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Pseudonaja spp. (Brown Snakes)

Pseudonaja spp. (Brown Snakes)
15.Aug.2022-Expires: 7 days - Do not archive







Brown snakes



Brown snakes (Pseudonaja spp.) are distributed throughout mainland Australia. They are not found in Tasmania or on the islands off the southern coast of Australia. They may be found in essentially all habitats, including urban and metropolitan areas.[1]


Intervention Level

Child and Adult

Medical assessment and observation, preferably in an advanced care facility, is recommended for:
- Any individual bitten or suspected to have been bitten by a snake[2]
Immediately apply pressure bandage with immobilization first aid if not already applied, unless the patient is in a medical facility and does not have clinical evidence of severe envenoming.

Observation Period

Observation at Home

All patients require medical attention.

Medical Observation

Even trivial looking bites may result in severe envenoming; asymptomatic patients following possible envenoming must be observed for a minimum of 12 hours and should be observed overnight.[3][4]
Patients must be closely observed for the onset of symptoms including:
Bleeding/ooze from bite or venepuncture sites
Bleeding gums
Paralysis (may be subtle)
Ptosis (drooping eyelids)
Ophthalmoplegia (paralysis of motor nerves of the eye)
Bulbar palsy
Descending flaccid paralysis
Acute kidney injury
The coagulation screen and blood investigations along with a neurological examination must be performed upon presentation, 1 hour after removal of the pressure bandage, and repeated at 6 hours and 12 hours after the bite.[4]
If at 12 hours post-bite all the blood tests are normal and there is no clinical signs of neurotoxicity the patient is eligible for discharge.[4] The patient should be advised to return if there is any indication of illness including change in their urine color or if they develop any muscle pain, tenderness, or weakness.
Removal of Pressure Bandage with Immobilization First Aid
If envenoming is evident, do not remove pressure bandage with immobilization first aid until antivenom has been administered.[3]
If there are no clinical or biochemical signs of envenoming only remove pressure bandage with immobilization first aid once an IV line has been inserted and antivenom and advanced resuscitation facilities are at hand.[3][4][5] A bite site swab can be saved for possible venom detection kit (VDK) testing if evidence of envenoming becomes evident. However, VDK analysis is not always necessary. Determination of the appropriate antivenom required to treat an envenomed patient can often be determined through clinical and laboratory features of envenoming and the geographical location of the snakebite.
Once the pressure bandage is removed repeat blood tests at 1 hour after removal.[4] If these results are normal and there are no signs of neurotoxicity repeat blood tests again at 6 hours (unless already > 6 hours) and 12 hours after the bite.[4] If clinical signs or biochemical findings indicate systemic envenoming then antivenom should be administered.[6] If at 12 hours post-bite all the blood tests are normal and there is no clinical signs of neurotoxicity the patient is eligible for discharge.[4]
Intravenous Fluids
Adequate hydration is required to reduce the incidence of renal damage.[6]
Hydration should be maintained through administration of oral or intravenous fluid to ensure a good urine output.
Normal (0.9%) saline dose
Adjust adult dose to body weight
Initial fluid load
1 L IV over 2 to 3 hours
Continue infusion at
100 to 150 mL IV per hour for 6 to 12 hours
Be circumspect when inserting IV lines, as there will be continued oozing from all sites until the coagulopathy reverses, which will be at least 6 hours, usually more. Avoid insertions in sites where bleeding cannot be easily controlled, such as subclavian, femoral, and jugular veins.


