Art & science | poisoning
Effects of snake envenomation:
a guide for emergency nurses
Correspondence
stephenmcghee@health.usf.edu
Stephen McGhee is a clinical
instructor at the University of
South Florida College of Nursing,
Tampa, Florida, United States
Alan Finnegan is Ministry of
Defence professor of nursing
and head of the academic
department of military nursing
at the Royal Centre for Defence
Medicine, Birmingham
John M Clochesy is director of
faculty mentorship and assistant
dean of the doctoral programme
Constance Visovsky is associate
dean of student affairs and
community engagement
Both at the University of South
Florida College of Nursing,
Tampa, Florida, United States
Date of submission
December 8 2014
Date of acceptance
December 16 2014
Peer review
This article has been subject
to double-blind review and
has been checked using
antiplagiarism software
Author guidelines
rcnpublishing.com/r/
en-author-guidelines
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EN_0010.indd 24
Stephen McGhee and colleagues explain how practitioners should
care for people bitten by snakes, including those not native to the
UK, and how to recognise the effects of different forms of venom
Abstract
Only one species of venomous snake, the adder,
is indigenous to the UK, but many people keep
venomous snakes as pets and others travel to places,
such as the United States, where a wider variety of
venomous snakes can be found. Emergency nurses
should therefore be prepared to treat bite wounds
caused by venomous and non-venomous snakes.
This article offers an overview of the most common
forms of envenomation in the UK and makes
recommendations for the clinical care of people who
have sustained snake bites.
Keywords
Snake bite, adder bite, venom, envenomation
SNAKES HAVE a reclusive nature and prefer a
rural habitat, and usually bite humans only when
they sense they are under threat (Klug et al 2010,
Evans and Nelson 2013). Nevertheless, venomous
snake bites are associated with significant morbidity
and mortality worldwide (World Health Organization
(WHO) 2010). There have been 14 fatalities from
snake bites in the UK since 1876 and the most recent
of them, in 1975, involved a child in Scotland (Reid
1976). However, there were 510 cases of snake bite
reported to the National Poisons Information Service
between 2004 and 2010. Snakes are not indigenous
to Northern Ireland.
The European adder, or Vipera berus,
is responsible for 52% of snake bites in the UK,
with exotic species accounting for 26% and the
European grass snake for 4%. The causes of the
remaining 18% of snake bites are unidentified
(Coulson et al 2013). While life-threatening
envenomation is rare in the UK, people who have
Copyright 2015 RCNi Ltd. All rights reserved.
been bitten can experience long periods of pain and
distress (Warrell 2005).
Although the adder is the only venomous
snake indigenous to the UK, many pet enthusiasts
keep snakes that pose a risk of life-threatening
envenomation (Persson 2001). Significant
envenomation by any of these snakes is considered a
medical emergency requiring anti-venom therapy.
Every year around the world there are about
five million snake-bite envenomations (Girish and
Kemparaju 2011), of which about 125,000 result
in death and another 375,000 cause pain, loss of
function or both (WHO 2010).
Some people, including members of the military,
farm workers and children who live in isolated
rural areas, are especially at risk of envenomation
due to their occupations or geographic locations
(Johnson et al 2013). Most snake bites are
inflicted on the feet and ankles (WHO 2010),
with envenomation often causing neurotoxic and
haemotoxic effects accompanied by tissue necrosis
(Heiner et al 2013).
Members of the British armed forces are often
deployed to areas where there is a significant risk
of snake bite (Wall 2012), although since 1990 there
has been only one published case of non-fatal
snake-bite envenomation involving a British soldier
(Krysta-Clark et al 2004). Although envenomation
has occurred among US forces taking part in combat
operations in Afghanistan and Iraq, there are little
data about the magnitude of the problem.
In a voluntary cross-sectional survey of 390 US
military personnel leaving Afghanistan, Shiau et al
(2007) found there had been seven incidents of
snake bite, and that military personnel there were
at greater risk of snake bite than those in Iraq. In a
more recent case review conducted in Afghanistan,
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 Heiner et al (2013) reported on 17 snake bites
involving 15 Afghan nationals and two members of
the US military who had been bitten mainly on the
fingers, hands, feet, ankles or lower legs. Because
these are common locations for snake bites, troops
in jungle locations must wear boots and gloves,
and should exercise appropriate caution when lifting
items from the jungle floor (Kasturiratne et al 2008).
Envenomation from snake bites is also an
important public health issue in tropical countries.
In Sierra Leone, for example, nearly 7,000 people
are bitten by snakes every year and almost
500 die due to lack of timely access to anti-venom
(Kasturiratne 2008).
Venomous snake species
The two types of venomous snakes discussed in
this article are the Viperidae and Elapidae. Snakes
of the Viperidae family include many of those
found in the south-eastern US. They include the
copperhead (Agkistrodon contortrix), water moccasin
or cottonmouth (A. piscivorus), eastern diamondback
(Crotalus adamanteus) and European adder (V. barus)
(Evans and Nelson 2013).
Snakes of the Elapidae family are also found in
north America, as well as Africa, Asia, Australia and
South America. They include cobras (genus Naja),
the common krait (genus Bungarus), coral snakes
(genus Micrurus) and mambas (genus Dendroaspis)
(Evans and Nelson 2013). Some of these snakes are
pictured in Figure 1.
The European adder can be found in most
of mainland Britain. Adder bites usually occur
between February and October, with the number of
bites peaking during the summer months (Warrell
2005), a seasonal pattern that is thought to be
associated with the adders hibernation periods
(Coulson et al 2013). Meanwhile, about 75 different
types of non-native snakes are kept as pets in the
UK and envenomation from these occurs most
often when they are being fed, their cages are being
cleaned or their venom milked, or their owners
handle them while intoxicated (Warrell 2005,
Evans and Nelson 2013).
Viperidae inject venom into their victims and
leave painful, deep puncture wounds (Ferri 2012),
although about 25% of Viperidae bites do not cause
envenomation and are termed dry bites (Ashton et al
2011, Evans and Nelson 2013). Viperidae inject
a haemotoxic venom, while snakes of the Elapidae
family inject a neurotoxic venom that attacks blood
and nerve tissue (Juckett and Hancox 2002).
Clinical features
The first clinical manifestation of a snake bite is
anxiety. Patients, even those who have sustained
dry bites, may therefore report anxiety-associated
autonomic arousal symptoms, including
breathlessness, dizziness, numbness in the fingers,
palpitations, sweating, tightness in the chest and
tingling (Bates 2001). When practitioners attend to,
transfer and treat patients, therefore, they must

