What are the other Names for this Condition? (Also known as/Synonyms)

• Crotalus Ruber Snake Bite
• Monserrate Red Diamond Rattlesnake Bite
• Red Diamond-Backed Rattlesnake Bite

What is Red Diamond Rattlesnake Bite? (Definition/Background Information)

• The red diamond rattlesnake (Crotalus ruber) is a venomous snake that ranges in size from 2.5-3.5 feet found almost only in the Baja peninsula of Mexico, the southwest regions of California, and few islands in the Gulf of California
• It belongs to the sub-species of pit vipers, family Viperidae, and is regarded as the most docile of the diamondback rattlesnakes (that includes the eastern and western diamondback rattlesnakes). Pit vipers are termed so, due to the presence of certain heat-sensing organs located in a recess/notch between their eyes and nostrils
• The reptile is found on mountain sides, rocky slopes, chaparral (thorny shrub and bush patches), forests, grasslands, and even deserts. The snake may be identified by its triangular-shaped head, narrowed neck, heavy body, mostly brick red to brown color body (although some are pinkish, and very young snakes are grayish), and diamond patterns on its back
• The following sub-species of red diamond rattlesnakes are described in the scientific literature, typically based on the region they are found in:
  • Crotalus ruber exsul, or Cedros Island red diamond rattlesnake, confined to Cedros Island, Mexico, in the Pacific Ocean
  • Crotalus ruber lorenzoensis, or San Lorenzo Island red diamond rattlesnake, confined only to San Lorenzo Island, Mexico, in the Gulf of California
  • Crotalus ruber lucasensis, or San Lucan red diamond rattlesnake, found towards the southern part of Baja peninsula of Mexico
  • Crotalus ruber ruber, which is the most common among all the sub-species and found in southwest California and Baja peninsula of Mexico
• The red diamond rattlesnake has characteristic black and white ringed bands towards the end of its tail, before the rattle, just like a few other rattlesnakes. Also, like other rattlesnakes, the red diamond rattlesnake may coil, make hissing sounds, and shake/rattle its tail as a warning sign and announce its presence to any intruder
• With a well-developed vision, keen sense of smell, thermal detection, vibration awareness, and less-aggressive behavior, Red Diamond Rattlesnake Bites involving humans are very infrequent. However, a bite from a fully-grown red diamond rattlesnake can result in severe envenomation (venom injection) and death, in the absence of adequate treatment
• The signs and symptoms of Red Diamond Rattlesnake Bite may include intense pain, swelling, blistering, along with nausea and vomiting. The venom can also impair blood coagulation and breakdown the red blood cells, leading to severe systemic symptoms including shock and multiple organ damage
• Early administration of suitable antivenom (or antivenin) is the mainstay of treatment. Apart from this, symptomatic treatment is necessary, which may include the use of pain medication, platelet (blood) transfusion, and peritoneal dialysis. The prognosis of Red Diamond Rattlesnake Bite with prompt and effective therapy is usually good

Who gets Red Diamond Rattlesnake Bite? (Age and Sex Distribution)

• Red Diamond Rattlesnake Bite may occur to any individual exposed to the snake, particularly in its natural habitat
• Individuals of any age and gender are prone to snake bites
• The distribution of the red diamond rattlesnake includes certain southwest counties of California state (San Bernardino and Riverside counties), Baja peninsula of Mexico, and a few islands in the Gulf of California

What are the Risk Factors for Red Diamond Rattlesnake Bite? (Predisposing Factors)

The risk factors for Red Diamond Rattlesnake Bite include the following factors:

• Hiking and trekking in red diamond rattlesnake endemic regions
• Mountain climbing in unknown terrain, especially using one’s bare hands
• Living or residing in areas where the snake is found
• Walking unprotected through bushes, woods, and savannahs
• Venturing outdoors during the night without adequate protection
• Wildlife enthusiasts and scientific study groups, who explore the region
• Keeping them as pets
• Handling dead or live snakes; intentionally or accidentally picking up the snake
• The snakes are excellent swimmers, thus putting individuals at risk near water bodies too
• Drug addicts and alcoholics who come into contact with the snake have a greater risk for being bitten
• Children, elderly adults, and individuals with weak immune system have a higher risk for severe symptoms

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Red Diamond Rattlesnake Bite? (Etiology)

Red Diamond Rattlesnake Bite can take place when one comes into contact with the venomous snake, usually unintentionally or inadvertently.

