September 2006

Diagnosis And Management Of Authors

Volume 8, Number 9

North American Snake And Melissa W Costello, MD

Assistant Professor of Emergency Medicine,
University of South Alabama, Mobile, Alabama
Scorpion Envenomations Alan Heins, MD
Assistant Professor of Emergency Medicine,
University of South Alabama, Mobile, Alabama
Case #1: A 45-year-old man presents, via rural EMS, with a chief complaint
Daniel A Zirkin, MD
of “snakebite.” EMS reports that the patient ran over a 6 to 8ft snake with his Resident Physician, Department of Emergency
pickup truck, cutting it in half. The patient doubled back to pick up the dead Medicine, Emory University, Atlanta, Georgia
snake (foreseeing a nice new pair of snakeskin boots) and when he grabbed it, Peer Reviewers
the snake “came around” and bit his hand. He has two puncture wounds almost Frank Lovecchio, DO, MPH, FACEP
Medical Director, Banner Good Samaritan Regional
7cm apart on his right hand surrounded by dark purple ecchymosis and the start Poison Center; Research Director, Maricopa Medical
of bullae formation. He has edema and erythema of his hand and arm to the Center, Department of EM; Associate Professor, AZ
elbow and is having fasciculations of most of his large skeletal muscle groups. He College of Osteopathic Medicine
is in pain and EMS reports that he seemed to be getting progressively confused Robert Barish, MD
Professor of Emergency Medicine, Vice Dean for
and lethargic during their 70 minute transport. He is hypotensive, tachycardic,
Clinical Affairs, University of Maryland School of
and is oozing blood from his IV sites. You realize that his life depends on your Medicine, Baltimore, MD
actions... Charles Stewart, MD, FAAEM, FACEP
Case #2: A 30-year-old man presents with a chief complaint of “snakebite.” Emergency Physician, Colorado Springs, CO
About 30 minutes prior to arrival he was wading in murky water cleaning debris CME Objectives
out of a stream and felt a bite on his hand. As he pulled his hand out of the water, Upon completion of this article, you should be able to:
he briefly caught a glimpse of a snake as it swam away; he gives a fairly good 1. Name the types of venomous snakes native to
the United States.
description of a small copperhead. He has two small punctures on his right index 2. Describe the key characteristics for identifying
finger about 1 cm apart. He is currently pain free, without erythema, swelling, or venomous versus non-venomous snakes.
ecchymosis. His vitals and remaining physical exam are normal. He wants to 3. Explain the grading system for envenomations.
4. Describe the indications and administration of
know if he can go home... CroFabTM.
Case #3: A 39-year-old man presents to your Florida ED about four hours 5. Effectively evaluate and manage severe snake
after being bitten on the forearm by a small red, yellow, and black snake while and scorpion envenomations.
6. Prevent and treat adverse effects of antivenom
clearing brush. The snake escaped and was thought to be a king snake. There was administration.
minimal pain at the site of the bite and no swelling or bleeding, so he continued 7. Describe multiple resources available to assist in
working. The patient started to get worried when he developed twitching in his the management and treatment of snake enveno-
mations.
arms and face about one hour before arrival at the ED. Soon after the twitching
Date of original release: September 12, 2006.
started, he began having difficulty talking and swallowing and had an episode of Date of most recent review: September 1, 2006.
double vision, prompting him to call 911. On arrival, the patient is awake, alert, See “Physician CME Information” on back page.

Editor-in-Chief
Andy Jagoda, MD, FACEP, Professor
and Vice-Chair of Academic Affairs,
Department of Emergency Medicine;
Mount Sinai School of Medicine;
Medical Director, Mount Sinai Hospital,
New York, NY.
Associate Editor
John M Howell, MD, FACEP, Clinical
Professor of Emergency Medicine,
Michael J Gerardi, MD, FAAP, FACEP,
George Washington University,
Washington, DC; Director of Academic
Affairs, Best Practices, Inc, Inova
Fairfax Hospital, Falls Church, VA.
Editorial Board
Michael A Gibbs, MD, FACEP, Chief,
William J Brady, MD, Associate
Professor and Vice Chair, Department
of Emergency Medicine, University of
Steven A Godwin, MD, FACEP,
Virginia, Charlottesville, VA.
Peter DeBlieux, MD, LSUHSC
Professor of Clinical Medicine; LSU
Health Science Center, New Orleans,
LA.
Wyatt W Decker, MD, Chair and
Associate Professor of Emergency
Medicine, Mayo Clinic College of
Medicine, Rochester, MN.
Francis M Fesmire, MD, FACEP,
Director, Heart-Stroke Center,
Erlanger Medical Center; Assistant
Professor, UT College of Medicine,
Chattanooga, TN.
Director, Pediatric Emergency
Medicine, Children’s Medical Center,
Atlantic Health System; Department of
Emergency Medicine, Morristown
Memorial Hospital, NJ.
Department of Emergency Medicine,
Maine Medical Center, Portland, ME.
Assistant Professor and Emergency
Medicine Residency Director,
University of Florida
HSC/Jacksonville, FL.
Gregory L Henry, MD, FACEP, CEO,
Medical Practice Risk Assessment,
Inc; Clinical Professor of Emergency
Medicine, University of Michigan, Ann
Arbor.
Keith A Marill, MD, Instructor,
Department of Emergency Medicine,
Massachusetts General Hospital,
Harvard Medical School, Boston, MA.
Charles V Pollack, Jr, MA, MD, FACEP,
Professor and Chair, Department of
Emergency Medicine, Pennsylvania
Hospital, University of Pennsylvania
Health System, Philadelphia, PA.
Michael S Radeos, MD, MPH,
Assistant Professor of Emergency
Medicine, Lincoln Health Center,
Bronx, NY.
Robert L Rogers, MD, FAAEM,
Assistant Professor and Residency
Director, Combined EM/IM Program,
University of Maryland, Baltimore,
MD.
Alfred Sacchetti, MD, FACEP, Beth Wicklund, MD, Regions Hospital
Assistant Clinical Professor, Emergency Medicine Residency,
Department of Emergency Medicine, EMRA Representative.
Thomas Jefferson University,
Philadelphia, PA. International Editors
Corey M Slovis, MD, FACP, FACEP, Valerio Gai, MD, Senior Editor,
Professor and Chair, Department of Professor and Chair, Dept of EM,
Emergency Medicine, Vanderbilt University of Turin, Italy.
University Medical Center, Nashville,
TN.
Peter Cameron, MD, Chair, Emergency
Medicine, Monash University; Alfred
Jenny Walker, MD, MPH, MSW, Hospital, Melbourne, Australia.
Assistant Professor; Division Chief,
Amin Antoine Kazzi, MD, FAAEM,
Family Medicine, Department of
Associate Professor and Vice Chair,
Community and Preventive Medicine,
Department of Emergency Medicine,
Mount Sinai Medical Center, New
University of California, Irvine;
York, NY.
American University, Beirut, Lebanon.
Ron M Walls, MD, Professor and Chair,
Hugo Peralta, MD, Chair of Emergency
Department of Emergency Medicine,
Services, Hospital Italiano, Buenos
Brigham & Women’s Hospital, Boston,
Aires, Argentina.
MA.
Maarten Simons, MD, PhD,
Research Editors Emergency Medicine Residency
Director, OLVG Hospital, Amsterdam,
Nicholas Genes, MD, Mount Sinai
The Netherlands.
Emergency Medicine Residency.
and anxious. His heart rate is 92, blood pressure 140/85, tem-
perature 98.2°F orally, respiratory rate 22, and oxygen satura-
tion 95% on room air. You note right eye ptosis; the pupils are
equal, round, and reactive to light, but the right eye does not
move past the midline on lateral gaze. Mild dysarthria is pres-
ent. There are two tiny puncture marks on the right forearm
with 1-2cm of surrounding ecchymosis, but no swelling.
During your exam, respirations became shallower and labored,
with some snoring upper airway sounds. You realize that this
might be more than just the bite of a king snake...
S nakes, both native and imported, and scorpions
produce clinically important envenomations in
the United States. While envenomations have long
been considered the purview of the Southeastern US
and the desert Southwest, the widespread and ever-
growing population of people who maintain these
animals in collections and as “pets” has made the
presentation of a snakebite or scorpion sting possible
in any emergency department (ED) in the country.
These animals can produce devastating injuries and
must be recognized promptly and treated appropri-
ately to prevent significant morbidity and death.
Not all envenomations need treatment. Indeed, there
are times when the risk of treatment outweighs the
benefit. However, failure to aggressively treat in the
appropriate situation may result in a disastrous out-
come for the patient and for the clinician who does
not meet the standard of care expected of the emer-
gency medicine specialist.
This article will divide the discussion of snakes
and the management of snake and scorpion enveno-
mations into two sections. The first section will deal
exclusively with pit vipers (Crotalids), their identifi-
cation, envenomation signs and symptoms, and
treatment with CroFabTM. Changes and controversies
in the care of patients with Crotalid envenomations
will also be addressed. The second section will deal
with coral snakes and the identification and treat-
ment issues that they present, along with a brief dis-
cussion of scorpion stings and the “exotics:” The
non-native captive snakes that are found more and
more commonly in the US, both in zoos and as pets.
Critical Appraisal Of The Literature
Unfortunately, evidence from well-conducted clinical
research is in short supply to guide the management
of envenomations. The literature supporting the ED
evaluation and treatment of envenomations is gener-
ally weak, with few randomized trials or meta-analy-
ses, and many review articles rehashing the same
weak literature. Even the epidemiology of
Emergency Medicine Practice©
snakebites and scorpion stings is unclear, supported
by large, but not population-based studies. The
American Association of Poison Control Centers
(AAPCC) compiles data from their Toxic Exposure
Surveillance System (TESS) and publishes a compre-
hensive annual analysis of all toxic exposures,
including envenomations, reported to all of the US
Poison Control Centers. These reports include infor-
mation on exposures, ED use, and clinical outcomes
including death.1-2 In spite of this centralized clear-
inghouse/reporting system, the consensus among
experts in the field is that relying on self-reported
data in the cases of envenomations that do not
require ED visits results in a true incidence on
envenomation that is as high as three to four times
the number reported by TESS.3-5
The body of current literature on North
American snake envenomations can generally be
divided into two categories; pre-CroFabTM and post-
CroFabTM. The Crotalidae Polyvalent Immune Fab
Ovine (CroFabTM) was approved by the US Food and
Drug Administration in October of 2000 essentially
replacing the older Antivenom Crotalidae Polyvalent
(ACP) available since 1954. Indications and adminis-
tration of CroFabTM will be discussed in detail later in
this article. Dozens of articles have been published
on the topic of snake envenomations since the
approval of CroFabTM, but the vast majority are
review articles by a small pool of authors. Very little
original research has been done since the CroFabTM
research in 1999. The research that has been done
has typically been in small populations and does not
include a single randomized, blinded clinical trial of
any medication, device, or technique for snakebite
management.
The most recent comprehensive review identi-
fied was “North American snake envenomation:
diagnosis, treatment and management” by Gold,
Barish, and Dart in the Emergency Medicine Clinics of
North America.4 This group of authors has written
extensively in the emergency medicine and wilder-
ness medicine literature on the topic of snake enven-
omations. In addition to the review article above,
they participated in a four article symposium in the
Annals of Emergency Medicine6 (presenting the data
from the October 1999, North American Congress of
Clinical Toxicology’s, “Advances in the Management
of Snakebite” Symposium), and a full review of ven-
omous snakebites in the New England Journal of
Medicine.5 Most of the recent research-based litera-
ture has focused on the limited areas of field man-
2 September 2006 • EBMedice.net
agement changes, trials of venom extraction devices, Epidemiology And Etiology
surgical management, and the expansion of the use
Given the multitude of people who have an intense
of CroFabTM to non-Crotalidae envenomations; all of
and occasionally irrational fear of snakes, it is hard
which will be discussed in this article.
to believe that snakebites are a relatively infrequent
Coral snake envenomations are not treated with
occurrence. Even harder to believe, is that fatalities
CroFabTM and thus will be reviewed separately. It is
from snake envenomations are exceedingly rare. It is
fairly rare and human treatment studies include only
estimated that there are approximately 45,000
case series.7 Additionally, one well-designed animal
snakebites per year in the United States.12 Seven
model study explored a technique for first aid of
thousand to 8000 of these bites are attributed to ven-
coral snake envenomations.8 Similarly, the evalua-
omous snakes, but these bites only result in five to
tion and management of scorpion envenomations is
six deaths annually.3,12 The Toxic Exposure
supported by only one randomized, placebo-con-
Surveillance System (TESS) report for 2004 breaks
trolled trial from Tunisia that enrolled a group with
down snakebites by species, with 98% of bites by
few severely affected people, and a systematic
venomous snakes in the US from the Crotalids; there
review including a randomized trial and three cohort
were a total of 5046 reported bites, with 167 major
studies.9,10
complications and two deaths. TESS reported 97
Non-native venomous snakes represent a hetero-
coral snake envenomations in 2004, with four major
geneous group of animals kept by collectors and
complications and no deaths. Envenomations by poi-
zoos. These snakes cause some dangerous enveno-
sonous exotic snakes resulted in 131 reported cases
mations each year in the United States, but the
in 2004. These bites were more severe than coral
majority of the literature on evaluation and treat-
snakebites with morbidity and mortality rates similar
ment of these snakes is published in the countries
to that of rattlesnakes; about 35% moderate injury,
where the snakes are native. Most of these reports
7% major injury, and one death.
are low quality, but a few randomized, controlled tri-
One of the major limitations of the data reported
als support practice and are available through online
by TESS is that, generally speaking, the data is com-
databases by searching the specific species of snake
piled only from snake envenomations that result in
responsible for the envenomation.
visits to a physician (ED or other) or a call to the
Clinical guidelines are of virtually no help in
regional or national Poison Control Center. Many
guiding the assessment and treatment of envenoma-
people who sustain minor envenomations or dry
tions. A search of the National Guidelines
bites (bites where no venom is injected) will not seek
Clearinghouse using various key words, including
medical care. It is reasonable to conclude that the
snakebite, envenomation, rattle snake, coral snake,
patients who do not seek medical care generally will
scorpion, cobra, krait, venom, etc. yielded only one
not take the time to report their envenomation to
relevant guideline, entitled, “First aid: 2005
TESS. Thus, authors of scientific and medical writ-
International Consensus Conference on
ings are left to speculate on the true incidence of
Cardiopulmonary Resuscitation and Emergency
envenomations. The current consensus seems to be
Cardiovascular Care Science with Treatment
based on the estimate given by Parish in a 1954
Recommendations,” published in Circulation.11 The
report on the incidence of treated snakebites in the
two suggestions for the first aid of snakebites are:
US (45,000),12 and a report by Langley and Morrow
1) First aid providers should not apply suction to
estimating that the actual incidence and death rate
snakebite envenomation sites; this recommendation
from snakebites was three to four times that reported
is supported by a few Class II and III studies.
by TESS.3 The majority of deaths occur among chil-
2) Properly performed pressure immobilization
dren and the elderly, among those for whom
is recommended for first aid treatment of Elapid
antivenom is not given, is postponed, or is adminis-
snakebites. The first aid provider creates this
tered in insufficient quantities, and among members
pressure by applying a snug bandage that allows
of fundamentalist religious groups who handle poi-
a finger to slip under the bandage; this recommen-
sonous snakes during religious rituals.13
dation is supported by a single Class III study in
Rattlesnakes, with their presence in virtually all of
a porcine model of a coral snake envenomation.
the continental US and the high potency of their
venom, are responsible for the majority of snakebite

