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GLOBAL SNAKE ENVENOMATION
There are 3 major clinical syndromes of snakebite envenomation worldwide and 3 major signs
and symptoms of each. All dangerous snakes capable of injuring or killing a human will produce
at least one sign or symptom from at least one of the 3 major snakebite syndromes (neurotoxic,
hemotoxic, and cytotoxic). Specific antivenoms required will vary regionally, but the major triads
are applicable globally.
BILATERAL COAGULOPATHY SEVERE
PTOSIS (VICC) PAIN

DESCENDING DYSPNEA/ LOCAL SYSTEMIC PROGRESSIVE TISSUE
PARALYSIS AMS BLEEDING BLEEDING EDEMA DESTRUCTION
• NEUROTOXIC SYNDROME: Anticipate the need for aggressive airway management with
intubation and prolonged ventilation in all patients presenting with neurotoxic envenomation.
˚ With cholinergic crisis: Consider Atropine 0.5mg IV/IO titrated by auscultation to dry up
bronchial and oral hypersecretions.
˚ Without cholinergic crisis: Consider Atropine 0.5mg IV/IO followed by
˚ Neostigmine 1.0mg IV/IO to temporarily reverse neuromuscular weakness and delay the
need for intubation.
• HEMOTOXIC SYNDROME: All internal and external active bleeding should cease within
30–60min of antivenom administration once the appropriate dose has been given.
˚ Packed red blood cell or whole blood transfusion can be considered if the patient is in
hemorrhagic shock.
˚ Platelets, fresh frozen plasma, cryoprecipitate, TXA, and other agents are not effective in
these cases due to the mechanism of the venoms.
• CYTOTOXIC SYNDROME: Separately mark the leading edge of both pain (dashed line) and
edema (solid line) with a permanent marker and record the time of observation next to
each line.
˚ It is important to keep the limb significantly elevated (>60º is ideal) whenever possible to
limit dependent edema and swelling.
Transport Factors
If the patient is being medically evacuated from the field or between roles of care, confirm that the
receiving facility has an adequate supply of the appropriate regionally specific antivenoms.
NOTE: Evacuation is not an alternative to antivenom administration. A patient whose snakebite
warrants evacuation will require antivenom. The earlier it is given, the greater the chance of full
recovery without permanent disability.
DO NOT delay administration of antivenom in the field if available to a patient with an
envenomation.
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32 • MEDICAL