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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

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
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 ( 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
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 . '

R i d g e - n o s eR
d atllesnake Mountains o{ s. Arizona & adjacent New Mexico.
Sistturus catenLtus 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)
Agkistrodon contontir Copperhead Sourhern Ne* Engiand to Florida penhandle, we* ro
Trans'PecosTexas, north to se. Nebraska,cenlral Indiana
& 0hio
ABkistro.Ionpiscirotus 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
Micruroides curyxanthus 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-
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 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-
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 includingthe most dangerousspecies,may in-
half-mileof the vicrim'shome.Writing of his ex' ject little or no venomwhenthey bite. According
tensiveexperience in California,Russell(1980p. to one study, only about half the bites by the
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 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
snakebites in the United Statesoccur within a (Reid 1964).In 16 of 3l coral snakebitesin the
shortdistancefrom medicalcare.In California, southeastern U.S.,no poisoningdeveloped (Neill
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 1957,Parrish& Khan 196?).Rattlesnakes, cop-
within city limits or within 2 milesof city limits perheads, and cottonmouths appearto be more
in foothill area.., Felr bites occur in efficientbiters with about 75 percentof bites
backpackers, serioushunters,or fishermen. . . In resulting in envenomation.Experirnentsin lab-
the past 20 years, there has been only one oratoriesin severalparts of the world agreethat
backpackerin the Sierras of California, who I snakesrarelyinject more than half their available
knowof, who has beenbitten by a rattlesnake, venomin a singlebite. There is somesuggestion
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 that a defensivebite directed againsta predator
at the end of his hike." or an animal too large to seNe as food results
in lessvenom injection than a bire intended to
Until about 1950,most snakebitesin the kill prey. However,rattlesnakesattacking prey
United Stateswere associated with what could may alsodeliverrelativelyineffectivestrikes(Kar-
broadlybe calledagriculturalactivities.When dong l986). The degreeto which snakescontrol
I wasgrowingup in southernIndiana,the first 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 -
snakebiteof the seasonmight occurwith mush- tions remainsessentially unknown.
room hunting in late April but was more likely
to be associated with strawberryor blackberry When a rattlesnakeor other pit viper delivers
picking in late May or June.Other bitesweresus- an effectivebite, pain is usually immediateand
tainedwhilelifting rocks,clearingweedsor rub- intense,although occasionally,and usually with
bish,or doing other choresaboutthe farm. To- a very severebite, theremay be numbnessaround
daythere are many fewersmallfarmswheremost the areaof the bite lastingaslong as 30 minutes.
Puncture wounds are obvious and bleed longer
of the work is doneby hand,and therehasbeen
and more freely than a nonvenomousltound.
a great increasein large scale mechanized
agriculture.0n the other hand, there has also Swellingusuallybeginswithin a few minutesand
beena decidedincreasein permanentor seasonal spreadsboth peripherallyand centrally. Discol-
oration around the bite usually is evidentwithin
rural living. Rural children ages5-12havealways
beena comparativelyhigh risk group if rhey live a few minutes.If pain, swelling,and discoloration
are absenl 15-30minutes after a pit viper bite,
where venomoussnakesare relatively plentiful.
the odds are very good no venom was injected.
Children of this age are more likely to go
Important exceptionsare individuals bitten by
barefootand be lessthan carefulwherethey step
rattlesnakeswhosevenomsare low in those tox-
or where they put their hands. Many small
ins that are responsiblefor local swelling and
childrenare insatiablycuriousaboutsnakesand
discoloration.This includessomepopulationsof
today are more likely to try to catchreptilestheir
the Mohaverattlesnake, speckledrattlesnake, rock
grandparents at the sameagewouldhavekilled
rattlesnake,and tiger rattlesnake.Swelling and
forthright.Todaya much higherpercentageof
discolorationmay alsobe minimal in the rare in-
bites involvedeliberatecontactwith venomous
stancewhen most of the venomis injected intra-
snakes. Snakecatching,snakehandling,and the
venously.However,the individual who sustains
keepingof venomoussnakesin captivityattract
such a bite quickly showssigns of generalized
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 .
poisoning,and the diagnosisof envenomationis
tific interestto exhibitionismand religiousfer-
rarely in doubt. Individuals under the influence
vor. With a few,abuseof alcoholand drugsmay
of alcohol or drugs may not have normal pain
contributeto the risk.
perceptionand may displaybizarre symptoms.A
reliablesign of envenomation, usuallyseenwithin
The Bite and lts Effects the first hour after a bite, is painful swellingof
An important fact not always appreciated by lymph nodesin the groin if the bite is on the foot
physicians or laymen is that venomous snakes, or leg and in the axilla if on the hand or arm.

