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CORAL SNAKES

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Coral snakes found in the United States have broad rings of red and black separated by narrow rings of yellow. Several harmless snakes in the United States have red and yellow rings separated by black rings. Coral snakes from other countries may not have the characteristic "red on yellow" markings. Micrurus laticollaris, a coral snake from Southern Mexico, has a red on black banding pattern.

Specific Substances

    A) CORAL SNAKES IN THE UNITED STATES
    1) MICRUROIDES EURYXANTHUS (SCIENTIFIC NAME)
    2) WESTERN CORAL SNAKE (COMMON NAME)
    3) MICRUROIDES EURYXANTHUS EURYXANTHUS (SCIENTIFIC NAME)
    4) ARIZONA CORAL SNAKE (COMMON NAME)
    5) MICRURUS FULVIUS (SCIENTIFIC NAME)
    6) EASTERN CORAL SNAKE (COMMON NAME)
    7) MICRURUS FULVIUS FULVIUS (SCIENTIFIC NAME)
    8) EASTERN CORAL SNAKE (COMMON NAME)
    9) MICRURUS FULVIUS TENERE (SCIENTIFIC NAME)
    10) TEXAS CORAL SNAKE (COMMON NAME)
    11) Reference: Gomez & Dart, 1995
    CORAL SNAKES OF MEXICO
    1) MICRURUOIDES EURYSANTHUS (SCIENTIFIC NAME)
    2) CORALILLO DE SONORA (COMMON NAME)
    3) MICRURUS BERNADI (SCIENTIFIC NAME)
    4) CORAL, CORALILLO (COMMON NAME)
    5) MICRURUS BOGERTI (SCIENTIFIC NAME)
    6) CORAL, CORALILLO (COMMON NAME)
    7) MICRURUS BROWNI (SCIENTIFIC NAME)
    8) CORAL DE CANUTOS (COMMON NAME)
    9) MICRURUS DIASTEMA (SCIENTIFIC NAME)
    10) CORAL, CORALILLO (COMMON NAME)
    11) MICRURUS DISTANS (SCIENTIFIC NAME)
    12) CORAL, CORALILLO (COMMON NAME)
    13) MICRURUS ELEGANS (SCIENTIFIC NAME)
    14) CORAL PUNTEADO (COMMON NAME)
    15) MICRURUS EPHIPPIFER (SCIENTIFIC NAME)
    16) CORAL, CORALILLO (COMMON NAME)
    17) MICRURUS FULVIUS (SCIENTIFIC NAME)
    18) CORAL, CORALILLO (COMMON NAME)
    19) MICRURUS LATICOLLARIS (SCIENTIFIC NAME)
    20) CORAL, CORALILLO (COMMON NAME)
    21) MICRURUS LATIFASCIATUS (SCIENTIFIC NAME)
    22) CORAL, CORALILLO (COMMON NAME)
    23) MICRURUS LIMBATUS (SCIENTIFIC NAME)
    24) CORAL, CORALILLO (COMMON NAME)
    25) MICRURUS PROXIMANS (SCIENTIFIC NAME)
    26) CORAL, CORALILLO (COMMON NAME)
    27) MICRURUS NIGROCINCTUS (SCIENTIFIC NAME)
    28) CORAL, CORALILLO (COMMON NAME)
    29) Reference: Gomez & Dart, 1995.
    CORAL SNAKES OF CENTRAL AMERICA
    1) MICRURUS ALLENI (SCIENTIFIC NAME)
    2) CORAL, CORALILLO (COMMON NAME)
    3) MICRURUS ANCORALIS (SCIENTIFIC NAME)
    4) CORAL, CORALILLO (COMMON NAME)
    5) MICRURUS BROWNI (SCIENTIFIC NAME)
    6) CORAL, CORALILLO (COMMON NAME)
    7) MICRURUS CLARKI (SCIENTIFIC NAME)
    8) CORAL, CORALILLO (COMMON NAME)
    9) MICRURUS DIASTEMA (SCIENTIFIC NAME)
    10) CORAL, CORALILLO (COMMON NAME)
    11) MICRURUS DISSOLEUCUS (SCIENTIFIC NAME)
    12) CORAL, CORALILLO (COMMON NAME)
    13) MICRURUS ELEGANS (SCIENTIFIC NAME)
    14) CORAL, CORALILLO (COMMON NAME)
    15) MICRURUS HIPPOCREPIS (SCIENTIFIC NAME)
    16) CORAL, CORALILLO (COMMON NAME)
    17) MICRURUS LATIFASCIATUS (SCIENTIFIC NAME)
    18) CORAL, CORALILLO (COMMON NAME)
    19) MICRURUS MIPARTITUS (SCIENTIFIC NAME)
    20) CORAL, GARGANTILLA (COMMON NAME)
    21) MICRURUS NIGROCINCTUS (SCIENTIFIC NAME)
    22) CORAL, CORALILLO (COMMON NAME)
    23) MICRURUS RUATANUS (SCIENTIFIC NAME)
    24) CORAL, CORALILLO (COMMON NAME)
    25) MICRURUS STUARTI (SCIENTIFIC NAME)
    26) CORAL, CORALILLO (COMMON NAME)
    27) MICRURUS STEWARTI (SCIENTIFIC NAME)
    28) CORAL, GARGANTILLA (COMMON NAME)
    29) Reference: Gutierrez, 1995
    CORAL SNAKES OF SOUTH AMERICA
    1) MICRURUS CORALLINUS
    2) MICRURUS FRONTALIS
    3) MICRURUS HEMPRICHI
    4) MICRURUS IBIBBOCA
    5) MICRURUS LEMINISCATUS
    6) MICRURUS SPIXII
    7) MICRURUS SURINAMENSIS
    8) Reference: Fan & Cardoso, 1995
    GENERAL TERMS
    1) CORAL SNAKES
    2) SNAKES, CORAL
    3) SNAKE VENOM POISONING, CORAL
    4) SNAKE BITE (CORAL)