EBMedicine.net • September 2006 3 Emergency Medicine Practice©

fatalities with the diamondback rattlesnake account-
ing for 95% of these fatal bites.14-15
Snakebites are more common during the spring
and summer months when both snakes and people
are more active outdoors. Very little has changed in
the literature regarding the demographics of snake
envenomations since 1966, when Parish published
one of the first comprehensive survey results in
Public Health Reports.12 Best summarized by Gold et
al, “the majority of victims remain men between the
ages of 17 and 27 years. More than 95% of the bites
are on the extremities, and most occur between April
and October, the peak months being in July and
August.”4 Nonetheless, an emergency physician in
any part of the country can potentially see snakebites
at any time of the year, often from deliberate expo-
sure to captive snakes.16
Of the nearly 3000 species of venomous and non-
venomous snakes worldwide, there are less than 40
species of venomous snakes in North America. To
simplify things even further for the non-herpetolo-
gist, the venomous species of North America can be
divided into four main types: Rattlesnakes (consist-
ing of species from both the Crotalus and the
Sistrurus genus), copperheads (genus Agkistrodon),
cottonmouths (genus Agkistrodon), and coral snakes.
The first three types are members of the Viper family
and the Crotalinae subfamily; coral snakes are North
America’s only native member of the family of
snakes called Elapids.4,17 The family Elapidae also
includes many of the most dangerous snakes in the
world including cobras, kraits, adders, and mambas.
Three different species of Elapids can be found in
North America from North Carolina to Arizona and
as far south as several hundred miles south of the
US-Mexican border. The Eastern coral snake
(Micrurus fulvius) is the most dangerous of the coral
snakes. The highest concentrations are found in
Florida, but it has also been found from North
Carolina to Louisiana. The Western coral snake
(Micruroides euryxanthus) is found in the Sonoran
Desert of Arizona, northern Mexico, and the south-
west corner of New Mexico below 5800 feet. The
third Elapid in the US is the Yellow-bellied sea snake
(Pelamis platurus). It has weak venom relative to the
other Elapids, but it can still be dangerous to
humans. The range of this sea snake in North
America is limited to the southernmost areas of
California and the northern pacific coast of Mexico.
Exotic snakes are held by collectors and zoos in scat-
tered places throughout the country and may repre-
Emergency Medicine Practice©
sent any of the venomous species found in the
world, but are most commonly cobras, kraits, and
true vipers (as opposed to the pit vipers).
Scorpions
Scorpions are arthropods in the class Arachnida,
sharing some characteristics with spiders, and are
found worldwide. Most species of scorpions deliver
venom that is not dangerous to humans, but there
are a noteworthy few that deliver a potent, although
not deadly, venom. In the US, scorpions are found
primarily in the desert Southwest, with only one
species, the Bark scorpion Centruroides sculpturatus
(aka exilicauda), dangerous to humans. The Bark
scorpion is only found in Arizona and Northern
Mexico.
The South African and Tunisian scorpions are
very different from the Southwestern scorpion. In
the US, most envenomations are treated at home,
with very few advancing to pulmonary edema or
shock. Most of the large case series and controlled
trials have been performed outside the US, and cau-
tion must be used when extrapolating these studies
to the management of patients in the US.
Pathophysiology
Pit Vipers/Crotalids
Crotalid venom is a stunningly complex mixture of
proteins that include proteolytic enzymes, collage-
nases, phospholipases, nucleotidase, hyaluronidase,
acetylcholinesterase, and amino acid oxidase. In
addition, it contains elemental metals, amino acids,
carbohydrates, lipids, serotonin, and even hista-
mine.18 Local toxic effects include swelling, pain,
ecchymosis, and blebs; systemic effects result in
coagulopathy, myocardial injury, muscular paralysis,
and central nervous system injury. 4,6 See Table 1 for
a more detailed description of venom effects.
Crotalid venom has multiple effects on many
organ systems and one of the most prominent is the
venom’s power as an anticoagulant. Recently, it has
been the subject of studies looking into clinical appli-
cations of a number of proteins isolated from venom
for development of new anticoagulant drugs. These
proteins have shown to inhibit platelet adhesion by
interfering with the binding of vWF to the GPIb
receptor and may provide an entirely new target for
antiplatelet agents.19
Venom composition will change depending on
the species of snake, age, diet, geographic location,
4 September 2006 • EBMedice.net
and time of the year.4 Several types of Crotalids, once scorpion antivenom conducted in Tunisia, 82.4% of
mature, have the ability to vary the amount of venom 825 patients had only local effects. The other 17.6%
injected during a strike. Generally, the younger the exhibited systemic effects, primarily autonomic
snake, the more potent their venom.20 instability, e.g. hypertension, sweating, and fever.
Nine (1%) of 825 patients experienced cardiogenic
Coral Snakes shock, six (0.8%) had pulmonary edema, and two
Coral snake venom is a heterogeneous mixture of (0.25%) died.23
peptides and enzymes with primarily neurotoxic
effects on nerve conduction and neuromuscular
transmission.7 The mechanism of action and phar-
macodynamics of coral snake venom is unclear and Section 1. The Pit Vipers (Family Viperidae,
has apparently not been the subject of any published Subfamily Crotalidae): Rattlesnakes, Cotton-
research. It is unlikely that this uncertainty will be mouths (Water Moccasins), And Copperheads
addressed unless, like the Crotalids, a researcher
determines a potential clinical use for Elapid venom
or one of its components. Some cytotoxic effects Identification
may occur but are usually minor especially when
compared to Crotalid venom. Often, there are no Identification of the snake that produced the bite can
symptoms for one to five hours but, once they begin, be extremely helpful. Accurate information about
systemic signs and symptoms may progress rapidly. the identity of a snake can provide information on
Tremors and cranial nerve dysfunction resulting in the potency of the venom (rattlesnake venom being
ptosis, dysarthria, and dysphagia are common in the most potent among native US snakes) and the
substantial envenomations. Respiratory depression patient’s expected clinical course and response to
occurs more rarely and late in the course. antivenom. Often, well-meaning patients or
bystanders will bring in the snake for identification;
Non-native Venomous Snakes it goes without saying that unless you have signifi-
Imported snakes of the family Elapidae share some cant experience handling snakes it is best not to han-
of the characteristics of coral snakes, including a dle specimens that are brought in...alive or dead! If
tendency for elapid venom to cause
Table 1: Snake Venom
mostly neurotoxic effects. Snakes of the
Components And Their Effects
family Viperidae, including Central and
South American and Asian pit vipers
and the true vipers of Africa, the
Middle East, and Europe, are similar
in effect to the Crotalid pit vipers of
North America, with primarily cytotox-
ic venom, resulting in local tissue dam-
age, coagulopathy, and organ dysfunc-
tion.

