes,
PoisonousSnakesand Snakebitein the U.S.
includingthe most dangerousspecies,may in-
ject little or no venomwhenthey bite. According
to one study, only about half the bites by the
nidell-feared A s i a nc o b r ar e s u l li n p o i s o n i n g
(Reid 1964).In 16 of 3l coral snakebitesin the
southeastern U.S.,no poisoningdeveloped (Neill
1957,Parrish& Khan 196?).Rattlesnakes, cop-
perheads, and cottonmouths appearto be more
efficientbiters with about 75 percentof bites
resulting in envenomation.Experirnentsin lab-
oratoriesin severalparts of the world agreethat
snakesrarelyinject more than half their available
venomin a singlebite. There is somesuggestion
that a defensivebite directed againsta predator
or an animal too large to seNe as food results
in lessvenom injection than a bire intended to
kill prey. However,rattlesnakesattacking prey
may alsodeliverrelativelyineffectivestrikes(Kar-
dong l986). The degreeto which snakescontrol
t h e a m o u n lo f v e n o mi n j e c t e di n v a r i o u s i l u a -
tions remainsessentially unknown.
When a rattlesnakeor other pit viper delivers
an effectivebite, pain is usually immediateand
intense,although occasionally,and usually with
a very severebite, theremay be numbnessaround
the areaof the bite lastingaslong as 30 minutes.
Puncture wounds are obvious and bleed longer
and more freely than a nonvenomousltound.
Swellingusuallybeginswithin a few minutesand
spreadsboth peripherallyand centrally. Discol-
oration around the bite usually is evidentwithin
a few minutes.If pain, swelling,and discoloration
are absenl 15-30minutes after a pit viper bite,
the odds are very good no venom was injected.
Important exceptionsare individuals bitten by
rattlesnakeswhosevenomsare low in those tox-
ins that are responsiblefor local swelling and
discoloration.This includessomepopulationsof
the Mohaverattlesnake, speckledrattlesnake, rock
rattlesnake,and tiger rattlesnake.Swelling and
discolorationmay alsobe minimal in the rare in-
stancewhen most of the venomis injected intra-
venously.However,the individual who sustains
such a bite quickly showssigns of generalized
poisoning,and the diagnosisof envenomationis
rarely in doubt. Individuals under the influence
of alcohol or drugs may not have normal pain
perceptionand may displaybizarre symptoms.A
reliablesign of envenomation, usuallyseenwithin
the first hour after a bite, is painful swellingof
lymph nodesin the groin if the bite is on the foot
or leg and in the axilla if on the hand or arm.
133
Tingling of the face and metallic taste in the
mouth are commonsymptomsof rattlesnakebite.
Nausea, vomiting,chills,sweating, andrhirstare
commonsymptomsof pit viper biteswithin the
first hour. Hemorrhagicblebsmay appearwithin
two hoursafter a bite or be delayedmuch longer.
Thesesymptomsdefinitelyindicatepoisoningbut
not necessarily a seriousor life-threatening bite.
A persistentfall in blood pressureis probably
t h em o s tr e l i a b l ei n d i r " a t i oonf a s c r i o u p" i t v i p e r
bite. This may manifestitself as faintnessor loss
of consciousness with pallor and a weak,rapid
pulse. Other ominous signs are generalized
musculartwitching,videspreadappearance of
large hives(angioneuroticedema),diarrhea,con-
tractedpupils,and sensation ofyellowvision.All
may developwithin an hour after the individual
is bitten.
Coralsnakebitesare not very painful;there
is little or no swellingand no discoloration.Fang
puncturesbleedlittle and may be almostunde-
tectablea few hours after the bite. Character-
isticallythere is an asymptomaticperiod that can
last up to sevenhours.In fact, in abouthalf the
cases,no definitesignsof poisoningeverdevelop.
Not many casesof coral snakebiteshave been
reportedin detail,but symptomsseemto be quite
variable.Sometimes, there are pains radiating
from the locationof the bite or in the abdomen.