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) SPECIES/GEOGRAPHIC LOCATION: Coral snakes are venomous elapids that can bite and envenomate. Bites by the Eastern coral snake, Micrurus fulvius (found in Florida, Georgia, Alabama, Mississippi, South Carolina and possibly Louisiana) are generally more toxic than the Texas coral snake, Micrurus tener (found in Texas, Louisiana, and Arkansas). Bites by the Western (Arizona) coral snake, Micruroides euryxanthus (found in Arizona, New Mexico) have not produced significant toxicity.
    B) PHYSICAL DESCRIPTION: Coral snakes found in the United States have broad rings of red and black separated by narrow rings of yellow. Several harmless snakes in the United States have red and yellow rings separated by black rings. Coral snakes from other countries may not have the characteristic "red on yellow" markings or may have them reversed. The pupils are round.
    C) TOXICOLOGY: Coral snake venom contains primarily pre- and post-synaptic neurotoxins as well as a cardiotoxin. In general, they lack proteolytic enzymes. Envenomation can result in cranial nerve paralysis, progressing to respiratory paralysis. Nausea and vomiting are common and local swelling, without necrosis, occurs in up to 40% of patients.
    D) EPIDEMIOLOGY: These snakes are not aggressive, and bites are not common (estimated 20 to 25 bites a year in the United States) and are often in the setting of handling the snake. Bites generally occur in endemic areas. Collectors, zoo workers and others who handle snakes are also at risk.
    E) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE ENVENOMATION: Envenomation by the Eastern coral snake (M. fulvius) and Texas coral snake (M. tener) can result in major neurologic dysfunction, including cranial nerve paralysis (i.e., diplopia, ophthalmoplegia, dysphonia, dysphagia, ptosis and loss of pupil reactivity), paresthesia, dizziness, weakness, confusion, dyspnea, and fasciculations. Respiratory paralysis is the immediate cause of death. Nausea and vomiting are also common. Local signs and symptoms may occur in up to 40% of individuals, but are usually mild and often misleading. The lack of major local findings is not uncommon even in severe coral snake envenomations. While dry bites do occur, many patients develop evidence of envenomation, although signs and symptoms may be delayed.
    a) ONSET: A lack of early symptoms is not uncommon, even in major envenomations. Symptoms may be delayed for up to 13 hours; however, once symptoms appear the effects tend to progress rapidly.
    b) INCIDENCE: Envenomation occurred in 75% of persons bitten in one series.
    2) SEVERE ENVENOMATION: The most severe effects involve neurologic dysfunction and respiratory paralysis. These may be delayed for up to 13 hours; however, once symptoms appear the effects tend to progress rapidly.
    0.2.3) VITAL SIGNS
    A) WITH POISONING/EXPOSURE
    1) Respiratory depression and hypotension may occur.
    0.2.5) CARDIOVASCULAR
    A) WITH POISONING/EXPOSURE
    1) Tachycardia is common.
    0.2.6) RESPIRATORY
    A) WITH POISONING/EXPOSURE
    1) Dyspnea progressing to respiratory paralysis is a major complication.
    0.2.7) NEUROLOGIC
    A) WITH POISONING/EXPOSURE
    1) Weakness and paralysis usually start with cranial nerves and may progress to diffuse muscle weakness and respiratory paralysis. Ptosis, ophthalmoplegia, diplopia, and difficulty speaking are common early effects.
    2) Euphoria, anxiety, lethargy, drowsiness and headache have been reported.
    0.2.8) GASTROINTESTINAL
    A) WITH POISONING/EXPOSURE
    1) Nausea, vomiting and salivation are common.
    0.2.14) DERMATOLOGIC
    A) WITH POISONING/EXPOSURE
    1) Local effects are generally mild. Apparent envenomation has been reported without evidence of fang marks.
    0.2.15) MUSCULOSKELETAL
    A) WITH POISONING/EXPOSURE
    1) Muscle pain and tenderness have been observed.

