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  4. Pit Vipers
  5. Clinical entry: Crotalus sp. (without C. durissus ssp.)

Clinic: Crotalus sp. (without C. durissus ssp.)

Examine for venom effects

Autopharmacological effects

  • Nausea, vomiting
  • Sweating
  • Urticaria, angiooedema
  • Generalized oedema
  • Arterial hypotension / hypovolaemic shock (transient, recurrent)
  • Diarrhoea
  • Bronchospasm 

Local Effects

  • Pain
  • Tender local (spreading) swelling
  • Blistering
  • Lymphangiopathy and lymphadenopathy
  • Necrotic skin; can include muscle locally.

Haematological effects 

  • Clotting disturbances:
    • Bleeding from the fang marks and from injuries, in particular ones that are not located in the region in which venom application occurred.
    • Bleeding into the skin (ecchymosis, petechiae)
    • Gingival bleeding, bleeding from the nose, conjunctiva, haematemeis, bleeding per rectum, including melaena, haematuria, haemoptysis.
    • Oliguria, anuria (VICC / AKI)
  • Bleeding and/or haemolytic anaemia:
    • Arterial hypotension (haemorrhagic shock)
    • Acute abdomen (intra-abdominal bleeding!)
    • Loin pain/renal bed sensitive to percussion (ischaemia, renal haemorrhage!)
    • Local neurological signs, meningism, coma (intracranial bleeding!)
    • Pale sclera
    • Oliguria, anuria (acute kidney injury - AKI)

Neurological effects

  • Descending flaccid paralysis (rarely progresses to involve bulbar and respiratory muscles):
    • Ptosis (not to be mixed up with tiredness / drowsiness; test: lid retraction with upward gaze).
    • Double vision (external ophthalmoplegia)
    • Difficulties to swallow (dysphagia) (bulbar paralysis) > inhalation of vomitus!
    • Difficulties to lift the head when lying on the back (‘broken neck syndrome’)
    • Cyanosis, shallow breathing, respiratory arrest (respiratory paralysis); respiratory arrest may be precipitated by obstruction of the upper airway by the paralysed tongue or inhaled vomitus. 
    • Weakness or loss of voluntary movement; movements of digits may still be possible, allowing the patient to communicate.
    • Loss of consciousness and generalized convulsions caused by hypoxaemia in patients who have respiratory paralysis.  
  • Myokymia
    • Clinically, myokymia manifests itself as spontaneous continuous undulating fine contractions of multiple individual motor units. The clinical appearance is similar to fasciculations but more arrhythmic. (Lewis and Gutmann 2004, video: Ramacharan et al. 2016). 

Muscular effects

  • Generalized rhabdomyolysis:
    • Muscles pain and tenderness, painful on passive stretching, muscle stiffness, trismus
    • Bulbar and respiratory muscle weakness.
    • Dark brown urine. 
    • Renal failure (AKI)
    • Laboratory: Generalized rhabdomyolysis: defined by a serum creatine kinase level > 10,000 U/l
    • ECG: Signs of hyperkalaemia. 

Cardiac Effects

  • Bradycardia, tachycardia, arrhythmias
  • Arterial hypotension
  • Heart failure
  • ECG: Tachyarrhythmias, sinus bradycardia, ST-T wave changes, varying degrees of atrioventricular block, and evidence of hyperkalaemia.

Species-specific envenoming pattern

The assessment of the envenoming pattern is based on the data from publication in which the identification of the snakes is clearly specified and in accordance with accepted criteria.

   Autopharma-
cological
effects1		 Local
effects2
 		 Haematological effects Neurological
effects6 		 Musular
effects7 
 Bleeding3  Coagulopathy4,5 
Crotalus adamanteus            
Crotalus atrox            
Crotalus helleri            
Crotalus horridus            
Crotalus molossus molossus  ?       ?  
Crotalus oreganus            
Crotalus polystictus            
Crotalus scutulatus scutulatus            
Crotalus viridis             
       
Crotalus simus 
(formerly classified as Crotalus durissus)		            

1Autopharmacological effects

Nausea, vomiting, angioedema, arterial hypotension / shock from third-spacing, vasodilatation (Lavonas et al. 2011). 

