Tiger snake (Notechis spp) envenoming: Australian Snakebite Project (ASP-13)

Geoffrey K Isbister, Margaret A O’Leary, Matthew Elliott and Simon G A Brown
Med J Aust 2012; 197 (3): 173-177. || doi: 10.5694/mja11.11300


Objectives: To describe the clinical syndrome associated with definite tiger snake (Notechis spp) envenoming and to examine the ability of tiger snake antivenom (TSAV) to bind free venom in vivo.

Design, setting and participants: We conducted a prospective cohort study within the Australian Snakebite Project, reviewing all definite tiger snake envenoming cases between October 2004 and June 2011. Definite cases were identified by venom-specific enzyme immunoassay or expert snake identification.

Main outcome measures: Clinical effects of tiger snake envenoming; peak venom concentrations; number of vials of antivenom administered.

Results: Fifty-six definite tiger snake envenomings were identified. Clinical effects included venom-induced consumption coagulopathy (VICC) (n = 53), systemic symptoms (n = 45), myotoxicity (n = 11) and neurotoxicity (n = 17). Thrombotic microangiopathy occurred in three patients, all of whom developed acute renal failure. There were no deaths. A bite-site snake venom detection kit test was done in 44 patients, but was positive for tiger snake in only 33 cases. Fifty-three patients received TSAV and eight of these patients had immediate hypersensitivity reactions, severe enough in one case to satisfy diagnostic criteria for severe anaphylaxis. The median peak venom concentration in 50 patients with pretreatment blood samples available was 3.2 ng/mL (interquartile range [IQR], 1–12 ng/mL; range 0.17–152 ng/mL). In 49 patients with post-treatment blood samples available, no venom was detected in serum after the first antivenom dose. Ten patients were given 1 vial of TSAV; the median dose was 2 vials (range, 1–4 vials). Pretreatment serum venom concentrations did not vary significantly between patients given 1 vial of TSAV and those given 2 or more vials.

Conclusion: Tiger snake envenoming causes VICC, systemic symptoms, neurotoxicity and myotoxicity. One vial of TSAV, the dose originally recommended when the antivenom was first made available, appears to be sufficient to bind all circulating venom.

  • Geoffrey K Isbister
  • Margaret A O’Leary
  • Matthew Elliott
  • Simon G A Brown



Tiger snakes are one of the most frequent causes of envenoming in Australia, particularly in Victoria, and are the most important venomous snake in Tasmania. There are two species of tiger snake — Notechis scutatus (mainland tiger snake) and Notechis ater (black tiger snake) ...

Competing interests:

No relevant disclosures.