Laboratory Monitoring

    A) Monitor respiratory rate, vital signs and neurologic status.
    B) Pulse oximetry and/or arterial blood gas values may be useful in assessing respiratory function.
    C) Coral snake venom does not appear to result in any significant hematologic, electrolyte, or coagulation defects.
    D) Serial pulmonary function studies (negative inspiratory force, vital capacity) may be helpful in assessing respiratory function.

Treatment Overview

    0.4.7) BITES/STINGS
    A) MANAGEMENT OF MILD TO MODERATE ENVENOMATION
    1) Monitor respiratory and neurologic function closely; respiratory paralysis is the immediate cause of death. Local signs and symptoms may occur, but are usually mild (a lack of major local findings is not uncommon even with severe envenomations). While dry bites do occur many patients develop evidence of envenomation. Signs and symptoms may be delayed up to 13 hours. Establish intravenous access. Serious symptoms may occur rapidly. Antivenom is recommended for a confirmed M. fulvius bite and possibly bites by M. tener.
    B) MANAGEMENT OF SEVERE ENVENOMATION
    1) Neurologic and respiratory dysfunction may develop rapidly; an intensive care setting is indicated. Monitor respiratory effort, pulse oximetry and arterial blood gases. Rapid endotracheal intubation may be needed if bulbar paralysis develops. Administer antivenin as appropriate; immediate resuscitation equipment and anaphylaxis treatment should be available.
    C) DECONTAMINATION
    1) PREHOSPITAL: Immobilize the bite site in the functional position at or below heart level. Consider applying a pressure immobilization bandage. Use a wide, elastic, stretchy, crepe bandage (10 cm wide and at least 4.5 meters) or any long strip of material. Wrap the bandage firmly around the entire bitten limb; start distally around the fingers or toes and move proximally to include a rigid splint. The bandage should be wrapped similar to a sprained ankle in which the wrap is sung, but does not occlude the peripheral pulses and a finger can be easily slipped between the layers. Establish intravenous access. Monitor vital signs, and monitor carefully for evidence of neurologic or other venom effects.
    2) HOSPITAL: Due to the possible rapid onset of serious symptoms, coral snake antivenom is recommended for confirmed bites by M. fulvius and possibly bites by M. tener. Some practitioners observe bites by M. tener and initiate treatment at the first sign of neurologic toxicity. Bites by the Arizona coral snake (Micruroides euryxanthus) do not generally require antivenom. Coral snake venom does not appear to result in any significant hematologic, electrolyte, or coagulation defect. CONTRAINDICATED TREATMENTS: Do NOT apply arterial or venous tourniquets. Do NOT incise or suck on the bite; apply heat or cold; or perform other invasive local measures.
    D) AIRWAY MANAGEMENT
    1) Monitor pulse oximetry and/or arterial blood gas values to assess respiratory function. Serial pulmonary function studies (negative inspiratory force, vital capacity) may be helpful in assessing respiratory function. Endotracheal intubation is recommended if any signs of bulbar paralysis develops.
    E) ANTIDOTE
    1) Wyeth-Ayerst has stopped the production of the Antivenin Micrurus fulvius, the only USFDA approved coral snake antivenom. (NOTE: The manufacturer reports that although the antivenom is no longer produced, supplies are still available. Contact the manufacturer for further information; the US FDA extended the expiration date of the antivenin for use until October 31, 2009). If available, the recommended dose is 3 to 5 vials diluted in 250 to 500 mL of NaCl 0.9% as soon as possible after a confirmed bite and before signs and symptoms develop. ADDITIONAL DOSING: If manifestations do develop or progress, an additional 3 to 5 vials may be given.
