Snakebite

Snakebite
A snakebite is an injury caused by the bite

of a snake, especially a venomous
snake.[9] A common sign of a bite from a
venomous snake is the presence of two
puncture wounds from the animal's
fangs.[1] Sometimes venom injection from
the bite may occur.[3] This may result in
redness, swelling, and severe pain at the
area, which may take up to an hour to
appear.[1][2] Vomiting, blurred vision,
tingling of the limbs, and sweating may
result.[1][2] Most bites are on the hands,
arms, or legs.[2][10] Fear following a bite is
common with symptoms of a racing heart
and feeling faint.[2] The venom may cause
bleeding, kidney failure, a severe allergic
reaction, tissue death around the bite, or
breathing problems.[1][3] Bites may result in
the loss of a limb or other chronic
problems or even death.[11][3]
The outcome depends on the type of

snake, the area of the body bitten, the
amount of snake venom injected, the
general health of the person bitten and
whether or not anti-venom serum has been
administered by a
Snakebite
doctor in a timely
manner.[11][8]
Problems are often
more severe in
A cobra bite on the
children than adults,
foot of a girl in
due to their smaller
Thailand
size.[3][12][13] Allergic
Specialty Emergency
reactions to snake
medicine
venom can further
Symptoms Two
complicate
puncture
outcomes and can
wounds,
include anaphylaxis,
redness,
requiring additional
swelling,
treatment and in severe
some cases pain at
resulting in the
death.[11] area[1][2]
Complications Bleed
Snakes bite both as failure
a method of allerg
hunting, and as a tissue
means of aroun
protection.[14] Risk breath
factors for bites proble

ampu
include working
enven
outside with one's
hands such as in Causes Snakes[1]
farming, forestry, Risk Working outs
and factors with one's ha

(farming,
construction.[1][3]
forestry,
Snakes commonly
construction)
involved in harassment;[
envenomations drunkenness
include elapids Prevention Protective

(such as kraits, footwear,
cobras and avoiding

areas
mambas), vipers,
where
and sea snakes.[7]
snakes
The majority of
live, not
snake species do handling
not have venom and snakes[1]
kill their prey by
Treatment Washing t
constriction wound wi
(squeezing them).[2] soap and
Venomous snakes water,
can be found on antivenom
every continent
except Prognosis Depends
Antarctica.[14] on type
Determining the of
type of snake that snake[8]
caused a bite is Frequency Up to 5
often not possible.[7] million a

year[3]
The World Health
Organization says Deaths 94,000–
snakebites are a 125,000

per
"neglected public
year[3]
health issue in many
tropical and
subtropical countries",[13] and in 2017, the
WHO categorized snakebite envenomation
as a Neglected Tropical Disease (Category
A). The WHO also estimates that between
4.5 and 5.4 million people are bitten each
year, and of those figures 40–50% develop
some kind of clinical illness as a result.[15]
Furthermore, the death toll of such an
injury could range between 80,000 and
130,000 people per year.[16][15] The
purpose was to encourage research,
expand accessibility of antivenoms, and
improve snakebite management in
"developing countries".[17]
Prevention of snake bites can involve

wearing protective footwear, avoiding
areas where snakes live, and not handling
snakes.[1] Treatment partly depends on the
type of snake.[1] Washing the wound with
soap and water and holding the limb still is
recommended.[1][7] Trying to suck out the
venom, cutting the wound with a knife, or
using a tourniquet is not recommended.[1]
Antivenom is effective at preventing death
from bites; however, antivenoms
frequently have side effects.[3][18] The type
of antivenom needed depends on the type
of snake involved.[7] When the type of
snake is unknown, antivenom is often
given based on the types known to be in
the area.[7] In some areas of the world,
getting the right type of antivenom is
difficult and this partly contributes to why
they sometimes do not work.[3] An
additional issue is the cost of these
medications.[3] Antivenom has little effect
on the area around the bite itself.[7]
Supporting the person's breathing is
sometimes also required.[7]
The number of venomous snakebites that

occur each year may be as high as five
million.[3] They result in about 2.5 million
envenomations and 20,000 to 125,000
deaths.[3][14] The frequency and severity of
bites vary greatly among different parts of
the world.[14] They occur most commonly
in Africa, Asia, and Latin America,[3] with
rural areas more greatly affected.[3][13]
Deaths are relatively rare in Australia,
Europe and North America.[14][18][19] For
example, in the United States, about seven
to eight thousand people per year are
bitten by venomous snakes (about one in
40 thousand people) and about five people
die (about one death per 65 million
people).[1]
Signs and symptoms
The most common symptoms of any kind of snake