Crotalus simus 
Envenomation by Crotalus snakes in Central America is characterized by effects similar to those of Bothrops envenomation.” (Malaque and Gutiérrez 2017). 

2Local effect

Pain, tenderness, redness, swelling, blisters, myonecrosis; spreading with the movement of the venom through lymphatic vessels; soft tissue necrosis (Lavonas et al. 2011).

If these do not occur within 15–30 min after the bite, it is highly likely that no venom was injected. Important exceptions to this rule are some populations of Crotalus scutulatus ("type A"), C. mitchelli, C. lepidus and C. tigris, which can cause systemic envenoming without significant local effects (Minton 1987a). 

Crotalus simus 
Pain, redness, swelling; can affect the entire limb. Ecchymosis, blisters, bleeding. Rarely necrosis (Crotalus simus; formerly classified as Crotalus durissus  Bolanos et al. 1981; Malaque and Gutiérrez 2017)

Hematological effects

3Bleeding

Oozing of blood from the bite site and ecchymosis are common. Even with severe defibrination or thrombocytopenia most patients do not develop medically significant bleeding. However, fatal bleeding complications have been reported (Lavonas et al. 2011).

4Coagulopathy

Type of haemostatic defect

North Amerian rattle snakes: Coagulopathy primarily due to thrombin-like venom components, thrombocytopenia, or a combination of the two.Components affecting endothelial cell linage.

Crotalus adamanteus (Kitchens and Mierop 1983).

Crotalus atrox (Reid and Theakston 1978).

Effects of ontogenetic differences in venom composition on the symptoms of envenoming: The venom of juvenile snakes up to the age of approx. 8 months possesses components with fibrinogen-coagulating ("thrombin-like") activity that are subsequently lost (Reid and Theakston 1978). In contrast, the venom of adult snakes only shows fibrin(ogen)olytic activity. This fact could explain the sometimes conflicting reports of the course of C. atrox envenoming. The differences in venom composition between juvenile and adult C. atrox imply that juvenile animals cause more severe envenoming than do adults.

Crotalus molossus molossus (Hardy et al. 1982).

Crotalus polystictus (Hardy 1982).

Crotalus scutulatus scutulatus (Greene et al. 2023).

C. horridus horridus (Bond and Burkhart 1997, Hasiba et al. 1975, Trautman and Pizon 2023).

C. viridis

Effect of ontogenetic differences in venom composition on the symptoms of envenoming: The venom of juvenile snakes (6–12 months) appears to be significantly more toxic than that of adult snakes and can cause unexpectedly severe envenoming (Fiero et al. 1972, Glenn and Straight 1982, Minton 1967).
Crotalus simus 
Venom-induced consumption coagulopathy (VICC); thrombocytopenia is rarely recorded (Malaque and Gutiérrez 2017). 

5Recurrent and persistent coagulopathy following pit viper envenoming (various Crotalus ssp.):

“Significant hypofibrinogenemia and thrombocytopenia, lasting up to 2 weeks, may be common after envenomation by North American (Boyer et al. 1999). 

6Neurological effects 

Myocomia+ occurs in envenoming by some species of North American rattlesnakes (eg, Crotalus adamanteus, Crotalus horridus, Crotalus scutellatus, Crotalus lutosus, and Crotalus helleri) and the common lancehead pit viper (Bothrops atrox) in Trinidad" (Warrell and Willimas 2023, cit Lewis and Gutmann 2004, video: Ramcharan et al. 2016). 

Crotalus adamanteus 
Local and perioral fasciculations+, metallic taste in the mouth (Van Mierop and Kitchens 1980, Kitchens and Eskin 2008).

Crotalus viridis decolor

Myocomia (LoVecchio et al 2005).

Crotalus helleri

“Wide range of neurotoxicity, including ataxia, dysarthria, dysphagia, and myokymia.” (Levine et al. 2022).

“... respiratory insufficiency requiring ventilatory support appeared related to respiratory muscle incoordination as extremity motor function remained intact” (Richardson et al. 2007).