    2) ALTERNATIVE ANTIVENIN THERAPY: The following antivenins have shown efficacy in an animal model of Micrurus fulvius coral snake envenomation and may be considered if the FDA-approved product is not available: Micrurus antivenom (Coralmyn(R), Instituto Bioclon, Mexico City), Anti-Coral Polyvalent Antivenom (Instituto Clodomiro Picado, Costa Rica), and Notechis antivenom (Tiger Snake Antivenom, CSL Limited, Australia). In addition, a variety of coral snake antivenoms (i.e., Central and South American Micrurus envenomations) have been developed with varying degrees of cross-species activity. A regional poison center (1-800-222-1222) can assist in locating the nearest source of exotic antivenoms. WESTERN (ARIZONA) CORAL SNAKE: Antivenom is NOT available for patients bitten by the Western Coral Snake (Micruroides euryxanthus); treatment is supportive.
    F) SKIN TEST
    1) Skin testing with antivenoms has not been found to be completely reliable in predicting which patients might react to the antivenom. A positive result should not preclude its use when indicated, and a negative result should not fail to prepare and treat a potential hypersensitivity reaction. Since the antivenom is effective at stopping progression, but not readily reversing effects, treatment of life-threatening effects should not be delayed for a skin test.
    G) ALLERGIC REACTION
    1) Pretreatment is not recommended. MILD/MODERATE: Antihistamines with or without inhaled beta agonists, corticosteroids or epinephrine. SEVERE: Oxygen, aggressive airway management, antihistamines, epinephrine, and corticosteroids. Additional treatment includes IV fluids. Monitor ECG and respiratory function. Perform endotracheal intubation and begin mechanical ventilation as indicated.
    H) NEOSTIGMINE
    1) Neostigmine has been used to prevent or reverse neurotoxicity in several South American coral snake envenomations. It may be considered with North American coral snake envenomations as an adjunct or when antivenom is not available. The suggested dose is 0.5 to 2 mg by slow intravenous push, which is similar to reverse neuromuscular blockade by neuromuscular paralytic agents. Atropine may be used to prevent or mitigate unwanted cholinergic effects.
    I) PATIENT DISPOSITION
    1) HOME CRITERIA: As there is no reliable method to determine if envenomation has occurred, any individual who has been bitten by a "positively identified" coral snake should be hospitalized for observation and/or treatment. Even if asymptomatic, patients should be observed for 24 hours for development of late symptoms.
    2) OBSERVATION CRITERIA: Observation and/or treatment must be in a facility with equipment and healthcare personnel necessary for oxygen administration, assisted or controlled respiration, and endotracheal intubation. Observation should include monitoring of respiratory rate, vital signs, and neurologic status. Adequate supplies of antivenom should be available or obtained, if possible. The patient should be transferred to an appropriately staffed/equipped facility if these are not available at the initial treating facility.
    3) CONSULT CRITERIA: Consultation with a medical toxicologist or regional poison center is recommended for any known or suspected coral snake bite.