envenomation.[20][21][22] However, there is vast
variation in symptoms between bites from different
types of snakes.[20]
The most common first symptom of all
snakebites is an overwhelming fear, which
may contribute to other symptoms, and
may include nausea and vomiting,
diarrhea, vertigo, fainting, tachycardia, and
cold, clammy skin.[2][23] Snake bites can
have a variety of different signs and
symptoms depending on their species.[11]
Dry snakebites and those inflicted by a

non-venomous species may still cause
severe injury. The bite may become
infected from the snake's saliva. The fangs
sometimes harbor pathogenic microbial
organisms, including Clostridium tetani,
and may require an updated tetanus
immunization.[24][15]
Most snakebites, from either a venomous

or a non-venomous snake, will have some
type of local effect.[25] Minor pain and
redness occur in over 90 percent of cases,
although this varies depending on the
site.[2] Bites by vipers and some cobras
may be extremely painful, with the local
tissue sometimes becoming tender and
severely swollen within five minutes.[18]
This area may also bleed and blister, and
may lead to tissue necrosis. Other
common initial symptoms of pit viper and
viper bites include lethargy, bleeding,
weakness, nausea, and vomiting.[2][18]
Symptoms may become more life-
threatening over time, developing into
hypotension, tachypnea, severe
tachycardia, severe internal bleeding,
altered sensorium, kidney failure, and
respiratory failure.[2][18]
Bites by some snakes, such as the kraits,

coral snake, Mojave rattlesnake, and the
speckled rattlesnake, may cause little or
no pain, despite their serious and
potentially life-threatening venom.[2] Some
people report experiencing a "rubbery",
"minty", or "metallic" taste after being
bitten by certain species of rattlesnake.[2]
Spitting cobras and rinkhalses can spit
venom in a person's eyes. This results in
immediate pain, ophthalmoparesis, and
sometimes blindness.[26][27]
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.[28]
Some Australian elapids and most viper

envenomations will cause coagulopathy,
sometimes so severe that a person may
bleed spontaneously from the mouth,
nose, and even old, seemingly healed
wounds.[18] Internal organs may bleed,
including the brain and intestines,[29] and
ecchymosis (bruising) of the skin is often
seen.[30]
The venom of elapids, including sea

snakes, kraits, cobras, king cobra,
mambas, and many Australian species,
contains toxins which attack the nervous
system, causing neurotoxicity.[2][18][31] The
person may present with strange
disturbances to their vision, including
blurriness. Paresthesia throughout the
body, as well as difficulty in speaking and
breathing, may be reported.[2] Nervous
system problems will cause a huge array
of symptoms, and those provided here are
not exhaustive. If not treated immediately
they may die from respiratory failure.[32]
Venom emitted from some types of

cobras, almost all vipers and some sea
snakes causes necrosis of muscle
tissue.[18] Muscle tissue will begin to die
throughout the body, a condition known as
rhabdomyolysis. Rhabdomyolysis can
result in damage to the kidneys as a result
of myoglobin accumulation in the renal
tubules. This, coupled with hypotension,
can lead to acute kidney injury, and, if left
untreated, eventually death.[18]
Snakebite is also known to cause

depression and post-traumatic stress
disorder in a high proportion of people
who survive.[33]
Cause
In the developing world most snakebites

occur in those who work outside such as
farmers, hunters, and fishermen. They
often happen when a person steps on the
snake or approaches it too closely. In the
United States and Europe snakebites most
commonly occur in those who keep them
as pets.[34]
The type of snake that most often delivers

serious bites depends on the region of the
world. In Africa, it is mambas, Egyptian
cobras, puff adders, and carpet vipers. In
the Middle East, it is carpet vipers and
elapids. In Latin America, it is snakes of
the Bothrops and Crotalus types, the latter
including rattlesnakes.[34] In North
America, rattlesnakes are the primary
concern, and up to 95% of all snakebite-
related deaths in the United States are
attributed to the western and eastern
diamondback rattlesnakes.[2] In South
Asia, it was previously believed that Indian
cobras, common kraits, Russell's viper, and
carpet vipers were the most dangerous;
other snakes, however, may also cause
significant problems in this area of the
world.[34]
Pathophysiology
Since envenomation is completely

voluntary, all venomous snakes are
capable of biting without injecting venom
into a person. Snakes may deliver such a
"dry bite" rather than waste their venom on
a creature too large for them to eat, a
behaviour called venom metering.[35]
However, the percentage of dry bites
varies among species: 80 percent of bites
inflicted by sea snakes, which are normally
timid, do not result in envenomation,[31]
whereas only 25 percent of pit viper bites
are dry.[2] Furthermore, some snake
genera, such as rattlesnakes, significantly
increase the amount of venom injected in
defensive bites compared to predatory
strikes.[36]
Some dry bites may also be the result of

