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  • Pit vipers (Crotalids) account for the majority of snake envenomations in pediatric patients. Because of their small body weight, young children are relatively more vulnerable to severe envenomation.

  • Pit viper (Crotalinae) envenomations result in hematotoxicity while coral snakes (Elapidae) cause neurotoxicity.

  • Crotaline snakes are responsible for the vast majority of snake envenomations in the United States. Identification of exact species is not essential since treatment is similar for all indigenous American pit vipers.

  • Prehospital management of snakebites includes immobilization of the bitten extremity, minimization of physical activity, and fluid administration. No “first aid” technique has been demonstrated to improve outcome after envenomation. Rapid transport for administration of antivenom is the most important intervention in prehospital care.

  • Antivenom, such as Crotaline Fab antivenom, consisting of highly purified papain-digested antibodies, is the current standard of care for treatment of crotaline snake envenomation.

  • Antivenom dosing in pediatric patients is based on potential venom load, not kilogram size of the patient.


Worldwide, approximately 90,000 to 125,000 fatal snakebites are sustained each year.1,2 Of the 120 snake species indigenous to the United States, approximately 20% are venomous (Table 134-1). Venomous snakes are classified into two families: Viperidae and Elapidae. Crotalinae is a subfamily of Viperidae better known as pit vipers due to the heat-sensing organs on either side of the head. The Crotalinae subfamily includes three genera: Crotalus (rattlesnakes), Agkistrodon (copperheads and cottonmouths), and Sistrurus (pigmy rattlesnakes and massasaugas).3 While copperhead (Agkistrodon contortrix) and cottonmouth (A. piscivorus) snakes are primarily found in the southern and eastern United States, several species of rattlesnake are found throughout the continental United States. Although snakebites are typically underreported, it is estimated that 8000 crotaline envenomations occur in the United States annually. Approximately 30% of snakebites called to US poison control centers involve patients younger than 20 years, with 12% of all cases being children aged 9 years or younger.4

TABLE 134-1Indigenous Poisonous Snakes of the United States

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