Snake Bites

18th May 2026


When we talk about overseas travel and remote area risk assessments, many people imagine snake bites and IEDs as a plausible risk when in reality, for most people, more valid concerns would be environmental illness and D&V.

But, depending on where you are travelling, snake envenomation may be a very real concern.

Epidemiology

Accurate snakebite statistics are difficult to assemble because (1):

  • Non-fatal bites by venomous species are underreported by epidemiological databases

  • Poison centres are not consulted on all bites

  • Many bites are never reported beyond a primary treating facility.

  • Finally, an unknown but likely significant number of snakebite casualties never seek medical treatment, especially if alarming symptoms fail to develop.

With that in mind, snakebites are estimated to lead to as many as 9,000 emergency department visits annually in the United States. Venomous species account for approximately one-third of these visits, almost all of which are pit viper bites. (2)

In Australia, 16 deaths from envenomation were reported between 2000 and 2016. (3)

Most snakebite casualties are male, with white men 25 to 34 years old being at the greatest risk of life-threatening envenomations. (4)  This is commensurate with most trauma being associated with men participating in higher-risk activities and misadventure.

The majority of envenomations occur during intentional interaction with the snake, sometimes associated with alcohol or drug intoxication (5-7), and typically occur when people try to catch, kill, or interfere with a wild snake, as well as when handling or caring for captive snakes.  Bites from intentional encounters are predominantly on the hands and arms. (2)

Bites from unintentional encounters are predominantly on the lower extremities. (2) Certain protective clothing, such as leather or heavy boots, offers a protective barrier against envenomation, and denim may reduce the amount of venom by two-thirds.  (8, 9)

 

Types of Venomous Snakes

Whilst there are many thousands of sake species, only some are venomous, and only some of those are dangerous enough to present a danger to humans.  Many of these snakes are inoffensive or far too small to envenomate a person effectively.

In broad terms, the three families of venomous snakes of concern are Elapidae, Viperidae and Atractaspididae

Elapidae

These include

  • Cobra:  South and South East Asia and Africa.

  • Coral snake:  The southern United States through Central America to Argentina.

  • Taipan:  Australia and New Guinea

  • Mambas:  Sub-Saharan Africa

  • Kraits:  South and Southeast Asia, ranging from Pakistan to southern China, and down into Indonesia.

Characterized by their permanently erect fangs at the front of the mouth.   Most species are neurotoxic.  The main group of toxins are PLA2 and three-finger toxins (3FTx).

Other toxic components in some species comprise cardiotoxins and cytotoxins, which cause heart dysfunctions and cellular damage, respectively.  Cobra venom also contains hemotoxins that clot or solidify blood.

 

Viper

Viper species can be found across the Americas, Africa, Eurasia, and South Asia.

All viperines are venomous and have long (relative to non-vipers), hinged fangs that permit deep envenomation of their prey.  Most viper venom contains a range of protein-degrading enzymes, called proteases, that produce symptoms such as pain, strong local swelling and necrosis, blood loss from cardiovascular damage, complicated by coagulopathy.  Also being haemotoxic in nature, viperine venom causes vascular endothelial damage and haemolysis (rupturing of red blood cells).  Death is usually caused by a collapse in blood pressure.  

 

Atractaspididae

These include Mole vipers, stiletto snakes, or burrowing asps and are found in sub-Saharan Africa and parts of the Middle East, including Israel and Jordan.

Many of these snakes are inoffensive or far too small to envenomate a person effectively.  Some bites can still be excruciatingly painful, the stiletto snake, for example, and some can inflict severe tissue necrosis.

Some of the long-fanged species are able to envenomate even while their mouths are closed, and the typical grasp used by herpetologists to securely hold venomous snakes is not safe for this group.  (10, 11).  This ability to stab sideways even with a closed mouth is the basis for an English name used for some of them: "side-stabbing snakes" or "side-stabbers". (12)

 

