Coral Snake Envenomation

16 years ago I arrived in Texas with a total experience of two patients who had been bitten by venomous snakes.  My first week I was called on six patients.  Welcome to April in Texas.  Since that time I was involved in the management of hundreds of snake bite patients.  One of my memories from Boy Scouts was learning, "Red on Yellow, kill a fellow, red on black venom lack".  Many of you learned the same rhythm.  All the text books tell us to treat coral snake bites with antivenom regardless of symptoms.  Their bite will "kill a fellow".  And that coral snake venom is the most toxic venom in the US.  Interestingly, no one ever seemed to get sick from a coral snake bite.  The only really sick patients I heard about had an adverse reaction to the antivenom.  Over a number of years we published numerous research abstracts and one paper on the Texas coral snake.  Our recommendation; do not treat people bitten by coral snakes with antivenom.  Coincidentally the current manufacturer of antivenom (Wyeth) ceased making it.  But in Florida, where a different coral snake species lives, the use of antivenom continued. 

Last week two fascinating developments occurred in the coral snake treatment saga.  First, the last few remaining supplies of antivenom had their expiration date extended by the FDA through October 31 of this year.  Good news, at least for a few weeks.  Second, a group of toxicologists in Florida presented their work on coral snake bites at the North American Congress of Clinical Toxicology.  They presented 12 years of data, 387 patients.  As expected the majority of patients were males bitten on their fingers and hands.  (There was no comment on co-ingestants, i.e. ethanol.)  65 % of the patients were given antivenom.  18.5 % of those had an adverse reaction.  Of interest, asymptomatic patients given antivenom when they initially arrived in the ED had the worse outcomes.  Those patients given antivenom only when they developed symptoms did better.  So following the textbook was bad for the patient.  Maybe Florida and Texas snakes are not so different after all. 

To give your patient antivenom or not, the controversy will remain.  Old practice habits die hard.  But ultimately it will make no difference, we won't have any antivenom to give.