PoisonousSnakesand Snakebitein the U.S. 133

Tingling of the face and metallic taste in the tain blood clotting factors with resultant internal
mouth are commonsymptomsof rattlesnakebite. and external hemorrhages and related complica-
Nausea, vomiting,chills,sweating, andrhirstare tions. Rhabd,ophis is closely related to the North
commonsymptomsof pit viper biteswithin the American garter snakes (Thamnophis\ ard water
first hour. Hemorrhagicblebsmay appearwithin snakes(flerodla), so it is not surprising that a few
two hoursafter a bite or be delayedmuch longer. cases of envenomationscharacterized by pain,
Thesesymptomsdefinitelyindicatepoisoningbut swelling, and ecchymosis have been reported
not necessarily a seriousor life-threatening bite. following bites of garter snakes.Two plentiful
A persistentfall in blood pressureis probably and r,videlydistributed species, the wandering
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 garter snake (7. elegans ,a,.o/rs) and common
bite. This may manifestitself as faintnessor loss garter snake (7. sirtalis\ have been implicated.
of consciousness with pallor and a weak,rapid Similar cases have been reported following bites
pulse. Other ominous signs are generalized by hognose snakes (Heterodon). However,
musculartwitching,videspreadappearance of perhaps only one in several thousand bites by
large hives(angioneuroticedema),diarrhea,con- thesepresunably nonvenomouscolubrids results
tractedpupils,and sensation ofyellowvision.All in poisoning. The answer may be in the nature
may developwithin an hour after the individual of the colubrid venom apparatus. Duvernoy's
is bitten. gland, roughly the equivalent of the pit viper
Coralsnakebitesare not very painful;there 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
is little or no swellingand no discoloration.Fang least some colubrid snakes.But it has a very small
puncturesbleedlittle and may be almostunde- lumen for venom storage. And a solid tooth is
tectablea few hours after the bite. Character- not so effective for introducing venom into a
isticallythere is an asymptomaticperiod that can wound as one that is grooved or hollow. When
last up to sevenhours.In fact, in abouthalf the a colubrid snake feeds,it often holds and chews
cases,no definitesignsof poisoningeverdevelop. its prey. This gives time for Duvernoy's gland
Not many casesof coral snakebiteshave been to secrete venom which is worked into wounds
reportedin detail,but symptomsseemto be quite made by the teeth. It probably is significant that
variable.Sometimes, there are pains radiating a majority of human envenomations by colubrids
from the locationof the bite or in the abdomen. involve snakesthat hung on for severalseconds.
Seriousmanifestations includedroopingof the And in some cases,a captive snake bit when be-
eyelids, difficulty in speaking and swallowing, ing offered food.
generalized muscularweakness and incoordina-
lion, drowsiness, and difficulty in breathing.This FirstAid and DefinitiveTreatment
can progressto a completeand fatal paralysis.
Statedsimply,the objectivesof snakebitetreat,
A curiousand not well understoodphenom- ment are:(l) Removevenombeforeit can com-
enon is thal of venomousbites by presumably bine with targettissues.(2)Neutralizevenomthat
nonvenomous snakesof the family Colubridae. cannot be removed.(3) Counteracteffectsof
Somecolubridshaveenlarged,groovedfangsin venomthat cannotbe neutralized. (4) When all
the rear of the upperjaw, and at leasttwo African the abovefail, repair the damage.
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 Snakebite treatmentin the UnitedStateshas
enter the United States along the Mexican seen a number of colorful and downright
border,and a few casesof mild venomousbites dangerous procedures advocated, sometimesby
by them havebeenreported.The most serious scientistsand physicians.In southern[ndianain
casesreportedin the United Stateshaveresulted the 1920's and 30's, whiskeywas a popular
from bites of Asian snakessuch as the yama- remedylnearlyeveryfarmerkepta bottleor two
kagashi (Rhabdophis tigrinus) and red-necked "just in case." Other popular
keelback(R. subminiatus\pvchased as rnnocu- applicationof the split body of a freshly-killed
ous pets (Mittleman & Goris 1974, Cable et al. chickento the bite or soakingthe bitten pan in
l9B4).Thesesnakeshaveenlargedbut ungrooved keroseneor turpentine.First aid techniquesin-
teeth in the rear of the upper jaw. Poisoningby volvingligature,incision,and suctionhavebeen
thesesnakesresultsin a dramaticdecreasern cer- widelyadvocated and are soundin principlebut

