Snakebite Protocol: Copperhead
Overview: The copperhead is a ground dwelling pitviper with generally minimal to moderate effects compared to other pitvipers in the southeast. Bites are most common to hands, due to handling of the snake, and the feet and legs due to stepping on the snake, either day or night. Bites to the feet at night are almost always due to walking without a flashlight. Deaths from copperhead bites are extraordinarily rare, and have been attributed to factors such as: facial bites or bites to the tongue or mouth area that lead to swelling of the tongue and occlusion of the airway; or a previous bite and subsequent anaphylaxis.
Appearance: Copperheads generally have a tan ground color with chocolate markings. From above, the markings are usually described as bowties or dumbbells. From the side however, which is the most accurate way to identify this species, the markings appear to be a row of Hershey’s Kisses.
Behavior: Copperheads are usually active when the temps are above 72F and below 85F. That means the time of day when they are active will change throughout the year, but temperature is the most vital factor in predicting movement. They seek deep cover below 50F, and above 95F.
Diet: In nature, newborn copperheads (which are born live about 5 to 6 inches in length), will feed on tiny frog, lizard and skink species. As adults, reaching a maximum length of around 4 feet but more commonly 2 to 3 feet, copperheads will primarily eat small rodents. Other creatures, such as cicadas, may occasionally be eaten.
Young: Newborn copperheads will have the same markings as the adults, except that the tail will be sulfur yellow. The tail is used to mimic a small worm, which attracts frogs and lizards.
Bites: Bites by copperheads usually cause immediate pain, which has been described as “hitting your thumb with a hammer”, “stepping on a bare electrical wire”, or “being repeatedly stabbed with a knife”. In other words, it is very painful. If for no other reason, bite patients will go to the ER for pain management. Morphine is most commonly given for pain, but vomiting is also common for moderate to severe evenomations, and either Phenergan or Zofran are typically given. Initially, blue bruising appears around the fang marks, almost without exception. Swelling is always present in an evenomation, and soft, pliable skin around the bite without bruising is a good indicator that the patient has not been envenomated, or has possibly been bitten by a non-venomous species. If swelling and bruising are present, be prepared for the patient to deteriorate. The swelling will progress up the limb, and the patient may develop numbness and tingling in the face, mouth or scalp, nausea and vomiting, chills, abdominal cramping, and rapid heart rate (due to pain and discomfort).
Treatment: Positive identification of a copperhead bite in the pre-hospital setting is an indicator that pain management should be initiated promptly. [Morphine 2 to 10mg titrated to the patient’s pain level.] The only downside is that patients that receive analgesics pre-hospital can enter the Emergency Room in very little distress, thereby causing a delay in antivenom administration if ER personnel base their treatment on distress alone. However, with copperhead bites most often antivenom is given simply to decrease the amount of local tissue morbidity and save the limb or limb function rather than saving the life of the patient. Fortunately, the new generation of antivenoms are hypo-allergenic, [CroFab, Antivipmyn] and we are able to administer them without nearly as much concern for anaphylaxis as the first generation antivenoms [Ex: Wyeth ACP]. With CroFab, 6 vials is a good starting dose for copperhead bites with both swelling and bruising, followed by subsequent doses, up to around 12 vials. [***When mixing antivenom, be sure to swirl and NEVER shake the bottle.***]
Coagulopathy isn’t normally a concern with copperheads, but rather reversal of all systemic symptoms, such as nausea, vomiting, chills and paresthesias. In my experience, although you may see a decrease in the swelling, it will persist from 1 to 5 days even with antivenom administration. And it should be noted that fasciotomies are almost unheard of in copperhead bites.
Local tissue damage however, is common, as is the loss of tissue and loss of mobility of a joint near the bite. Once again, this can be greatly limited by giving an adequate quantity of antivenom early in the treatment.
Pediatrics: If small children are bitten, the concern should be much greater, and antivenom in the same or higher quantities should be administered as soon as possible. Bites with systemic symptoms (nausea, vomiting, numbness and tingling, metallic taste in the mouth), should receive antivenom in appropriate quantities without delay. Only after the initial treatment is on board should a facility transfer the patient to a higher level of care.
EMS Instructions for Copperhead Bites:
1. Attempt to positively identify the snake. This is vital to antivenom administration. Look for the pattern of Hershey’s kisses along the side of the snakes body.
2. Never transport a live snake in an ambulance. Dead snakes should NEVER be handled, unless the head has been separated from the body and the head isolated in a puncture proof container. The head of a dead pitviper is fully capable of injecting venom for several days after death. Treat dead venomous snakes with caution!!! Consider the risk and liability when dealing with them.
3. Establish baseline vital signs.
4. The affected limb is best kept in a neutral position. Do not be overly concerned in the pre-hospital setting with elevation or dependence. It won’t change the outcome of the bite.
5. Attempt to start at least an 18g IV above the level of the bite, and on the opposite side of the body. For copperhead bites, 1000 ml of NS is sufficient. Antivenom is given through Normal Saline IV lines.
6. Provide Oxygen appropriate for your patient’s level of consciousness and level of distress. When in doubt, give high flow O2.
7. Transport your patient to the nearest hospital that has antivenom. This should be prearranged. ****And NEVER ice the bite or use tourniquets!****
• Daniel Duff, www.GeorgiaTimberDens.org, “Northern Copperhead sunning on rock” • Chris Harper, NREMT-P, “Copperhead bite to index finger after 24 hours”
Copyright 2011, Chris Harper, NREMT-P, www.VenomousReptiles.org
To download a pdf of this snakebite protocol, click HERE.
Daniel Duff has had a lifelong love for nature, sparked in childhood from a fascination with dinosaurs. He can most often be found hiking the most remote regions of the North Georgia Mountains, or camping on the black water rivers of South Georgia, reflecting peacefully by a campfire. Armed with a research permit from the Georgia DNR and US Forest Service, Daniel spends much of his field herping time gathering notes from the field. He currently resides in Gwinnett County, Georgia with his family.