Coral bite: Coral Snake Bite Treatment | Poison Control

07.04.202121.07.2023 by alexxlab

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Coral Snake Bite Treatment | Poison Control

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“Red touch yellow, kills a fellow; red touch black, venom lack.“ Of all the childhood rhymes we’ve grown up learning, this one might be high on the list of ones to remember if you live in coral snake country. If you aren’t familiar with this saying, it refers to distinguishing the venomous coral snake from its nonvenomous look-alikes (e.g., the king snake, shovel-nosed snake, and milk snake). It’s important to note that this general rule doesn’t apply to non-native coral snake species, which might have different patterns. Coral snakes are members of the Elapidae family, which includes cobras. Coral snakes usually have a pattern of red, black, yellow (or white) colored rings that span their bodies. For the purposes of this article, we’ll focus primarily on the three species found in the US, which are:

Eastern coral snake (Micrurus fulvius) – Found in Florida and the southeastern US
Texas coral snake (Micrurus tener) – Found in Texas and northwestern Mexico
Arizona or Sonoran coral snake (Micruroides euryxanthus) – Found in southeastern US, and Sonora, Mexico)

By nature, coral snakes are reclusive and seldom bite unless they’re provoked or threatened. Compared to their pit viper counterparts (e.g., rattlesnakes), coral snake bites are uncommon and represent only about 2% of snake bites reported to US Poison Centers annually. Of the three species in the US, bites by the eastern coral snake tend to be the most severe, while those of the Arizona/Sonoran and Texas coral snakes aren’t generally associated with serious side effects or death.

Coral snakes have small, fixed fangs, and when they bite they tend to latch onto their prey and “chew” for a few seconds in order to deliver their venom. Compared to other venomous snakes, their bite marks can be easily missed, often showing no significant local tissue damage, obvious injury, or pain. However, the venom of the Eastern coral snake contains very potent neurotoxins that can cause severe illness or death if left untreated. The neurotoxic venom blocks an important neurotransmitter called acetylcholine, which is important for the activation of muscles in the body. Blockade of acetylcholine after envenomation can lead to weakness and paralysis and even complete respiratory failure in severe cases. The effects of the venom are usually delayed (up to 13 hr) but progress rapidly once they develop. Symptoms of a coral snake envenomation can include nausea, vomiting, paresthesias (abnormal sensations), slurred speech, double vision, ptosis (drooping eye), muscle twitching, weakness, and paralysis. The major cause of death from coral snake envenomations is respiratory failure as a result of neuromuscular weakness.

Given the potentially serious outcomes after a coral snake bite, all people with a suspected envenomation should be seen in a hospital immediately and observed for at least 24 hours. The traditional treatment for coral snake envenomation has been a horse-derived IgG antibody antivenom produced by Wyeth Pharmaceuticals (now a subsidiary of Pfizer, Inc.) called the North American Coral Snake Antivenin. However, the manufacturer stopped production in 2006. The remaining available antivenom has passed the manufacturer-assigned expiration date of 2008, but FDA continues to provide information on expiration date extensions based evaluation of stability data. Because having a supply of the antivenom is uncommon in most hospitals, healthcare providers need to work with their regional Poison Control Center to locate a source of supply. If the antivenom is available, if and when to start is decided on a case-by-case basis after careful risk/benefit assessment as antivenom administration is not without dangers. If the antivenom is unavailable, management of the patient is focused on supportive care, which includes airway management with mechanical ventilation. There are other treatment options that have been shown to possibly provide benefit for certain coral snake bites, like the anticholinesterase drug neostigmine. However, data on its efficacy is limited and inconsistent. In all cases, discussion among the healthcare providers, Poison Control Centers, and toxicologists is key to providing optimal care for each patient.

If you or someone you know has been bitten by a coral snake, seek medical attention by calling 911 or Poison Control (1-800-222-1222), or use the webPOISONCONTROL^®^{^{online tool for guidance.}}

Kristina Yee, PharmD
Certified Specialist in Poison Information

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Prevention Tips

Coral snakes aren’t usually aggressive unless they feel threatened or are provoked. If you come across one, leave it alone!
If someone has been bitten by a coral snake, seek medical evaluation immediately. Do NOT wrap the area in a tourniquet, cut the wound, or attempt to “suck the venom out.” None of these are helpful and can potentially make things worse.

This Really Happened

Case 1. A 9-year-old boy was bitten on the right index finger after a coral snake was thrown at him. He reported local and radiating pain at the bite site as well as abdominal pain. One hour after the incident, he was taken to a hospital and received 5 vials of antivenom. He was observed in the ICU and only developed mild local swelling. He was discharged after 3 days in the hospital.

Case 2. A 15-year-old girl was bitten on her arm by an exotic coral snake. She was taken to a hospital and observed in the ICU. She was not treated with antivenom due to its unavailability. Her only reported symptoms were vomiting and swelling, and she was discharged after 3 days in the hospital.

Case 3. A 6-year-old boy was bitten while catching a coral snake. He developed anaphylaxis during antivenom administration. Nine hours after the bite he had drooling and difficulty swallowing and required mechanical ventilation for 8 days. He was discharged after 16 days in the hospital.

For More Information

Expiration date extension for North American coral snake antivenin (Micurus fulvius) (equine origin) lot L67530 through January 32, 2020. Silver Spring (MD): US Food and Drug Administration; 2019 Feb 1 [cited 2020 Aug 31].

Sartore J. Eastern coral snake [photo].Washington: National Geographic Society [cited 2020 Aug 31].

References

Corbett B, Clark RF. North American snake envenomation. Emerg Med Clin North Am. 2017 May;35(2):339-54.

Hessel MM, Sauerberg N, McAninch SA. Coral snake toxicity. Treasure Island (FL): StatPearls Publishing; 2020 Apr 23 [cited 2020 Aug 31].

Hoffman, RS, Howland, MA, Lewin, NA, Nelson, LS, Goldfrank, LR, editors. Goldfrank’s toxicologic emergencies. 10th ed. New York: McGraw Hill; c2015. Chapter 122, Native (US) venomous snakes and lizards.

McAninch SA, Morrissey RP, Rosen P, Meyer TA, Hessel MM, Vohra MH. Snake Eyes: Coral Snake Neurotoxicity Associated With Ocular Absorption of Venom and Successful Treatment With Exotic Antivenom. J Emerg Med. 2019 May;56(5):519-522.

Pawar DK, Singh H. Elapid snake bite. Br J Anaesth. 1987 Mar;59(3):385-7.

Peterson ME. Snake bite: coral snakes. Clin Tech Small Anim Pract. 2006 Nov;21(4):183-6.

Sánchez EE, Lopez-Johnston JC, Rodríguez-Acosta A, Pérez JC. Neutralization of two North American coral snake venoms with United States and Mexican antivenoms. Toxicon. 2008 Feb;51(2):297-303.

Sasaki J, Khalil PA, Chegondi M, Brzezinski A, Meyer KG, et al. Coral snake bites and envenomation in children: a case series. Pediatr Emerg Care. 2014 Apr;30(4):262-5.

Wood A, Schauben J, Thundiyil J, Kunisaki T, Sollee D, et al. Review of eastern coral snake (Micrurus fulvius fulvius) exposures managed by the Florida Poison Information Center Network: 1998-2010. Clin Toxicol (Phila). 2013 Sep-Oct;51(8):783-8.