134 Minton
of dubiousvaluein practice.Ligaturesincrease the bite and extendedup the bitten limb to the
pain andhavelittle effectin rctardingspreadof trunk if thereis enoughbandage.I am told that
venom. Incision followed by suction does panty hosemake an acceptable substitute.The
facilitateremovalof somevenom.However,in- limb is then immobilizedwith a splint.The ban-
cisionsmay damagelargebloodvessels, nenes, dagesare left in placeuntil the victirnreaches
or tendons,provideentry for infection,and be 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
follovedby seriousbloodlossparticularlysince travenousadministrationof antivenomhavebeen
many snake venoms markedly impair blood made.Both experimentaland clinicalevidence
coagulation.Excision-cutting out the entire indicate the technique is quite effective in
areaarounda bite-is almostcertainto do more preventingabsorptionof venomfrom a bitten
harm than good and cannotbe recommended. limb (Sutherland 1983, pp. 22'32).The rnethod
Chillingthe areaarounda bite by useof ice or wasdeveloped in Australiawherethe important
chemicalspraywith or withouta ligatureis inef- snakeshavevenomsthat are highly lethal but not
fective and can do seriousdamageif continued very destructivelocally.If usedfor treating bites
for a prolongedperiod.Recently,electricshock by rattlesnakesand other pit vipers whose
using high voltage,low amperagecurrent from venomscausesignificantlocal damage,it must
an outboardmotor, lawn mower'or othet source be with the realizationthat generalized poison-
hasbeensuggestedasfirst aid for snakebite.The 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
methodis underinvestigationbut cannotcurent- local darnage.It is the recomrnendedprocedure
Iy be advocated. for bites by coral snakeswhosevenomsare more
like thoseof Australiansnakes.
As alreadymentioned,most personsbitten by
snakescan reach definitive medical care within Another new technique is use of a trlo-
30-50minutes.Realizingthis, I havemaintained charnberedsuction devicethat producesone at-
for the last decadeor so that the most useful mospherenegativepressure.This is appliedto
snakebitefirst aid kit consistsof car keys and the bite as quicklyas possible@itlro&,making
somecoinsfor a call to a hospital.If at all pos' any incisions and left in place about three
sible,the actualdriving to the hospitalshould minutes.Suctioncan be repeatedas necessary.
be entrustedto someone else.The stressof driv- Preliminary animal experimentsindicate up to
ing in traffic doesnot help a snakebiteand vice half an injecteddoseof rattlesnakevenomcan
versa.Callingaheadis important.It givesthe be removed.The devicewasalsotestedon three
emergencyroom time to pfeparefor the patient's personsbitten during a rattlesnakeroundupin
arrival,and the physicianon duty can consull the Southwestwith apparentlygood results
with colleaguesor call a Poison Information (Bronsteine, oL l9B5).SawyerProductsof Long
Centerif he wishes.The snakeshouldbe brought Beach,California,marketsthe devicein a small,
to the hospitalwith the victim if possibleso its light, durable kit suitable for field use.
identitycanbe verified.It is betterif the reptile Scientific evaluationof theseand other first
is dead.A live snakein a hospitalemergency aid measures hasbeenpossible throughdevelop-
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 ment of very sensitiveand specificenzymeJinked
hazard.Identificationis especially importantif immunoassay(ELISA) for snake venoms.Af
a coralsnakeis suspected, for harmlessmimics thoughthesetestsare not generallyavailablein
ofcoralsnakesoccurin manypartsof the United the United States,enoughexperimentalwork has
States.In casesof bitesby exoticsnakeskept as been done to demonstratetheir value both in
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 ' diagnosisof snakebiteand evaluationof treat'
tant also. ment. Sincethe test can be done in about two
Two relativelynewprocedures seemto be ef- hours,determiningpresenceof venomin blood
fectiveand safe enoughthat their use can be and urine can be helpful in distinguishinga
cautiouslyadvocatedfor the small number of relativelyminor bite from a potentiallyserious
snakebites that occurundercircumstances such one.Theseassays havealsocontributedto bet'
that a delayof 30 minutesor more in reaching ter understanding the pathophysiology of snake
a medicalfacilitycan be anticipated.0ne is the cnvenomation O.n e i n l e r e s t i n g ic
useof elasticbandagessuchas are widelyused that venomsof somesnakescan be detectedat
to treat sprainsw.appedsnuglyoverthe areaof the site of a bite after severaldays.