imprecise timing on the snake's part, as
venom may be prematurely released
before the fangs have penetrated the
person.[35] Even without venom, some
snakes, particularly large constrictors such
as those belonging to the Boidae and
Pythonidae families, can deliver damaging
bites; large specimens often cause severe
lacerations, or the snake itself pulls away,
causing the flesh to be torn by the needle-
sharp recurved teeth embedded in the
person. While not as life-threatening as a
bite from a venomous species, the bite
can be at least temporarily debilitating and
could lead to dangerous infections if
improperly dealt with.
While most snakes must open their

mouths before biting, African and Middle
Eastern snakes belonging to the family
Atractaspididae are able to fold their fangs
to the side of their head without opening
their mouth and jab a person.[37]
Snake venom
It has been suggested that snakes evolved

the mechanisms necessary for venom
formation and delivery sometime during
the Miocene epoch.[38] During the mid-
Tertiary, most snakes were large ambush
predators belonging to the superfamily
Henophidia, which use constriction to kill
their prey. As open grasslands replaced
forested areas in parts of the world, some
snake families evolved to become smaller
and thus more agile. However, subduing
and killing prey became more difficult for
the smaller snakes, leading to the
evolution of snake venom.[38] Other
research on Toxicofera, a hypothetical
clade thought to be ancestral to most
living reptiles, suggests an earlier time
frame for the evolution of snake venom,
possibly to the order of tens of millions of
years, during the Late Cretaceous.[39]
Snake venom is produced in modified

parotid glands normally responsible for
secreting saliva. It is stored in structures
called alveoli behind the animal's eyes, and
ejected voluntarily through its hollow
tubular fangs.
Venom in many snakes, such as pit vipers,

affects virtually every organ system in the
human body and can be a combination of
many toxins, including cytotoxins,
hemotoxins, neurotoxins, and myotoxins,
allowing for an enormous variety of
symptoms.[2][40] Snake venom may cause
cytotoxicity as various enzymes including
hyaluronidases, collagenases, proteinases
and phospholipases lead to breakdown
(dermonecrosis) and injury of local tissue
and inflammation which leads to pain,
edema and blister formation.[41]
Metalloproteinases further lead to
breakdown of the extracellular matrix
(releasing inflammatory mediators) and
cause microvascular damage, leading to
hemorrhage, skeletal muscle damage
(necrosis), blistering and further
dermonecrosis.[41] The metalloproteinase
release of the inflammatory mediators
leads to pain, swelling and white blood cell
(leukocyte) infiltration. The lymphatic
system may be damaged by the various
enzymes contained in the venom leading
to edema; or the lymphatic system may
also allow the venom to be carried
systemically.[41] Snake venom may cause
muscle damage or myotoxicity via the
enzyme phospholipase A2 which disrupts
the plasma membrane of muscle cells.
This damage to muscle cells may cause
rhabdomyolysis, respiratory muscle
compromise, or both.[41] Other enzymes
such as bradykinin potentiating peptides,
natriuretic peptides, vascular endothelial
growth factors, proteases can also cause
hypotension or low blood pressure.[41]
Toxins in snake venom can also cause
kidney damage (nephrotoxicity) via the
same inflammatory cytokines. The toxins
cause direct damage to the glomeruli in
the kidneys as well as causing protein
deposits in Bowman's capsule. Or the
kidneys may be indirectly damaged by
envenomation due to shock, clearance of
toxic substances such as immune
complexes, blood degradation products or
products of muscle breakdown
(rhabdomyolysis).[41]
In venom-induced consumption
coagulopathy, toxins in snake venom
promote hemorrhage via activation,
consumption and subsequent depletion of
clotting factors in the blood.[41] These
clotting factors normally work as part of
the coagulation cascade in the blood to
form blood clots and prevent hemorrhage.
Toxins in snake venom (especially the
venom of new world pit vipers (the family
crotalina)) may also cause low platelets
(thrombocytopenia) or altered platelet
function also leading to bleeding.[41]
Snake venom is known to cause

neuromuscular paralysis, usually as a
flaccid paralysis that is descending;
starting at the facial muscles, causing
ptosis or drooping eyelids and dysarthria
or poor articulation of speech, and
descending to the respiratory muscles
causing respiratory compromise.[41] The
neurotoxins can either bind to and block
membrane receptors at the post-synaptic
neurons or they can be taken up into the
pre-synaptic neuron cells and impair
neurotransmitter release.[41] Venom toxins
that are taken up intra-cellularly, into the
cells of the pre-synaptic neurons are much
more difficult to reverse using anti-venom
as they are inaccessible to the anti-venom
when they are intracellular.[41]
The strength of venom differs markedly