Figure 1 Snakes of the Viperidae and Elapidae families

Left: the
iStock

coral snake,
asnake ofthe
Elapidae family

Clockwise from
right: an eastern
diamondback,
awatermoccasin
anda European
adder, all of the
Viperidae family

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EN_0010.indd 25 03-02-2015 19:59:43

 Art & science | poisoning
acute care
offer them reassurance at all times. There follows a
checklist of good practice in managing snake bites:
Keep calm, ensure you appear and sound
confident, and maintain good eye contact
with the patient.
Place patient in a comfortable sitting position.
If the patient is hyperventilating, encourage him
or her to take deep and slow breaths, and praise
their efforts.If the patient has a dry mouth,
give him or her water.
If the patient is panicking, explain that this is
a normal reaction.
Explain what the treatment involves but do
not overwhelm the patient with information.
Avoid using jargon or clinical terms unless you
are sure the patient understands them.
Explain that pain does not necessarily mean harm.
Be positive about outcomes but keep to the facts.
Avoid negative messages and do not speculate.
Provide the patient with an opportunity to ask
questions and acknowledge his or her concerns.
After you have explained the treatment, ask the
patient to confirm that he or she understands
what has been said.
The presenting signs and symptoms of
envenomation depend on the variety of snake
responsible for the bite. Snakes such as the spitting
cobra and South African rinkhals (Hemachatus
heamachatus) spit a form of venom that can
cause venom ophthalmia if it enters the eyes.
Venom ophthalmia can cause painful chemical
Table 1 Systemic and localised effects of Viperidae and Elapidae venom
Effects of Snake family
envenomation
Viperidae Elapidae
Haemotoxic Ecchymosis, epistaxis, Not applicable
haematemesis, hypovolemia and
shock, serious clotting defects, and
persistent bleeding from puncture
wounds, venipuncture sites and gums
Neurotoxic Not applicable Blurred vision, confusion,
fasciculation, flaccid
paralysis, headache,
heaviness of the eyelids,
paresthesia, ptosis,
respiratory depression
or arrest, renal failure,
vomiting
Localised Lymphatic spread
Pain, redness, swelling, tenderness, bullae
(Adapted from Bates 2001)
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EN_0010.indd 26
conjunctivitis, sometimes leading to corneal
ulceration and anterior uveitis, with the potential for
secondary infection (Warrell 2005).
Practitioners in Australia often use the
enzyme-linked immunosorbent assay-based rapid
snake venom detection kit (SVDK), which involves
taking a swab of the patients bite area or a
urine sample to identify the correct anti-venom
to administer. SVDKs are not used in the
UK or US, however.
A summary of the localised and systemic effects
of Viperidae and Elapidae venom is listed in Table 1.
Recommendations
Most emergency department (ED) nurses in
the UK will lack experience in treating patients
who present with snake bite (Bates 2001).
When someone with suspected snake bite presents
to or contacts the ED, clinicians most important
task is to identify the type of snake involved.
There are recorded cases of envenomation in
people handling the dead bodies or severed heads
of snakes (Suchard and LoVecchio 1999), so anyone
who has been bitten should be discouraged from
bringing these to an ED. Instead, they should be
asked to take a photograph of the snake (Warrell
2005), ideally by smartphone or digital camera
so that the photograph can be shared easily.
The National Poisons Information Service has a list
of herpetologists who can give expert advice on
snake species and the actions of their venom.
First aid Initial first aid should involve safe transfer
of the patient to hospital as quickly and with
as little movement as possible (Gold and Barish
1992). Any delay in administering anti-venom
can lead to significant complications or even
mortality (Sharma et al 2004, Narvencar 2006).
Reassurance must be given at all times when
moving or transferring patients and during the
treatment process.
Rings and other tight-fitting jewellery should
be removed from the patient in case of local
swelling (Bates 2001), while a splint or sling
can be applied to the affected limb area for
immobilisation during transfer (Warrell 2005).
For some Elapidae species, immediate pressure
immobilisation is advocated due to the rapid action
of neurotoxic venom (Bates 2001, Warrell 2005,
Wall 2012). However, pressure immobilisation is
not advocated for a patient bitten by a Viperidae
species, such as the adder.
Figure 2 shows the British armed forces method
of pressure immobilisation adapted from Ministry of
Defence (2012) clinical guidelines for operations.
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03-02-2015 19:59:43
 Figure 2 British armed forces method of pressure immobilisation following snake bite