PoisonousSnakesand Snakebitein the U.S. 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.

Literature Cited Clenn, J. L., R. C. Straighi, M. C. Wolfe, and D. L. Ha.dy.

1983.Geographicalvariariot in Crotdlus scututatus
B r o n s t e i nA, . C . , F . E . R u s s e l lJ, . B . S u l l i r a n ,N . B . E g e n ,
a n dB . R . R u m a c \ .1 q 8 5N . e g a r i r ep r e * u r p . u . r i n n (Mojave rattlesnake) venom properties. Toxicon
in field lrealneni of rattlesnakebite. Vet. Hun. Tox 2l:119-130.
icol. 28:297,185. Hardy, D. L. 1986.Fslal rattlcsnakeenvenonationin Arizona.
Cable, D., W. McCehee,W. A. Wingert, and F. E. Russell. J. Tox. Clin. Tox. 24:l 10.
1984. Prolonged defibrination after a bite fron a Kardong, K. V. 1986.Th predatorystrike ofthe rauiesnale:
lnale. JAMA 251:925-926. when thinss so amiss. Copeia 1986:816-820.
Fiero, M. K., M. W. Seifert,T. J. Weaver, and C. A. Bonilla. Minron, S. A. 1953.Variation in venom samplesfron cop-
1972.Conparative study ofjuvenile and adult prairie
p e r h e a d s a n d t i m b e r r a t l l e s n a k e s .C o p e i a
rattlesnake(Croralrs li'idrr !,r.d6) venoms.Toxicon
t96?. Observationson tonicity and anligenic
C t e n n ,J . L . a n d R . C . S r r a i g h t .1 9 8 2 .T h e r a t t l e s n a k easn d
their venon yild and lethal toricity. 1l[ Tu, A. T. makeup of venons of juvenile snakes.1N Russell,
(ed.) RattlesnakeVenons: their Actions and Trear- F. E. and P. R. Saundere(eds.)Animal Toxins 0x-
m e n t . N e w Y o r k . M a r c e l D e k k e r .P p . 3 1 1 9 . f o r d . P e r g a m o nP r e s s .P p . 2 1 1 2 2 2 .

136 Minton