When snakes bite: the management of North American Crotalinae snake envenomation

There are more than 120 species of snakes indigenous to the United States, 25 of which are venomous. Although snake envenomation carries a relatively low risk of mortality in the United States, it can result in significant morbidity if left untreated. The venom of Crotalinae snakes contains a complex mixture of enzymatic proteins with various clinical implications. Of these complications, the most significant are consumptive coagulopathy, compartment syndrome, and hypovolemic shock. The development of ovine Crotalidae polyvalent immune Fab antivenin (CroFab) has greatly changed the approach to snake envenomation. Nevertheless, multiple factors complicate its use and the overall management of this clinical presentation. The intent of this review is to discuss relevant management issues associated with Crotalinae envenomation in the emergency department.