Crotalus oreganus abyssus
Myokymia+ and respiratory compromise (Heise et al. 2020).

Crotalus scutulatus scutulatus

Arizona / California

20 cases: Arizona: 9 (definite 4, likely 5); California: 11 (definite 2, likely 6, unavailable 3)

“Neurotoxicity is not a feature of Mohave rattlesnake envenomation in AZ. Although neurotoxicity is observed in CA Mohave envenomations, it was limited to paresthesias and myokymia+/ fasciculations+ without objective weakness and respiratory failure in this study.” (Greene et al. 2023).

California

11-year-old patient presented with hypoventilation and shock requiring Intubation. Improved rapidly after fluid resuscitation and antivenom administration and was extubated four hours after envenomation and did well. The patient subsequently developed increased weakness and cranial nerve paresis and required reintubation for respiratory failure at 30 hours (Jansen et al. 1992).

Arizona

“We found no case reports of neurotoxic respiratory weakness following Arizona rattlesnake bites in the literature and such reports in surrounding states were scant. We conclude that neurotoxic respiratory failure in this region following rattlesnake envenomation is extraordinarily rare“ (Smelski et al. 2023).

In 15 patients no neurological effects apart from 1 patient with ptosis. In particular, no clinical evidence of respiratory muscle weakness (Hardy 1983).

+ “The terms fasciculation and myokymia are often used interchangeably in the medical literature addressing rattlesnake envenomation. However, the term fasciculation technically refers to only a single motor unit firing, and myokymia refers to bursts of multiple motor unit action potentials" (Heise et al. 2020).

+“Myokymia, a slower and more regular form of fine contractions than fasciculations that is distinguishable from fasciculations electrophysiologically, is reversible with intravenous calcium chloride. It occurs in envenoming by some species of North American rattlesnakes (eg, Crotalus horridus, Crotalus scutellatus, Crotalus lutosus, and Crotalus helleri) and the common lancehead pit viper (Bothrops atrox) in Trinidad" (Warrell and Willimas 2023, cit Lewis and Gutmann 2004, video: Ramcharan et al. 2016). 

7Muscular effects

C. horridus atricaudatus

Serum creatinine kinase 2,830,000 IU/dl (at autopsy, severe, acute rhabdomyolysis could be clearly distinguished from post mortem autolysis) (Kitchens et al. 1987).

Crotalus scutulatus scutulatus

California

24 hrs after envenoming: Rhabdomyolysis and renal failure (Jansen et al. 1992)

Other effects

Cardiac effects

Crotalus oreganus

ECG: normal sinus rhythm with no ST segment changes; high burden of premature ventricular contractions in a bigeminy pattern. Initial troponin I level was 0.21 ng/ml (reference\0.055 ng/ml). (Slade et a. 2021)

Clinical management

See also (depending on the origin of the culprit)

Clinical Management: North America

Clinical Management: Mexico and Central America

 for advice on post-First Aid measures, diagnosis (clinical, laboratory) and treatment (supportive, antivenom).

First Aid

Release of any type of tourniquet follow links above.

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care
Necroses: debridement; split-thickness skin grafting
Systemic antibiotics: standard indications
WHO (2010) 

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

Follow SAMPLE & ABCDE ApproAch

Obey Rattlesnake - specific features

see

  • 'Species-specific envenoming pattern above'

and

  • Evidence-informed unified treatment algorithm for pit viper snakebite management in the US (Lavonas et al. 2011)
  • Brandehoff et al. (2026)

Publications reporting broadly on Crotalus sp. envenoming in Central and South America

Malaque and Gutiérrez (2017); Warrell (2004).

Key issues

see footnotes above.