Scorpions
Scorpion venom is delivered through a
tail stinger from two venom glands and
is a combination of peptides and pro-
teins with proteolytic and neurotoxic
effects. Neurotoxic effects are proposed
to be mediated by effects at sodium and *Refers to quantity of the envenomation.
potassium channels of neurons.21-22 Though not comprehensive, this table is designed to provide an
easy reference in clinical practice.
Most envenomations produce only local
Reprinted from Kiran S, Senthilnathan TA Update in Anesthesia, Issue 16 (2003) Article 6.
effects of pain and swelling. In a ran-
domized, placebo-controlled trial of

EBMedicine.net • September 2006 5 Emergency Medicine Practice©

the animal is brought in dead or in parts, keep in Prehospital / Wilderness Care
mind that snakes retain the ability to strike, bite, and
Multiple methods for treating snakebites in the
potentially cause a significant envenomation for sev-
field have gone in and out of vogue over the years,
eral minutes after death or decapitation. If you have
and have been discussed at length both in the med-
been provided a specimen that is fairly intact and is
ical and non-medical literature. Recently, the
in an appropriate container to allow for safe inspec-
recommended first aid measures for snakebites
tion (and you don’t develop profound cataplexy at
have been revised to exclude many treatments of
the thought of handling a snake), then knowing a
the past. Arterial tourniquets, aggressive wound
few good resources can be helpful in accurate identi-
incision/excision, electric shock, and ice submer-
fication; see Table 5 on page 18.
sion/cryotherapy may all worsen a patient’s
Figure 1 shows some of the characteristic fea-
condition.16-17 Current recommendations for field care
tures that help distinguish the venomous pit vipers
call for very little beyond rapid transportation; see
from the thousands of non-venomous species of
Table 2.
snakes in the US. In general, pit vipers will have a
Field care by bystanders or emergency medical
triangular shaped head, elliptical pupils, and a heat
services should include removing the patient from
sensing pit in front of the eye. These snakes will also
the area where the bite occurred. It is not recom-
have a set of retractable fangs and may or may not
mended to try to catch or kill the offending snake
have a rattle on the tail. The body markings on the
simply to bring it to the hospital. In other words,
Crotalids are widely variable and can be helpful in
common sense and discretion should prevail. A
identifying the specific species of snake. The fourth
snake that has taken up residence under the slide on
species of native venomous snake, the coral snake, is
a school playground is very different from a snake
in a totally different subfamily of snakes and does
that strikes because you stepped on its home in the
not have any of this characteristic set of pit viper fea-
middle of the woods. A good description of the
tures despite possessing very potent venom. The
snake in combination with the patient’s signs and
clinically important feature to know with coral
snakes is the difference in the markings between a
coral snake (venomous) and a king snake (non-ven- Table 2: Prehospital Care of Snake
omous) which has evolved very similar markings to Envenomations
the coral snake in order to fool its prey. The old say-
ing, “red on yellow kills a fellow; yellow on black,
venom lack,” works well to differentiate the corals
from the king snakes in North America ONLY. Both
species are found throughout the geographical distri-
bution of the coral snake.
Generally speaking, if you see more than two or
three snakebites a year or if you are the regional
referral center for snake envenomations (like we
are), you may also want to keep a field guide
specific to your region in your ED reference library.
Peterson Field Guides publishes two titles on
reptiles and amphibians, one for Eastern and
Central North America and one for the Western
US.24-25 These guides are recommended by several
herpetology sources and are inexpensive (approxi-
mately $15 each) references to keep handy. Other
potentially useful resources are poison control cen-
ters, medical toxicology divisions of large hospitals,
state agriculture departments, university veterinary
programs, and local zoos that keep and care for rep-
tiles.

Emergency Medicine Practice© 6 September 2006 • EBMedice.net

 Figure 1: Comparison Of Venomous Snakes (Pit Vipers)
And Nonvenomous Snakes In The US

From Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med 2002;347(5):347-58; with permission.

