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Snake Envenomations, Sea

Last Updated: March 14, 2006
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Synonyms and related keywords: sea snakes, Hydrophiidae, Pelamis platurus, P platurus, Enhydrina schistosa, E schistosa, sea snake venom, neurotoxins, myotoxins, snake envenomations, sea snake envenomations, sea snake bite, sea snake neurotoxin, sea snake wound, snake bite

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Author: James Foster, MD, MS, Consulting Staff, Department of Emergency Medicine, Palomar Pomerado Health

James Foster, MD, MS, is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, California Medical Association, and Phi Beta Kappa

Editor(s): Robert Norris, MD, Chief, Associate Professor, Department of Surgery, Division of Emergency Medicine, Stanford University Medical Center; John T VanDeVoort, PharmD, Clinical Assistant Professor, College of Pharmacy, University of Minnesota; James S Walker, DO, Program Coordinator, Associate Professor, Department of Emergency Medicine, University of Oklahoma Health Sciences Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School

Disclosure


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Background: Sea snakes, which comprise approximately 70 species, are the most abundant and widely dispersed group of poisonous reptiles in the world. Most (approximately 50) sea snake species are members of the family Hydrophiidae and are characterized by vertically flattened tails and nostrils with valvelike flaps. Unlike eels, sea snakes have scales but lack gills or fins. While they spend much of their time underwater, they must surface periodically to breathe. They are typically about 1 m in length, but some species may grow to 3 m.

Sea snakes are found predominantly in tropical and subtropical waters in the western Pacific and Indian Oceans, often in protected coastal waters and near river mouths. However, they do thrive in a variety of habitats, ranging from muddy or turbid water to clear waters and coral reefs. The pelagic sea snake, Pelamis platurus, has a remarkably wide geographic range, which reaches the western coasts of North and South America from the Baja peninsula to Ecuador, along with the waters around Hawaii. Sea snakes are not found in the Atlantic Ocean, the Caribbean, or along the North American coast north of Baja.

Generally, sea snakes are not aggressive. They are not thought to strike humans unless provoked, nor do they typically actively pursue swimming prey.

Pathophysiology: The venom apparatus of sea snakes is fairly rudimentary, consisting of 2-4 short hollow maxillary fangs associated with a pair of venom glands. The venom ducts open near the tips of the fangs. The fangs are dislodged easily from their sockets and may remain embedded in the skin of victims.

Nearly 80% of sea snake bites fail to produce significant envenomation, and bites may be inconspicuous, painless, and free of edema. However, sea snake venom is extremely potent, and a complete envenomation by an adult sea snake may contain enough venom to kill 3 adult people. The clinically relevant toxins in sea snake venom are neurotoxins and myotoxins.

The primary neurotoxin causes peripheral paralysis by competitively binding to postsynaptic nicotinic acetylcholine receptors at the neuromuscular junction. Potent myotoxins account for the significant muscle necrosis, with consequent myoglobinemia and hyperkalemia that may occur following envenomation. Sea snake venom does not affect blood coagulation to a significant degree.

Sea snakes are closely related to Australian elapids; some paraspecificity exists between sea snake antivenom and Australian elapid antivenom.

Frequency:

  • In the US: Hawaii is the only US state where sea snakes are found.
  • Internationally: Sea snake envenomations occur throughout the serpents' geographic ranges, but accurate data about the incidence of envenomation are not available. Victims most commonly are fishermen bitten while handling nets or after stepping on a snake.

Mortality/Morbidity: Before the development of sea snake antivenom, the mortality rate associated with sea snake bites was approximately 10%. With timely administration of antivenom and aggressive supportive care, the mortality rate currently is much lower, although accurate numbers are not available.

Race: No inherent racial predilection exists for sea snake bites; however, the best-represented races in areas with endemic sea snake populations are the most commonly bitten.

Sex: Males are bitten much more commonly than females, with a male-to-female ratio of approximately 4:1, because of the increased occupational exposure to sea snakes by male fishermen.

Age: Age is a factor in determining sea snake bites only insofar as it occurs with potential recreational or occupational exposure to the serpents.


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History: The diagnosis of sea snake envenomation requires the establishment of the potential for exposure to a sea snake (eg, exposure to water in an area known to harbor sea snakes), identification of symptoms of envenomation, and demonstration of evidence of a bite (eg, multiple puncture wounds or reliable history of observed bite).

