Snakebite is a potential medical emergency and must receive high-priority assessment and treatment, even in patients who initially appear well.
Patients should be treated in hospitals with onsite laboratory facilities, appropriate antivenom stocks and a clinician capable of treating complications such as anaphylaxis.
All patients with suspected snakebite should be admitted to a suitable clinical unit, such as an emergency short-stay unit, for at least 12 hours after the bite. Serial blood testing (activated partial thromboplastin time, international normalised ratio and creatine kinase level) and neurological examinations should be done for all patients.
Most snakebites will not result in significant envenoming and do not require antivenom.
Antivenom should be administered as soon as there is evidence of envenoming. Evidence of systemic envenoming includes venom-induced consumption coagulopathy, sudden collapse, myotoxicity, neurotoxicity, thrombotic microangiopathy and renal impairment.
Venomous snake groups each cause a characteristic clinical syndrome, which can be used in combination with local geographical distribution information to determine the probable snake involved and appropriate antivenom to use. The Snake Venom Detection Kit may assist in regions where the range of possible snakes is too broad to allow the use of monovalent antivenoms.
When the snake identification remains unclear, two monovalent antivenoms (eg, brown snake and tiger snake antivenom) that cover possible snakes, or a polyvalent antivenom, can be used.
One vial of the relevant antivenom is sufficient to bind all circulating venom. However, recovery may be delayed as many clinical and laboratory effects of venom are not immediately reversible.
For expert advice on envenoming, contact the National Poisons Information Centre on 13 11 26.
- 1. Ireland G, Brown SG, Buckley NA, et al. Changes in serial laboratory test results in snakebite patients: when can we safely exclude envenoming? Med J Aust 2010; 193: 285-290. <MJA full text>
- 2. White J. Clinical toxicology of snakebite in Australia and New Guinea. In: Meier J, White J, editors. Handbook of clinical toxicology of animal venoms and poisons. New York: CRC Press, 1995: 595-618.
- 3. Isbister GK, Buckley NA, Page CB, et al. A randomized controlled trial of fresh frozen plasma for treating venom-induced consumption coagulopathy in cases of Australian snakebite (ASP-18). J Thromb Haemost 2013; 11: 1310-1318.
- 4. Currie BJ. Snakebite in tropical Australia: a prospective study in the “Top End” of the Northern Territory. Med J Aust 2004; 181: 693-697. <MJA full text>
- 5. 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>
- 6. Johnston CI, O’Leary MA, Brown SG, et al. Death adder envenoming causes neurotoxicity not reversed by antivenom – Australian Snakebite Project (ASP-16). PLOS Negl Trop Dis 2012; 6: e1841.
- 7. Isbister GK. Snakebite doesn’t cause disseminated intravascular coagulation: coagulopathy and thrombotic microangiopathy in snake envenoming. Semin Thromb Hemost 2010; 36: 444-451.
- 8. Isbister GK, White J, Currie BJ, et al. Clinical effects and treatment of envenoming by Hoplocephalus spp. snakes in Australia: Australian Snakebite Project (ASP-12). Toxicon 2011; 58: 634-640.
- 9. Isbister GK, Scorgie FE, O’Leary MA, et al. Factor deficiencies in venom-induced consumption coagulopathy resulting from Australian elapid envenomation: Australian Snakebite Project (ASP-10). J Thromb Haemost 2010; 8: 2504-2513.
- 10. Currie BJ. Snakebite in tropical Australia, Papua New Guinea and Irian Jaya. Emerg Med 2000; 12: 285-294. doi: 10.1046/j.1442-2026.2000.00150.x.
- 11. Allen GE, Brown SG, Buckley NA, et al. Clinical effects and antivenom dosing in brown snake (Pseudonaja spp.) envenoming – Australian Snakebite Project (ASP-14). PLOS One 2012; 7: e53188.
- 12. Isbister GK, O’Leary MA, Elliott M, Brown SG. Tiger snake (Notechis spp) envenoming: Australian Snakebite Project (ASP-13). Med J Aust 2012; 197: 173-177. <MJA full text>
- 13. Johnston CI, Brown SG, O’Leary MA, et al. Mulga snake (Pseudechis australis) envenoming: a spectrum of myotoxicity, anticoagulant coagulopathy, haemolysis and the role of early antivenom therapy - Australian Snakebite Project (ASP-19). Clin Toxicol (Phila) 2013; 51: 417-424.
- 14. Isbister GK, Brown SG, MacDonald E, et al. 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>
- 15. 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>
- 16. 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.
- 17. Toxicology and Wilderness Expert Group. Therapeutic guidelines: toxicology and wilderness. Version 2. Melbourne: Therapeutic Guidelines Limited, 2012.
- 18. Cubitt M, Armstrong J, McCoubrie D, et al. Point-of-care testing in snakebite: an envenomed case with false negative coagulation studies. Emerg Med Australas 2013; 25: 372-373.
- 19. Isbister GK, Maduwage K, Shahmy S, et al. Diagnostic 20-min whole blood clotting test in Russell’s viper envenoming delays antivenom administration. QJM 2013; 106: 925-932.
- 20. White J, Williams V, Duncan B. Lymphopenia after snakebite. Lancet 1989; 2: 1448-1449.
- 21. Isbister GK, Brown SG. Bites in Australian snake handlers — Australian snakebite project (ASP-15). QJM 2012; 105: 1089-1095.
- 22. White J. CSL antivenom handbook. 2nd ed. Melbourne: CSL Ltd, 2001.
- 23. Sutherland SK, Coulter AR, Harris RD. Rationalisation of first-aid measures for elapid snake bite. Lancet 1979; 1: 183-185.
- 24. Canale E, Isbister GK, Currie BJ. Investigating pressure bandaging for snakebite in a simulated setting: bandage type, training and the effect of transport. Emerg Med Australas 2009; 21: 184-190.
- 25. Howarth DM, Southee AE, Whyte IM. Lymphatic flow rates and first-aid in simulated peripheral snake or spider envenomation. Med J Aust 1994; 161: 695-700.
- 26. Pearn J, Morrison J, Charles N, Muir V. First-aid for snake-bite: efficacy of a constrictive bandage with limb immobilization in the management of human envenomation. Med J Aust 1981; 2: 293-295.
- 27. Lalloo DG, Trevett AJ, Korinhona A, et al. Snake bites by the Papuan taipan (Oxyuranus scutellatus canni): paralysis, hemostatic and electrocardiographic abnormalities, and effects of antivenom. Am J Trop Med Hyg 1995; 52: 525-531.
- 28. Isbister GK, Duffull SB, Brown SG. Failure of antivenom to improve recovery in Australian snakebite coagulopathy. QJM 2009; 102: 563-568.
- 29. Yeung JM, Little M, Murray LM, et al. Antivenom dosing in 35 patients with severe brown snake (Pseudonaja) envenoming in Western Australia over 10 years. Med J Aust 2004; 181: 703-705. <MJA full text>
- 30. Brown SG, Blackman KE, Stenlake V, Heddle RJ. Insect sting anaphylaxis; prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. Emerg Med J 2004; 21: 149-154.
- 31. Brown SG, Mullins RJ, Gold MS. Anaphylaxis: diagnosis and management. Med J Aust 2006; 185: 283-289. <MJA full text>
- 32. Isbister GK, Shahmy S, Mohamed F, et al. A randomised controlled trial of two infusion rates to decrease reactions to antivenom. PLOS One 2012; 7: e38739.
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