Range Of Toxicity

    A) An estimated human (adult) lethal dose of dried coral snake venom is 4 to 5 milligrams. A large coral snake has the potential to inject in excess of 20 milligrams.
    B) Venom from the Arizona coral snake (Micruroides) is much less toxic than the Micrurus species; there are no reported fatalities with the Arizona coral snake.

Clinical Effects

Summary Of Exposure

    A) SPECIES/GEOGRAPHIC LOCATION: Coral snakes are venomous elapids that can bite and envenomate. Bites by the Eastern coral snake, Micrurus fulvius (found in Florida, Georgia, Alabama, Mississippi, South Carolina and possibly Louisiana) are generally more toxic than the Texas coral snake, Micrurus tener (found in Texas, Louisiana, and Arkansas). Bites by the Western (Arizona) coral snake, Micruroides euryxanthus (found in Arizona, New Mexico) have not produced significant toxicity.
    B) PHYSICAL DESCRIPTION: Coral snakes found in the United States have broad rings of red and black separated by narrow rings of yellow. Several harmless snakes in the United States have red and yellow rings separated by black rings. Coral snakes from other countries may not have the characteristic "red on yellow" markings or may have them reversed. The pupils are round.
    C) TOXICOLOGY: Coral snake venom contains primarily pre- and post-synaptic neurotoxins as well as a cardiotoxin. In general, they lack proteolytic enzymes. Envenomation can result in cranial nerve paralysis, progressing to respiratory paralysis. Nausea and vomiting are common and local swelling, without necrosis, occurs in up to 40% of patients.
    D) EPIDEMIOLOGY: These snakes are not aggressive, and bites are not common (estimated 20 to 25 bites a year in the United States) and are often in the setting of handling the snake. Bites generally occur in endemic areas. Collectors, zoo workers and others who handle snakes are also at risk.
    E) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE ENVENOMATION: Envenomation by the Eastern coral snake (M. fulvius) and Texas coral snake (M. tener) can result in major neurologic dysfunction, including cranial nerve paralysis (i.e., diplopia, ophthalmoplegia, dysphonia, dysphagia, ptosis and loss of pupil reactivity), paresthesia, dizziness, weakness, confusion, dyspnea, and fasciculations. Respiratory paralysis is the immediate cause of death. Nausea and vomiting are also common. Local signs and symptoms may occur in up to 40% of individuals, but are usually mild and often misleading. The lack of major local findings is not uncommon even in severe coral snake envenomations. While dry bites do occur, many patients develop evidence of envenomation, although signs and symptoms may be delayed.
    a) ONSET: A lack of early symptoms is not uncommon, even in major envenomations. Symptoms may be delayed for up to 13 hours; however, once symptoms appear the effects tend to progress rapidly.
    b) INCIDENCE: Envenomation occurred in 75% of persons bitten in one series.
    2) SEVERE ENVENOMATION: The most severe effects involve neurologic dysfunction and respiratory paralysis. These may be delayed for up to 13 hours; however, once symptoms appear the effects tend to progress rapidly.

Vital Signs

    3.3.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Respiratory depression and hypotension may occur.
    3.3.2) RESPIRATIONS
    A) WITH POISONING/EXPOSURE
    1) Dyspnea progressing to respiratory paralysis has been reported (Kitchens & Van Mierop, 1987).
    3.3.4) BLOOD PRESSURE
    A) WITH POISONING/EXPOSURE
    1) Hypotension has been reported.
    3.3.5) PULSE
    A) WITH POISONING/EXPOSURE
    1) Tachycardia and a weak and irregular pulse has been observed.

Heent

    3.4.3) EYES
    A) WITH POISONING/EXPOSURE
    1) Diplopia or blurring of vision are common cranial nerve effects (Vital Brazil & Vieira, 1996; (Kitchens & Van Mierop, 1987; Pettigrew & Glass, 1985).
    2) Paralysis of the extraocular muscles is also common (Vital Brazil & Vieira, 1996; Coelho et al, 1992).
    3) Pupils may be miotic, mydriatic or mid-position and unreactive (Manock et al, 2008; Coelho et al, 1992; Van Mierop, 1976a; Parrish & Khan, 1967) .
    4) Ptosis is a common manifestation of cranial nerve paralysis (Manock et al, 2008; Vital Brazil & Vieira, 1996; Coelho et al, 1992).
    3.4.6) THROAT
    A) WITH POISONING/EXPOSURE
    1) Dysphonia and slurred speech may develop secondary to cranial nerve weakness (Pettigrew & Glass, 1985; Van Mierop, 1976a; Coelho et al, 1992)
    2) Dysphagia may also develop (Manock et al, 2008; Coelho et al, 1992; Pettigrew & Glass, 1985; Van Mierop, 1976a)

Cardiovascular

    3.5.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Tachycardia is common.
    3.5.2) CLINICAL EFFECTS
    A) HYPOTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) Hypotension has been reported.
    B) HYPERTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 66-year-old man with a history of hypertension presented with a blood pressure of 200/130 mmHg after envenomation by Micrurus corallinus (Coelho et al, 1992).
    C) TACHYARRHYTHMIA
    1) WITH POISONING/EXPOSURE
    a) In a series of three patients envenomated by Micrurus corallinus, two presented with tachycardia (Coelho et al, 1992). Tachycardia has also been reported in other cases of coral snake envenomation (Pancorbo et al, 2000).

Respiratory

    3.6.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Dyspnea progressing to respiratory paralysis is a major complication.
    3.6.2) CLINICAL EFFECTS
    A) DYSPNEA
    1) WITH POISONING/EXPOSURE
    a) Dyspnea has been reported (Vital Brazil & Vieira, 1996; Kitchens & Van Mierop, 1987).
    B) PARALYSIS
    1) WITH POISONING/EXPOSURE
    a) Fatal respiratory paralysis has occurred within four hours of an envenomation (Kitchens & Van Mierop, 1987).