between species and even more so
between families, as measured by median
lethal dose (LD50) in mice. Subcutaneous
LD50 varies by over 140-fold within elapids
and by more than 100-fold in vipers. The
amount of venom produced also differs
among species, with the Gaboon viper
able to potentially deliver from 450 to 600
milligrams of venom in a single bite, the
most of any snake.[42] Opisthoglyphous
colubrids have venom ranging from life-
threatening (in the case of the boomslang)
to barely noticeable (as in Tantilla).
Prevention
Sign at Sylvan Rodriguez Park in

Houston, Texas, warning of the
presence of snakes.
Snakes are most likely to bite when they

feel threatened, are startled, are provoked,
or when they have been cornered. Snakes
are likely to approach residential areas
when attracted by prey, such as rodents.
Regular pest control can reduce the threat
of snakes considerably. It is beneficial to
know the species of snake that are
common in local areas, or while travelling
or hiking. Africa, Australia, the Neotropics,
and South Asia in particular are populated
by many dangerous species of snake.
Being aware of—and ultimately avoiding—
areas known to be heavily populated by
dangerous snakes is strongly
recommended.
When in the wilderness, treading heavily
creates ground vibrations and noise, which
will often cause snakes to flee from the
area. However, this generally only applies
to vipers, as some larger and more
aggressive snakes in other parts of the
world, such as mambas and cobras,[43] will
respond more aggressively. If presented
with a direct encounter, it is best to remain
silent and motionless. If the snake has not
yet fled, it is important to step away slowly
and cautiously.
The use of a flashlight when engaged in

camping activities, such as gathering
firewood at night, can be helpful. Snakes
may also be unusually active during
especially warm nights when ambient
temperatures exceed 21 °C (70 °F). It is
advised not to reach blindly into hollow
logs, flip over large rocks, and enter old
cabins or other potential snake hiding-
places. When rock climbing, it is not safe
to grab ledges or crevices without
examining them first, as snakes are cold-
blooded and often sunbathe atop rock
ledges.
In the United States, more than 40 percent

of people bitten by snakes intentionally put
themselves in harm's way by attempting to
capture wild snakes or by carelessly
handling their dangerous pets—40 percent
of that number had a blood alcohol level of
0.1 percent or more.[44]
It is also important to avoid snakes that

appear to be dead, as some species will
actually roll over on their backs and stick
out their tongue to fool potential threats. A
snake's detached head can immediately
act by reflex and potentially bite. The
induced bite can be just as severe as that
of a live snake.[2][45] As a dead snake is
incapable of regulating the venom
injected, a bite from a dead snake can
often contain large amounts of venom.[46]
Treatment
It may be difficult to determine if a bite by

any species of snake is life-threatening. A
bite by a North American copperhead on
the ankle is usually a moderate injury to a
healthy adult, but a bite to a child's
abdomen or face by the same snake may
be fatal. The outcome of all snakebites
depends on a multitude of factors: the
type of snake, the size, physical condition,
and temperature of the snake, the age and
physical condition of the person, the area
and tissue bitten (e.g., foot, torso, vein or
muscle), the amount of venom injected,
the time it takes for the person to find
treatment, and finally the quality of that
treatment.[2][47] An overview of systematic
reviews on different aspects of snakebite
management found that the evidence base
from majority of treatment modalities is
low quality.[48] An analysis of World Health
Organization guidelines found that they
are of low quality, with inadequate
stakeholder involvement and poor
methodological rigour.[49]
Snake identification
Identification of the snake is important in

planning treatment in certain areas of the
world, but is not always possible. Ideally
the dead snake would be brought in with
the person, but in areas where snake bite
is more common, local knowledge may be
sufficient to recognize the snake. However,
in regions where polyvalent antivenoms
are available, such as North America,
identification of snake is not a high priority
item. Attempting to catch or kill the
offending snake also puts one at risk for
re-envenomation or creating a second
person bitten, and generally is not
recommended.[50]
The three types of venomous snakes that

cause the majority of major clinical
problems are vipers, kraits, and cobras.
Knowledge of what species are present
locally can be crucial, as is knowledge of
typical signs and symptoms of
envenomation by each type of snake. A
scoring system can be used to try to
determine the biting snake based on
clinical features,[51] but these scoring
systems are extremely specific to
particular geographical areas and might
be compromised by the presence of
escaped or released non-native
species.[50]
First aid
Snakebite first aid recommendations vary,

in part because different snakes have
different types of venom. Some have little
local effect, but life-threatening systemic
effects, in which case containing the
venom in the region of the bite by pressure
immobilization is desirable. Other venoms
instigate localized tissue damage around
the bitten area, and immobilization may
increase the severity of the damage in this
area, but also reduce the total area
affected; whether this trade-off is
desirable remains a point of controversy.
Because snakes vary from one country to
another, first aid methods also vary.
Many organizations, including the

