secretion (e.g., long, healthy fangs or full stores of venom) add to the toxicity of the bite An angered and hungry rattlesnake unloads more venom than a recently satiated and surprised rattlesnake It is important for the emergency provider to be aware that coral snake venom may be absorbed without a bite through routes such as the ocular mucous membranes, which can lead to severe neurotoxicity Since the FDA-approved coral snake antivenin is in limited supply, clinicians should consider non–FDA-approved alternative antivenins as well as adjunctive pharmacologic treatments such as neostigmine, under the guidance of a toxicologist Clinical Recognition Generally, it is useful to have a photograph of the snake responsible for the attack when possible, since it can be shared with an expert and used for identification and further management Pit viper A Crotalus envenomation causes intense local pain and burning within a couple of minutes Victims of a significant rattlesnake bite often complain within minutes of perioral numbness, extending to the scalp and periphery, with a metallic taste in the mouth Local ecchymoses and vesicles usually appear within the first few hours, and hemorrhagic blebs are often present by 24 hours Lymphadenitis and lymph node enlargement may also become apparent Without appropriate therapy, there may be progression to necrosis that may extend throughout the bitten extremity Secondary infection is a risk as the snake’s oral flora includes gram-negative bacteria Table 90.22 summarizes local characteristics of pit viper bites Patients may have nausea, vomiting, weakness, chills, sweating, syncope, and other more ominous symptoms of systemic venom absorption such as bleeding, angioedema, and hypotension A copperhead or pygmy rattlesnake envenomation produces fewer local symptoms, and systemic consequences are often minimal or nonexistent unless a small child, multiple bites, or larger than average snake is involved The water moccasin’s effects are more variable There is a relative lack of serious pain or swelling with the Mojave rattlesnake bite, although, as in other Crotalus bites, the patient may complain of paresthesia in the affected extremity Within several hours, these patients may develop neuromuscular symptoms such as diplopia, difficulty in swallowing, lethargy, nausea, and progressive weakness from the large dose of neurotoxin delivered by this species