Types of venom

Toxin Effects Snakes
Cardiotoxins Damage heart muscle (cardiomyocytes) by disrupting cell membranes, leading to depolarization, calcium influx, and ultimately, heart dysfunction or arrest. Cobras and Puff Adder
Cytotoxins Destroys cells and tissues (necrosis) at the site of the bite, causing severe pain, swelling, blistering, and potential limb damage, often through enzymes that attack cell membranes, leading to localized tissue death. Typically, Cobras and some spiders
Dendrotoxins Neurotoxins that work by blocking specific voltage-gated potassium channels in nerve cells, which enhances the release of the neurotransmitter acetylcholine, leading to increased nerve excitability, seizures, and potential respiratory paralysis in animals. Mambas
Haemotoxins Disrupt blood clotting either causing (cobra) or preventing clotting (viperidae).
Early signs of coagulopathy include uncontrollable bleeding from the wound site or bleeding gums.		 Vipers and Rattlesnakes
Myotoxins Muscle spasms and paralysis. Sea snakes and Crotaline
Neurotoxins Block nerve signals to muscles, leading to rapid paralysis, respiratory failure, and potentially death, often acting quickly and without intense localized pain.
Early signs of neurotoxicity include drooping eyelids followed by decreasing loss of motor control, starting with the digits.		 Cobras, Mambas, Kraits, and Death Adders.
Proteolytic Contains enzymes that break down proteins and tissues, aiding digestion and causing immediate local damage. Found in most venoms, especially vipers.



Symptoms

Severe tissue necrosis following Bothrops asper envenomation that required amputation above the knee. The person was an 11-year-old boy, bitten two weeks earlier in Ecuador, but treated only with antibiotics.

Gutiérrez JM, Theakston RD, Warrell DA (June 2006). "Confronting the neglected problem of snake bite envenoming: the need for a global partnership". PLOS Medicine. 3 (6) e150. doi:10.1371/journal.pmed.0030150. PMC 1472552. PMID 16729843.

Local tissue effects from hemotoxins can cause significant erythema, swelling, and tenderness at the envenomation site and can spread proximally and distally.

Local tissue effects are the most common physical manifestations of viper envenomations and occur in more than 90% of casualties with medically significant envenomations. (13)

Systemic symptoms, including hypotension, bleeding, angioedema, vomiting, and neurotoxicity, indicate more severe envenomation. (14)

Haematologic effects are multi-factorial and include the degradation of fibrinogen and platelet aggregation or destruction. Although the majority of casualties do not develop medically significant bleeding, the casualty should be carefully examined for petechiae, ecchymosis, gingival (gum) bleeding, epistaxis or retinal haemorrhage. (15)

Vomiting can also arise from an autonomic response to fear and anxiety, and may be misleading.  Hypotension can result from vasodilatation and third-spacing ( the unintentional passage of fluid through increased porosity of the vessel walls due to vasodilation into surrounding tissue or interstitial spaces. 

 

Treatment

  • Retreat

    • Immediately move away from the area where the bite occurred.

    • If the snake is still attached, use a stick or tool to make it let go.  Sea snake victims need to be moved to dry land to avoid drowning.

       

  • Identify

    • In areas where there are more than one naturally occurring venomous snake species and the offending snake has been killed, it should be brought with the casualty for identification.  Care should be taken to avoid touching the head, as even a dead or decapitated snake may have intact bite reflexes. (16, 17) 

    • No attempt should be made to pursue the snake into the undergrowth, risking further bites.

    • Try to identify the snake – determining whether the biting snake is a venomous species or not can make the difference between simple superficial wound care and a potentially hazardous and expensive evacuation.

    • There can be real difficulties in identifying snakes: 

      • A good photograph, however, carefully taken from a safe distance (i.e. of more than the length of the snake) can sometimes be sent via cell or satellite phone to an expert and may be valuable later for identification.

      • For the Responder familiar with envenomations, a positive identification of a non-venomous snake would not necessitate evacuation; however, identification must be certain.  Observation for the sake of risk stratification is not recommended. (1)

      • Field guides and other publications list literally hundreds of “dangerous” species literally; however, the taxonomy of these snakes remains incompletely defined as ongoing genetic analyses are improving species characterisation.  (18)  Some experts suggest the elimination of many subspecific designations altogether. (19)

      • Practically, there are issues with snake identification; anecdotally, most envenomated casualties describe simply seeing a dark flash as the snake quickly envenomates and moves away, usually into hiding.

         

  • Reassure

    • Many will fear sudden death and may behave irrationally or even hysterically.  The basis for reassurance is the fact that many venomous bites do not result in envenoming, the relatively slow progression to severe envenoming (hours following elapid bites, days following viper bites) and the effectiveness of modern medical treatment.

      • Many snake bites are caused by non-venomous snakes.

      • Many bites from venomous snakes are ‘dry bites’ where little or no venom is released.