In all cases of suspected snakebite conduct:
Blood investigations
Snake venom detection kit test depending on geographical location of snakebite
All patients must then be observed for a minimum of 12 hours.[4]
Snake Venom Detection Kit Identification
The role of venom detection kit in the management of snakebite in Australia varies across geographical areas. In some areas the choice of antivenom in cases of envenoming can be made based on the clinical syndrome and geographical area the snakebite occurred. Snake venom detection kits are more likely to be useful in areas where the envenoming may have been caused by more than two possible snakes. The opinion of the patient or a witness, no matter how experienced in snake identification, should not be accepted without question.[7] The Snake Venom Detection Kit is used to establish the correct antivenom to administer - if required. The result of a snake venom detection kit does not indicate that major envenoming has occurred and is not an indication antivenom is required.[8] A positive snake venom detection result from the bite site (preferred sample site) indicates venom is present and the type of antivenom required to treat the patient in the case of clinical or laboratory evidence that envenoming has occured.[9] The decision to give antivenom should be based on clinical and laboratory evidence of systemic envenoming.[2][9][8][10][11] Conversely, a negative result should not be used to exclude envenoming.[8]
Urine may be tested using the snake venom detection kit if there is evidence of significant systemic envenoming and a bite site swab is either unavailable, or has tested negative. Urine may sometimes give false positives[8] and should not be tested in patients who do not have evidence of systemic envenoming.[10]
If pressure bandage with immobilization first aid has been applied, do not remove the bandage, rather, cut away a section immediately over the bite area and swab for venom detection.[5] Retain the cut section of bandage as it may later be used for further venom identification.
Blood Investigations
Insert a secure intravenous line and take blood for:
Coagulopathy screen:
International normalized ratio (INR)
Activated partial thromboplastin time (aPTT)
Fibrinogen concentration
Quantitative D-dimer/Fibrin degradation products
Point of care testing devices for coagulation studies have been shown to produce false positive results in cases of snakebite, and should not be used.
Full blood count (FBC) including:
White blood cells (especially absolute lymphocyte count)
Serum electrolytes including:
Serum urea
Serum creatinine
Serum creatine kinase (CK)
Collect urine
Visually check for hemoglobinuria/myoglobinuria (dark-red/brown coloration)
May be required for subsequent Snake Venom Detection Kit testing

Admission Criteria

Admission to an intensive care environment is recommended for patients who develop any signs of envenoming or abnormal blood results.



Consultation with a medical toxicologist (at the bedside or through a Poison Center) is advised for this poisoning as toxicity can be life-threatening.
Rapid and effective diagnosis is imperative. While 75% of brown snake bites do not lead to systemic envenoming, all cases should be considered potentially lethal, and all must be admitted to a hospital capable of providing definitive care. Application of pressure bandage with immobilization first aid prior to initial patient movement can be life-saving in conjunction with subsequent antivenom administration. Cardiac dysrhythmia/arrest and seizure or collapse may require immediate management.
If there is evidence of systemic envenoming, administration of appropriate antivenom to neutralize circulating venom is crucial. Further supportive care may be required. Venom induced consumptive coagulopathy is characteristic of Australian brown snake envenoming, although hemorrhage may not be clinically apparent unless bleeding from a traumatic injury. Any injury to the head (possibly associated with a post-bite collapse) is a potential source of intracranial hemorrhage. Routine administration of blood products including fresh frozen plasma is not indicated, unless there is uncontrolled life-threatening bleeding. Any factor potentially causing hypertension should be avoided. Intravenous fluid hydration is required to ensure renal perfusion; renal damage is a concern and should be managed following standard protocols if antivenom does not prove adequate.
Paralysis is uncommon but may be heralded by onset of ptosis and ophthalmoplegia several hours after a bite. Antivenom may prove beneficial but may not fully reverse established paralysis. Pain is unlikely to be a feature; avoid drugs with anti-platelet function including aspirin and NSAIDs. Potent analgesics including opioids that potentially produce respiratory depression are usually not required, but can be used in monitored clinical environments. Infection is uncommon and therefore prophylactic antibiotics are not required; if infection becomes evident then an appropriate antibiotic should be administered. Tetanus status should be reviewed, and a booster administered if required; to avoid iatrogenic intramuscular hematoma do not give any IM injections until coagulopathy is reversed. Myolysis is not a feature of brown snake envenoming. Serum sickness may occur following antivenom administration; follow up and/or steroid treatment may be required.
Emergency Stabilization
Enhanced Elimination
Supportive Care


Ensure Adequate Cardiopulmonary Function

Ensure the airway is protected if compromised (intubation may be necessary).
Immediately establish secure intravenous access.
Be circumspect when inserting IV lines, as there will be continued oozing from all sites until the coagulopathy reverses, which may take at least 6 hours, usually more.[12] Avoid insertions in sites where bleeding cannot be easily controlled, such as subclavian, femoral, and jugular veins.[10]

Pressure Bandage with Immobilization First Aid

- Reassure the patient and ensure they remain still.[10]
- Remove any watches, rings, bracelets, or other jewelry from the bitten limb.[10][1]
- A broad elasticized compression bandage should be applied over the bitten area about as firmly as that used for a sprained ankle but not so tight that circulation is compromised. Elasticized bandages are preferable,[13] but crepe bandages, clothing strips, towels, or pantyhose will suffice in an emergency.[10][13]
- It is very important that the patient is not moved. A compression bandage should be applied over clothing - rather than move an arm or leg.[1]
- Bandage upward from the lower portion of the bitten limb. Apply the bandage as far as possible up the limb.[1]
- If bite is on the arm, bandage the arm with the elbow bent and leave the tips of the fingers unbandaged to allow circulation to be checked. Bind a splint to the forearm and immobilize the arm with a sling.[1]
- If the bite is on the leg, leave the tips of the toes unbandaged to allow circulation to be checked. Immobilize the leg by bandaging a splint to the limb to prevent movement.[1]
- On the overlying bandage mark the location of the bite.[1]
- Ensure the patient is told not to move the affected limb at all.[10][1]
- Transport (preferably an ambulance) should be brought to the patient to prevent movement. If this cannot be done, the patient should be carried rather than walk.[1]
- Do not give alcohol, fluid, or food by mouth. If the patient will not reach medical care for a long period, only water should be given by mouth.[10]
- Transport to hospital.[10]
- Tourniquets should not be used. The bite site should not be washed, cleaned, cut, sucked, or treated with any substance.[10]