Specific treatment (antivenoms)

Species-specific evidence

Crotalus adamanteus

  • Kitchens C, Eskin T. Fatality in a case of envenomation by Crotalus adamanteus initially successfully treated with polyvalent ovine antivenom followed by recurrence of defibrinogenation syndrome. J Med Toxicol. 2008 Sep;4(3):180-3. PMID: 18821492; PMCID: PMC3550043.https://doi.org/10.1007/bf03161198
  • Kitchens CS, Van Mierop LH. Mechanism of defibrination in humans after envenomation by the Eastern diamondback rattlesnake. Am J Hematol. 1983 Jun;14(4):345-53. PMID: 6859033. https://doi.org/10.1002/ajh.2830140405
  • Van Mierop LH, Kitchens CS. Defibrination syndrome following bites by the Eastern diamondback rattlesnake. J Fla Med Assoc. 1980 Jan;67(1):21-7.PMID: 7351526.
  • Weiss HJ, Allan S, Davidson E, Kochwa S. Afibrinogenemia in man following the bite of a rattlesnake (Crotalus adamanteus). Am J Med. 1969 Oct;47(4):625-34. PMID: 5822979. https://doi.org/10.1016/0002-9343(69)90192-2

Crotalus atrox

  • Budzynski AZ, Pandya BV, Rubin RN, Brizuela BS, Soszka T, Stewart GJ. Fibrinogenolytic afibrinogenemia after envenomation by western diamondback rattlesnake (Crotalus atrox). Blood. 1984 Jan;63(1):1-14. PMID: 6537796.
  • Griffen D, Donovan JW. Significant envenomation from a preserved rattlesnake head (in a patient with a history of immediate hypersensitivity to antivenin). Ann Emerg Med. 1986 Aug;15(8):955-8. PMID: 3740586. https://doi.org/10.1016/s0196-0644(86)80685-0
  • Reid HA, Theakston RD. Changes in coagulation effects by venoms of Crotalus atrox as snakes age. Am J Trop Med Hyg. 1978 Sep;27(5):1053-7. PMID: 717632. https://doi.org/10.4269/ajtmh.1978.27.1053
  • Sivaprasad R, Cantini EM. Western diamondback rattlesnake (Crotalus atrox) poisoning. Postgrad Med. 1982 Jun;71(6):223-7, 230. PMID: 7079204. https://doi.org/10.1080/00325481.1982.11716105

Crotalus helleri

  • Levine M, Tashman D, Recchio I, Friedman N, Seltzer J, Minns A, LoVecchio F. Neurotoxicity Associated With the Southern Pacific Rattlesnake (Crotalus helleri). Ann Emerg Med. 2023 Mar;81(3):318-322. Epub 2022 Oct 15. PMID: 36253294. https://doi.org/10.1016/j.annemergmed.2022.08.020

Crotalus horridus 

Crotalus horridus atricaudatus

  • Kitchens CS, Hunter S, Van Mierop LH. Severe myonecrosis in a fatal case of envenomation by the canebrake rattlesnake (Crotalus horridus atricaudatus). Toxicon. 1987;25(4):455-8. PMID: 3617084. https://doi.org/10.1016/0041-0101(87)90080-8

Crotalus horridus horridus

  • Brick JF, Gutmann L. Rattlesnake venom-induced myokymia. Muscle Nerve. 1982;5(9S):S98-100. PMID: 7170003. https://doi.org/10.1212/wnl.37.9.1545
  • Brick JF, Gutmann L, Brick J, Apelgren KN, Riggs JE.Timber rattlesnake venom-induced myokymia: evidence for peripheral nerve origin. Neurology. 1987 Sep;37(9):1545-6. PMID: 3627455. https://doi.org/10.1212/wnl.37.9.1545
  • Bond RG, Burkhart KK. Thrombocytopenia following timber rattlesnake envenomation. Ann Emerg Med. 1997 Jul;30(1):40-4. PMID: 9209223. https://doi.org/10.1016/s0196-0644(97)70108-2
  • Hasiba U, Rosenbach LM, Rockwell D, Lewis JH. DiC-like syndrome after envenomation by the snake, Crotalus horridus horridus.N Engl J Med. 1975 Mar 6;292(10):505-7. PMID: 1167934. https://doi.org/10.1056/nejm197503062921004
  • Trautman W, Pizon A. Severe, persistent thrombocytopenia in Crotalus horridus envenomation despite antivenom: A retrospective review. Toxicon. 2023 Mar 1;224:107029. Epub 2023 Jan 20. PMID: 36682501. https://doi.org/10.1016/j.toxicon.2023.107029

