What is the treatment for a snakebite?

Treatment of Snakebite

Activate emergency services immediately, rapidly transport the victim to a medical facility, and administer antivenom as the definitive treatment—starting with 10 vials intravenously for pit viper envenomations—while avoiding harmful interventions like tourniquets, ice, incisions, or suction devices. 1, 2

Immediate Field Management

Critical First Actions

• Call emergency services immediately for any venomous or potentially venomous snakebite, as definitive treatment is only available in hospitals 1
• Remove all rings, watches, and constricting items from the bitten extremity immediately to prevent ischemic injury as swelling progresses 1, 2
• Immobilize the affected extremity and minimize victim movement to reduce systemic venom absorption through the lymphatic system 1
• Transport rapidly to the nearest medical facility capable of administering antivenom, as this is the only effective treatment 1

Absolutely Contraindicated Interventions

• Do NOT apply ice—it causes tissue injury without benefit 1
• Do NOT use tourniquets—they worsen local tissue necrosis 1
• Do NOT incise the wound or use suction devices—these are ineffective for venom removal and cause additional tissue damage 1, 3
• Do NOT apply electric shock—it is both ineffective and dangerous 1
• Do NOT use pressure immobilization bandaging in North America—this technique, developed for neurotoxic Australian snakes, worsens tissue injury from the cytotoxic venoms of North American pit vipers 1

The evidence strongly contradicts older recommendations: while one 1991 study suggested wound incision and suction if medical care was >30 minutes away 4, current guidelines from the American Heart Association and American College of Cardiology explicitly warn against these practices due to tissue injury risk and lack of efficacy 1.

Hospital-Based Medical Management

Antivenom Administration

• Administer 10 vials of Anti-Snake Venom intravenously as the initial dose for pit viper envenomations—this single dose is practical and does not increase adverse reaction risk compared to lower doses 2
• Have 12 vials available in the emergency department, as 10 vials typically suffices for initial treatment but additional doses may be needed 2
• Perform hypersensitivity testing before administration to identify patients at risk for allergic reactions 2
• Administer antivenom as soon as evidence of envenomation appears, ideally within 4 hours of the bite for maximum effectiveness 4

Indications for Antivenom

• Pain, swelling, or ecchymoses at the bite site 4
• Systemic symptoms including coagulopathy, sudden collapse, myotoxicity, or neurotoxicity 5
• Abnormal laboratory findings (prolonged aPTT, elevated INR, elevated creatine kinase) 5
• Renal impairment or cardiovascular instability 5

Supportive Care

• Ensure airway management and ventilatory support for neurotoxic envenomations, particularly with coral snakes 2
• Have epinephrine immediately available: 0.01 mg/kg (maximum 0.3 mg) in children or 0.3-0.5 mg in adults, administered intramuscularly in the anterolateral thigh for anaphylactic reactions 2
• Administer plasma expanders, analgesics, tetanus prophylaxis, and antibiotics as needed 4

Monitoring Protocol

• Admit all suspected snakebite patients for at least 12 hours of observation, even if initially asymptomatic 5
• Perform serial laboratory testing: aPTT, INR, and creatine kinase levels 5
• Conduct serial neurological examinations to detect delayed neurotoxic effects 5
• Monitor compartment pressures if significant swelling develops, though compartment syndrome requiring fasciotomy is rare 6

Special Considerations

Geographic and Species Variations

• Pit vipers (rattlesnakes, copperheads, cottonmouths) cause 99% of US envenomations and produce primarily cytotoxic effects with local tissue necrosis 4
• Coral snakes produce neurotoxic effects rather than tissue injury and require different management considerations 1
• Most bites occur during warmer months and involve extremities, with 8,000-10,000 cases treated annually in the US 1

Hospital Preparedness

• Conduct hazard vulnerability assessments to determine appropriate antivenom stocking levels based on geographic location and endemic snake species 2
• Ensure hospitals have onsite laboratory facilities and clinicians capable of managing anaphylaxis 5

Critical Pitfalls to Avoid

• Delaying transport to attempt ineffective first aid measures—get the patient to definitive care immediately 1
• Failing to remove constricting items early—rings become impossible to remove as swelling progresses 1
• Excessive victim movement during transport—this accelerates venom absorption 1
• Applying pressure immobilization for North American snakebites—this worsens cytotoxic venom injury 1
• Withholding antivenom due to allergy concerns—modern ovine-derived antivenoms (CroFab) are much less allergenic than older equine products, and benefits outweigh risks in true envenomations 3, 6