Cardiac Arrest

Cardiac arrest or dysrhythmia are likely short-lived as the precipitating blood clot will be dissolved by fibrinolysis.[14] Resuscitation should follow standard procedures for cardiac arrest.


Toxic seizures are generally self-limiting and are unlikely to require specific treatment.


Hypotension in children is determined by age and systolic blood pressure
Hypotension if Systolic Blood Pressure (mm Hg) is:
0 to 28 days
< 60
1 to 12 months
< 70
1 to 10 years
< 70 + (age in years x 2)
> 10 years
< 90
Administer an isotonic crystalloid fluid
10 mL/kg IV over 5 to 10 minutes
If the systolic blood pressure does not return to the normal range, give a further 10 mL/kg body weight of the isotonic crystalloid over 5 to 10 minutes.
The intraosseous route can be used if IV access is difficult or delayed.
Administer a bolus of isotonic crystalloid fluid if systolic blood pressure is less than 100 mmHg.
Isotonic crystalloid fluid dose:
20 mL/kg IV over 5 to 10 minutes
If the systolic blood pressure does not return to the normal range, give a further 10 mL/kg body weight normal saline over 5 to 10 minutes.
The intraosseous route can be used if IV access is difficult or delayed.

Emergency Monitoring

Coagulopathy screen
Full blood count
Serum electrolytes
Serum urea
Serum creatinine
Serum creatine kinase (CK)
Heart rate
Blood pressure
Respiratory function
12 lead ECG
Fluid balance
Plasma glucose
Head CT scan (if altered mental status)



Decontamination Not Recommended

Do not clean the wound prior to use of a Snake Venom Detection Kit. This will remove venom which otherwise might allow identification of the culprit.[3][15][16]


Brown Snake Antivenom

Australian Polyvalent Snake Antivenom

Antivenom is most effective when administered early following snakebite, and is less likely to be beneficial once major envenoming syndromes have been established.[17] Brown Snake Antivenom is the preferred antivenom. Polyvalent Snake Antivenom is an alternative if a suitable monovalent antivenom is not available.


In the majority of cases of brown snake bite, antivenom will not be required.[18]
Antivenom administration is indicated in any patient where there is:
History of unconsciousness, collapse, seizure, or cardiac arrest
INR > 1.3, prolonged bleeding from wounds or venepunctures
Neurotoxic paralysis
Any flaccid paralysis including ptosis, opthalmoplegia, limb or respiratory muscle weakness (unless present without worsening for 6 hours)
Antivenom administration may be indicated in the following circumstances. In these instances discussion with a medical toxicologist is recommended.
Renal damage
Elevated creatinine and urea
Any abnormality of APTT, INR, D-dimer, FBC
Significant symptoms including headache and vomiting
Any patient who appears systemically unwell