American Medical Association and
American Red Cross, recommend washing
the bite with soap and water. Australian
recommendations for snake bite
treatment recommend against cleaning
the wound. Traces of venom left on the
skin/bandages from the strike can be used
in combination with a snake bite
identification kit to identify the species of
snake. This speeds determination of which
antivenom to administer in the emergency
room.[52]
Pressure immobilization
A Russell's viper is being "milked".

Laboratories use extracted snake
venom to produce antivenom, which
is often the only effective treatment
for potentially fatal snakebites.
As of 2008, clinical evidence for pressure

immobilization via the use of an elastic
bandage is limited.[53] It is recommended
for snakebites that have occurred in
Australia (due to elapids which are
neurotoxic).[54] It is not recommended for
bites from non-neurotoxic snakes such as
those found in North America and other
regions of the world.[54][55] The British
military recommends pressure
immobilization in all cases where the type
of snake is unknown.[56]
The object of pressure immobilization is to

contain venom within a bitten limb and
prevent it from moving through the
lymphatic system to the vital organs. This
therapy has two components: pressure to
prevent lymphatic drainage, and
immobilization of the bitten limb to
prevent the pumping action of the skeletal
muscles.
Antivenom
Until the advent of antivenom, bites from

some species of snake were almost
universally fatal.[57] Despite huge
advances in emergency therapy,
antivenom is often still the only effective
treatment for envenomation. The first
antivenom was developed in 1895 by
French physician Albert Calmette for the
treatment of Indian cobra bites. Antivenom
is made by injecting a small amount of
venom into an animal (usually a horse or
sheep) to initiate an immune system
response. The resulting antibodies are
then harvested from the animal's blood.
Antivenom is injected into the person
intravenously, and works by binding to and
neutralizing venom enzymes. It cannot
undo damage already caused by venom,
so antivenom treatment should be sought
as soon as possible. Modern antivenoms
are usually polyvalent, making them
effective against the venom of numerous
snake species. Pharmaceutical companies
which produce antivenom target their
products against the species native to a
particular area. Although some people
may develop serious adverse reactions to
antivenom, such as anaphylaxis, in
emergency situations this is usually
treatable and hence the benefit outweighs
the potential consequences of not using
antivenom. Giving adrenaline (epinephrine)
to prevent adverse reactions to antivenom
before they occur might be reasonable in
cases where they occur commonly.[58]
Antihistamines do not appear to provide
any benefit in preventing adverse
reactions.[58]
Chronic Complications
Chronic health effects of snakebite include

but is not limited to non-healing and
chronic ulcers, musculoskeletal disorders,
amputations, chronic kidney disease, and
other neurological and endocrine
complications.[59][60] The treatment of
chronic complications of snakebite has
not been well researched and there a
systems approach consisting of a multi-
component intervention.[61][48]
Outmoded
Old-style snake bite kit that should not

be used.
The following treatments, while once

recommended, are considered of no use
or harmful, including tourniquets,
incisions, suction, application of cold, and
application of electricity.[55] Cases in which
these treatments appear to work may be
the result of dry bites.
Application of a tourniquet to the bitten

limb is generally not recommended.
There is no convincing evidence that it is
an effective first-aid tool as ordinarily
applied.[62] Tourniquets have been found
to be completely ineffective in the
treatment of Crotalus durissus bites,[63]
but some positive results have been
seen with properly applied tourniquets
for cobra venom in the Philippines.[64]
Uninformed tourniquet use is
dangerous, since reducing or cutting off
circulation can lead to gangrene, which
can be fatal.[62] The use of a
compression bandage is generally as
effective, and much safer.
Cutting open the bitten area, an action
often taken prior to suction, is not
recommended since it causes further
damage and increases the risk of
infection; the subsequent cauterization
of the area with fire or silver nitrate (also
known as infernal stone) is also
potentially threatening.[65]
Sucking out venom, either by mouth or
with a pump, does not work and may
harm the affected area directly.[66]
Suction started after three minutes
removes a clinically insignificant
quantity—less than one-thousandth of
the venom injected—as shown in a
human study.[67] In a study with pigs,
suction not only caused no
improvement but led to necrosis in the
suctioned area.[68] Suctioning by mouth
presents a risk of further poisoning
through the mouth's mucous tissues.[69]
The helper may also release bacteria
into the person's wound, leading to
infection.
Immersion in warm water or sour milk,
followed by the application of snake-
stones (also known as la Pierre Noire),
which are believed to draw off the
poison in much the way a sponge soaks
up water.
Application of a one-percent solution of
potassium permanganate or chromic
acid to the cut, exposed area.[65] The
latter substance is notably toxic and
carcinogenic.
Drinking abundant quantities of alcohol
following the cauterization or
disinfection of the wound area.[65]
Use of electroshock therapy in animal
tests has shown this treatment to be
useless and potentially
dangerous.[70][71][72][73]
In extreme cases, in remote areas, all of

