Snake Bite Management
For any venomous or possibly venomous snake bite in North America, immediately activate emergency services, rest and immobilize the bitten extremity, remove constricting objects, and transport rapidly to a hospital for antivenom—the only definitive treatment—while avoiding all traditional first aid measures like tourniquets, ice, suction, incision, or electric shock, which are ineffective and potentially harmful. 1, 2
Immediate Actions at the Scene
What TO Do
Activate emergency medical services immediately for any person bitten by a venomous or possibly venomous snake, as antivenom is only available in hospital settings and cannot be administered in the field 1, 2
Rest and immobilize the bitten extremity to reduce systemic venom absorption through the lymphatic system—walking or exertion for ≥10 minutes increases venom spread 1, 2
Remove all rings, watches, and constricting jewelry from the affected limb before swelling develops, as progressive edema can cause ischemic injury to digits 1, 2
Transport the victim to a medical facility as quickly as possible, prioritizing speed over field interventions, as time to antivenom is the most critical prognostic factor 2
What NOT To Do (All Potentially Harmful)
Do NOT apply ice or cryotherapy—this has unproven benefit for snakebite and case reports demonstrate tissue injury from aggressive cold application 1, 2
Do NOT use suction devices (with or without incision)—systematic reviews show these are ineffective at removing venom and may cause additional tissue damage 1, 2
Do NOT apply tourniquets—human and animal studies demonstrate they are ineffective at preventing systemic envenomation and worsen local tissue injury 1, 2
Do NOT use electric shock therapy—systematic reviews of human experience and animal experiments show this is both ineffective and potentially harmful 1, 2
Do NOT apply pressure immobilization bandaging for North American snake bites (pit vipers and coral snakes)—this technique may worsen tissue injury with cytotoxic venoms and studies show even trained personnel have low rates of appropriate placement 1, 2
Clinical Context and Epidemiology
North American Venomous Snakes
Pit vipers (Crotalinae) cause >95% of venomous bites in North America, including rattlesnakes, copperheads, and cottonmouths 1, 2
Pit viper venom causes tissue injury with wounds that are red, warm, tender, and swollen, plus potential systemic effects including hypotension, bleeding, and muscle fasciculations leading to paralysis 1
Coral snakes (Elapidae) cause <1% of bites but produce primarily neurotoxic effects rather than tissue injury, requiring different clinical monitoring 2, 3
Approximately 8,000-10,000 people are treated annually for snakebites in the United States, with 12-15 deaths per year, mostly in children, elderly, and untreated individuals 1, 4, 5
Hospital-Based Definitive Treatment
Antivenom Administration
Antivenom is the cornerstone and only definitive treatment for venomous snakebites and must be administered intravenously in a hospital setting 1, 2, 6
Antivenom is most effective when given within 4 hours of the bite, though it remains beneficial even when delayed 4, 6
Dosing varies by severity: mild envenomation may require up to 5 vials, moderate cases 10-15 vials, and severe cases 15-20 vials 6
Skin testing for hypersensitivity is mandatory before antivenin administration, with diphenhydramine and epinephrine readily available for potential anaphylactic reactions 6
Supportive Care
Administer broad-spectrum antibiotics to prevent secondary infection of the wound 6
Update tetanus prophylaxis as indicated by immunization history 6
Provide pain medication and plasma expanders as needed for symptom management 4
Critical Pitfalls to Avoid
Delaying transport to attempt field interventions wastes critical time—the priority is rapid delivery to a facility with antivenom capability 2, 5
Assuming no envenomation based on lack of immediate symptoms is dangerous—coral snake neurotoxicity can be delayed up to 13 hours despite minimal local findings 3
Failing to remove constricting items early allows progressive swelling to cause ischemic injury as edema develops 2
Using outdated first aid techniques like tourniquets, incision, suction, or ice application not only wastes time but may worsen outcomes 1, 5
Inadequate observation periods risk missing delayed toxicity—patients require hospital admission for minimum 48 hours with continuous monitoring, particularly for coral snake bites where neurotoxicity onset can be significantly delayed 3