EBMedicine.net • September 2006 7 Emergency Medicine Practice©

symptoms is generally adequate to initiate in-hospi-
tal treatment.
Patients should be reassured, placed at rest, kept
warm, and transported immediately to the closest
medical facility. The bitten extremity should be
immobilized and kept at or below the level of the
heart, and all constrictive clothing, jewelry and
watches should be removed.4,15,26 Closely monitor
vital signs to assess for hypotension as a sign of sys-
temic toxicity and hypotension should prompt a
bolus of intravenous isotonic fluids.5,17 Incision and
suction, once the standard of care for the treatment
of snakebites, is no longer recommended and may, in
fact, pose more risk than benefit.27 Incision has
never been shown to be beneficial for extracting
venom and can cause unintended and potentially
disabling injury to digital nerves, arteries, and ten-
dons even when performed by an experienced
provider.28 Oral suction of the venom is strongly dis-
couraged both for its lack of effectiveness in remov-
ing venom and because of the possibility of introduc-
ing oral flora into the wound, potentially complicat-
ing treatment.
There are several commercial snakebite kits on
the market containing a multitude of items for the
treatment of snakebites. Generally there is some
combination of venous and/or arterial tourniquets,
Table 3: Severity Grading69
Emergency Medicine Practice©
lancets or scalpels, antiseptic wipes, and various suc-
tion devices. Most of the kits were developed and
marketed since before the “incision and suction”
treatment went out of vogue.
The most recognized and researched of these
suction devices is the Sawyer Venom Extractor®.
The marketing information available on the internet
for this product references its ability to remove “up
to 30%” of the snake venom based on two small
studies (one animal in 1985 and one human in 1986)
by Bronstein et al.29-30 A well-designed, 2004 human
study by Alberts et al27 using simulated radiolabeled
snake venom demonstrated minimal (0.04%) venom
extraction from a simulated snakebite wound and
only a 2% reduction of total body venom load.
Given the poor performance of this device in the
controlled trials and the elimination of most of the
former interventions from the field treatment recom-
mendations, Johnson said it best when he stated,
“the best snakebite kit is probably the keys to a car
that runs.”15
EMS may be faced with a snakebite victim who
has had one or more well-intentioned field interven-
tions by a bystander and it is important to know
which should be discontinued and which should
remain until hospital evaluation is complete.
Incision is one of the most likely field interventions
8 September 2006 • EBMedice.net
the EMS provider may encounter. In cases where an
incision has been made, control bleeding and apply a
moist dressing.17 If an extractor device is correctly in
place it should be left in place until the arrival at the
hospital.17 Arterial tourniquets should be removed
due to the potential for limb ischemia but venous
tourniquets or “constriction bands,” defined as wide,
flat bands that restrict venous and lymphatic flow to
impede absorption of venom, can be left in place.
These constriction bands, which should be loose
enough to allow two fingers to slip easily under-
neath, have shown some benefit in delaying
absorption of venom in experimental models and
have been suggested as therapy in patients with
prolonged transport times.17,31 If a device has been
applied and it is not causing vascular compromise, it
should be left in place by EMS during transport.
EMS personnel should frequently reassess the ten-
sion of any constrictive device to ensure that pro-
gressive limb edema does not result in a venous con-
striction band becoming an inadvertent arterial
tourniquet.10
ED Management And Stabilization
Initial Stabilization
Upon arrival in the ED, whether by ambulance or
by personal vehicle, a rapid assessment of the
patient should obviously include an evaluation
of airway, breathing, and circulation. Barring a
situation in which these are compromised and
need to be addressed immediately, the initial stabi-
lization of a snakebite victim includes many of the
interventions that are recommended for the field
providers.
Obtain an initial set of vital signs, place the
patient on continuous cardiac, BP, and pulse oxime-
try monitoring (on an unaffected extremity), remove
constrictive clothing and jewelry, establish intra-
venous access, and draw blood for labs including
tubes for a type and screen and coagulation studies.
Supplemental oxygen can be given on a case-by-case
basis. Use a Sharpie® or surgical marker to mark
and time the leading edge of erythema. Also, mark
two to three sites above the bite as locations for serial
measurement of limb circumference.
Once a clinically significant envenomation has
been identified, rapidly begin the process of obtain-
ing the appropriate antivenom and begin the mixing
process, and/or arrange for rapid transfer of the
patient to a facility capable of handling snake enven-
EBMedicine.net • September 2006
omations. Patients with significant envenomations
will have considerable pain both from the local cyto-
toxic effects of the venom and the diffuse muscle fas-
ciculations caused by the neurotoxins and myotoxins
in Crotalid venom. It is acceptable to give narcotics
and benzodiazepines for comfort while antivenom is
being prepared except in the cases of a coral snake,
Mojave rattlesnake, or Eastern Diamondback rat-
tlesnake envenomation where the neurotoxic effects
of the venom can result in severely impaired mental
status. There are no good, evidence-based recom-
mendations in the literature for choice of drugs or
dosing. NSAIDs should be avoided due to their
antiplatelet effects potentially worsening venom-
induced coagulopathy.
History
Once the patient arrives in the ED, key pieces of
information pertaining to the snakebite itself must be
ascertained; see Table 4. Ask the patient about
symptoms that may indicate a significant envenoma-
tion; particularly pain, numbness, nausea, tingling
around the mouth, metallic taste, muscle cramps or
fasciculations, dyspnea, diplopia, or dizziness.4,14-15,18-28
Additionally, ascertain the traditional components of
a patient history including a comprehensive review
of any co-morbid medical conditions (particularly
cardiac disease and coagulopathy), a list of current
medications, allergies (especially to papain or
papaya based extracts, latex, and horse-based or
sheep-based products), the time of last oral intake
and the patient’s tetanus status. Obtaining the histo-
ry should not interfere with the initiation of treat-
ment in the critically ill or clinically deteriorating
patient.
Table 4: Key Questions In The History
Of A Patient With A Snakebite
• The location of the wound or wounds
• The time of the bite
• The type of snake
• Treatment provided by prehospital
bystander or EMS
• Changes in the patient’s condition since
the time of the bite
9 Emergency Medicine Practice©
Physical Exam
Focus the initial physical exam on the evaluation of
the ABCs and provision of adequate resuscitation.
Once the adequacy of all elements of the primary
survey is established and the steps outlined in the
initial stabilization are completed, the evaluation of
the bite site can commence. As mentioned, one-
fourth of snakebites are dry. Examine the site of the
bite for fang marks or scratches and consider the
possibility of other types of animal bites or injuries if
the diagnosis of a snake envenomation is in doubt.
Pay particular attention to any local signs of enveno-
mation, i.e. edema, petechiae, ecchymosis, or bullae
formation.18 Document circumferential measurements
at several sites above and below the bite site.16 Mark
a line at the site of each measurement to ensure accu-
rate reproducibility. Repeat these measurements
every 15 to 30 minutes during the course of treat-
ment. Also, mark and time the edge of the swelling
to serve as an index of local progression.4
Focus the remainder of the physical exam prima-
rily on the cardiovascular, pulmonary, and neurolog-
ic systems. Patients may be hypotensive due to third
space losses and hemorrhage. Initial treatment for
hypotension is intravenous isotonic fluids.28 The
neurologic exam becomes particularly important in
severe envenomations, especially in cases of Mojave
rattlesnake, coral snake, or non-native/exotic enven-
omations where altered mental status and neurologic
impairment can be a significant and often delayed
feature of the envenomation.18
Diagnostic Studies
The number and type of recommended diagnostic
studies in a patient with a snake envenomation
varies throughout the snakebite literature. However,
the majority of authors agree that a core group of
tests is indicated: A baseline complete blood count
(CBC) with platelet count, coagulation studies
including prothrombin time, partial-thromboplastin
time, activated partial-thromboplastin time, fibrino-
gen level, fibrin split products (fibrin degradation
products), basic electrolytes, blood urea nitrogen,
serum creatinine, and urinalysis. Patients bitten by
an unknown species with no evidence of toxicity
require, at a minimum, coagulation studies which
are necessary for the grading of the envenomation.
Various sources also recommend obtaining an elec-
trocardiogram, a specimen for type and screen or
type and crossmatch for blood products (as cross-
match may be more difficult following the adminis-
Emergency Medicine Practice©
tration of antivenom), liver function tests, total crea-
tine kinase, serum myoglobin, arterial blood gases,
and chest radiography.4,14-15,18,28 This second set of tests
can be ordered judiciously on a case-by-case basis,
taking into account severity of the envenomation and
co-morbid disease. Grading severity of envenoma-
tions will be discussed in detail in the next section.
Compartment pressures: The other diagnostic test
that can be performed in selected cases is the meas-
urement of compartment pressures. Most enveno-
mations involve only subcutaneous deposition of
venom. In the rare intramuscular envenomation,
compartment syndrome may develop but it is often
impossible to distinguish the symptoms of compart-
ment syndrome (classically the 5 “P’s:” pain out
of proportion, pallor, parasthesia, paralysis, and
pulselessness) from the symptoms of a significant
envenomation. Formerly, fasciotomy was the recom-
mended treatment for snakebites with suspected
compartment syndrome, but current review suggests
a more conservative treatment plan involving serial
Stryker measurement for compartment pressures.
Treatment
General Principles
The treatment of patients with snake envenomations
entails aggressive supportive care and early adminis-
tration of adequate doses of antivenom when indi-
cated.4 Airway, breathing, and circulation are of pri-
mary importance. Establish peripheral intravenous
access in an unaffected extremity. Hypotensive
patients should receive fluid boluses to replace third
space losses and may require blood transfusion if a
venom-induced coagulopathy has resulted in signifi-
cant hemorrhage. The transfusion of blood products
will only temporize coagulopathy and ongoing
blood losses until the venom is neutralized by
antivenom. To be clear...fresh frozen plasma does
not fix an envenomation induced coagulopathy.
Analgesics
Consider analgesics part of the standard therapy for
envenomations. Pain control will usually require
parenteral narcotics for the first 24 to 48 hours of
therapy in patients that are receiving antivenom.33
Skeletal muscle fasciculations can be treated with
parenteral benzodiazepines.
10 September 2006 • EBMedice.net
Wound Care
Even in the absence of a clinically significant enveno-
mation, snakebites are puncture wounds and there-
fore require local wound cleansing and tetanus pro-
phylaxis. Interestingly, there is good data to show
that snakebites have very low rates of infection.34-35
In spite of a broad spectrum of oral flora cultured
from the mouths of snakes, the venom is postulated
to have antibacterial properties.36 Based on these
studies, prophylactic antibiotics are not currently rec-
ommended for snakebites.33
Compartment Syndrome
In cases with documented pressures above 30mmHg,
give an additional four to six vials of antivenom
along with 1 to 2gm/kg of mannitol over 30 minutes;
limb elevation and re-evaluation of pressures after
one hour should occur prior to consideration of fas-
ciotomy.4,28,32 It is recommended that the appropriate
service that handles fasciotomy in your facility (gen-
erally, surgery or orthopedics) be consulted early in
the course of treatment despite the rarity of enveno-
mations that ultimately require this procedure.
Crotalidae Polyvalent Immune Fab (CroFab™)
CroFab™ was approved by the FDA in October of
2000. CroFab™ is a preparation of ovine Fab (mono-
valent) immunoglobulin fragments obtained from the
blood of healthy sheep flocks. These sheep are
immunized with one of the following North
American snake venoms: Crotalus atrox (Western
Diamondback rattlesnake), Crotalus adamanteus
(Eastern Diamondback rattlesnake), Crotalus scutula-
tus (Mojave rattlesnake), and Agkistrodon piscivorus
(Cottonmouth or Water Moccasin).37 Note that cop-
perhead venom is not included in the immunizations.
According to the CroFab™ package insert,
patients with allergies to papain, chymopapain, other
papaya extracts, or the pineapple enzyme bromelain
may be at risk for an allergic reaction to CroFab™. In
addition, it has been noted in the literature that some
dust mite allergens and some latex allergens share
antigenic structures with papain and patients with
these allergies may be allergic to papain.38-39
Indications: Initiating treatment of an envenomation
with CroFab™ is largely based on physical findings,
their severity, and development over time.
Classically, envenomation severity has been deter-
mined based on symptoms and quantified using one
of a few accepted grading scales. These scales typi-
EBMedicine.net • September 2006
cally break envenomations into four or five cate-
gories, ranging from “dry bite” or nonenvenomation
to severe/very severe. Table 3 on page 8 is a synthe-
sis of several scoring systems from different authors
and can be used to grade the envenomations of all
pit viper or suspected pit viper envenomations3.
Envenomations are graded based on the symptom or
sign that places the patient in the highest (most
severe) category.4 Treat moderate and severe/very
severe envenomations (Grades II-IV) with antiven-
om. We have combined the Grade III and IV cate-
gories for simplicity since the treatment remains the
same and the signs and symptoms differ only in
matter of degree.
CroFab™ was FDA approved in 2000 for the
treatment of all “mild to moderate North American
Crotalidae envenomations;” however, all of the
research upon which this approval was based was
done with rattlesnake envenomations.37,40
Copperheads, while a member of the Crotalidae sub-
family of vipers, are a separate species from the rat-
tlesnakes and copperhead venom is not used in the
preparation of CroFab™. As recently as 2004,
authors have recommended against the administra-
tion of CroFab™ for copperhead bites because the
venom effects were not “serious enough” and the
risks of antivenom outweighed the benefits.40 One
retrospective review of copperhead bites by a group
at Carolinas Medical Center showed that CroFab™
administration resulted in an improvement in local
symptoms.41 Unfortunately, this was a small study
involving only 32 patients. The selection criteria for
treating with antivenom were not standardized and
the “treatment group” represented only 8% of the
copperhead envenomations that presented to
Carolinas Medical Center during the review period.
A larger, multicenter, randomized controlled study of
CroFab™ in the treatment of copperhead bites is cer-
tainly warranted and needs to include comparisons
not only of local symptoms, but also of short- and
long-term disability and adverse events associated
with treatment versus non-treatment.
After the severity of the envenomation has been
determined, patients with an indication to receive
CroFab™ should have the drug administered as soon
as possible. Early (< 6 hrs) administration of
CroFab™ has been clinically shown to reduce clinical
decline and systemic coagulopathy. Reassess and
admit these patients to the ICU for monitoring and
the completion of the CroFab™ treatment.
When the possibility of an envenomation by a
11 Emergency Medicine Practice©
coral snake or Mojave rattlesnake exists, the scale
presented in Table 3 should not be used. The signs
and symptoms of such venom may be significantly
delayed and have their primary effects on the nerv-
ous system. In these cases, extend the observation
period to at least 12 hours from the time of the injury
to account for this delay.4-5,18 Confusing matters
somewhat, some authors recommend admission of
all suspected coral snake envenomations for close
monitoring.4 Presumably the authors are differentiat-
ing “observation” in the ED from “admission” mean-
ing 23 hours or more. Unfortunately, there is no
good clinical data upon which these recommenda-
tions are based.
Preparation and Administration: If possible, obtain
written, informed consent prior to the administration
of CroFab™, advising the patient primarily of the
risks of anaphylaxis, delayed serum sickness, and/or
death. In the initial clinical studies of CroFab™, the
rates of allergic reaction were low and skin testing
was not done. Skin testing done in the setting of the
older polyvalent antivenom administration (which
had a much higher anaphylaxis rate) has been shown
to have both high false-positive rates and false-nega-
tive rates, 33% and 10 to 36% respectively. As clini-
cal experience and comfort with CroFabTM have
