The Case

Margaret (name changed for privacy), a 71-year-old avid gardener, arrived at our emergency department after being bitten by what she believed was a baby rattlesnake while gardening. She felt a "sting" in her pinky finger while wearing gloves, discovered two puncture wounds with bleeding, and rushed to the ED after she noticed her finger begin to swell.

This case highlights both the dangers lurking in Georgia's backyards and the effectiveness of modern antivenom therapy.

Image showing bite area of left little finger (obtained with patient consent).

Image showing bite area of left little finger (obtained with patient consent).

Georgia's Six Venomous Snakes

Of the 46 species of snakes known from Georgia, only six species are venomous: Copperhead, Cottonmouth, Eastern Diamondback Rattlesnake, Timber/Canebrake Rattlesnake, Pigmy Rattlesnake and Eastern Coral Snake. Only the Timber Rattlesnake, Eastern Diamondback Rattlesnake and Cottonmouth realistically represent a serious threat to human life.

The Rattlesnakes

Eastern Diamondback (Crotalus adamanteus) - The largest venomous snake in North America, reaching up to 7 feet but typically 3-5 feet. Found in Georgia's Coastal Plain with distinctive diamond patterns.

Timber/Canebrake Rattlesnake (Crotalus horridus) - Large snakes up to 6 feet with dark chevron patterns and solid black tails, earning the nickname "Velvet Tail."

Pygmy Rattlesnake (Sistrurus miliarius) - The smallest at 16-23 inches, but their venom can still cause significant complications, especially in children and elderly patients.

The Vipers

Copperhead (Agkistrodon contortrix) - The most commonly encountered venomous snake in metro Georgia, identifiable by hourglass-shaped crossbands that are wider at the sides.

Cottonmouth (Agkistrodon piscivorus) - Semi-aquatic snakes that prefer swampy habitats. They display defensive behavior by opening their mouth wide to show the white interior.

Eastern Coral Snake (Micrurus fulvius) - Distinguished by red, black, and yellow banding. Remember: "Red touch yellow, deadly fellow; red touch black, venom lack."

Margaret's Clinical Presentation

Margaret showed classic signs of pit viper envenomation:

• Local effects: Pain, swelling, and purplish discoloration at the bite site
• Progressive edema: Swelling from finger to wrist
• Systemic signs: Elevated heart rate and blood pressure (184/88)
• Lab findings: Elevated lactate (3.10), normal coagulation studies

We documented baseline circumferential measurements at four sites to monitor progression:

• Finger joint: 5 cm
• Left mid palm: 23 cm
• Left wrist: 16 cm
• Forearm: 15 cm

Treatment with CroFab®

After consulting Georgia Poison Control (1-800-222-1222), we administered six vials of CroFab® antivenom. CroFab® Crotalidae Polyvalent Immune Fab (Ovine) is a sheep-derived antivenin indicated for the management of adult and pediatric patients with North American crotalid envenomation.

In pre- and postmarketing studies, 67-88% of patients achieved initial control with an initial dose of 4-6 vials when given according to recommended dosing.

Our Protocol:

• Given six vials of CroFab® IV
• Admitted to the ICU for monitoring with continuous cardiac monitoring
• Serial labs: CBC, BMP, coagulation studies, lactic acid, fibrinogen Q2H assessment of erythema leading edge and 4 documented measurement sites; monitoring for compartment syndrome
• Elevation of the arm and adequate pain control
• Escalation: If envenomation progressed beyond the marked boundaries, the plan was to restart a maintenance dose of CroFab 2 vials Q6H × 3 doses over 18 hours and to continue Q2H reassessment

Key Medical Considerations

Recurrent Coagulopathy: In clinical trials, recurrent coagulopathy occurred in approximately half of the patients studied. Recurrent coagulopathy may persist for 1 to 2 weeks or more.

Dosing Guidelines: Administer an initial dose of 4-6 vials and monitor for signs of progression. Once initial control is achieved, administer an additional 2 vials every 6 hours for up to 18 hours (total of 3 doses).

Prevention Strategies

For Gardeners:

• Wear thick gloves and closed-toe shoes
• Don't reach into areas you can't see clearly
• Be aware of surroundings, especially near brush piles

Important Facts:

• Most bites occur when people try to kill or handle snakes
• According to the American Association of Poison Control Centers, only 20 venomous snake bites reported nationwide during the same period were fatal, an average of two fatalities a year.
• In Georgia, it is illegal to possess or kill many of the state's nongame wildlife species, including non-venomous snakes (punishable by up to a $1,000 fine and a year in jail).

First Aid Guidelines

DO:

• Stay calm and get to the hospital immediately
• Call 911 or Georgia Poison Control (1-800-222-1222)
• Identify the snake by sight only
• Keep patient calm and affected limb level

DON'T:

• Try to kill the snake
• Use a tourniquet
• Cut the wound or suck venom
• Pack in ice
• Give food, drink, or medication

Margaret's Outcome

Margaret recovered completely. The CroFab® controlled envenomation progression within hours, and she was monitored in the ICU for 48 hours with no coagulopathy complications.

Clinical takeaways

If you're managing a snake bite: document swelling progression with serial circumferential measurements. That objective data is what guides your treatment decisions. Call poison control early. They'll help with both initial treatment and ongoing management. Most patients need at least 24 hours of observation because of systemic signs and coagulopathy risk. And watch for recurrent coagulopathy, which can show up as late as two weeks after treatment.

Georgia has 47 snake species, one of the highest diversities of any U.S. state. That's a sign of a healthy ecosystem. Venomous snakes included, they provide real ecological benefits like rodent control. Knowing which snakes are dangerous and respecting the ones that aren't goes a long way toward preventing bites and protecting species that don't deserve to be killed on sight.

Conclusion

Margaret did well. With proper identification, fast treatment, and CroFab, her envenomation was controlled and she recovered fully. The lesson: prevention is better than treatment. Wear gloves in the garden, don't reach where you can't see, and if you do get bitten, get to a hospital fast.

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Patient details were been modified to protect privacy while maintaining clinical accuracy. For snake bite emergencies, always call 911 and Georgia Poison Control at 1-800-222-1222.