      • On average, 50% of snakebites are dry bites (20), depending on where you are in the world:

        • Taipans inflict dry bites only 5% of the time. (21)

        • Cortalines (pit vipers, including rattlesnakes) deliver dry bites 25% of the time. (13)

        • Australian eastern brown snakes (Pseudonaja textilis) can inflict dry bites 80% of the time. (21)

    • A dry bite should never be assumed, and serial observations and laboratory tests should be performed as indicated to monitor the possible development of envenoming.  If there are fang marks and a positive identification of a venomous snake, one must assume there is associated envenomation and seek medical attention immediately because delaying care increases morbidity and mortality.  If evacuation is difficult or prolonged, the absence of local or systemic symptoms 8 hours after the bite may indicate a dry bite (1).

    • In most venomous snake bites, the risk of death is not immediate.

       

  • Initiate Evacuation

    • Remove any constrictions (rings, bracelets, shoes etc. ) from the injured limb in anticipation of swelling.

    • Arrange urgent evacuation:  There is nothing that can be done in the field to significantly alter the outcome of a serious snake bite, and field first aid should not delay rapid transfer to a facility capable of safely administering antivenom. (22) 

    • Evacuation must be to a healthcare facility with access to antivenom.  The nearest healthcare facility should be contacted ahead of time. If antivenom is unavailable, it may be sent from another facility, or the casualty’s immediate transport to a different facility should be arranged. This process can also be coordinated by contacting poison control directly.

      Further reading:  Travel Risk Assessments

    • First aid and wound care can be administered whilst waiting for evacuation or en route.

    • Time and date of the snake bite should be noted, either on the casualty or in an incident report. 

    • The circumference of the bitten appendage should be measured above and below the snake bite for later comparison and determination of subsequent swelling. (23, 24)

 

Immobilisation & Pressure bandages

The benefit of pressure immobilisation bandaging depends on whether the bite is from a viper or elapid:

Vipers

Pressure Immobilisation is not recommended for Viper bites. (25-27)  There have been no studies directly assessing immobilisation alone for the improvement of snake bite outcomes.  Limiting movement of the affected area by immobilisation with splinting techniques (without compression) may benefit the casualty, although no rigorous trials have validated this practice.

Crotaline venom causes more localised tissue damage, and pressure bandaging may instead increase the severity of tissue damage; one animal study demonstrated lethal hyperkalemia when the pressure wrap was removed. (28)

 

Elipidae

There is some evidence that pressure bandaging can decrease morbidity and mortality in life-threatening Elapidae snakebites containing neurotoxic venom (such as Australian or elapids or the Black Mamba in Sub-Saharan Africa) (27, 29) and Coral snakes (30).

Pressure bandaging must be applied appropriately:  two studies indicated that physicians and lay people rarely apply pressure bandaging correctly (31-33), and a third showed that even after training, practitioners were still unsuccessful at effective immobilisation in cases of simulated snakebites. (34)

Pressure bandaging is thought to restrict the blood flow and progression of venom to systemic circulation by reducing lymphatic and venous return.  One study using a porcine model with a lethal dose of venom showed that pressure immobilisation increased intracompartmental pressure after envenomation and delayed mortality. (35)

  • The limb and joints should be kept in a functional position in case they swell or the joints become immobile.  (36,37)

  • Tourniquets are not recommended as they can lead to ischemia and compartment syndrome, which can result in a higher amputation frequency or antivenom requirements.  No studies have conclusively demonstrated that tourniquets improve casualty outcomes.  (22, 38, 39)

Further Reading – Compartment Syndrome

Vomiting may occur, so place the unconscious casualty in the Safe Airway Position.

Closely monitor the airway and breathing and be ready to resuscitate if necessary.

Further Reading: CPR in Remote Environments

 

Wound Care and Infection

Snakebites should be approached in a manner similar to that for any other puncture wound or laceration.  Without delaying transport, the wound should be quickly cleaned in standard fashion (soap and running water, high-pressure irrigation or an antiseptic solution or both) and a sterile dressing applied to protect the wound. (40)

Anaerobic and aerobic bacteria can be introduced by the snake’s fangs during the bite.  (41)

  • Despite this inoculation, wound infections occur in only 3% of pit viper bites.  (42)

  • A prospective trial compared prophylactic antibiotic treatment to none after pit viper envenomation and found no significant differences in rates of infection between the groups. (43)  One analysis noted 0% infection rate after crotaline envenomation and prophylactic antibiotics.  (44)

  • Chloramphenicol failed to reduce the frequency of abscess formation complicating pit viper snakebites in a randomised controlled trial. (45)

  • Based on current evidence, prophylactic antibiotics are not recommended, and antibiotics should only be administered if signs of infection develop, such as purulence (other signs of infection may be obscured by local tissue changes caused by venom (1) ).