Neurologic

    3.7.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Weakness and paralysis usually start with cranial nerves and may progress to diffuse muscle weakness and respiratory paralysis. Ptosis, ophthalmoplegia, diplopia, and difficulty speaking are common early effects.
    2) Euphoria, anxiety, lethargy, drowsiness and headache have been reported.
    3.7.2) CLINICAL EFFECTS
    A) PARALYSIS
    1) WITH POISONING/EXPOSURE
    a) Weakness and paralysis of cranial motor nerves has occurred are common early findings and may develop within 1 hour of envenomation (Vital Brazil & Vieira, 1996; Van Mierop, 1976a; Coelho et al, 1992).
    b) Signs and symptoms include diplopia, blurred vision, ptosis, dysphagia, dysphonia, slurred speech, salivation, ophthalmoplegia, non-reactive pupils, and loss of facial expression (Vital Brazil & Vieira, 1996; Van Mierop, 1976a; Coelho et al, 1992).
    c) CASE REPORT: Facial paralysis, horizontal nystagmus, bilateral ptosis, dysarthria, dysphagia, and salivation were reported in a 27-year-old man approximately 14 hours after being bitten by a snake. Following confirmed identification of the snake as Micrurus lemniscatus helleri (South American coral snake) and subsequently obtaining the anti-coral antivenom, the patient was given 10 vials of the antivenom approximately 50 hours post-envenomation. However, despite antivenom treatment, the patient developed respiratory failure and was intubated 72 hours post-envenomation. Over the next 38 hours, the patient was extubated and re-intubated 3 times due to complications including bacterial pneumonia, a pneumothorax, and development of mucus plugs resulting in bronchial obstruction. After removal of the mucus plugs via bronchoscopy, the patient gradually recovered with supportive care and was discharged 15 days post-envenomation (Manock et al, 2008).
    B) FATIGUE
    1) WITH POISONING/EXPOSURE
    a) Weakness and paralysis of the extremities may develop (Vital Brazil & Vieira, 1996; Coelho et al, 1992). In severe cases respiratory depression and paralysis may develop.
    b) CASE SERIES: In a series of 39 patients with coral snake bites, 15% developed weakness (Kitchens & Van Mierop, 1987).
    c) Limb weakness was observed after the bites of M. laticollaris (Pettigrew & Glass, 1985) and M. lemniscatus helleri (Manock et al, 2008).
    C) SPASMODIC MOVEMENT
    1) WITH POISONING/EXPOSURE
    a) CASE SERIES: In a series of three patients envenomated by Micrurus corallinus, two developed muscle fasciculations (Coelho et al, 1992).
    b) CASE SERIES: In a series of 39 patients with coral snake bites, 5% developed fasciculations (Kitchens & Van Mierop, 1987).
    c) CASE REPORT: A 38-year-old man bitten by a Brazilian coral snake developed muscle fasciculations (Vital Brazil & Vieira, 1996).
    D) CENTRAL NERVOUS SYSTEM FINDING
    1) WITH POISONING/EXPOSURE
    a) Euphoria, anxiety, lethargy, drowsiness, headache, and confusion have been reported (Manock et al, 2008; Kitchens & Van Mierop, 1987; Parrish & Khan, 1967).
    E) PARESTHESIA
    1) WITH POISONING/EXPOSURE
    a) Paresthesias of the area bitten may develop (Manock et al, 2008; Vital Brazil & Vieira, 1996; Van Mierop, 1976a)
    b) CASE SERIES: In a series of 39 patients with coral snake bites, 35% developed paresthesias (Kitchens & Van Mierop, 1987).
    F) SEIZURE
    1) WITH POISONING/EXPOSURE
    a) Children may be prone to seizures (Norris & Dart, 1989; Wingert & Wainschel, 1975; McCollough & Gennaro, 1963).
    b) The mechanism for seizures is unclear because snake neurotoxins do not cross the blood-brain barrier; it is suggested that the cause may be secondary to respiratory failure.
    G) PAIN
    1) WITH POISONING/EXPOSURE
    a) Severe local pain has been reported after the bite of M. lemniscatus carvalhoi. A finger bite resulted in episodic arm pain that was not responsive to a local block, meperidine, or IM diclofenac. Pain duration was 7 hours (Nishioka et al, 1993).
    b) Pain starts at the bite site and follows the distribution of the peripheral nerve (Nishioka et al, 1993).
    c) Pain is not often mentioned as a sign of coral snake bite.
    d) CASE REPORT: A 27-year-old man, who was bitten on his right thumb by a snake later identified as a South American coral snake (Micrurus lemniscatus helleri), reported severe pain and paresthesia in the right arm. Over the next 7 hours, the pain eventually resolved following morphine administration (Manock et al, 2008).
    H) FLACCID PARALYSIS
    1) WITH POISONING/EXPOSURE
    a) Postsynaptic blockage was seen after the bite of M. laticollaris (Pettigrew & Glass, 1985).