Symptoms are attributable to multiple organ systems, with neurological symptoms predominating. They may occur as early as 5 minutes or as late as 8 hours following the bite, but they usually occur within 2 hours.

  • Euphoria
  • Anxiety
  • Malaise
  • Drowsiness or mild confusion
  • Headache
  • Myalgias (worse with movement and usually begin in the bitten extremity and neck 30-60 min after envenomation)
  • Arthralgias
  • Ptosis
  • Mydriasis with sluggish light reaction
  • Ophthalmoplegia, leading to diplopia
  • Failing vision (usually a terminal symptom)
  • Sialorrhea
  • Facial paralysis
  • Muscle paralysis (usually ascending, may be flaccid or spastic)
  • Dyspnea
  • Nausea, vomiting, abdominal pain, and cramping
  • Change in urine color (dusky yellow to reddish brown)
  • Oliguria
  • Thirst

Physical:

  • Fang marks (usually 2 or more small circular dots, may be difficult to identify)
  • Local reaction (usually absent or minimal)
  • Paralysis (usually ascending)
  • Hyporeflexia, progressing to loss of reflexes
  • Hypersalivation
  • Trismus
  • Bulbar paralysis
  • Ptosis
  • External ophthalmoplegia
  • Dysarthria, slurred speech
  • Dysphagia
  • Respiratory distress or respiratory failure
  • Tachypnea
  • Cyanosis
  • Apnea
  • Cardiac arrest (hyperkalemic)
  • Fever (variable)
  • Lymphadenopathy (nodes draining bite site)

Causes:

  • Occupational exposure - Usually fishermen handling nets
  • Accidental exposure - Stepping on sea snakes in shallow water
  • Nonaccidental exposure - Intentionally handling sea snakes (eg, home aquariums)
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Guillain-Barré Syndrome
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Lab Studies:

  • Obtain arterial blood gas (ABG) measurements if the patient's respiratory status is questionable.
  • Urinalysis
    • Myoglobinuria may be found, typically 3-6 hours following envenomation.
    • The urine may test positive for protein and occult blood one hour before myoglobin is detected.
  • Creatine kinase (CK) may be elevated because of muscle damage.
  • Serum glutamic-oxaloacetic transaminase (SGOT) may be elevated because of muscle damage.
  • Electrolyte levels may indicate hyperkalemia from myonecrosis.
  • Assess blood urea nitrogen (BUN) and creatine levels to monitor renal function.
  • Obtain a complete blood count (CBC). Leukocytosis higher than 20,000 suggests significant envenomation.

Imaging Studies:

  • Chest radiography may be useful to exclude other causes of respiratory distress and is mandatory in patients requiring intubation and mechanical ventilation.
  • Soft tissue films of the bitten extremity may reveal embedded fangs.

Other Tests:

  • An electrocardiogram (ECG) is useful to look for signs of hyperkalemia, including peaked T waves, a widened QRS complex, or ventricular arrhythmias.
  • Before antivenom administration, if time permits, skin testing to assess for allergy to horse serum is indicated, but it is not mandatory if the patient is unstable. The results of skin testing are not completely reliable.
    • Intradermal injection of 0.02-0.03 mL of a 1:10 dilution of normal horse serum is the most commonly described technique; however, the test is more accurate if a 1:10 dilution of actual reconstituted antivenom is used.
    • Skin test results are positive if a wheal develops in 5-30 minutes.
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Prehospital Care: Initial stabilization with airway control, pressure immobilization of the bitten extremity, and prompt transport to a facility capable of providing advanced medical care (including antivenom administration) are the critical components of prehospital care for sea snake bites.

  • A brief attempt to visually identify the offending snake is warranted, but prolonged attempts to kill or capture the snake should be avoided. The bite reflex persists for up to an hour even after the snake is decapitated, making it possible for dead snakes to inflict a serious bite.
  • Institute supportive measures, including endotracheal intubation and mechanical ventilation, as clinically indicated.
  • Apply pressure immobilization of the bitten extremity as quickly as possible because it may impede venom spread. Rapidly wrap the limb with a broad pressure bandage, starting at the wound site and extending as high up the extremity as possible. The bandage should be wrapped to venous occlusive pressure (approximately 70 mm Hg) in a manner similar to wrapping a sprained ankle. An extremity splint completes the immobilization.
  • Avoid incision, ice, or other cooling measures.
  • Suction is unlikely to be beneficial and only should be attempted if a mechanical suction device is immediately available.