these misguided attempts at treatment
have resulted in injuries far worse than an
otherwise mild to moderate snakebite. In
worst-case scenarios, thoroughly
constricting tourniquets have been applied
to bitten limbs, completely shutting off
blood flow to the area. By the time the
person finally reached appropriate medical
facilities their limbs had to be amputated.
In development
Several new drugs and treatments are

under development for snakebite. For
instance, the metal chelator dimercaprol
has recently been shown to potently
antagonize the activity of Zn2+-dependent
snake venom metalloproteinases in
vitro.[74] New monoclonal antibodies,
polymer gels and a small molecule
inhibitor called Varespladib are in
development.[75] A core outcome set
(minimal list of consensus outcomes that
should be used in future intervention
research) for snakebite in South Asia is
being developed.[76]
Epidemiology
Map showing the approximate world distribution of snakes.
Map showing the global distribution of snakebite morbidity.
Earlier estimates for snakebite vary from

1.2 to 5.5 million, with 421,000 to
2.5 million being envenomings, and
causing 20,000 to 125,000 deaths.[3][14]
More recent modelling estimates that in
2019, about 63,400 people died globally
from snakebite, with 51,100 of these
deaths happenning in India.[77] Since
reporting is not mandatory in much of the
world, the data on the frequency of
snakebites is not precise.[14] Many people
who survive bites have permanent tissue
damage caused by venom, leading to
disability.[18] Most snake envenomings and
fatalities occur in South Asia, Southeast
Asia, and sub-Saharan Africa, with India
reporting the most snakebite deaths of
any country.[14] Available evidence on the
effect of climate change on the
epidemiology of snakebite is limited but it
is expected that there will be a geographic
shift in risk of snakebite: northwards in
North America and southwards in South
America and in Mozambique, and increase
in incidence of bite in Sri Lanka.[78]
Most snakebites are caused by non-

venomous snakes. Of the roughly 3,000
known species of snake found worldwide,
only 15% are considered dangerous to
humans.[2][14] Snakes are found on every
continent except Antarctica.[14] The most
diverse and widely distributed snake
family, the colubrids, has approximately
700 venomous species,[79] but only five
genera—boomslangs, twig snakes,
keelback snakes, green snakes, and
slender snakes—have caused human
fatalities.[79]
Worldwide, snakebites occur most

frequently in the summer season when
snakes are active and humans are
outdoors.[14][80] Agricultural and tropical
regions report more snakebites than
anywhere else.[14][28] In the United States,
those bitten are typically male and
between 17 and 27 years of age.[2][80][81]
Children and the elderly are the most likely
to die.[2][47]
Mechanics
Basic diagram of a snake's venom

delivery system
When venomous snakes bite a target, they

secrete venom through their venom
delivery system. The venom delivery
system generally consists of two venom
glands, a compressor muscle, venom
ducts, a fang sheath, and fangs. The
primary and accessory venom glands
store the venom quantities required during
envenomation. The compressor muscle
contracts during bites to increase the
pressure throughout the venom delivery
system. The pressurized venom travels
through the primary venom duct to the
secondary venom duct that leads down
through the fang sheath and fang. The
venom is then expelled through the exit
orifice of the fang. The total volume and
flow rate of venom administered into a
target varies widely, sometimes as much
as an order of magnitude. One of the
largest factors is snake species and size,
larger snakes have been shown to
administer larger quantities of venom.[82]
Predatory vs. defensive bites
Snake bites are classified as either