Crotalus molossus molossus

  • Hardy DL, Jeter M, Corrigan JJ Jr.Envenomation by the northern blacktail rattlesnake (Crotalus molossus molossus): report of two cases and the in vitro effects of the venom on fibrinolysis and platelet aggregation. Toxicon. 1982;20(2):487-93. PMID: 7080054. https://doi.org/10.1016/0041-0101(82)90012-5

Crotalus oreganus

  • Heise CW, Cunningham C, Ruha AM, O'Connor AD. One Bite, Two Patients: Disparate Clinical Courses Following Simultaneous Crotalus oreganus abyssus Envenomation. Wilderness Environ Med. 2020 Sep;31(3):354-357. Epub 2020 Aug 18. PMID: 32826164. https://doi.org/10.1016/j.wem.2020.05.004
  • Slade J, Baja A, Al Zaki A, Auerbach P, Rodriguez F. Wilderness Cardiology: A Case of Envenomation-Associated Cardiotoxicity Following a Rattlesnake Bite. Cardiol Ther. 2021 Jun;10(1):271-276. Epub 2021 Feb 23. PMID: 33620669; PMCID: PMC8126537. https://doi.org/10.1007/s40119-021-00215-9

Crotalus polystictus

  • Hardy DL. Envenomation by the Mexican lance-headed rattlesnake Crotalus polystictus: a case report. Toxicon. 1982;20(6):1089-91. PMID: 7164112. https://doi.org/10.1016/0041-0101(82)90112-x

Crotalus scutulatus scutulatus

  • Greene S, Gilbert M, Wolk B, Campleman S, Ruha AM; ToxIC Snakebite Study Group. Geographic variation in the clinical features of Mohave rattlesnake (Crotalus scutulatus) envenomations reported to the North American Snakebite Registry. Toxicon X. 2023 Nov 10;21:100171. PMCID: PMC10689943. https://doi.org/10.1016/j.toxcx.2023.100171
  • Hardy DL. Envenomation by the Mojave rattlesnake (Crotalus scutulatus scutulatus) in southern Arizona, U.S.A. Toxicon. 1983;21(1):111-8. PMID: 6302953. https://doi.org/10.1016/0041-0101(83)90054-5
  • Jansen PW, Perkin RM, Van Stralen D. Mojave rattlesnake envenomation: prolonged neurotoxicity and rhabdomyolysis.Ann Emerg Med. 1992 Mar;21(3):322-5. PMID: 1536496. https://doi.org/10.1016/s0196-0644(05)80898-4
  • Smelski G, Cardwell M, Larsen J. Neurotoxic respiratory failure absent following Arizona rattlesnake bites. Toxicon. 2023 Mar 1;224:107034. Epub 2023 Jan 20. PMID: 36690088. https://doi.org/10.1016/j.toxicon.2023.107034

Crotalus simus 

(Crotalus simus: formerly classified as Crotalus durissus)

Costa Rica, Honduras

  • Warrell DA.Epidemiology, clinical features and management of snakebites in Central and South America. In: Campbell J, Lamar WW, editors. Venomous Reptiles of the Western Hemisphere.Ithaca: Cornell University Press; 2004. p. 709–61.

Costa Rica

  • Bolaños, R., Marín, O., Mora-Medina, E., Alfaro, E.A., 1981. El accidente ofídico por cascabela (Crotalus durissus durissus) en Costa Rica. Acta Med. Costarric. 24, 211–214. 