Emergency Department Care:

  • Stabilization of airway, breathing, and circulation (ABCs)
  • Intravenous access
  • Cardiac monitoring and continuous pulse oximetry
  • Tetanus prophylaxis
  • Antivenom administration is indicated for any patient with signs of envenomation. The agent of choice is polyvalent sea snake antivenom (Commonwealth Serum Laboratories, Melbourne, Australia). Alternatively, tiger snake (Notechis scutatus) antivenom can be substituted because of the close relationship of tiger snake and sea snake venoms.
    • Indications for antivenom use include shock, respiratory distress or failure, generalized myalgias, trismus, moderate-to-severe pain with passive movement of extremities, myoglobinuria, elevated creatine kinase (>600 IU/l), altered level of consciousness, hyperkalemia, or leukocytosis.
    • Administer antivenom as soon as possible. Benefits may be observed up to 36 hours after the bite.
    • For early mild-to-moderate envenomation, use one ampule of antivenom (1000 U). Later or severe envenomation typically requires 3-10 ampules (3000-10,000 U) of antivenom, respectively.
  • If antivenom is not available, consider dialysis. Sea snake neurotoxin is of low enough molecular weight to be dialyzable. Furthermore, dialysis may be life saving in cases of severe hyperkalemia.
  • Aggressive hydration with diuresis can help promote renal myoglobin clearance. Urine alkalinization may be of some benefit in cases of myoglobinuria.

Consultations:

  • Poison control centers, zoos, or experts in snake envenomation may help guide the management of sea snake envenomations and assist with the location of antivenom.
  • In cases of serious envenomation, internists or intensivists should be consulted for admission to the hospital or intensive care unit.

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The mainstay of medical therapy for sea snake venom poisoning is antivenom. If time permits, a skin test for sensitivity to horse serum may be performed before antivenom administration. The purpose of skin testing is to try to predict possible anaphylaxis, rather than determine whether antivenom should be used. Omit skin testing if the patient clearly needs antivenom because skin testing reliability is low. Closely monitor patients during antivenom administration and begin aggressive treatment if any evidence of allergic reaction is observed.