Any significant open wounds should be treated with moist dressings changed twice daily, and large debrided areas treated with negative pressure dressings.  (40)

Tetanus immunisation should be updated if needed. (46)

In Viperidae bites where pressure immobilisation is not recommended, early active and passive physical therapy with range of motion is recommended, especially for hand and digit bites to avoid stiffness and long-term dysfunction. (47)

 

Pain Relief

Opioids are preferred for pain control.  Aspirin and nonsteroidal anti-inflammatory drugs are relatively contraindicated owing to risks of increased bleeding, platelet dysfunction, and potential for renal issues in casualties with rhabdomyolysis.  (48-50)

 

Antivenoms

Anitvenoms alone are not a panacea; Intravenous access should be achieved early, the hydration state determined and corrected if needed, and vital signs must be closely monitored.

The early administration of an adequate dose of effective antivenom to casualties with signs of envenomation is critical, so plans should be made in advance to identify the nearest sources of antivenom.  If this is not possible, then symptomatic treatment, including support of airway patency and breathing, maintenance of circulation and control of bleeding, pain relief and the treatment of local wounds, should be prioritised as appropriate.


Special Cases

Pregnancy

Pregnant women with envenomations should be managed in close collaboration with an obstetrician.  Snakebite envenomations may lead to increased morbidity to the foetus, and as many as 20% of documented viper envenomations in pregnancy have associated foetal death, with or without antivenom treatment. There have been no reported adverse reactions to crotaline antivenom in the mother or fetus (51); however, owing to envenomation, the foetus is at higher risk of coagulopathy-related complications such as placental abruption. (52)  

Therefore, snakebite casualties who are pregnant should receive antivenom as indicated and foetal assessment or monitoring. (53)

 

Paediatrics

Pediatric viper snakebite casualties should receive the same dose of crotaline FabAV antivenom as an adult.  The antivenom counteracts snake venom and is dosed according to the amount of venom injected, not the casualty’s body weight.  Crotaline FabAV Antivenom has been shown to be safe to use in paediatric and infant populations.  (54-59)

 

Anaphylaxis

Antivenom-induced hypersensitivity reactions and serum sickness occur in approximately 8% and 13%, respectively, of casualties treated with FabAV.  (60)  Some can be severe, and providers should be prepared to treat with adrenaline, steroids, antihistamines and emergency airway management. (61)

Pretreatment for the prophylaxis of allergic reactions should be given to casualties who have had prior allergic reactions to antivenom and should be considered for casualties with a history of asthma, atopy, or multiple allergies.

 

Diagnostics

Spontaneous haemorrhage due to envenoming by some snake species is an important clinical indication for antivenom.  Diagnosis is aided by a test known as the 20 Minute Whole Blood Clotting Test (20WBCT).  A clean, dry glass bottle or vial into which 1-2 millilitres of venous blood is added, is allowed to stand at room temperature for 20 minutes, and is then inverted and the presence or absence of a complete clot is recorded. Where a blood clot is present, the test result is negative, whereas if no clot forms and the blood remains liquid, the test result is positive, indicating the presence of a coagulopathy and the need for antivenom treatment.

The result should be communicated to the receiving facility as this can improve the reporting of snakebite envenoming and assist in determining optimal antivenom needs for regions.

 

DO NOT

  • Use a mechanical suction device or ‘venom extractor’; experimental models showed that mechanical suction devices can increase localised tissue damage around the wound in the shape of the device, causing tissue necrosis and sloughing, resulting in tissue loss that prolonged healing by weeks. (62-66)

  • Attempt to suck venom from the wound; it is ineffective, can introduce bacteria to the wound and can be potentially dangerous for the person performing the suction (62, 66)

  • Use electrical shock therapy.  (67-69)

  • Use ice.  Packing the affected limb in ice (cryotherapy) is contraindicated, as it may worsen necrosis.  (70-72)

  • Use aspirin or Ibuprofen, as these may exacerbate haemorrhage bleeding.

  • Use alcohol on the wound or as an oral analgesic.

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