increased, the need for skin testing prior to adminis-
tration has never been shown to be useful.
Additionally, skin testing delays the onset of defini-
tive treatment and the risk of true anaphylaxis with
CroFab™ is substantially lower than with the older
Antivenom Crotalid Polyvalent (ACP).42 Despite this
data, the treating physician should always be pre-
pared for an anaphylactic reaction to antivenom with
basic supplies such as epinephrine, diphenhy-
dramine, airway equipment, oxygen, and pressors.
CroFab™ is packaged as a shelf-stable
lyophilized powder in a vial. Reconstitute each vial
of CroFabTM with 10mL of Sterile Water for Injection
USP (diluent is not included). After being thorough-
ly mixed, further dilute each of the reconstituted
vials to be used in a given dose in a single 250mL
bag of 0.9% Sodium Chloride USP. Use this reconsti-
tuted and diluted product within four hours of mix-
ing. The reconstitution and dilution process is time
consuming; even in the most practiced hands, prepa-
ration of an initial dose of CroFab™ takes more than
30 minutes. Given this, our recommendation is that
the mixing of CroFab™ should begin as soon as the
patient demonstrates evidence of a significant enven-
omation. Occasionally, in select scenerios, when
patients are being transported for treament, the
Emergency Medicine Practice©
reconstitution of CroFab™ can begin prior to patient
arrival. Nonetheless, the eagerness to begin the
process of mixing needs to be tempered by the possi-
bility of not needing to use a treatment which has an
average cost of nearly $1000 per vial.
The recommended initial dose of CroFab™ is
four to six vials. Dosage requirements are dependent
upon the individual patient response. The use of the
recommended adult dosages in the pediatric popula-
tion appears to be safe.43-44 The initial dose should
not be reduced in a pediatric patient because, despite
their smaller size, the volume of venom to be neu-
tralized is not reduced. Anecdotal experience with
the older ACP venom indicates that antivenom
requirements may, in fact, be higher in pediatrics; but
no clear clinical correlation between age, size,
weight, or snake species and antivenom requirement
has ever been demonstrated with either antivenom
preparation. However, the fluid status of the pedi-
atric patient should be taken into account when
deciding on the initial dilution of the dosage to be
given. Most children can handle the 250cc volumes
without difficulty as this correlates to a 20cc/kg
bolus for a 12.5kg child, but fluid status may become
an issue in children less that 10kg.44 Unfortunately,
there are no controlled studies to provide guidance
on the delivery of higher concentrations.
Deliver the initial dose at a rate of 25 to 50mL/hr
for the first ten minutes. If no acute allergic reaction
is noted after this initial time; deliver the remainder
of the first four to six vial dose at the full rate of
250mL/hr. If a reaction occurs, administer both H1-
and H2-receptor blockers. If the symptoms resolve
and the reaction was mild, the infusion can be con-
tinued with close monitoring. In a retrospective
review of CroFab™ safety by Dart and McNally, the
two patients with severe reactions (cough and wide-
spread urticaria +/- wheezing) had infusions dis-
continued, diphenhydramine and an H2-receptor
blocker given, and then infusions restarted. In one
patient the reaction recurred and no further antiven-
om was given. In the other patient, the infusion was
restarted and completed without incident with the
precaution of an epinephrine infusion which is only
described as being administered “in standard
doses”45-46 or as a “low dose infusion” which was
stopped 30 minutes after the completion of the infu-
sion of CroFab™.47
After the initial dose of four to six vials, “initial
control” is achieved when an adequate clinical
response has occurred, i.e. no further progression of
12 September 2006 • EBMedice.net
any local symptoms, systemic symptoms, or coagu-
lopathy. Observe the patient while administering
two additional vials every six hours for three addi-
tional doses. If, after completion of the initial dose,
the patient’s symptoms continue to progress (wors-
ening of the local injury or systemic effects such as
muscle fasciculation, parasthesias, abnormal mental
status, tachypnea, tachycardia, or hypotension), an
additional four to six vials is recommended. This
additional dose is also warranted if laboratory stud-
ies show prolonged coagulation times, decreasing
fibrinogen levels, or worsening platelet count. If a
second four to six vial dose is given, the patient
needs to be reassessed for “initial control” and a
third round of four to six vials may be needed in the
most severe cases. Multiple studies of CroFab™
indicate that the dose required for initial control can
range from 4 to 18 vials. If three rounds of four to
six vials fail to achieve control of an envenomation,
consider an alternative diagnosis, such as another
type of envenomation, a toxic overdose, or an exotic
species.
The elimination half-life for CroFab™ is estimat-
ed to range from 12 to 23 hours.37 Further study has
shown that Fab molecules have a shorter half-life
than the IgG used in traditional polyvalent antiven-
om.45 Early studies of CroFab™ reported cases of
recurrence of signs and symptoms of the original
envenomation after intital control. This may be due
to a Fab half-life that is shorter than the elimination
half-life of snake venom, thus the administration of
CroFab™ includes three additional doses to prevent
symptom recurrence. Once initial control is
obtained, admit the patient to the ICU and give two
vials of CroFab™ at 6, 12, and 18 hours after the
completion of the control doses.
Monitoring: After stabilization and initial control of
the patient’s symptoms have been achieved, and the
administration of the scheduled doses has begun,
continue close surveillance of the patient’s condition.
Observation includes monitoring of limb circumfer-
ence, both above and below the bite, and using a pen
to outline the edematous area every 30 to 60 minutes.
Obtain laboratory determinations of the patient’s
coagulation status every four hours.28 If symptoms
or laboratory data warrants, the treating physician
can give an additional two vials. Any unscheduled
re-dosing after initial control does not reset the 6, 12,
18 hour schedule to the beginning.
When compared to polyvalent antivenom, the
EBMedicine.net • September 2006
incidence and severity of reactions to CroFab™
appears to be significantly reduced. In the initial
clinical studies discussed above, seven of the first 42
patients treated had an early, though relatively
minor, reaction (five urticaria, one cough, one
urticaria/dyspnea and wheezing). However, it is
important to note that there have been case reports
of serious reactions and serum sickness related to
CroFab™.46-47
Disposition
Patients who have no findings of envenomation (dry
bites/Grade 0) can be discharged after a four to six
hour observation period.18 Patients who have limited
local signs of envenomations but do not meet the cri-
teria for CroFab™ need to be monitored for progres-
sion of symptoms in the ED or observation unit for
a minimum of 8 to 12 hours from the time of the
bite4-5,18,28 Although most patients with Crotalidae
envenomations begin to manifest local symptoms
within 10 minutes of a bite and virtually all have
some findings within 30 to 60 minutes, there are some
patients who will not manifest symptoms for several
hours, although the mechanism for this is unclear.4 In
those cases where the patient does not initially meet
treatment criteria, observation and intermittent
reassessment is critical since local findings or symp-
toms that would upgrade the envenomation into a
treatment category may be absent initially.
Patients who receive CroFab™ are admitted to
the hospital as discussed in the previous section. The
half-life of CroFab™ is less than that of polyvalent
antivenom. This fact, coupled with the persistent
activity of the depot-style delivery of the venom, can
lead to recurrent coagulopathy despite appropriate
antivenom treatment.68 Such recurrence is character-
ized by decreased platelets, elevated prothrombin
time, and decreased fibrinogen. During the initial
trials, such a recurrent coagulopathy was observed
only in those patients experiencing coagulation
abnormalities at initial presentation. After initial
treatment, this coagulopathy may be present for
weeks. Therefore, post treatment, monitor those
patients presenting with coagulopathy for signs and
symptoms of recurrent coagulopathy after discharge
every two to three days until the coagulopathy
resolves48-49 Advise patients to contact their physician
immediately if they experience new symptoms or
unusual bruising or bleeding after hospital discharge
as additional antivenom treatment may be needed.
13 Emergency Medicine Practice©
Emergency Medicine Practice© 14 September 2006 • EBMedice.net
EBMedicine.net • September 2006 15 Emergency Medicine Practice©
Emergency Medicine Practice© 16 September 2006 • EBMedice.net
Boyer et al recommend retreatment with two vials
of CroFab™ in the event of fibrinogen level
< 50mcg/mL, platelet count < 25,000, INR > 3.0,
aPTT > 50 seconds, multicomponent coagulopathy,
worsening trend in patients with prior severe coagu-
lopathy, high risk behavior for trauma, or comorbidi-
ties that increase the risk of hemorrhage.49
Instruct patients to report any signs or symp-
toms of delayed allergic reactions or serum sickness
after hospital discharge. Serum sickness is a delayed
hypersensitivity reaction to antivenom characterized
by fever, rash, arthralgias, and lymphadenopathy
which typically begin 7 to 21 days following antiven-
om administration. It is much more rare with
CroFab™ than with the older polyvalent antivenom
(3% versus more than 80%) and responds well to a
tapering course of prednisone starting at 60mg daily
and tapering over seven to ten days.4,33,45 Serum sick-
ness is the only indication from steroids in the treat-
ment of snake envenomation.
Controversies
Alternative Treatment
Several studies have addressed specific techniques
used in the care of snake envenomations and have
shown that many of the devices and techniques tra-
ditionally used in care of snake envenomations were
either of no benefit or were, in fact, harmful.
Incisions, suction devices, packing in ice (cryothera-
py), application of heat, and even application of elec-
trical shocks have all historically been used to treat
snake envenomations. While the application of a
stun-gun or “gasoline engine spark plugs” to a
patient may be intriguing, there is no clinical benefit,
and a handful of case studies show the danger of this
therapy, even in controlled settings.50 As discussed
in detail above, little role remains for any field treat-
ment beyond immobilization, reassurance, and rapid
transport.
Fasciotomy
Once considered part of the primary treatment of
snake envenomations, fasciotomy is the other contro-
versial issue that has yet to be addressed in this dis-
cussion. Good clinical data from animal studies
have shown that in snake envenomations, rabbits
that receive fasciotomy (with or without antivenom)
have poorer outcomes than those treated with
antivenom alone.51-52 The signs and symptoms of a
significant envenomation closely mimic the symp-
EBMedicine.net • September 2006
toms of compartment syndrome and it is clinically
impossible to establish the difference without direct
measurement of compartment pressures.53 Even in
the cases where compartment pressures exceed 30 to
40mm Hg, additional antivenom administration
(four to six vials) has been shown to reduce compart-
ment pressures, avoiding an unnecessary and disfig-
uring fasciotomy. Fasciotomy should only be consid-
ered in the extraordinarily rare cases where addition-
al antivenom doses have failed to reduce measured
pressures.
In the authors’ opinion, given the ”assess, treat,
reassess, treat” management strategy, and the sched-
uled dosing nature of current management, a medical
ICU service may be more appropriate than a surgical
service. Clearly, in the rare case of true elevated com-
partment pressures, a consultation to orthopedics or
surgery is warranted. That said, snake envenoma-
tions present such a complex interaction of multisys-
tem toxicologic effects that the determination of the
best admission service should be handled on a case-
by-case and hospital-by-hospital basis.
Section 2. Coral Snakes (Elapidae), Exotic
Snakes, And Scorpions
Prehospital Care
As with Crotalid envenomations, there are no specif-
ic prehospital interventions for scorpion or non-
Crotalid snake envenomations, other than removal
from danger, and rapid, safe transport. Immobiliza-
tion of the affected limb may be helpful.
An interesting experiment testing a novel immo-
bilization technique in a porcine model of a coral
snake envenomation has been published.8 The pres-
sure-immobilization technique is not a tourniquet,
but uses an elastic bandage applied from the enveno-
mation site and extended proximally. The goal is to
impede lymphatic flow, not venous or arterial flow.
Apply the bandage about as tight as a wrap for an
acute sprain, yet loose enough to allow a finger to be
inserted between skin and bandage without difficul-
ty. Also, splint the limb to limit motion. Elapid
snakebites in other countries, primarily Australia, are
treated with a similar pressure immobilization tech-
nique.54-55 Because of the low quality evidence, this
technique must be considered experimental, even
though it has been included in a clinical guideline
for the snakebite section of an emergency care guide-
17 Emergency Medicine Practice©
line, the 2005 International Consensus Conference on
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science with Treatment
Recommendations.11
Emergency Department Evaluation
Coral Snakes
Coral snakebites produce little, if any, pain and local
reaction. Assessment of signs of neuropathy must be
aggressively sought, as progression to bulbar paraly-
sis and respiratory failure may be rapid. The onset
of neurological symptoms may be delayed one to
four hours, but once neurological signs appear, pro-
gression to paralysis and respiratory failure may
Table 5: Useful Websites For Snake
Identification And Bite Management
Black and white photographs of snakes do very little to help in the identification of snakes and thus, are not reproduced in this article.
Fortunately, the internet has proven to be extremely useful for snake identification with many sites that provide a variety of full color
pictures and tools to help identify venomous snakes and differentiate them from their non-venomous counterparts. Using a search
engine and the topic "snake" or "snake identification" will result in websites that discuss the snakes that are indigenous to your region
and will aid in identification. This table lists some of the useful websites for snake identification and bite management.
• http://mdg.ext.msstate.edu/Tom_Snake/
index.html: One of the most user friendly sites
as it has been designed for identification of
snakes by the non-herpetologist. Snakes are
identified by name or features. It is based at
Mississippi State University and will identify the
snakes of the Southeast and the majority of the
snakes nationwide.
• www.snakesandfrogs.com: This site provides
excellent descriptions (with photos) of the
various characteristics that identify snakes.
Follow the links to "How to Identify Snakes."
It is a South Carolina based site that will work
for most snakes indigenous to the US East and
Southeast. It is an excellent site if you have
the specimen in front of you but tougher to navi-
gate if you are working solely from a patient’s
description.
• http://www.pitt.edu/~mcs2/herp/SoNA.html:
This site’s common name is "Snakes of North
America" and it can be found easily by searching
"snake identification" on Google. It is a compre-
hensive list of every snake native to North
America with a picture. Each snake only has
one photo and requires that you choose the
species in order to see the photo. This can
prove to be a challenging way to identify an
Emergency Medicine Practice©
occur over a few minutes. Tremors, ptosis, dyspho-
nia, dysphagia, and decreased deep tendon reflexes
are the most common neurologic signs and may indi-
cate impending respiratory paralysis.7
Non-native Venomous Snakes
Depending on the species, envenomations may pro-
duce mostly neurotoxic effects, especially from the
other Elapids, e.g. cobras, kraits, and mambas.
Cytotoxic and coagulopathic effects may predomi-
nate from bites of other snakes, especially the
Viperidae (both pit and true vipers). Once identifica-
tion is made, a poison center consultation and/or
accessing one of the available web resources will
help guide clinical decision making; see Table 5.
unknown snake, but if you have a good idea
of what you are looking for, this is an excellent
site for quick confirmation.
• http://trailquest.net/SNpoi.html: Avid hikers will
recognize this site as an excellent resource for all
things related to hiking. It also happens to con-
tain a complete list of "poisonous" and "nonpoiso-
nous" snakes that may be encountered while hik-
ing throughout the continental United States.
Like the previous site, it requires that you choose
a species to see a photo, but it does have better
descriptions of habitat and distributions of species
by state/region.
• www.aza.org: The American Zoo and Aquarium
Association (AZA) can be particularly helpful
when exotics are involved in an envenomation.
The AZA maintains the Antivenom Index, a list of
the types and locations of all species-specific
antivenoms for any of the venomous exotics
housed in US zoos and larger private collections.
The Antivenom Index is a members-only list, but