Gastrointestinal

    3.8.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Nausea, vomiting and salivation are common.
    3.8.2) CLINICAL EFFECTS
    A) NAUSEA AND VOMITING
    1) WITH POISONING/EXPOSURE
    a) Nausea and vomiting have been reported (Kitchens & Van Mierop, 1987; Van Mierop, 1976a)
    b) CASE SERIES - In a series of 39 patients with coral snake bites, 30% developed nausea and 25% vomited (Kitchens & Van Mierop, 1987).
    B) LOSS OF TASTE
    1) WITH POISONING/EXPOSURE
    a) Inability to taste salt or sweet has been reported after of M. laticollaris (Pettigrew & Glass, 1985).
    C) GASTROINTESTINAL HEMORRHAGE
    1) WITH POISONING/EXPOSURE
    a) Mild gastrointestinal bleeding was reported after the bite of M. laticollaris (Pettigrew & Glass, 1985).
    D) ABDOMINAL PAIN
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Diffuse crampy abdominal pain developed in a 66-year-old man after M. corallinus envenomation (Coelho et al, 1992).
    E) EXCESSIVE SALIVATION
    1) WITH POISONING/EXPOSURE
    a) Marked salivation is almost always present, due to inability to swallow rather than an increase in production (Van Mierop, 1976a).

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) BLOOD IN URINE
    1) WITH POISONING/EXPOSURE
    a) Microscopic hematuria was reported after a bite by M. laticollaris associated with coombs-negative hemolytic anemia and mild coagulopathy (Pettigrew & Glass, 1985).
    B) URINARY INCONTINENCE
    1) WITH POISONING/EXPOSURE
    a) Urinary incontinence was reported in a 27-year-old man approximately 40 hours after being bitten by a South American coral snake (Micrurus lemniscatus helleri) (Manock et al, 2008).
    3.10.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) HEMOLYSIS
    a) Hemoglobinuria has been observed in experimental animals.

Hematologic

    3.13.2) CLINICAL EFFECTS
    A) HEMOLYTIC ANEMIA
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: Coombs-negative hemolytic anemia and mild coagulopathy developed in a patient bitten by M. laticollaris. Signs and symptoms included petechiae, mild gastrointestinal bleeding, and microscopic hematuria (Pettigrew & Glass, 1985).
    B) THROMBOCYTOPENIC DISORDER
    1) WITH POISONING/EXPOSURE
    a) Thrombocytopenia and minimally prolonged prothrombin and partial thromboplastin times occurred in a 27-year-old man who was bitten by a South American coral snake (Micrurus lemniscatus helleri) (Manock et al, 2008).

Dermatologic

    3.14.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Local effects are generally mild. Apparent envenomation has been reported without evidence of fang marks.
    3.14.2) CLINICAL EFFECTS
    A) EXCESSIVE SWEATING
    1) WITH POISONING/EXPOSURE
    a) Diaphoresis has been reported (Manock et al, 2008; Pancorbo et al, 2000; Kitchens & Van Mierop, 1987).
    b) CASE SERIES: In a series of 39 patients with coral snake bites, 10% developed diaphoresis (Kitchens & Van Mierop, 1987).
    B) ERUPTION
    1) WITH POISONING/EXPOSURE
    a) Erythema and/or pain may be present at the site (Coelho et al, 1992).
    C) EDEMA
    1) WITH POISONING/EXPOSURE
    a) Necrosis does not occur and swelling is generally minimal.
    b) CASE SERIES: In a series of 39 patients with coral snake bites, 40% developed local swelling (Kitchens & Van Mierop, 1987).
    c) The bite of Micrurus laticollaris produced local edema and lymphatic vessel distension (Pettigrew & Glass, 1985).
    d) CASE REPORT: A 15-year-old developed facial pain and tongue swelling after being bitten on the left side of the tongue by a coral snake. Approximately 2 hours after the bite, swelling progressed to involve the entire tongue, the left side of the face, and the neck down to the upper thorax. He required intubation and mechanical ventilation and received 10 vials of antivenom. Two weeks later the tongue swelling resolved, but speech remained slightly slurred (Pancorbo et al, 2000).
    D) BITE - WOUND
    1) WITH POISONING/EXPOSURE
    a) The local injury may include scratch marks or puncture wounds, although a case suggestive of envenomation with no apparent fang marks has been reported (Norris & Dart, 1989).
    E) PURPURA
    1) WITH POISONING/EXPOSURE
    a) Multiple petechiae of the hands and feet were seen after a finger bite by M. laticollaris (Pettigrew & Glass, 1985).