Jos F Donneys
Clockwise from top left: applying pressure and splint to someone
withenvenomation to the lower leg

Below: pressure immobilisation with a sling in someone

withenvenomation to the lower arm

Emergency management A patient who is thought
to have been bitten by a poisonous snake requires
maintenance of airway, breathing and circulation,
and should be monitored for at least 24 hours or
until a diagnosis of venomous snake bite has been
excluded (Bates 2001, Evans and Nelson 2013).
If the patient is to be transferred by ambulance,
intravenous access must be achieved and a 0.9%
sodium chlorine infusion commenced (Pittman
2008). Envenomation symptoms can develop
between 30 and 60 minutes after a bite so it is
important to monitor the patients vital signs, and to
obtain a detailed clinical history that includes the
type of snake and time of bite (Peterson 2006).
A top-to-toe examination should then take place
to assess for signs of coagulopathy, and nurses
should assess for any puncture-type wounds
that have been inflicted by fangs or small teeth.
Treatment includes marking the border of swollen
and tender areas with a view to skin reassessment
every 15 minutes so that extension of the bite can
be assessed (Ferri 2012).
Lymphatic obstruction, swelling and blister
formation can be ameliorated by immobilisation
and extension of the limb with a simple splint
(Lavonas et al 2011). Tetanus immunisation will have
to be considered because cases of Clostridium tetani
infection have been reported following snake bite
(Ferri 2012). If the patient has been bitten by a snake
of the Viperidae family, anaphylactoid symptoms
can be treated early with oral or parenteral
H1 blockers (Bates 2001).
If the patient is in pain, non-steroidal
anti-inflammatory drugs (NSAIDs) should be
avoided because of the risk of bleeding and renal Erratum 6/2/15
dysfunction (Pittman 2008). Instead, the patient The copy, left, about the kinds
of pain relief that should be
should be given paracetamol or opiate-based administered has been changed
medication according to local guidelines. from the printed version.
The recommended laboratory tests and other
assessments are listed in Table 2, page 28.
Anti-venom Snake bites do not always result in
envenomation so the use of anti-venom is not always
indicated (Evans and Nelson 2013). However, its use

