Disposition

Patients are ready for discharge when swelling begins to resolve, the coagulopathy has been reversed, and the patient is ambulatory. During recovery, the bitten part (particularly the hand) should be regularly exercised to preserve as much function and strength as possible. Outpatient follow-up is necessary to monitor for infection and serum sickness.

It cannot be overemphasized that one can easily be deceived by a bite that initially appears innocuous. An unremarkable physical and laboratory examination at presentation does not reliably indicate an insignificant envenomation. We recommended that physicians observe patients for at least 8 h. Patients with severe or life-threatening bites and patients receiving antivenom should be admitted to an intensive care unit. The general ward is appropriate for patients with mild or moderate envenomations who have completed or do not require further antivenom therapy.

Patients with dry bites who have been observed for at least 8 h may be discharged. They should return if pain, swelling, or bleeding develops. CORAL SNAKE BITE

North American coral snakes include the eastern coral snake ( Micrurus fulvius fulvius), the Texas coral snake (Micrurus fulvius tenere), and the Arizona (Sonoran) coral snake (Micruroides euryxanthus). The eastern coral snake is found primarily in the southeast United States. The Texas and Arizona coral snakes are found primarily in the states that bear their names. Coral snakes account for 20 to 25 bites a year.

All coral snakes are brightly colored with black, red, and yellow rings. The red and yellow rings touch in coral snakes, but they are separated by black rings in nonpoisonous snakes, creating the well known rhyme: "Red on yellow, kill a fellow; red on black, venom lack." This rule is not true outside of the United States.

Coral snake venom is primarily composed of neurotoxic components that do not cause marked local injury. Elapid bites produce primarily neurologic effects: tremors, salivation, dysarthria, diplopia, bulbar paralysis with ptosis, fixed and contracted pupils, dysphagia, dyspnea, and seizures. The immediate cause of death is paralysis of respiratory muscles. Signs and symptoms may be delayed up to 12 h.

The potential coral snake victim should be admitted to the hospital for 24 to 48 h of observation. Coral snake venom effects may develop hours after a bite and are not easily reversed. It is suggested that 3 vials of the Antivenin ( Micrurus fulvius) be administered to patients who have definitely been bitten because it may not be possible to prevent further effects or reverse effects that have already developed. 7 Additional coral snake antivenom is reserved for the appearance of symptoms or signs of coral snake envenomation. However, because respiratory failure may result from clinical effects of the neurotoxin, baseline and serial pulmonary function parameters (such as inspiratory pressure and vital capacity) in addition to intensive care observation may be useful. Prolonged ventilatory support may be required in severe cases. The patient must be observed closely for signs of respiratory muscle weakness and hypoventilation. Bites by the Sonoran coral snake are mild. Medical care is not usually needed.

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