Snake Bites and Children

There are lots of animals that bite.  Since we all inhabit the same beautiful world, and sometimes we humans overtake previous habitats of animals, we inevitably will cross paths with an animal that bites us.  Usually, animals bite from fear or defense of their offspring (ex, Brown Recluse).  Sometimes they bite because that’s how they feed (ie, mosquitoes Eastern Equine Encephalitis).  Sometimes it’s a beloved pet who gets surprised or has an “off” day (Dog Bites and PTSD).  And sometimes those bites cause complications that we need to be aware of (RabiesRMSFRat Bite Fever).  In honor of St. Patrick’s Day, the day to remember the saint who drove the snakes out of Ireland, let’s chat about snake bites and children!  (Disclaimer: We are only going to focus on snake bites in the United States for today… as there are many other types of snakes around the world that require different management.  If you are managing a snake bite from a snake that does not typically reside in the U.S., please utilize other resources and local Toxicology experts for help with management protocols.)

Snake Bites: Basics

  • In the US, there are approximately 50,000 snake bites each year [Ahmed, 2008]
    • 7000-8000 of those bites are venomous [CDC, 2021; Ahmed, 2008; Meyers 2022]
  • Children will commonly get snake bites while they are out playing in the yard, in the woods around their houses, or while getting a toy that rolled under a wood pile or into some tall grass.
  • In the US, the venomous snakes include rattlesnakes, copperheads, cottonmouths/water moccasins, and coral snakes [CDC, 2021]
  • Rattlesnakes live all across the United States
    • Copperheads inhabit the eastern U.S. as far west as Texas
    • Cottonmouths/Water Moccasins live in the southeastern U.S. in wetlands, rivers, and lake areas
    • Coral snakes inhabit the southern U.S. in wooded, sandy, or marshy areas
  • Lower extremity bites are most common in children [Correa, 2014]

Snake Bites: Presentation and Exam 

  • Symptoms of a snake bite may include (CDC 2021)
    • Puncture marks at the wound
    • Redness, swelling, bruising, bleeding, or blistering around the bite
    • Severe pain and tenderness at the site of the bite
    • Nausea, vomiting, or diarrhea
    • Labored breathing (in extreme cases, breathing may stop altogether)
    • Rapid heart rate, weak pulse, low blood pressure
    • Disturbed vision
    • Metallic, mint, or rubber taste in the mouth
    • Increased salivation and sweating
    • Numbness or tingling around face and/or limbs
    • Muscle twitching
  • Phospholipase A2 and Hyaluronidase in Viperidae snake bites cause local tissue damage, while neurotoxins from Elapidae bites can cause more widespread paralysis (Ahmed 2008)
    • Venom contains proteins, phospholipases, enzymes that can cause necrosis and hemolysis [Meyers, 2022]

Snake Bites: Management 

  • When the patient first arrives (CDC 2021, Ahmed 2008)
    • Assess A, B, C’s… as always
    • Let them put the affected extremity in a neutral position of comfort and immobilize
    • Remove any rings or watches on the extremity, anything circumferential that can act as a tourniquet if there is swelling
    • Mark the edge of tenderness and swelling, and write the date/time
      • They have snake bite instructions that they can fax you
      • They can connect you with a Toxicologist
      • Talk with a Toxicologist before giving antivenom as they can help with the decision-making regarding this expensive treatment
    • Record circumference of the extremity at the bite site and at least two proximal locations 
      • Measure at the same sites every 15 minutes until progression stops
    • Monitor for compartment syndrome 
    • Reassure the patient that most bites are nonfatal and 50% of bite from venomous snakes are dry bites (Ahmed 2008)
  • Do NOT do the following for snake bites (CDC 2021, Ahmed 2008, Juckett 2002, Judge 2019)
    • Apply a tourniquet
    • Cut the wound with a knife or use venom extractors
    • Apply ice or immerse the bite site in water
    • Give NSAIDs 
    • Handle any snakes that a patient may bring with them! (I have no reference for this, but I think we can all agree this is prudent!)
  • Labs to be drawn (Ahmed 2008)
    • Complete blood count or at least hemoglobin level
    • Creatinine
    • Amylase
    • Creatinine phosphokinase
    • Prothrombin time (PT) and activated partial thromboplastin time (aPTT)
    • Fibrinogen and fibrin degradation products
    • Blood gas and electrolytes (if systemic symptoms)
    • Urinalysis looking for hematuria, proteinuria, hemoglobinuria, or myoglobinuria
    • Electrocardiogram to ensure no arrhythmias (EKG)
    • Electroencephalogram is recommended in the literature (but anecdotally this has never been recommended to me by the North Carolina Poison Center for an otherwise healthy and alert child)
  • Monitor patients who have been bitten for at least 8-12 hours as some symptoms can be delayed in onset (Judge 2019)