Dose and Administration

Only administer if there is clear evidence of envenoming.[9] The dose for a child is the same as that for an adult. Do not remove pressure bandage with immobilization first aid prior to administration, only after. Monovalent antivenom is preferable to polyvalent, and pre-testing or pre-medication is not required.[3][7][19]
In most instances of Australian snakebite an adequate initial dose of antivenom will be sufficient and past practices of multiple repeat doses are both unnecessary and potentially hazardous.[20] Nevertheless, it is important that the initial dose of antivenom not be considered the end of treatment and investigation.
Prior to use of snake antivenom ensure adequate resuscitation equipment is available for the management of anaphylaxis, and that an appropriate dose of epinephrine (adrenaline) is prepared for administration if necessary.[1][3][7][21]
Initial Brown Snake Antivenom Dose
1 vial IV[22][23][17]
Dilute antivenom up to 1 in 10 in an isotonic solution (e.g. normal [0.9%] saline); dilution should be less for children due to fluid load. Administer intravenously via a drip-set, commence very slowly and increase rate if there is no adverse reaction. Each dose should be given over 15 to 30 minutes.[1][3][10]
Patients must be closely monitored for anaphylaxis during and for 30 minutes after the infusion.[10]
Further Brown Snake Antivenom Doses
Current evidence indicates it may take at least 6 hours for evidence of recovery to become reliably detectable following antivenom.[24] Therefore, unless there is clear clinical indication for earlier testing, repeat blood tests and conduct a careful neurological examination at 6 hours post-antivenom.
If measured parameters are stable or are improving, further antivenom is not immediately required. If there is evidence of worsening paralysis, coagulopathy, myolysis, or kidney injury, it is recommend that advice from a medical toxicologist is obtained regarding whether further antivenom therapy is required.
Further blood testing and an on-going schedule of repeat examinations every 12 hours is appropriate for at least 24 hours post-antivenom or longer if envenoming has not completely resolved.
Polyvalent Snake Antivenom
For Polyvalent Snake Antivenom, follow the same dosage and administration guidelines as for Brown Snake Antivenom outlined above. Each vial of Polyvalent Antivenom carries the same neutralizing capacity as one vial of Brown Snake Antivenom.
Note that polyvalent antivenom is a greater volume of sera and therefore more likely to precipitate an adverse reaction; it is also more expensive than monovalent antivenom. In small children, high doses of polyvalent antivenom may be impractical because of fluid overload issues.


There is no absolute contra-indication to this potentially life-saving intervention. Pregnancy is not a contraindication to antivenom administration.[25]
Those at increased risk of severe reaction include patients with history of:
Previous reaction to antiserum

Adverse Effects

Closely monitor the patient for indications of anaphylaxis including:
Airways obstruction
Serum Sickness
Serum sickness may occur some 4 to 14 days following antivenom administration.[3][17][26]
Patients should be made aware of the signs and symptoms of serum sickness including:
Joint aches
If more than 25 mL of Brown Snake Antivenom is administered, prophylaxis with an oral steroid such as prednisolone may be considered, and follow-up arranged.[1][3] Commence prophylaxis on day 2 to 3 post-bite.
Prednisolone dose
1 mg/kg (up to 50 mg) per day orally for 5 days
50 mg per day orally for 5 days


Following a brown snake bite there is minimal or no local pain at the wound site, rarely swelling or erythema, and as the fangs are small the injury can be virtually invisible;[22][27][28] adults may not even be aware they have been bitten.[29][30]
Initial systemic symptoms can include nausea, vomiting, abdominal pain, headache, and dizziness.[31][32][33][34] Sudden loss of consciousness, typically with spontaneous recovery, may occur early in the course of envenoming.[22][32] There is potential for hypotension, cardiac dysrhythmia, and rarely arrest.[14][22][35] Bleeding and/or ooze from the bite site or subsequent venepuncture is an early indication of venom induced consumption coagulopathy (VICC), which is the hallmark of brown snake envenoming.[22][32][35] This coagulopathy may potentially lead to complete defibrination and non-clotting blood. International normalized ratio (INR) and activated partial thromboplastin time (aPTT) will be prolonged, fibrinogen low to absent, and fibrin degradation products (FDP) and D-dimer immunoassay elevated.[36][12][37][38][39][40] Although hemorrhage is a major concern, spontaneous bleeding is uncommon to rare.[14][35] Thrombotic microangiopathy with thrombocytopenia and microangiopathic hemolytic anemia may additionally occur,[35] but is not common; platelet counts typically remaining normal in most cases.
Neurotoxicity is rare and typically only results in mild effects such as ptosis.[22] Seizure may occur, more commonly in children, but it does not appear to be related to neurotoxins. Acute kidney injury may occur[35] and it more commonly develops in adults. It appears that most, possibly all cases of acute kidney injury are not primarily caused by venom nephrotoxicity but likely secondary to other effects of envenoming such as thrombotic microangiopathy.[37] Myolysis is not typically a feature of brown snake envenoming.[22][35]

Routes of Exposure

Clinical effects usually develop following a dermal exposure (bite). Snakebite to the eye or contamination of the eye with snake venom is an unlikely route of exposure.