Musculoskeletal

    3.15.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Muscle pain and tenderness have been observed.
    3.15.2) CLINICAL EFFECTS
    A) MUSCLE PAIN
    1) WITH POISONING/EXPOSURE
    a) Muscle pain and tenderness has been reported (Kitchens & Van Mierop, 1987; Coelho et al, 1992).
    b) CASE SERIES: In a series of 39 patients with coral snake bites, 10% developed muscle tenderness (Kitchens & Van Mierop, 1987).
    B) RHABDOMYOLYSIS
    1) WITH POISONING/EXPOSURE
    a) An elevated creatine kinase level (749 units/L), suggesting mild rhabdomyolysis, was reported in a 27-year-old man who was bitten by a South American coral snake (Micrurus lemniscatus helleri) (Manock et al, 2008).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor respiratory rate, vital signs and neurologic status.
    B) Pulse oximetry and/or arterial blood gas values may be useful in assessing respiratory function.
    C) Coral snake venom does not appear to result in any significant hematologic, electrolyte, or coagulation defects.
    D) Serial pulmonary function studies (negative inspiratory force, vital capacity) may be helpful in assessing respiratory function.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.6) DISPOSITION/BITE-STING EXPOSURE
    6.3.6.2) HOME CRITERIA/BITE-STING
    A) Any individual who has been bitten by a "positively identified" coral snake should be hospitalized for observation and/or treatment. Even if asymptomatic, patients should be observed for 24 hours for development of late symptoms (Smith & Figge, 1991).
    B) As there is no reliable method to determine if actual envenomation has occurred, all patients must be admitted for at least 24 hours. Observation should include careful monitoring of respiratory rate, vital signs, and neurologic status.
    6.3.6.3) CONSULT CRITERIA/BITE-STING
    A) Consultation with a medical toxicologist or regional poison center is recommended for any known or suspected coral snake bite.
    6.3.6.5) OBSERVATION CRITERIA/BITE-STING
    A) Observation and/or treatment must be in a facility with equipment and personnel necessary for oxygen administration, assisted or controlled respiration, and endotracheal intubation. Adequate supplies of antivenom should also be available. The patient should be transferred to an appropriately staffed/equipped facility if these are not available at the initial treating facility.

Monitoring

    A) Monitor respiratory rate, vital signs and neurologic status.
    B) Pulse oximetry and/or arterial blood gas values may be useful in assessing respiratory function.
    C) Coral snake venom does not appear to result in any significant hematologic, electrolyte, or coagulation defects.
    D) Serial pulmonary function studies (negative inspiratory force, vital capacity) may be helpful in assessing respiratory function.

Range Of Toxicity

Summary

    A) An estimated human (adult) lethal dose of dried coral snake venom is 4 to 5 milligrams. A large coral snake has the potential to inject in excess of 20 milligrams.
    B) Venom from the Arizona coral snake (Micruroides) is much less toxic than the Micrurus species; there are no reported fatalities with the Arizona coral snake.

Minimum Lethal Exposure

    A) ACUTE
    1) An estimated human (adult) lethal dose of dried coral snake venom is 4 to 5 milligrams. A large coral snake has the potential to inject in excess of 20 milligrams (Fix, 1980).

Toxicity Information

    7.7.1) TOXICITY VALUES

Pharmacology Toxicology

Toxicologic Mechanism

    A) VENOMS -
    1) Eastern coral snake venom (M. fulvius fulvius)
    a) Is believed to be similar in some respects to the cardiotoxin of cobra venom, instead of affecting neuromuscular transmission by blockade of acetylcholine receptors as do other elapid venoms (Van Mierop, 1976; Weis & McIsaac, 1971).
    b) Local signs and symptoms are unlikely because coral snake venom lacks significant proteolytic enzymatic function.
    2) MATICORA BIVIRGATA VENOM (LONG-GLANDED CORAL SNAKE) -
    a) Contains phospholipase A2 and cytotoxic homologues (Maticotoxins). It does not have postsynaptic neurotoxins.

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