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 Art & science | poisoning
acute care
Table 2 Assessments for envenomation after snake bite
Types of assessment Snake family
Viperidae Elapidae
Laboratory tests Full blood count
Coagulation
Urea and electrolytes in blood
Myoglobin in blood
Protein and blood in urine
Other assessments Bleeding from tooth sockets, None
conjunctivae, nose, skin and
gastrointestinal tract
following envenomation can prevent mortality and
reduce the time patients must spend in hospital
(Lavonas et al 2011).
The use of anti-venom is indicated when there is
all of the following:
Incoagulable blood or spontaneous
systemic bleeding.
Neurotoxicity or myotoxicity.
Renal failure.
Shock.
Sustained fall in blood pressure.
The NHS has access to a wide range of anti-venom
preparations (Warrell 2005). Some clinicians have
been reluctant to use anti-venom following adder
envenomation due to the risk of severe allergic
reaction (Coulson et al 2013). This is because in the
late 1950s a child with mild viper envenomation died
as a result of an anaphylactic reaction, and it was
assumed thereafter that the bite is less dangerous
than the anti-serum (McKiddie 1979). The risk of
anaphylactic reaction, which usually occurs between
ten and 18 minutes after administration, can be
mitigated by ensuring adrenaline is available during
anti-venom administration (Theakston and Reid
1976, Bates 2001).
Today the most commonly used anti-venom
in the UK is the Zagreb anti-venom, which is
an F(ab)2 antibody used primarily for viper
envenomation. Between 2004 and 2010, 85 patients
in the UK required anti-venom. No anaphylactic
or anaphylactoid reaction or signs of serum
sickness were reported during this period
(Coulson et al 2013).
For people bitten by the more exotic snakes of
the Viperidae family, many of which are popular
with snake enthusiasts, Crotalidae Polyvalent
Immune Fab (Ovine), or CroFab, is the anti-venom of
choice (Pittman 2008). Obtained from sheep serum
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EN_0010.indd 28
following injection of pit viper venom, CroFab is
used widely in the US (Evans and Nelson 2013).
Most patients given anti-venom show a rapid
improvement in hemodynamic status and level
of consciousness (Bates 2001). Any bleeding
should stop within 30 minutes of administration
and coagulation profiles should return to normal
within six hours.
Supportive care Secondary hypovolemia as a
result of haemorrhage and vasodilation should
be treated with a transfusion of whole blood
and plasma expanders (Bates 2001). Inotropes,
such as dopamine, should be administered to
support patients with hypotension as a result
of increased capillary permeability (Bates 2001,
Warrell 2005). In cases of envenomation that has
led to neurotoxicity, endotracheal intubation with
intermittent positive pressure ventilation may be
required (Warrell 2005). Anticholinesterase drugs
can be used to improve prognosis in patients with
neurotoxic envenomation by reversing the effects of
the neurotoxic venom (Watt et al 1986).
Elapidae envenomation produces a curare-type
effect in patients by blocking postsynaptic nicotinic
acetylcholine receptors at the neuromuscular junction
(Evans and Nelson 2013). These patients appear flaccid
and are in severe respiratory depression or arrest.
Anticoagulants and corticosteroids should be
avoided in all cases of envenomation due to the risks
of haemorrhage (Pittman 2008). Antibiotics may
be required if there are signs of bacterial infection,
but there is no evidence to support administration
of prophylactic antibiotics following envenomation
(Jorge et al 2004). Fasciotomy, a surgical procedure
that relieves pressure on the fascia, can treat
loss of circulation to some areas of tissue or
muscle and is useful for decompressing raised
compartment pressures, signs of which include the
five Ps: pain, pallor, paresthesia, pulselessness and
paralysis. Fasciotomy is justified only if there is a
compartmental pressure of more than 45mmHg,
which can result in ischemic necrosis, but can
take place only after normal coagulation has
returned (Bates 2001).
Care and follow up All patients administered
anti-venom will require follow up because they are
at risk of developing serum sickness, an allergy-type
disease (Pittman 2008). Patients given anti-venom
should be advised to look for signs of fever,
joint pain and malaise, all of which are typical of
serum sickness (Evans and Nelson 2013). Further
blood testing that includes coagulation assay
should be undertaken a few days after patients
EMERGENCY NURSE
03-02-2015 19:59:48
 initial discharge and they should be reviewed about Early assessment and effective first aid reduce the
three weeks later (Lavonas et al 2011). chances of significant envenomation, and triage
Patients who develop serum sickness should staff must be aware of the signs and symptoms of
Online archive
be administered prednisolone orally until the haemotoxic and neurotoxic envenomation to provide
signs and symptoms have resolved (Gold and effective assessment. ED staff should be prepared For related information, visit
our online archive and search
Barish 1992). During follow-up care, patients to initiate measures to reverse hypovolemia, using thekeywords
should be asked to report any signs of further bleeding and respiratory sequelae associated with
bleeding and infection (Evans and Nelson 2013), venomous snake bites.
Conflict of interest
and advised to avoid aspirin, NSAIDs, and all types Further studies of patients with venomous and None declared
of contact sports and dental work due to the risk of non-venomous snake bites are needed to advance
haemorrhage (Pittman 2008). clinical care and develop best practice for assessment, Acknowledgements
The author would like to thank
thereby increasing patients chances of survival. Defence Medical Services medical
Summary director Brigadier Timothy
All snake bites must be assessed by clinical Hodgetts for giving security

professionals so that the patients concerned receive

Find out more clearance and permission to
reproduce the British armed
the correct treatments for the specific snakes that forces pressure immobilisation
A list of herpetologists in the UK, who can give expert technique, and University
bit them. Photographs taken by smartphone can
advice on snake species and the actions of venoms, of South Florida multimedia
be useful for identifying the species of snake and assistant Jos FDonneys for
is available at www.npis.org
increase the likelihood of correct management. taking the photographs

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