national and regional Poison Control Centers
maintain active memberships and can access the
information needed to provide patient care
(American Association of Poison Control Centers,
www.aapcc.org, 800-222-1222).
18 September 2006 • EBMedice.net
Scorpions
Children are at the greatest risk of severe effects
because of low body weight to venom ratios. Elderly
people may also have lower reserves against the
physiologic insult of the toxins. Evaluation of local,
systemic, and neurological effects is essential.
Deaths occur from cardiopulmonary collapse or res-
piratory paralysis. Identification of impaired tissue
perfusion, tachycardia, tachypnea, hypoxemia,
hypotension, agitation, altered mental status, and/or
cranial and somatic neuromuscular dysfunction are a
prompt for aggressive treatment. A retrospective
study of 428 patients admitted to the intensive care
unit in Tunisia for scorpion envenomations found
that respiratory rate > 30 breaths per minute, agita-
tion, and sweating were predictors of pulmonary
edema.56
Diagnostic Studies
Coral Snakes
There is no adequate evidence to support the use of
any specific laboratory or imaging tests in cases of
coral snake envenomations. Since there are generally
few cytotoxic effects, there is probably no need for
testing. However, if the patient requires endotra-
cheal intubation and mechanical ventilation for res-
piratory failure, a chest x-ray to assess tube position
and arterial or venous blood gases to assess ventila-
tion status are indicated.
Key Points
1. Venomous snakes (domestic and imported) and
scorpions can produce devastating injuries and
must be recognized promptly and treated appro-
priately to prevent morbidity and death.
2. Identification of the snake that inflicted the bite is
important but not essential for appropriate man-
agement
3. Crotalid envenomations are graded based on the
most severe sign or symptom, and CroFab™
should be administered for all moderate and
severe envenomations.
4. Once a coral snake bite is confirmed, antivenom
should be given immediately, even if no symp-
toms are present.
EBMedicine.net • September 2006
Non-native Venomous Snakes
Again, guidance on testing will depend on the iden-
tification of the snake. Bites from other members of
the family Elapidae will likely require no testing.
Patients with bites from other Viperidae snakes will
probably require testing similar to that recommend-
ed previously for Crotalid envenomations, e.g. com-
plete blood count, comprehensive metabolic panel,
prothrombin time, partial thromboplastin time, fib-
rinogen level, blood type and antibody screening.
Compartment pressure measurement is indicated if
compartment syndrome is suspected.
Scorpions
A complete blood count and plasma protein concen-
tration may help predict the presence of pulmonary
edema, as will a chest x-ray. Cardiac enzymes may
demonstrate cardiac damage. Liver enzymes may
show liver damage which was correlated with poor
prognosis in a study of 951 patients admitted to a
Tunisian ICU.57 Echocardiography may be necessary
to evaluate cardiogenic shock or suspected cardiac
dysfunction.
Treatment
Prompt administration of specific antivenom, when
available and indicated, and supportive care of air-
way, breathing, circulation, and neurologic function
are the foundation of ED care for these envonoma-
tions and stings. Tetanus prophylaxis should be
5. Zoos maintain a stock of antivenoms for many
exotic, venomous snakes and may be a source for
treating envenomations from those snakes.
6. Your local poison control center has access to mul-
tiple sources for identifying venomous snakes
and obtaining specific antivenom. Call them.
7. Children and elderly are at the highest risk of
severe morbidity and death from scorpion stings
and require close observation.
8. Equipment and medications for management of
anaphylaxis should be in place during the admin-
istration of any antivenom.
19 Emergency Medicine Practice©
offered if there is no clear history of tetanus immu-
nization within five years and encouraged if it has
been more than ten years. Critical care services
including mechanical ventilation, pressor and
inotrope administration, intravenous hydration
and nutrition, and prolonged sedation are sometimes
required in severe envenomations. No credible evi-
dence supports the use of prophylactic antibiotics or
steroids in scorpion, coral snake, or non-native ven-
omous snake envenomations. Consideration of spe-
cial needs for individual cases is discussed later in
this article.
Adverse effects of antivenom administration,
often anaphylaxis, occur in the majority of patients
who receive antivenom derived from animal serum.
Universal preparation to treat these reactions is
required for all patients receiving antivenom. Two
prospective case series, one from Australia and one
from South Africa, found over a 70% occurrence of
immediate hypersensitivity reactions, with about
half of these anaphylaxis, after administration of
(non-Fab derived) snake antivenom.58-59 In a study of
181 patients who received Antivenom Crotalid
Emergency Medicine Practice©
Polyvalent (ACP), 56% experienced a rash 3 to 21
days after antivenom with several experiencing sub-
jective fever, itching, and arthralgias as well. These
findings appeared dose related with nearly all
patients receiving 30 or more vials of antivenom
experiencing a rash. Serum sickness, discussed previ-
ously, is much more common with the horse serum
derived antivenoms used for coral snake, exotic
snake, and scorpion envenomations than with
CroFab™.4 In a prospective observation study of
116 patients receiving scorpion (Centruroides)
antivenom for severe envenomations, four patients
had immediate reactions: Three cases of rash and one
case of anaphylaxis. Follow-up of the 99 patients was
conducted at one year; 61% experienced delayed
hypersensitivity reaction and serum sickness, which
responded to steroids and antihistamines.60
A prednisone taper, beginning at 60mg per day
over seven to ten days, along with oral antihista-
mines, is the most common treatments for serum
sickness.61 One randomized, controlled trial and a
systematic review of that trial concluded that the
administration of 0.25mg of 1:1000 epinephrine sub-
20 September 2006 • EBMedice.net
cutaneously in the forearm immediately before
antivenom infusion is started markedly reduced the
incidence of immediate hypersensitivity reactions;
absolute risk reduction 30%, number-needed-to-treat
was 3.3, with no significant adverse effects attributa-
ble to epinephrine.62-63
Coral Snakes
Place coral snake specific antivenom at the bedside
of all patients with a suspected coral snake bite.
Observe and treat at the first sign of envenomation,
however minor. The antivenom is derived from
horse serum and may result in an immediate or
delayed hypersensitivity reaction. The incidence data
for adverse reactions is not available.
Non-native Venomous Snakes
Early and sufficient antivenom administration is the
key to treatment of non-native venomous snakebites.
Again, positive identification of the snake is essential
so that specific antivenom can be obtained. Local
zoos are required to store antivenom, when avail-
able, for every venomous species in their collection.
Call your local zoo for availability of antivenom or
call the American Zoo and Aquarium Association
(301-562-0777) for access to their antivenom index.
Collectors of venomous snakes are not bound by
these same regulations, so a search for antivenom
must be conducted, after identification of the snake,
through local poison control centers or the American
Association of Poison Control Centers (800-222-1222).
Scorpions
Supportive care is the cornerstone of treatment.
Scorpion antivenom for Centruroides sculpturatus (aka
exilicauda), the only scorpion species in the US dan-
gerous to humans, was previously available only in
Arizona, but production stopped in 2001. Stocks
became outdated in 2004, and are not FDA approved
for the treatment of scorpion envenomations. In
addition, there are contradictory findings from
studies of the effectiveness of antivenom in treating
scorpion stings. Complicating this, is the fact that
most studies have been done on non-North
American scorpion envenomations. For example,
one randomized, placebo-controlled trial in Tunisia
and a systematic review including the randomized
trial and three cohort studies concluded that there
was no benefit to administering antivenom.9-10 More
relevant to US practice, but weaker evidence, a case
series and a natural before-after analysis of cohorts
EBMedicine.net • September 2006
before and after depletion of stocks of antivenom,
suggest that use of antivenom in children may pre-
vent some hospital and intensive-care unit admis-
sions.64-65
Controversies/Cutting Edge
A provocative pilot study was conducted in children
admitted to the hospital for a scorpion envenoma-
tion, using a before-after, quasi-experimental analysis
of an intervention using prazosin, an alpha-receptor
blocker. Unfortunately, this study was done in
Tunisia, involving severe envenomations by North
African scorpions and a control therapy using
insulin and dextrose which is not standard in the US.
Prazosin dosing was 30 micrograms/kg/dose orally
at the time of presentation and repeated three hours
after the first dose and every six hours thereafter as
needed to alleviate signs of autonomic instability.
Before beginning the prazosin intervention “stan-
dard therapy” was to use an insulin and dextrose
mixture, intravenous fluids, and treatment of associ-
ated complications. Standard therapy was given in
addition to prazosin. With 20 patients in the “before
cohort” and 16 patients in the “after cohort,” the
authors reported that the prazosin group experi-
enced fewer episodes of hypoglycemia and hyper-
kalemia; although, it is unclear if this is an effect of
the scorpion venom or a side effect of the
insulin/dextrose therapy. Only one of 16 patients in
the prazosin group died, compared to seven of 20 in
the control group. Hospital length-of-stay was
reduced in the prazosin group from a mean of 71.5
hours to 46.3 hours.66 With the unavailability of scor-
pion antivenom in Arizona, there is a pressing need
for a well designed, randomized, controlled trial of
prazosin in the treatment of scorpion envenomations
with systemic signs.
A randomized clinical trial of scorpion antiven-
om is currently being conducted. A two-year clinical
trial of 50 patients, supported by a FDA grant to the
University of Arizona, to study the effect of a new
scorpion FAB fragment antivenom has been complet-
ed but was only reported in a Tuscon, Arizona news-
paper.67 The drug, Anascorp™, is made in Mexico
and not yet approved for use by the FDA. The clini-
cal trial overseen by researchers at the University of
Arizona and the Arizona Poison Center in Tucson
reported that the drug used in > 100 Arizona chil-
dren demonstrated benefit.
21 Emergency Medicine Practice©
Disposition
Coral Snake
Any time a patient with a coral snake envenomation
exhibits severe systemic or neurological signs, admit
the patient to the intensive care unit. If the patient
does not exhibit any systemic symptoms or signs at
the end of a 12 hour ED observation period, the
patient may be discharged home.4
If the patient has systemic signs after four hours
and is requiring any supportive care, admit the
patient for at least a 24 hour observation period. At
the end of the observation period, patients no longer
requiring supportive care may be discharged.
Patients with continuing systemic signs and support-
ive needs should continue to receive antivenom and
be managed in an ICU setting.
Non-native Venomous Snakes
Because of the wide variety of snakes and venom
effects, no firm disposition criteria can be deter-
mined. Consult a poison control center to assist in
medical management decisions.68
Scorpions
Any time a patient with a scorpion envenomation
exhibits severe systemic signs, admit the patient to
the intensive care unit. If the patient does not exhibit
any systemic symptoms or signs at the end of a four
hour ED observation period, the patient may be dis-
charged home with no specific discharge instruc-
tions. If the patient has systemic signs or requires
supportive care, admit for at least a 12 to 24 hour
observation period. At the end of the observation
period, patients no longer requiring supportive care
may be discharged.
Conclusion
There are approximately 8000 venomous snakebites
in the US each year. The vast majoity of these bites
are from rattlesnakes, copperheads and water
mocosins. Management is based on early recogni-
tion, envenomation assessment, and administration
of the appropriate antivenom. Current concepts in
care have relenquished incision and suction tech-
niques to history books and have promoted antiven-
om that is immunotherapy based.
The three cases presented at the beginning of this
article illustrate scenarios that may confront any
emergency medicine physician. The case outcomes
show the benefit of proper clinical management.
Emergency Medicine Practice©
Case #1: This case represents a very severe enveno-
mation (Grade III/IV). This patient needed 12 vials of
CroFab™ to achieve initial control and resolve the coagu-
lopathy. He was admitted to the medical ICU and moni-
tored for several days. His pain was controlled with nar-
cotics and benzodiazepines; he ultimately did well and was
discharged home. He did not get a new pair of boots.
Case #2: This patient required eight hours of observa-
tion. The bite was a “Grade 0” at presentation and he
remained asymptomatic for the eight hour stay. The
patient was discharged home after wound cleansing and
administration of tetanus prophylaxis.
Case 3: In this case, the patient was experiencing
neurotoxic effects of a coral snake envenomation and was
at a high risk for respiratory failure. Three vials of North
American coral snake antivenom were given, with addi-
tional doses made available at the bedside. Aggressive
supportive care, including endotracheal intubation and
mechanical ventilation were required. The patient made an
uneventful recovery. He decided to hire someone the next
time the brush needed clearing.
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1005. (Retrospective chart review; 951 patients)
58. Moran NF, Newman WJ, Theakston RD, et al. High
incidence of early anaphylactoid reaction to SAIMR
polyvalent snake antivenom. Trans R Soc Trop Med
Hyg. 1998;92(1):69-70. (Prospective case series; 17
patients)
59. Isbister GK, Tankel AS, White J, et al. Med J Aus.
2006;184(8):419-20. (Prospective case series; 14
patients)
60. LoVecchio F, Welch S, Klemens J, et al. Incidence of
immediate and delayed hypersensitivity to
Centruroides antivenom. Ann Emerg Med
1999;34(5):615-619. (Prospective, cohort;116 patients)
61. Lo Vecchio F, Klemens J, Roundy EB, et al. Serum sick-
ness following administration of Antivenin
(Crotalidae) Polyvalent in 181 cases of presumed rat-
tlesnake envenomation. Wilderness Environ Med
2003;14(4)220-221. (Retrospective;181 patients)
62. Premawardhena AP, deSilva CE, Fonseka MMD, et al.
Low dose subcutaneous adrenaline to prevent acute
adverse reactions to antivenom serum in people bitten
by snakes: randomized, placebo controlled trial. BMJ
1999;318:1041-1043. (Prospective, randomized, con-
trolled;105 patients)
63. Nuchpraryoon I, Garner P. Interventions for prevent-
ing reactions to snake antivenom. Cochrane Database
Syst Rev 2000;(2):CD002153. (Systematic review)
64. LoVecchio F, McBride C. Scorpion envenomations in
young children in central Arizona. J Toxicol Clin
Toxicol 2003;41(7):937-40. (Prospective case series; 483
patients)
65. Riley BD, LoVecchio F, Pizon AF. Lack of Scorpion
Antivenom Leads to Increased Pediatric ICU
Admissions. Ann Emerg Med 2006;47(4):398-399.
(Before-after cohort; about 35,000 patients)
66. Gupta V. Prazosin: a pharmacological antidote for
scorpion envenomation. J Trop Pediatr 2006;52(2):150-
151. (Prospective, before-after, quasi-experimental;36
24 September 2006 • EBMedice.net
 patients) d. Grade III/IV (severe/very severe envenoma-
67. McClain C. 2-year scorpion-antivenin trials successful; tion)
FDA scrutiny next. Accessed 6 July 2006 at
36. If the patient in question three developed no
http://www.azstarnet.com/allheadlines/124591.
(Unpublished, prospective, randomized, controlled;
further symptoms, what is the correct manage-
50 patients) ment plan?
68. Hughes A. Observation of snakebite victims: is twelve
hours still necessary? Emerg Med (Freemantle) a. Mix CroFabTM and administer four vials
2003;15(5-6):511-517. (Two phase case series; 360 according to the treatment algorithm and
patients) then discharge home.
69. Norris R. “Snake Venom Poisoning In The United
b. Mix CroFabTM and administer four vials
States: A Medical Emergency!” Accessed 11 September
according to the treatment algorithm and
2006 at http://www.emed.stanford.education/didac-
tics/snakebites.htm. then admit for the completion of the
70. Gibly R, Williams M, Walter FG et al. Continuous CroFabTM treatment regimen.
intravenous midazolam infusion for Centruroides exili- c. Observe for four hours and discharge if
cauda scorpion envenomation. Ann Emerg Med unchanged.
1999;34(5): 669-670. d. Observe for eight hours and discharge if
unchanged.
CME Questions
37. If the patient in question three developed sig-
33. Which of the following anatomic regions is the
nificant altered mental status, but no other
location for more than 95% of snake enveno-
changes in his presentation, what grade should
mations?
be assigned to his envenomation?
a. Back
a. Grade 0 (nonenvenomation)
b. Extremities
b. Grade I (mild envenomation)
c. Head
c. Grade II (moderate envenomation)
d. Torso
d. Grade III/IV (severe/very severe envenoma-
tion)
34. Which of the following is a true statement?