Seriousmanifestations includedroopingof the
eyelids, difficulty in speaking and swallowing,
generalized muscularweakness and incoordina-
lion, drowsiness, and difficulty in breathing.This
can progressto a completeand fatal paralysis.
A curiousand not well understoodphenom-
enon is thal of venomousbites by presumably
nonvenomous snakesof the family Colubridae.
Somecolubridshaveenlarged,groovedfangsin
the rear of the upperjaw, and at leasttwo African
speciesare unequivocallydangerous.A few
s p e c i e sw i l h t h i s t y p e \ e n o m a p p a r a t u sj u s t
enter the United States along the Mexican
border,and a few casesof mild venomousbites
by them havebeenreported.The most serious
casesreportedin the United Stateshaveresulted
from bites of Asian snakessuch as the yama-
kagashi (Rhabdophis tigrinus) and red-necked
keelback(R. subminiatus\pvchased as rnnocu-
ous pets (Mittleman & Goris 1974, Cable et al.
l9B4).Thesesnakeshaveenlargedbut ungrooved
teeth in the rear of the upper jaw. Poisoningby
thesesnakesresultsin a dramaticdecreasern cer-
134 Minton
tain blood clotting factors with resultant internal
and external hemorrhages and related complica-
tions. Rhabd,ophis is closely related to the North
American garter snakes (Thamnophis\ ard water
snakes(flerodla), so it is not surprising that a few
cases of envenomationscharacterized by pain,
swelling, and ecchymosis have been reported
following bites of garter snakes.Two plentiful
and r,videlydistributed species, the wandering
garter snake (7. elegans ,a,.o/rs) and common
garter snake (7. sirtalis\ have been implicated.
Similar cases have been reported following bites
by hognose snakes (Heterodon). However,
perhaps only one in several thousand bites by
thesepresunably nonvenomouscolubrids results
in poisoning. The answer may be in the nature
of the colubrid venom apparatus. Duvernoy's
gland, roughly the equivalent of the pit viper
v e n o m g l a n d .h a s a h i g h l y t o x i c s e c r e l i o ni n a l
least some colubrid snakes.But it has a very small
lumen for venom storage. And a solid tooth is
not so effective for introducing venom into a
wound as one that is grooved or hollow. When
a colubrid snake feeds,it often holds and chews
its prey. This gives time for Duvernoy's gland
to secrete venom which is worked into wounds
made by the teeth. It probably is significant that
a majority of human envenomations by colubrids
involve snakesthat hung on for severalseconds.
And in some cases,a captive snake bit when be-
ing offered food.
FirstAid and DefinitiveTreatment
Statedsimply,the objectivesof snakebitetreat,
ment are:(l) Removevenombeforeit can com-
bine with targettissues.(2)Neutralizevenomthat
cannot be removed.(3) Counteracteffectsof
venomthat cannotbe neutralized. (4) When all
the abovefail, repair the damage.
Snakebite treatmentin the UnitedStateshas
seen a number of colorful and downright
dangerous procedures advocated, sometimesby
scientistsand physicians.In southern[ndianain
the 1920's and 30's, whiskeywas a popular
remedylnearlyeveryfarmerkepta bottleor two
"just in case." Other popular
treatmentswere
applicationof the split body of a freshly-killed
chickento the bite or soakingthe bitten pan in
keroseneor turpentine.First aid techniquesin-
volvingligature,incision,and suctionhavebeen
widelyadvocated and are soundin principlebut
of dubiousvaluein practice.Ligaturesincrease
pain andhavelittle effectin rctardingspreadof
venom. Incision followed by suction does
facilitateremovalof somevenom.However,in-
cisionsmay damagelargebloodvessels, nenes,
or tendons,provideentry for infection,and be
follovedby seriousbloodlossparticularlysince
many snake venoms markedly impair blood
coagulation.Excision-cutting out the entire
areaarounda bite-is almostcertainto do more
harm than good and cannotbe recommended.