predatory or defensive in nature. During
defensive strikes, the rate of venom
expulsion and total volume of venom
expelled is much greater than during
predatory strikes. Defensive strikes can
have 10 times as much venom volume
expelled at 8.5 times the flow rate.[83] This
can be explained by the snake's need to
quickly subdue a threat. While employing
similar venom expulsion mechanics,
predatory strikes are quite different from
defensive strikes. Snakes usually release
the prey shortly after the envenomation
allowing the prey to run away and die.
Releasing prey prevents retaliatory
damage to the snake. The venom scent
allows the snake to relocate the prey once
it is deceased.[82] The amount of venom
injected has been shown to increase with
the mass of the prey animal.[84] Larger
venom volumes allow snakes to effectively
euthanize larger prey while remaining
economical during strikes against smaller
prey. This is an important skill as venom is
a metabolically expensive resource.
Venom Metering
Venom metering is the ability of a snake to

have neurological control over the amount
of venom released into a target during a
strike based on situational cues. This
ability would prove useful as venom is a
limited resource, larger animals are less
susceptible to the effects of venom, and
various situations require different levels
of force. There is a lot of evidence to
support the venom metering hypothesis.
For example, snakes frequently use more
venom during defensive strikes, administer
more venom to larger prey, and are
capable of dry biting. A dry bite is a bite
from a venomous snake that results in
very little or no venom expulsion, leaving
the target asymptomatic.[85] However,
there is debate among many academics
about venom metering in snakes. The
alternative to venom metering is the
pressure balance hypothesis.
The pressure balance hypothesis cites the

retraction of the fang sheath as the many
mechanism for producing outward venom
flow from the venom delivery system.
When isolated, fang sheath retraction has
experimentally been shown to induce very
high pressures in the venom delivery
system.[86] A similar method was used to
stimulate the compressor musculature,
the main muscle responsible for the
contraction and squeezing of the venom
gland, and then measuring the induced
pressures. It was determined that the
pressure created from the fang sheath
retraction was at times an order of
magnitude greater than those created by
the compressor musculature. Snakes do
not have direct neurological control of the
fang sheath, it can only be retracted as the
fangs enter a target and the target's skin
and body provide substantial resistance to
retract the sheath. For these reasons, the
pressure balance hypothesis concludes
that external factors, mainly the bite and
physical mechanics, are responsible for
the quantity of venom expelled.
Venom Spitting
Venom spitting is another venom delivery

method that is unique to some Asiatic and
African cobras. In venom spitting, a
stream of venom is propelled at very high
pressures outwards up to 3 meters. The
venom stream is usually aimed at the eyes
and face of the target as a deterrent for
predators. There are non-spitting cobras
that provide useful information on the
unique mechanics behind venom spitting.
Unlike the elongated oval shaped exit
orifices of non-spitting cobras, spitting
cobras have circular exit orifice at their
fang tips.[87] This combined with the ability
to partially retract their fang sheath by
displacing the palato-maxillary arch and
contracting the adductor mandibulae,
allows the spitting cobras to create large
pressures within the venom delivery
system.[88] While venom spitting is a less
common venom delivery system, the
venom can still cause the effects if
ingested.
Society and culture
According to tradition, Cleopatra VII

famously committed suicide by
snakebite to her left breast, as
depicted in this 1911 painting by
Hungarian artist Gyula Benczúr.
Snakes were both revered and worshipped

and feared by early civilizations. The
ancient Egyptians recorded prescribed
treatments for snakebites as early as the
Thirteenth Dynasty in the Brooklyn
Papyrus, which includes at least seven
venomous species common to the region
today, such as the horned vipers.[89] In
Judaism, the Nehushtan was a pole with a
snake made of copper fixed upon it. The
object was regarded as a divinely
empowered instrument of God that could
bring healing to Jews bitten by venomous
snakes while they were wandering in the
desert after their exodus from Egypt.
Healing was said to occur by merely
looking at the object as it was held up by
Moses.
Historically, snakebites were seen as a

means of execution in some cultures.[90]
Reportedly, in Southern Han during China's
Five Dynasties and Ten Kingdoms period
and in India a form of capital punishment
was to throw people into snake pits,
leaving people to die from multiple
venomous bites.[91] According to popular
belief, the Egyptian queen Cleopatra VII
committed suicide by let herself be bitten
by an asp—likely an Egyptian cobra[89][92]—
after hearing of Mark Antony's death, while
some contemporary ancient authors rather
assumed a direct application of poison.[93]
Snakebite as a surreptitious form of

murder has been featured in stories such
as Sir Arthur Conan Doyle's The Adventure
of the Speckled Band, but actual
occurrences are virtually unheard of, with
only a few documented cases.[91][94][95] It
has been suggested that Boris III of
Bulgaria, who was allied to Nazi Germany
during World War II, may have been killed
with snake venom,[91] although there is no
definitive evidence. At least one attempted
suicide by snakebite has been
documented in medical literature involving
a puff adder bite to the hand.[96]
Research
In 2018, the World Health Organization