38. An 8-year-old, 35kg female presents to the

a. 25% of venomous snakebites in the US are
emergency department one hour after an iden-
fatal.
tified cottonmouth/water moccasin bite to the
b. 98% of venomous snakebites in the US are
leg while swimming in a local pond. She has
from Crotalids.
marked pain, severe edema and erythema to
c. Imported snakes account for the majority of
her entire leg, and has an elevated INR and
fatal snakebites in the US.
aPTT. Appropriate management should
d. Up to 20% of the venomous snakebites in the
include which of the following?
US can be attributed to coral snakes.

a. Three vials of CroFabTM, adjusted for weight,

35. A 25-year-old male presents to the ED 60 min-
mixed in 250cc NS, and given according to
utes after a brown snake bit his hand. He says
the treatment protocol.
the snake had a triangular head and a rattle on
b. Six vials of CroFabTM, with no weight adjust-
its tail. Currently, the patient has local
ment, mixed in 250cc NS and given accord-
swelling around 2 fang marks, some mild pain
ing to the treatment protocol.
in his hand, and minimal local swelling. His
c. Pretreatment with epinephrine 0.25mg IM
vitals and labs are normal. What Grade is this
prior to CroFabTM administration.
envenomation?
d. Skin testing to determine sensitivity to
CroFabTM.
a. Grade 0 (nonenvenomation)
b. Grade I (mild envenomation)
39. All of the following patients have received a
c. Grade II (moderate envenomation)