Chillingthe areaarounda bite by useof ice or
chemicalspraywith or withouta ligatureis inef-
fective and can do seriousdamageif continued
for a prolongedperiod.Recently,electricshock
using high voltage,low amperagecurrent from
an outboardmotor, lawn mower'or othet source
hasbeensuggestedasfirst aid for snakebite.The
methodis underinvestigationbut cannotcurent-
Iy be advocated.
As alreadymentioned,most personsbitten by
snakescan reach definitive medical care within
30-50minutes.Realizingthis, I havemaintained
for the last decadeor so that the most useful
snakebitefirst aid kit consistsof car keys and
somecoinsfor a call to a hospital.If at all pos'
sible,the actualdriving to the hospitalshould
be entrustedto someone else.The stressof driv-
ing in traffic doesnot help a snakebiteand vice
versa.Callingaheadis important.It givesthe
emergencyroom time to pfeparefor the patient's
arrival,and the physicianon duty can consull
with colleaguesor call a Poison Information
Centerif he wishes.The snakeshouldbe brought
to the hospitalwith the victim if possibleso its
identitycanbe verified.It is betterif the reptile
is dead.A live snakein a hospitalemergency
r o o mi s a n c p d l e sdsi s t r a . t i o na n d s o m e l i m eas
hazard.Identificationis especially importantif
a coralsnakeis suspected, for harmlessmimics
ofcoralsnakesoccurin manypartsof the United
States.In casesof bitesby exoticsnakeskept as
p e t s .i d e n l i f i c a t i oonf t h e r e p t i l ei s v " r y i m p o r '
tant also.
Two relativelynewprocedures seemto be ef-
fectiveand safe enoughthat their use can be
cautiouslyadvocatedfor the small number of
snakebites that occurundercircumstances such
that a delayof 30 minutesor more in reaching
a medicalfacilitycan be anticipated.0ne is the
useof elasticbandagessuchas are widelyused
to treat sprainsw.appedsnuglyoverthe areaof
PoisonousSnakesand Snakebitein the U.S.
the bite and extendedup the bitten limb to the
trunk if thereis enoughbandage.I am told that
panty hosemake an acceptable substitute.The
limb is then immobilizedwith a splint.The ban-
dagesare left in placeuntil the victirnreaches
in-
t h e h o s p i t aal n d p r e p a r a t i o nf os r b e g i n n i n g
travenousadministrationof antivenomhavebeen
made.Both experimentaland clinicalevidence
indicate the technique is quite effective in
preventingabsorptionof venomfrom a bitten
limb (Sutherland 1983, pp. 22'32).The rnethod
wasdeveloped in Australiawherethe important
snakeshavevenomsthat are highly lethal but not
very destructivelocally.If usedfor treating bites
by rattlesnakesand other pit vipers whose
venomscausesignificantlocal damage,it must
be with the realizationthat generalized poison-
i n g m a y b e p r e v e n t eadl l h e c o s lo f i n c r e a s i n g
local darnage.It is the recomrnendedprocedure
for bites by coral snakeswhosevenomsare more
like thoseof Australiansnakes.
Another new technique is use of a trlo-
charnberedsuction devicethat producesone at-
mospherenegativepressure.This is appliedto
the bite as quicklyas possible@itlro&,making
any incisions and left in place about three
minutes.Suctioncan be repeatedas necessary.
Preliminary animal experimentsindicate up to
half an injecteddoseof rattlesnakevenomcan
be removed.The devicewasalsotestedon three
personsbitten during a rattlesnakeroundupin
the Southwestwith apparentlygood results
(Bronsteine, oL l9B5).SawyerProductsof Long
Beach,California,marketsthe devicein a small,
light, durable kit suitable for field use.