Crotalus viridis

C. viridis lutosus

  • Dart RC, Gustafson RA.Failure of electric shock treatment for rattlesnake envenomation. Ann Emerg Med. 1991 Jun;20(6):659-61. PMID: 2039106. https://doi.org/10.1016/s0196-0644(05)82389-3

C. viridis helleri

  • Davidson TM. Intravenous rattlesnake envenomation. West J Med. 1988 Jan;148(1):45-7. PMID: 3341134; PMCID: PMC1026009.
  • Fiero MK, Seifert MW, Weaver TJ, Bonilla CA. Comparative study of juvenile and adult prairie rattlesnake (Crotalus viridis viridis) venoms. Toxicon. 1972 Jan;10(1):81-2. PMID: 5015546. https://doi.org/10.1016/0041-0101(72)90095-5
  • Glenn, J. L., R. C. Straight (1982) The rattlesnakes and their venom yield and lethal toxicity. In Tu, A. T. (ed.): Rattlesnake venoms: Their actions and treatment. Marcel Dekker, New York: 3-119
  • Minton, S. A. (1967) Observations on toxicity and antigenic makeup of venoms from juvenile snakes. In Russell, F. E., P. R. Saunders: Animal Toxins. Pergamon Press, Oxford: 211-222
  • Richardson WH, Goto CS, Gutglass DJ, Williams SR, Clark RF. Rattlesnake envenomation with neurotoxicity refractory to treatment with crotaline Fab antivenom. Clin Toxicol (Phila). 2007 Jun-Aug;45(5):472-5. PMID: 17503249. https://doi.org/10.1080/15563650701338187

Various Crotalus sp.

  • Boyer LV, Seifert SA, Clark RF, McNally JT, Williams SR, Nordt SP, Walter FG, Dart RC. Recurrent and persistent coagulopathy following pit viper envenomation. Arch Intern Med. 1999 Apr 12;159(7):706-10. PMID: 10218750. https://doi.org/10.1001/archinte.159.7.706

References

Publications reporting broadly on Crotalus sp. envenoming in Central and South America

Malaque and Gutiérrez (2017); Warrell (2004).

Publications reporting broadly on rattlesnake envenoming in the US

Greene et al. (2021), Ruha et al. (2017), Warpinski et al. (2022), Yu et al. (2024)

Evidence-informed unified treatment algorithm for pit viper snakebite management in the US

Lavonas et al. (2011)