  • 1. Rawlinson PA. Taxonomy and distribution of the Australian tiger snakes (Notechis) and copperheads (Austrelaps) (Serpentes: Elapidae). Proc R Soc Victoria 1991; 103: 125-135.
  • 2. Cogger HG. Reptiles and amphibians of Australia. Sydney: Reed New Holland, 2000.
  • 3. Tibballs J, Henning RD, Sutherland SK, Kerr AR. Fatal cerebral haemorrhage after tiger snake (Notechis scutatus) envenomation. Med J Aust 1991; 154: 275-276.
  • 4. Sutherland SK, Coulter AR. Three instructive cases of tiger snake (Notechis scutatus) envenomation — and how a radioimmunoassay proved the diagnosis. Med J Aust 1977; 2: 177-180.
  • 5. Penington A, Johnstone B. A case of local tissue necrosis following a bite by the Australian tiger snake Notechis scutatus. Aust N Z J Surg 1997; 67: 385-388.
  • 6. Ferguson LA, Morling A, Moraes C, Baker R. Investigation of coagulopathy in three cases of tiger snake (Notechis ater occidentalis) envenomation. Pathology 2002; 34: 157-161.
  • 7. Hood VL, Johnson JR. Acute renal failure with myoglobinuria after tiger snake bite. Med J Aust 1975; 2: 638-641.
  • 8. Harvey PM, Tabrett DG, Solomons BJ, Thomas MA. Envenomation by a King Island tiger snake (Notechis ater humphreysi). Med J Aust 1982; 2: 192-193.
  • 9. Scop J, Little M, Jelinek GA, Daly FF. Sixteen years of severe tiger snake (Notechis) envenoming in Perth, Western Australia. Anaesth Intensive Care 2009; 37: 613-618.
  • 10. White J. A review of 105 cases of suspected snakebite in South Australia. In: Gopalakrishnakone P, Tan C, editors. Progress in venom and toxin research. Singapore: National University of Singapore, 1987: 15-19.
  • 11. White J. CSL antivenom handbook. Melbourne: CSL, 2001.
  • 12. Parkin JD, Ibrahim K, Dauer RJ, Braitberg G. Prothrombin activation in eastern tiger snake bite. Pathology 2002; 34: 162-166.
  • 13. Isbister GK, Woods D, Alley S, et al. Endogenous thrombin potential as a novel method for the characterization of procoagulant snake venoms and the efficacy of antivenom. Toxicon 2010; 56: 75-85.
  • 14. Isbister GK, O’Leary MA, Schneider JJ, et al. Efficacy of antivenom against the procoagulant effect of Australian brown snake (Pseudonaja sp.) venom: in vivo and in vitro studies. Toxicon 2007; 49: 57-67.
  • 15. Churchman A, O’Leary MA, Buckley NA, et al. Clinical effects of red-bellied black snake (Pseudechis porphyriacus) envenoming and correlation with venom concentrations: Australian Snakebite Project (ASP-11). Med J Aust 2010; 193: 696-700. <MJA full text>
  • 16. Gan M, O’Leary MA, Brown SG, et al. Envenoming by the rough-scaled snake (Tropidechis carinatus): a series of confirmed cases. Med J Aust 2009; 191: 183-186. <MJA full text>
  • 17. Kulawickrama S, O’Leary MA, Hodgson WC, et al. Development of a sensitive enzyme immunoassay for measuring taipan venom in serum. Toxicon 2010; 55: 1510-1518.
  • 18. Isbister GK, Brown SG, MacDonald E, et al; Australian Snakebite Project Investigators. Current use of Australian snake antivenoms and frequency of immediate-type hypersensitivity reactions and anaphylaxis. Med J Aust 2008; 188: 473-476. <MJA full text>
  • 19. Isbister GK, White J, Currie BJ, et al; ASP Investigators. Clinical effects and treatment of envenoming by Hoplocephalus spp. snakes in Australia: Australian Snakebite Project (ASP-12). Toxicon 2011; 58: 634-640.
  • 20. Brown SG. Clinical features and severity grading of anaphylaxis. J Allergy Clin Immunol 2004; 114: 371-376.
  • 21. O’Leary MA, Isbister GK. Commercial monovalent antivenoms in Australia are polyvalent. Toxicon 2009; 54: 192-195.
  • 22. O’Leary MA, Isbister GK, Schneider JJ, et al. Enzyme immunoassays in brown snake (Pseudonaja spp.) envenoming: detecting venom, antivenom and venom–antivenom complexes. Toxicon 2006; 48: 4-11.
  • 23. Newcombe RG. Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 1998; 17: 857-872.
  • 24. Casamento AJ, Isbister GK. Thrombotic microangiopathy in two tiger snake envenomations. Anaesth Intensive Care 2011; 39: 1124-1127.
  • 25. Isbister GK, Scorgie FE, O’Leary MA, et al; ASP Investigators. Factor deficiencies in venom-induced consumption coagulopathy resulting from Australian elapid envenomation: Australian Snakebite Project (ASP-10). J Thromb Haemost 2010; 8: 2504-2513.
  • 26. O’Leary MA, Schneider JJ, Krishnan BP, et al. Cross-neutralisation of Australian brown and tiger snake venoms with commercial antivenoms: cross-reactivity or antivenom mixtures? Toxicon 2007; 50: 206-213.
  • 27. Sprivulis P, Jelinek GA, Marshall L. Efficacy and potency of antivenoms in neutralizing the procoagulant effects of Australian snake venoms in dog and human plasma. Anaesth Intensive Care 1996; 24: 379-381.


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