Scientific evaluationof theseand other first
aid measures hasbeenpossible throughdevelop-
ment of very sensitiveand specificenzymeJinked
immunoassay(ELISA) for snake venoms.Af
thoughthesetestsare not generallyavailablein
the United States,enoughexperimentalwork has
been done to demonstratetheir value both in
diagnosisof snakebiteand evaluationof treat'
ment. Sincethe test can be done in about two
hours,determiningpresenceof venomin blood
and urine can be helpful in distinguishinga
relativelyminor bite from a potentiallyserious
one.Theseassays havealsocontributedto bet'
ter understanding the pathophysiology of snake
cnvenomation O.n e i n l e r e s t i n g ic
ohserration
that venomsof somesnakescan be detectedat
the site of a bite after severaldays.
135
 Althoughit is not the purposeof this review Exceptin most unusualsituations,antivenom
to discusshospital managementof snakebite, shouldbe givenin a hospital.This is but one of
somethingshouldbe saidaboutantivenom.This numerousreasonswhy hospitalization ls recom-
is the only clinically effectiveantidote for snake mendedfor all but obviouslytrivial snakebites.
venompoisoningand is producedcommercially Blood pressureand other vital signsare more
by hyperinmunizationof horses with snake easilymonitored,and hypovolemicshock,the
venoms.The product commonlyused in the commonest causeof deathin pit viper bites,can
United Statesis madeagainstvenomsof three be detectedearlyand corrected,0ther dangerous
speciesof rattlesnakes and a large neotropical complicationsof snakebitesuchascoagulopathy,
pit viper of the genus Bothrops. lt is at least renal failure, respiratory failure, and infection
somewhateffectivein neutralizingvenomsof all can alsobe detectedearly and dealt with more
North American pit vipers and the most impor- effectively,In a seriesof 9 fatal rattlesnakebites
tant neotropicalspeciesaswell asthoseof a few in Arizona, two individuals refusedto go to the
O l d W o r l d r i p e r s .A c o r a ls n a k ea n t i v e n o mi s hospitaland three othersreachedthe hospital
availablein limited quantity in thosestaieswhere after delaysof 1.5 to 29 hours(Hardy 1986).
coral snakesoccur.Antivenomsare by no means A singlenonfatalsnakebiteconfersno effec-
ideal therapeutic agents. Their neutralizing l i v ei m m u n i l l .a n de r i d e n r eo f i m muni t y i n p r o -
capacityis relativelylow, hencelarge doses-400 fessionaland religious snakehandlerswho have
ml or more-sometimesmust be givenin a very survivedmany bitesis equivocal.Somehavedied
severeenvenomation.Not all venOmsand venom of snakebite aftersurvivinglen or moreprevious
fractions are equally well neutralized. Anti- bites.Immunizationwith toxoid,a strategyhighly
venomshave little effect against the factors in successfulin infections such as diptheria and
pit viper venomsthat causelocal swellingand tetanus, has been attempted with detoxified
necrosis.Being foreign proteins,antivenoms snakevenoms.The only large scaletrial, in the
commonlycauseserumsickness,lessfrequently Ryukyu Islands,was not particularly successful
anaphylaxis and otherformsof immunologicin- (Sawaiet al- 1969),but the procedureis being
jury. Significantimprovementin antivenomscan consideredin someother regionsof very high
be anricipated.Experimentalantivenompre- snakebiteincidence.In the United Statesit would
pared by affinity chromatographyhasmuch bet- be appropriateonly for a very small number of
ter neutralizingcapacityand is lesslikely to cause individuals.The bestsinglepreventativemeasure
anaphylaxis (Russellet al, 1985).A commercial is to avoid deliberatecontactwith veromous
product could be availablein a relatively short snakes."Illegitimate" snakebites,those sus-
time. Monoclonalantibodieshavebeenproduced tained by individualswho knowinglyplacethem-
against several snake venom toxins, but their selvesat risk, make up roughly half the snake-
therapeuticuse has not been explored. bites reportedin the United States.

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136 Minton