All references

  • Bolaños, R., Marín, O., Mora-Medina, E., Alfaro, E.A., 1981. El accidente ofídico por cascabela (Crotalus durissus durissus) en Costa Rica. Acta Med. Costarric. 24, 211–214.
  • Boyer LV, Seifert SA, Clark RF, McNally JT, Williams SR, Nordt SP, Walter FG, Dart RC. Recurrent and persistent coagulopathy following pit viper envenomation. Arch Intern Med. 1999 Apr 12;159(7):706-10.PMID: 10218750. https://doi.org/10.1001/archinte.159.7.706
  • Brick JF, Gutmann L. Rattlesnake venom-induced myokymia. Muscle Nerve. 1982;5(9S):S98-100. PMID: 7170003. https://doi.org/10.1212/wnl.37.9.1545
  • Brick JF, Gutmann L, Brick J, Apelgren KN, Riggs JE.Timber rattlesnake venom-induced myokymia: evidence for peripheral nerve origin.Neurology. 1987 Sep;37(9):1545-6. PMID: 3627455. https://doi.org/10.1212/wnl.37.9.1545
  • Bond RG, Burkhart KK. Thrombocytopenia following timber rattlesnake envenomation.Ann Emerg Med. 1997 Jul;30(1):40-4. PMID: 9209223. https://doi.org/10.1016/s0196-0644(97)70108-2
  • Budzynski AZ, Pandya BV, Rubin RN, Brizuela BS, Soszka T, Stewart GJ.Fibrinogenolytic afibrinogenemia after envenomation by western diamondback rattlesnake (Crotalus atrox).Blood. 1984 Jan;63(1):1-14. PMID: 6537796.
  • Dart RC, Gustafson RA.Failure of electric shock treatment for rattlesnake envenomation.Ann Emerg Med. 1991 Jun;20(6):659-61. PMID: 2039106. https://doi.org/10.1016/s0196-0644(05)82389-3
  • Davidson TM. Intravenous rattlesnake envenomation. West J Med. 1988 Jan;148(1):45-7.PMID: 3341134; PMCID: PMC1026009.
  • Fiero MK, Seifert MW, Weaver TJ, Bonilla CA.Comparative study of juvenile and adult prairie rattlesnake (Crotalus viridis viridis) venoms.Toxicon. 1972 Jan;10(1):81-2. PMID: 5015546. https://doi.org/10.1016/0041-0101(72)90095-5
  • Glenn, J. L., R. C. Straight (1982) The rattlesnakes and their venom yield and lethal toxicity. In Tu, A. T. (ed.): Rattlesnake venoms: Their actions and treatment.Marcel Dekker, New York: 3-119
  • Greene S, Cheng D, Vilke GM, Winkler G. How Should Native Crotalid Envenomation Be Managed in the Emergency Department? J Emerg Med. 2021 Jul;61(1):41-48. Epub 2021 Feb 20. PMID: 33622584. https://doi.org/10.1016/j.jemermed.2021.01.020
  • Greene S, Gilbert M, Wolk B, Campleman S, Ruha AM; ToxIC Snakebite Study Group. Geographic variation in the clinical features of Mohave rattlesnake (Crotalus scutulatus) envenomations reported to the North American Snakebite Registry. Toxicon X. 2023 Nov 10;21:100171. PMCID: PMC10689943. https://doi.org/10.1016/j.toxcx.2023.100171
  • Griffen D, Donovan JW. Significant envenomation from a preserved rattlesnake head (in a patient with a history of immediate hypersensitivity to antivenin).Ann Emerg Med. 1986 Aug;15(8):955-8. PMID: 3740586. https://doi.org/10.1016/s0196-0644(86)80685-0
  • Hardy DL. Envenomation by the Mexican lance-headed rattlesnake Crotalus polystictus: a case report.Toxicon. 1982;20(6):1089-91. PMID: 7164112. https://doi.org/10.1016/0041-0101(82)90112-x
  • Hardy DL. Envenomation by the Mojave rattlesnake (Crotalus scutulatus scutulatus) in southern Arizona, U.S.A. Toxicon.1983;21(1):111-8. PMID: 6302953. https://doi.org/10.1016/0041-0101(83)90054-5
  • Hardy DL, Jeter M, Corrigan JJ Jr.Envenomation by the northern blacktail rattlesnake (Crotalus molossus molossus): report of two cases and the in vitro effects of the venom on fibrinolysis and platelet aggregation. Toxicon. 1982;20(2):487-93. PMID: 7080054. https://doi.org/10.1016/0041-0101(82)90012-5
  • Hasiba U, Rosenbach LM, Rockwell D, Lewis JH. DiC-like syndrome after envenomation by the snake, Crotalus horridus horridus.N Engl J Med. 1975 Mar 6;292(10):505-7.PMID: 1167934. https://doi.org/10.1056/nejm197503062921004
  • Heise CW, Cunningham C, Ruha AM, O'Connor AD. One Bite, Two Patients: Disparate Clinical Courses Following Simultaneous Crotalus oreganus abyssus Envenomation. Wilderness Environ Med. 2020 Sep;31(3):354-357. Epub 2020 Aug 18. PMID: 32826164. https://doi.org/10.1016/j.wem.2020.05.004
  • Jansen PW, Perkin RM, Van Stralen D. Mojave rattlesnake envenomation: prolonged neurotoxicity and rhabdomyolysis.Ann Emerg Med. 1992 Mar;21(3):322-5. PMID: 1536496. https://doi.org/10.1016/s0196-0644(05)80898-4
  • Kitchens C, Eskin T. Fatality in a case of envenomation by Crotalus adamanteus initially successfully treated with polyvalent ovine antivenom followed by recurrence of defibrinogenation syndrome. J Med Toxicol. 2008 Sep;4(3):180-3. PMID: 18821492; PMCID: PMC3550043.https://doi.org/10.1007/bf03161198
  • Kitchens CS, Van Mierop LH. Mechanism of defibrination in humans after envenomation by the Eastern diamondback rattlesnake.Am J Hematol. 1983 Jun;14(4):345-53. PMID: 6859033. https://doi.org/10.1002/ajh.2830140405
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