EBMedicine.net • September 2006 25 Emergency Medicine Practice©

 dose of four to six vials of CroFabTM. Which of
the following has achieved “initial control”?
a. Swelling and redness have improved accord-
ing to the pen marks, and repeat labs show
an increase in INR from 2.5 to 3.0.
b. Swelling and redness have progressed
beyond the pen marks and the repeat labs
have returned to baseline normal levels.
c. Swelling and redness have remained the
same according to the pen marks and the
repeat labs are improved.
d. Swelling and redness have remained the
same according to the pen marks, the repeat
labs are improved, and the patient has devel-
oped confusion.
40. The patient has received six vials of CroFabTM
and has achieved initial control of the enveno-
mation. Three hours after his first two vial fol-
low-up dose of CroFabTM, his altered mental
status returns. What is the best course of
action at this point?
a. Administer two vials of CroFabTM and con-
tinue with his scheduled dosing regimen
according to the original times.
b. Administer two vials of CroFabTM and reset
the follow vial timing for additional doses at
6, 12, and 18 hours following the newest
dose.
c. Administer four to six vials of CroFabTM and
reassess in one hour.
d. Wait until the next six hour incremental dose
is due and administer two vials.
41. A patient who has received one dose of four
vials of CroFabTM following a severe (Grade III)
envenomation of the hand has developed
increased pain, pallor, and numbness of his
hand. Palpation of his forearm reveals a
very tight compartment and he has pain out
of proportion. What is the best course of
action?
a. Continue CroFabTM treatment according to
timed protocol, elevate his arm, and reexam-
ine in one hour.
b. Immediate fasciotomy to relieve compart-
ment sydrome.
c. Measure compartment pressures and consult
Emergency Medicine Practice©
surgery for fasciotomy if greater than
40mmHg.
d. Measure compartment pressures and admin-
ister an additional four to six vials of
CroFabTM with mannitol and arm elevation if
pressures are greater than 40mmHg.
42. Which of the following is a true statement?
a. Mojave rattlesnake envenomations present in
a similar fashion to other Crotalid enveno-
mations and can be assessed using the grad-
ing scale in Table 1.
b. Coral snake venom is classically considered
to be primarily cardiotoxic.
c. Crotalid venom is a complex mixture of pro-
teins and other substances that affect the car-
diac, neurologic, hematologic, and muscu-
loskeletal systems.
d. Venom extraction devices are an effective
field treatment for envenomations and
should be applied by bystanders or EMS
providers that have them available in the
field.
43. An 18-month-old, 12kg female was stung on the
leg by a scorpion while playing on her porch in
Tuscon, Arizona. Over the past few minutes,
she has started getting agitated, sweating pro-
fusely, vomiting, and passing watery stools. On
arrival to the ED by EMS, the patient was alert,
agitated, diaphoretic, tachypneic at 48 breaths
per minute with oxygen saturation 94% by
pulse oximetry, and tachycardic at 160 beats per
minute. After starting an IV line, placing oxy-
gen by mask, and instituting continuous moni-
toring, your best initial course of action is to:
a. Administer three vials scorpion antivenom
intravenously immediately with a 20ml/kg
bolus of normal saline.
b. Give 0.12mg epinephrine 1:1000 intramuscu-
larly in the thigh and 12.5mg diphenhy-
dramine intravenously.
c. Give midazolam intravenously, draw labs,
and plan for pediatric intensive care unit
admission.
d. Give metoprolol 2.5mg intravenously every
five minutes for three doses to establish beta-
receptor blockade, but hold for heart rate
less than 60 beats per minute.
26 September 2006 • EBMedice.net
44. The patient is a 39-year-old man who was bitten
on the hand while clearing brush at his Florida
home by a red, yellow, and black snake,
thought to be a coral snake. Injury occurred 30
minutes before ED arrival and the patient has
no symptoms, no pain, no paresthesias, and no
neurological deficits. What is the best course
of action?
a. Observe for 12 hours and, if no symptoms,
discharge home.
b. Obtain CBC, CMP, PT/PTT and fibrinogen at
baseline and after four hours while monitor-
ing for symptoms.
c. Immediately give coral snake antivenom.
d. Perform neuro checks every hour and give
antivenom when and if symptoms appear.
45. The patient is a 26-year-old man who was clean-
ing up in the trailer of a circus snake handler
and decided to “mess” with the snakes. A
monocle cobra bit him at least twice and
maybe three times on the right hand and fore-
arm about two hours ago. He tried to conceal
his injury from his boss, but started to have
severe pain, muscle twitching, and difficulty
swallowing so admitted the injury and was
brought into the ED. The snake handler brings
ten vials of polyvalent cobra antivenom with
the patient. What is the best initial course of
action?
a. Call the poison control and the regional zoo
for guidance in managing this patient.
b. Give midazolam 4mg intravenously, draw
labs, and plan for ICU admission.
c. Give 0.25mg epinephrine subcutaneously to
prevent immediate hypersensitivity reaction
and three vials of cobra venom intravenous-
ly.
d. Obtain CBC, CMP, PT/PTT, and fibrinogen
at baseline and perform type and cross for
packed red blood cells and fresh frozen plas-
ma.
46. The patient is a 52-year-old woman who was
bitten by a coral snake two hours ago and
given three vials of coral snake antivenom
about ten minutes ago. She complains of an
intensely itchy, blotchy rash all over the body
and face and swelling of the lips. On exam,
EBMedicine.net • September 2006
the patient is anxious, tachypneic at 32 breaths
per minute, with faint wheezes bilaterally.
After establishing IV access, placing oxygen by
nasal cannula, and instituting continuous car-
diac monitoring, what is the best initial course
of action?
a. Give 0.3mg epinephrine 1:1000 intramuscu-
larly in the thigh and 50mg diphenhy-
dramine intravenously.
b. Give three more vials of coral snake antiven-
om intravenously for progression of symp-
toms.
c. Perform neuro checks every hour to assess
for progression of symptoms.
d. Perform rapid sequence intubation for
impending respiratory failure.
47. The patient is a 44-year-old man who received
polyvalent, horse serum-derived antivenom for
bites from a Gaboon viper while working at
the zoo two weeks ago. He presents to the ED
for evaluation of an itchy, red rash on trunk
and arms that has been increasing for the past
three days. What is the best treatment plan for
this patient?
a. Obtain additional Gaboon viper antivenom
to give additional treatment for unresolved
envenomation.
b. Give 0.3mg epinephrine 1:1000 intramuscu-
larly in the thigh and 50mg diphenhy-
dramine intravenously.
c. Obtain CBC, CMP, PT/PTT and fibrinogen at
baseline and after four hours while monitor-
ing for symptoms.
d. Give prednisone 60mg and diphenhy-
dramine 50mg PO in the ED and prescribe a
steroid taper for ten days and prn diphenhy-
dramine.
48. The patient is a 36-year-old collector of ven-
omous snakes who was bitten by one of his
black mamba (Dendroaspis polylepis) snakes
about one hour ago. He has no clear symptoms,
but says he feels funny and anxious. His vital
signs are stable and he is in no distress. He
reports that he has antivenom for almost all of
his snakes, but he has never been able to obtain
antivenom for this snake species. After estab-
lishing IV access, placing oxygen by nasal can-
27 Emergency Medicine Practice©
 nula, and instituting continuous cardiac moni- Committees of the American Heart emergency cardiac care. Emergency
Association and representatives Cardiac Care Committee and
toring, what is the best initial course of action? from the resuscitation councils of Subcommittees, American Heart
ILCOR: How to Develop Evidence- Association. Part IX. Ensuring effec-
Based Guidelines for Emergency tiveness of community-wide emer-
a. Call your local poison center or national poi- Cardiac Care: Quality of Evidence gency cardiac care. JAMA
and Classes of Recommendations; 1992;268(16):2289-2295.
son center hotline 800-222-1222 for help also: Anonymous. Guidelines for
cardiopulmonary resuscitation and
obtaining antivenom.
b. Give coral snake antivenom three vials intra-
venously to capitalize on cross-reactivity of
the species.
Physician CME Information
c. Give 0.3mg epinephrine 1:1000 intramuscu- Credit Designation: The Mount Sinai School of Medicine designates this
educational activity for a maximum of 48 AMA PRA Category 1
larly in the thigh and 50mg diphenhy- Credit(s)TM per year. Physicians should only claim credit commensurate
with the extent of their participation in the activity.
dramine intravenously.
Credit may be obtained by reading each issue and completing the printed
d. Obtain CBC, CMP, PT/PTT, and fibrinogen post-tests administered in December and June or online single-issue
post-tests administered at EBMedicine.net.
at baseline and after four hours while moni-
Target Audience: This enduring material is designed for emergency medi-
toring for symptoms. cine physicians.
Needs Assessment: The need for this educational activity was determined
by a survey of medical staff, including the editorial board of this publica-
tion; review of morbidity and mortality data from the CDC, AHA, NCHS,
and ACEP; and evaluation of prior activities for emergency physicians.
Date of Original Release: This issue of Emergency Medicine Practice was
Coming in Future Issues: published September 12, 2006. This activity is eligible for CME credit
through September 12, 2009. The latest review of this material was
Acutely Decompensated Heart Failure September 1, 2006.
Weakness Discussion of Investigational Information: As part of the newsletter, fac-
Complications In Pregnancy ulty may be presenting investigational information about pharmaceutical
products that is outside Food and Drug Administration approved labeling.
Information presented as part of this activity is intended solely as contin-
uing medical education and is not intended to promote off-label use of
Class Of Evidence Definitions any pharmaceutical product. Disclosure of Off-Label Usage: This issue of
Emergency Medicine Practice discusses no off-label use of any pharma-
Each action in the clinical pathways section of Emergency Medicine ceutical product.
Practice receives a score based on the following definitions. Faculty Disclosure: It is the policy of Mount Sinai School of Medicine to
ensure objectivity, balance, independence, transparency, and scientific
Class I Class III rigor in all CME-sponsored educational activities. All faculty participating
• Always acceptable, safe • May be acceptable in the planning or implementation of a sponsored activity are expected to
• Definitely useful • Possibly useful disclose to the audience any relevant financial relationships and to assist
• Proven in both efficacy and • Considered optional or alternative in resolving any conflict of interest that may arise from the relationship.
effectiveness treatments Presenters must also make a meaningful disclosure to the audience of
their discussions of unlabeled or unapproved drugs or devices.
Level of Evidence: Level of Evidence: In compliance with all ACCME Essentials, Standards, and Guidelines, all
• One or more large prospective • Generally lower or intermediate faculty for this CME activity were asked to complete a full disclosure
studies are present (with rare levels of evidence statement. The information received is as follows: Dr. Costello, Dr. Heins,
exceptions) • Case series, animal studies, con- Dr. Zirkin, Dr. Lovecchio, Dr. Barish, and Dr. Stewart report no significant
• High-quality meta-analyses sensus panels financial interest or other relationship with the manufacturer(s) of any
• Study results consistently positive • Occasionally positive results commercial product(s) discussed in this educational presentation.
and compelling
For further information, please see The Mount Sinai School of Medicine
Indeterminate
website at www.mssm.edu/cme.
Class II • Continuing area of research
• Safe, acceptable • No recommendations until further ACEP Accreditation: Emergency Medicine Practice is approved by the
• Probably useful research American College of Emergency Physicians for 48 hours of ACEP
Category 1 credit per annual subscription.
Level of Evidence: Level of Evidence: AAFP Accreditation: Emergency Medicine Practice has been reviewed
• Generally higher levels of evidence • Evidence not available and is acceptable for up to 48 Prescribed credits per year by the
• Non-randomized or retrospective • Higher studies in progress American Academy of Family Physicians. AAFP Accreditation begins
studies: historic, cohort, or case- • Results inconsistent, contradictory August 1, 2006. Term of approval is for two years from this date. Each
control studies • Results not compelling issue is approved for 4 Prescribed credits. Credits may be claimed for
• Less robust RCTs two years from the date of this issue.
• Results consistently positive Significantly modified from: The
AOA Accreditation: Emergency Medicine Practice has been approved for
Emergency Cardiovascular Care
48 Category 2B credit hours per year by the American Osteopathic
Association.

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