Drug Category: Antivenom -- Conveys passive immunity to patients with sea snake bite.
Drug Name
Antivenin polyvalent sea snake -- Can be obtained from Commonwealth Serum Laboratories, Melbourne, Australia. DOC for treatment of symptomatic sea snake envenomation. Is a hyperimmune horse globulin prepared against the venoms of Enhydrina schistosa and N scutatus and is efficacious in the treatment of all sea snake envenomations.
An alternative to polyvalent sea snake antivenom is monovalent sea snake antivenom (Haffkine Institute, Bombay, India), prepared against the venom of E schistosa, which is effective against most sea snake venoms. Finally, tiger snake (N scutatus) antivenom (Commonwealth Serum Laboratories, Melbourne, Australia) displays substantial activity against sea snake venoms because of a close relationship between tiger snake and sea snake venoms.
Early or mild envenomation can be treated with 1 ampule, while late and/or severe envenomations should be treated with 3-10 ampules. Snake antivenom only is administered IV.
IV infusion should be started at a slow rate, which may be increased if no evidence of significant allergic reaction exists. Most authorities recommend premedication with diphenhydramine.
Adult DoseEarly and mild envenomations: Administer 1000 U
Late envenomations: Administer 3000 to 10,000 U
1000 U = 1 ampule
Pediatric DoseAdminister as in adults
ContraindicationsDocumented hypersensitivity; may give in severe envenomation despite hypersensitivity
Interactions None reported
Pregnancy B - Usually safe but benefits must outweigh the risks.
PrecautionsBecause of presence of horse serum, agents for emergency treatment of anaphylaxis should be available; in the event of a severe reaction, antivenom administration usually can be restarted at a slower rate with concurrent infusion of IV epinephrine and close patient monitoring
Drug Category: Antihistamines -- Used to treat minor allergic reactions and anaphylaxis.
Drug Name
Diphenhydramine (Benadryl) -- May be used to pretreat patients with prior documentation of minor allergic reactions. Used as a prophylactic treatment and for treatment of allergic reactions to antivenom.
Adult Dose1 mg/kg IV; not to exceed 100 mg
Pediatric Dose1 mg/kg IV q6h
ContraindicationsDocumented hypersensitivity; MAOIs
InteractionsPotentiates effect of CNS depressants; because of alcohol content, do not give syrup dosage form to patients taking medications that can cause disulfiramlike reactions
Pregnancy C - Safety for use during pregnancy has not been established.
PrecautionsMay exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction
Drug Category: Immunizations -- Active immunity can prevent hypersensitivity reactions and neutralize toxoids.
Drug Name
Diphtheria-Tetanus Toxoid -- Used to induce active immunity against tetanus in selected patients. The immunizing agents of choice for most adults and children >7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen–containing product.
In children and adults, may administer into the deltoid or midlateral thigh muscles. In infants, the preferred site of administration is the mid thigh laterally.
The tetanus immunization status should be updated for any patient bitten by a sea snake. The precise formulation used is dependent on the patient's age and prior immunization status.
Adult DosePrimary immunization: Administer 0.5 mL IM, give 2 injections 4-8 wk apart and a third dose 6-12 mo after the second injection.
Booster dose: Administer 0.5 mL q10y
Pediatric DoseAdminister as in adults
ContraindicationsDocumented hypersensitivity; a history of any type of neurological symptoms or signs following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
InteractionsPatients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization because of poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol because it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (nevertheless, interaction is clinically insignificant and does not preclude its concurrent use)
Pregnancy C - Safety for use during pregnancy has not been established.
PrecautionsDo not use to treat actual tetanus infections or for immediate prophylaxis of unimmunized individuals (use tetanus antitoxin instead, preferably human tetanus immune globulin); diminished antibody response to active immunization may be observed in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic persons with HIV infection is recommended
Drug Category: Cardiovascular agents -- These agents are useful for treatment or prophylaxis of acute allergic reactions and for support of blood pressure in patients with shock.
Drug Name
Epinephrine (Epi-Pen, Adrenaline) -- DOC for the treatment of anaphylactoid reactions and should be considered as pretreatment before giving antivenom. Has alpha-agonist effects that include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. Beta-agonist effects include bronchodilatation, chronotropic cardiac activity, and positive inotropic effects.
Adult DoseInitial dose of epinephrine is 0.01 mL/kg IM/SC of 1:1000 solution; not to exceed 0.5 mL of 1:1000 solution (0.5 mg)
Fraction of total dose (0.1 to 0.2 mL) at site of antigenic exposure, if accessible
Severe anaphylaxis (laryngeal edema, respiratory failure, shock): 10 mL of 1:100,000 dilution of aqueous epinephrine IV over 10 min
If no improvement observed, establish a continuous infusion starting at 1 µg/min of 4-µg/mL concentration; increase to 4 µg/min prn
Pediatric Dose0.1 mcg/kg/min SC q15min for 2 doses, then q4h with increments of 0.1 mcg/kg/min prn; not to exceed 1.5 µg/kg/min
ContraindicationsDocumented hypersensitivity; cardiac arrhythmias or angle-closure glaucoma; local anesthesia in areas such as fingers or toes because vasoconstriction may produce sloughing of tissue; do not use during labor (may delay second stage of labor)
InteractionsIncreases toxicity of beta- and alpha-blocking agents and that of halogenated inhalational anesthetics
Pregnancy C - Safety for use during pregnancy has not been established.
PrecautionsCaution in elderly persons, prostatic hypertrophy, hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias
Drug Category: Corticosteroids -- Anti-inflammatory agents are useful in the management of acute and delayed allergic reactions to sea snake envenomation or antivenom administration.
Drug Name
Methylprednisolone (Solu-Medrol, Depo-Medrol) -- Steroids ameliorate delayed effects of anaphylactoid reactions and may limit biphasic anaphylaxis. In severe cases of serum sickness, parenteral steroids may be beneficial to reduce inflammatory effects of this immune-complex mediated disease.
Adult Dose10-125 mg IV q6-8h
Pediatric Dose1-2 mg/kg IV q6-8h
ContraindicationsDocumented hypersensitivity; viral, fungal, or tubercular skin infections
InteractionsCoadministration with digoxin, may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics
Pregnancy C - Safety for use during pregnancy has not been established.
PrecautionsHyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use
Drug Name
Prednisone (Deltasone, Orasone, Meticorten) -- Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult Dose1-2 mg/kg qd or divided bid until symptoms resolved, followed by a 1-wk taper
Pediatric DoseAdminister as in adults
ContraindicationsDocumented hypersensitivity; viral, fungal, or tubercular infections
InteractionsCoadministration with estrogens may decrease clearance; concurrent use with digoxin, may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Pregnancy C - Safety for use during pregnancy has not been established.
PrecautionsAbrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
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Further Inpatient Care:

