Open Access Highly Accessed Research article

Unified treatment algorithm for the management of crotaline snakebite in the United States: results of an evidence-informed consensus workshop

Eric J Lavonas12*, Anne-Michelle Ruha3, William Banner45, Vikhyat Bebarta6, Jeffrey N Bernstein78, Sean P Bush9, William P Kerns10, William H Richardson1112, Steven A Seifert1314, David A Tanen1516, Steve C Curry3 and Richard C Dart12

Author Affiliations

1 Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colorado, USA

2 Division of Medical Toxicology, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA

3 Department of Medical Toxicology, Banner Good Samaritan Medical Center, Phoenix, Arizona, USA

4 Oklahoma Poison Center, College of Pharmacy, University of Oklahoma, Oklahoma City, Oklahoma, USA

5 Pediatric Intensive Care Unit, Integris Baptist Medical Center, Oklahoma City, Oklahoma, USA

6 Department of Emergency Medicine, Wilford Hall Medical Center, San Antonio, Texas, USA

7 Florida Poison Information Center, Miami, Florida, USA

8 Emergency Care Center, Jackson Memorial Hospital, Miami, Florida, USA

9 Department of Emergency Medicine, Loma Linda University School of Medicine, Loma Linda, California USA

10 Division of Medical Toxicology, Department of Emergency Medicine and Carolinas Poison Center, Carolinas Medical Center, Charlotte, North Carolina, USA

11 Department of Emergency Medicine, Palmetto Health Richland, Columbia, South Carolina, USA

12 Palmetto Poison Center, University of South Carolina, Columbia, South Carolina, USA

13 New Mexico Poison and Drug Information Center, College of Pharmacy, University of New Mexico, Albuquerque, New Mexico, USA

14 Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA

15 Naval Medical Center, San Diego, California, USA

16 Division of Medical Toxicology, Department of Emergency Medicine, University of California at San Diego, San Diego, California, USA

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BMC Emergency Medicine 2011, 11:2  doi:10.1186/1471-227X-11-2

Published: 3 February 2011



Envenomation by crotaline snakes (rattlesnake, cottonmouth, copperhead) is a complex, potentially lethal condition affecting thousands of people in the United States each year. Treatment of crotaline envenomation is not standardized, and significant variation in practice exists.


A geographically diverse panel of experts was convened for the purpose of deriving an evidence-informed unified treatment algorithm. Research staff analyzed the extant medical literature and performed targeted analyses of existing databases to inform specific clinical decisions. A trained external facilitator used modified Delphi and structured consensus methodology to achieve consensus on the final treatment algorithm.


A unified treatment algorithm was produced and endorsed by all nine expert panel members. This algorithm provides guidance about clinical and laboratory observations, indications for and dosing of antivenom, adjunctive therapies, post-stabilization care, and management of complications from envenomation and therapy.


Clinical manifestations and ideal treatment of crotaline snakebite differ greatly, and can result in severe complications. Using a modified Delphi method, we provide evidence-informed treatment guidelines in an attempt to reduce variation in care and possibly improve clinical outcomes.