listed snakebite envenoming as a
neglected tropical disease.[97][98] In 2019,
they launched a strategy to prevent and
control snakebite envenoming, which
involved a program targeting affected
communities and their health
systems.[99][100] A policy analysis however
found that the placement of snakebite in
the global health agenda of WHO is fragile
due to reluctance acceptance of the
disease in the neglected tropical disease
community and the perceived colonial
nature of the network driving the
agenda.[101]
Key institutions conducting snakebite

research on snakebite are George Institute
for Global Health, Liverpool School of
Tropical Medicine and Indian Institute of
Science.
Other animals
Several animals acquired immunity

against venom of snakes that occur in the
same habitat.[102] This has been
documented in some humans as well.[103]
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Bibliography
Greene HW (1997). Snakes: The Evolution of

Mystery in Nature (https://archive.org/detail
s/snakesevolutiono00fogd) . Berkeley, CA:
University of California Press. ISBN 978-0-
520-20014-2.
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Venoms and Toxins of Reptiles (2nd ed.).
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9165-1.
Valenta J (2010). Venomous Snakes:
Envenoming, Therapy (2nd ed.). Hauppauge,
NY: Nova Science Publishers. ISBN 978-1-
60876-618-5.
Further reading
Campbell JA, Lamar WW (2004). The

Venomous Reptiles of the Western
Hemisphere. Ithaca, NY: Cornell University
Press 978-0-8014-4141-7.
Spawls S, Branch B (1995). The Dangerous
Snakes of Africa: Natural History, Species
Directory, Venoms and Snakebite. Sanibel
Island, FL: Ralph Curtis Publishing. ISBN 978-
0-88359-029-4.
Sullivan JB, Wingert WA, Norris Jr RL (1995).
"North American Venomous Reptile Bites".
Wilderness Medicine: Management of
Wilderness and Environmental Emergencies.
3: 680–709.
Thorpe RS, Wüster W, Malhotra A. Venomous
Snakes: Ecology, Evolution, and Snakebite.
Oxford, England: Oxford University Press.
ISBN 978-0-19-854986-4.
External links
WHO Snake Antivenoms Database (http

s://web.archive.org/web/201005060222
08/http://apps.who.int/bloodproducts/s
nakeantivenoms/database/)
Organization (2016). Guidelines for the
management of snakebites. Regional
Office for South-East Asia, World Health
Organization. hdl:10665/249547 (http
s://hdl.handle.net/10665%2F249547) .
ISBN 978-92-9022-530-0.
Retrieved from
"https://en.wikipedia.org/w/index.php?
title=Snakebite&oldid=1198595069"
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14:39 (UTC). •
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A snakebite is an injury caused by the bite

The outcome depends on the type of

factors for bites proble

farming, forestry, Risk Working outs

and factors with one's ha

include elapids Prevention Protective

cobras and avoiding

type of snake that snake[8]

caused a bite is Frequency Up to 5

often not possible.[7] million a

snakebites are a 125,000

Prevention of snake bites can involve

The number of venomous snakebites that

Signs and symptoms

The most common symptoms of any kind of snake

Dry snakebites and those inflicted by a

Most snakebites, from either a venomous

Bites by some snakes, such as the kraits,

Severe tissue necrosis

Some Australian elapids and most viper

The venom of elapids, including sea

Venom emitted from some types of

Snakebite is also known to cause

In the developing world most snakebites

The type of snake that most often delivers

Since envenomation is completely

Some dry bites may also be the result of

While most snakes must open their

It has been suggested that snakes evolved

Snake venom is produced in modified

Venom in many snakes, such as pit vipers,

Snake venom is known to cause

The strength of venom differs markedly

Sign at Sylvan Rodriguez Park in

Snakes are most likely to bite when they

The use of a flashlight when engaged in

In the United States, more than 40 percent

It is also important to avoid snakes that

It may be difficult to determine if a bite by

Identification of the snake is important in

The three types of venomous snakes that

Snakebite first aid recommendations vary,

Many organizations, including the

A Russell's viper is being "milked".

As of 2008, clinical evidence for pressure

The object of pressure immobilization is to

Until the advent of antivenom, bites from

Chronic health effects of snakebite include

Old-style snake bite kit that should not

The following treatments, while once

Application of a tourniquet to the bitten

In extreme cases, in remote areas, all of

Several new drugs and treatments are

Map showing the approximate world distribution of snakes.

Map showing the global distribution of snakebite morbidity.

Earlier estimates for snakebite vary from

Most snakebites are caused by non-