Snake Bite: Treatment

  • For copperhead and rattlesnake bites, often elevation of the extremity above the level of the heart is recommended
    • This mitigates the local tissue destruction by diluting the venom protein components
  • Anti-venom could fill up an entire morsel by itself!
    • May be needed for severe sequelae of bites, severe systemic symptoms, or rapid progression of bite sequelae.  (Ahmed 2008)
    • **Talk with a Medical Toxicologist who can help you determine if anti-venom is needed, what kind is needed, and how to get it. (Judge 2019)
    • Best when given within 4 hours of the bite, but still effective within 24 hours
    • Always give an entire vial of antivenom, never a partial vial. It’s expensive, so if you’re giving some of a vial, give it all.
  • Patient may need IV fluids (Meyers 2022)
  • Coagulopathy may need to be treated with anti-venom, fresh frozen plasma, cryoprecipitate (fibrinogen, factor VIII), fresh whole blood, or platelet concentrates (Ahmed 2008)
  • Neurotoxic bites (Elapid bites) may need anticholinesterase medications to mitigate or reverse paralysis symptoms (discuss with Toxicology first) (Ahmed 2008)
    • Neostigmine can be used to reduce muscle weakness as well 
  • Prophylactic antibiotics can prevent subsequent infection at the bite site from snake oral bacteria. (Ahmed 2008)
  • Tetanus toxoid booster is usually recommended. (Ahmed 2008, Meyers 2022)
  • Of course, treat any other systemic symptoms (like respiratory failure, hypotension) as you typically would.

Snake Bite: Complications

  • While death from a snake bite in the US is rare, there can be many complications from snake bites
    • Only about 5-15 out of 7000-8000 people in the US will die from a snake bite from a domestic snake (CDC 2021, Ahmed 2008, Meyers 2022)
    • 10-44% of people in the U.S. will have long term effects from a snake bite (CDC 2021)
    • Mortality in other countries with exotic snakes is much higher- 30,000 per year in India (Ahmed 2008)
  • Envenomations can have a concomitant allergic response leading to the release of histamine and bradykinin which can result in hypotension (Meyers 2022)
  • Coagulopathy can cause major bleeding complications (Ahmed 2008, Meyers 2022)
  • Neurotoxic bites can cause paralysis that requires ICU level care (Ahmed 2008)
  • Fasciotomies for compartment syndrome can be avoided by early and frequent discussion with your local Toxicologist
    • Should not be attempted until coagulopathies have been corrected (Ahmed 2008, Juckett 2002)
    • Can worsen myonecrosis in envenomated muscles (Ahmed 2008)
  • Acute kidney injury can occur (Sarkar 2021)
  • There is a case report of a neurotoxic snake bite mimicking brain death with temporary loss of brainstem reflexes for several days (John 2008)
  • Other complications can include (Meyers 2022)
    • Shock
    • Respiratory failure
    • Acute renal failure
    • Local skin infection
    • Compartment syndrome
    • Serum sickness

Moral of the Morsel

  • Kids like playing where snakes live! But that puts them at risk for snake bites in some areas.
  • Basics are best! Start with basic wound management, give pain medications, and help your patient be comfortable.
  • Call your friends … at the Poison Center! Your state poison center and local toxicologists are a wealth of knowledge and help for management and treatment.
  • Pictures are worth a 1,000 words. There are some great guides for identifying different snakes that share our outdoor spaces ( )
  1. Ahmed SM, Ahmed M, Nadeem A, Mahajan J, Choudhary A, Pal J. Emergency treatment of a snake bite: Pearls from literature. J Emerg Trauma Shock. 2008;1(2):97-105. doi:10.4103/0974-2700.43190
  2. Venomous snake bites: Symptoms & first aid. Centers for Disease Control and Prevention. Published June 28, 2021. Accessed March 13, 2023.
  3. Meyers SE, Tadi P. Snake Toxicity. [Updated 2022 Sep 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
  4. Correa JA, Fallon SC, Cruz AT, et al. Management of pediatric snake bites: are we doing too much?. J Pediatr Surg. 2014;49(6):1009-1015. doi:10.1016/j.jpedsurg.2014.01.043 
  5. Juckett G, Hancox JG. Venomous snakebites in the United States: management review and update [published correction appears in Am Fam Physician 2002 Jul 1;66(1):30]. Am Fam Physician. 2002;65(7):1367-1374.
  6. Bryan Judge MD. ACMT toxicology visual pearls: Exotic Viper Envenomation. ALiEM. Published November 13, 2019. Accessed March 17, 2023.
  7. Sarkar S, Sinha R, Chaudhury AR, et al. Snake bite associated with acute kidney injury. Pediatr Nephrol. 2021;36(12):3829-3840. doi:10.1007/s00467-020-04911-x
  8. John J, Gane BD, Plakkal N, Aghoram R, Sampath S. Snake bite mimicking brain death. Cases J. 2008;1(1):16. Published 2008 Jun 12. doi:10.1186/1757-1626-1-16
Christyn Magill
Christyn Magill
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