Onset/Duration of Symptoms

Early collapse, if present, is typically the first feature, developing within 5 to 30 minutes.[22][32] Between 30 and 120 minutes there may be lymph node pain and early nonspecific systemic features. Coagulopathy typically develops over 1 to 2 hours post-envenoming,[12] although complete defibrination can occur by 15 to 30 minutes.[14] If neuromuscular paralysis develops the first signs of ptosis may be evident 2 to 6 hours post-bite. Paralysis can be also delayed and may evolve over 12 to 24 hours.[7][21][31][41]
Coagulopathy typically resolves over 12 to 18 hours.[22][42] Paralysis following snakebite may take days or weeks to resolve.[43]

Severity of Envenoming

The following are typical features indicating severity in patients known to be envenomed, but it is important to note that the isolated presence of (particularly mild) features does not always indicate that envenoming has occurred.
Mild Pseudonaja EnvenomingModerate Pseudonaja EnvenomingSevere Pseudonaja Envenoming
Abdominal pain
Venom induced consumption coagulopathy
Microangiopathic hemolytic anemia
Intracranial hemorrhage
Acute renal failure
Respiratory failure
Cardiac arrest


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[2] Jelinek GA, Hamilton T, Hirsch RL. Admissions for suspected snake bite to the Perth adult teaching hospitals, 1979 to 1988. Med J Aust 1991 Dec 2-16; 155 (11-12): 761-4.
[3] Isbister GK. Snake bite: a current approach to management. Aust Prescr 2006; 29 (5): 125-9.
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[5] Sutherland SK. When do you remove first aid measures from an envenomed limb? [Letter] Med J Aust 1981 May 16; 1 (10): 542, 544.
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[13] Canale E, Isbister GK, Currie BJ. Investigating pressure bandaging for snakebite in a simulated setting: bandage type, training and the effect of transport. Emerg Med Australas 2009 Jun; 21 (3): 184-90.
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[15] Fatovich DM, Hitchcock T, White J. Mild snake envenomation. Emerg Med (Fremantle) 2002 Mar; 14 (1): 85-8.
[16] Jelinek GA, Breheny FX. Ten years of snake bites at Fremantle Hospital. Med J Aust 1990 Dec 3-17; 153 (11-12): 658-61.
[17] Isbister GK, Brown SG, Page CB, McCoubrie DL, Greene SL, Buckley NA. Snakebite in Australia: a practical approach to diagnosis and treatment. Med J Aust 2013 Dec 16; 199 (11): 763-8.
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[22] Allen GE, Brown SG, Buckley NA, O'Leary MA, Page CB, Currie BJ, White J, Isbister GK. Clinical effects and antivenom dosing in brown snake (Pseudonaja spp.) envenoming--Australian snakebite project (ASP-14). PLoS One 2012; 7 (12): e53188.
[23] Isbister GK, O'Leary MA, Schneider JJ, Brown SG, Currie BJ. Efficacy of antivenom against the procoagulant effect of Australian brown snake (Pseudonaja sp.) venom: in vivo and in vitro studies. Toxicon 2007 Jan; 49 (1): 57-67.
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[25] Sutherland SK, Leonard RL. Snakebite deaths in Australia 1992-1994 and a management update. Med J Aust 1995 Dec 4-18; 163 (11-12): 616-8.
[26] Ryan NM, Downes MA, Isbister GK. Clinical features of serum sickness after Australian snake antivenom. Toxicon 2015 Dec 15; 108 (): 181-3.
[27] Campbell CH. Clinical aspects of snake bite in the Pacific area. Toxicon 1969 Jun; 7 (1): 25-8.
[28] White J. Local tissue destruction and Australian elapid envenomation. Toxicon 1983; 21 (Suppl 3): 493-6.
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[37] Isbister GK, Little M, Cull G, McCoubrie D, Lawton P, Szabo F, Kennedy J, Trethewy C, Luxton G, Brown SG, Currie BJ. Thrombotic microangiopathy from Australian brown snake (Pseudonaja) envenoming. Intern Med J 2007 Aug; 37 (8): 523-8.
[38] Henderson A, Baldwin LN, May C. Fatal brown snake (Pseudonaja textilis) envenomation despite the use of antivenom. Med J Aust 1993 May 17; 158 (10): 709-10.
[39] Lalloo DG, Trevett AJ, Owens D, Minei J, Naraqi S, Saweri A, Hutton RA, Theakston RD, Warrell DA. Coagulopathy following bites by the Papuan taipan (Oxyuranus scutellatus canni). Blood Coagul Fibrinolysis 1995 Feb; 6 (1): 65-72.
[40] Masci PP, Rowe EA, Whitaker AN, de Jersey J. Fibrinolysis as a feature of disseminated intravascular coagulation (DIC) after Pseudonaja textilis textilis envenomation. Thromb Res 1990 Sep 1; 59 (5): 859-70.
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[43] CAMPBELL CH, YOUNG LN. The symptomatology, clinical course and successful treatment of Papuan elapine snake envenomation. Med J Aust 1961 Apr 1; 48(1) (): 478-86.

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