Further Outpatient Care:

Transfer:

Deterrence/Prevention:

Complications:

Prognosis:

Patient Education:

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Medical/Legal Pitfalls:

  • Because of the relatively small size of sea snake fangs and the relative lack of local irritation, the diagnosis of envenomation may be inadvertently missed or patients may be prematurely discharged before serious symptoms occur.
  • Respiratory distress should be managed aggressively to prevent aspiration and hypoxemia.
  • Allergic reactions may occur in response to antivenom administration and may be life threatening. Informed consent should be obtained before administration, unless the patient is in extremis or unable to provide consent.
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Caption: Picture 1. Technique for application of pressure immobilization in field management of sea snake bites. See Image 2 for Figures 4-6. Figure 1, Apply a broad-pressure bandage over the bite site as soon as possible. Do not take off jeans because the movement of the doing so assists venom to enter the bloodstream. Keep the bitten leg still. Figure 2, The bandage should be as tight as would be applied to a sprained ankle. Figure 3, Extend the bandage as high as possible.
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Caption: Picture 2. Technique for application of pressure immobilization in field management of sea snake bites. See Image 1 for Figures 1-3. Figure 4, Apply a splint to the leg. Figure 5, Bind the splint firmly to as much of the leg as possible. If the bandages and splint are applied correctly, they will be comfortable and may be left on for several hours. They should not be taken off until the patient has reached medical care. The doctor will decide when to remove the bandages. If venom has been injected, it will move into the bloodstream quickly once the bandages are removed. The doctor should leave the bandages and splint in position until he or she has assembled appropriate antivenom and drugs that may need to be used when the dressings and splint are removed. Figure 6, For bites on a hand or forearm, bind to the elbow with bandages, use a splint to the elbow, and use a sling.
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  BIBLIOGRAPHY Section 11 of 11   Click here to go to the previous section in this topic Click here to go to the top of this page
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  • Auerbach PS: Marine envenomations. N Engl J Med 1991 Aug 15; 325(7): 486-93[Medline].
  • Baxter EH, Gallichio HA: Cross-neutralization by tiger snake (Notechis scutatus) antivenene and sea snake (Enhydrina schistosa) antivenene against several sea snake venoms. Toxicon 1974 May; 12(3): 273-8[Medline].
  • Chetty N, Du A, Hodgson WC: The in vitro neuromuscular activity of Indo-Pacific sea-snake venoms: efficacy of two commercially available antivenoms. Toxicon 2004 Aug; 44(2): 193-200[Medline].
  • Dunson WA: The Biology of Sea Snakes. Baltimore, Md: University Park Press; 1975.
  • Guenin DG, Auerbach PS: Trauma and envenomations from marine fauna. In: Tintinalli, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw-Hill; 1996:868-73.
  • Heatwole H: Sea Snakes. Krieger Publishing Company; 1999.
  • Minton SA Jr: Paraspecific protection by elapid and sea snake antivenins. Toxicon 1967 Jul; 5(1): 47-55[Medline].
  • Pinney R: Sea snakes. Reptile & Amphibian 1994; 26: 22-34.
  • Reid HA: Antivenom in sea-snake bit poisoning. Lancet 1975 Mar 15; 1(7907): 622-3[Medline].
  • Reid HA: Epidemiology of sea-snake bites. J Trop Med Hyg 1975 May; 78(5): 106-13[Medline].
  • Reid HA, Chan KE: The paradox in therapeutic defibrination. Lancet 1968 Mar 9; 1(7541): 485-6[Medline].
  • Senanayake MP, Ariaratnam CA, Abeywickrema S: Two Sri Lankan cases of identified sea snake bites, without envenoming. Toxicon 2005 Jun 1; 45(7): 861-3[Medline].
  • Tu AT: Biotoxicology of sea snake venoms. Ann Emerg Med 1987 Sep; 16(9): 1023-8[Medline].
  • Tu AT, Fulde G: Sea snake bites. Clin Dermatol 1987 Jul-Sep; 5(3): 118-26[Medline].
  • Vick JA: Medical studies of poisonous land and sea snakes. J Clin Pharmacol 1994 Jun; 34(6): 709-12[Medline].

NOTE:
Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER

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