• The snake typically stays away from developed areas. It is generally known to have a peaceful disposition and bites only under severe provocation, threat, or when cornered. The venom of a rattlesnake is known to contain certain hemotoxins that affect the blood and circulatory system including causing tissue necrosis
• The severity of the symptoms, among other factors, also depend on the size of the snake (i.e., amount of venom injected); the venom of a large adult red diamond rattlesnake is reportedly 6-15 times more powerful than the venom of a juvenile snake of the same species

What are the Signs and Symptoms of Red Diamond Rattlesnake Bite?

The signs and symptoms of Red Diamond Rattlesnake Bite can vary from one individual to another. The signs and symptoms depend on the age (whether child or adult), weight, and overall health status of the individual (whether having an underlying condition or illness). Also, the signs and symptoms vary according to the potency and amount of venom injected.

The signs and symptoms may develop within a period of 30 minutes to 6 hours and may include:

• Severe burning pain at the bite site; presence of noticeable fang marks, which may be single, double, or even three set of marks
• In a majority of cases, snake bites occur on the feet and ankles followed by the hands
• Skin discoloration; the skin color may change to blue and black
• Blistering of skin
• Swelling at the bite site that slowly involves a wider region; the severity of poisoning can be ascertained from the speed at which the swelling progresses up the arm or leg
• Bleeding from the wound; the oozing blood is thin
• Sensation of metallic taste in the mouth
• Twitching of eye and mouth; numbness
• Salivation
• Chills and sweating
• Breathing difficulties
• Nausea and vomiting
• Blurred vision and droopy eyelids
• Death of tissue (or necrosis) around the affected region or limb, observed within a few days
• Low blood pressure
• Feeling faint or dizzy
• Weakness and malaise

Some of the systemic signs and symptoms may include:

• Bleeding disorder due to:
  • Decreased blood platelets or thrombocytopenia
  • Destruction of red blood cells or hemolysis
• Internal hemorrhaging including:
  • Blood in urine
  • Bleeding from recent wounds
  • Mucosal bleeding - from nose, ears, eye, gastrointestinal tract, etc.
  • Anemia due to spontaneous bleeding
• Acute kidney injury or kidney failure
• In some cases, neurological symptoms

Note: 

• In some cases, the fang marks may not be pronounced or even visible. Sometimes only small scratch marks or lacerations may be observed. Thus, any contact with a rattlesnake merits immediate medical attention
• Severe anxiety may also result in some misleading symptoms of snakebites, such as sweating, fatigue, and shock, even when no bite has taken place (the individual may be imagining), or when it is a dry bite. Nevertheless, even in suspect cases, the presence of any such symptoms requires the attention of a qualified medical professional
• Also, if the individual has been treated using alternative/native medicines, it may present additional confusing symptoms. Thus, it is important to always consult a qualified healthcare provider promptly

How is Red Diamond Rattlesnake Bite Diagnosed?

Red Diamond Rattlesnake Bite may be diagnosed using the following tests and exams:

• Complete physical examination with comprehensive evaluation of medical history; a physical examination of the affected site by the physician may be normally sufficient to diagnose a snake bite
• The individual may be asked to provide an account (history) of the events that occurred (what took place and how), if possible
• Assessment of the signs and symptoms exhibited by the individual may be carefully observed
• Blood tests that may include: (many of these tests are repeated over the course of treatment)
  • Complete blood count (CBC) with differential and platelet count
  • White blood cell count
  • Hematocrit blood test: Hematocrit is the proportion of blood that is made up of red blood cells
  • Prothrombin time (PT) and partial thromboplastin time (PTT) tests
  • Fibrinogen blood test
  • Lactate dehydrogenase (LDH) test
  • Serum electrolytes including blood urea nitrogen (BUN) and creatinine levels
  • Arterial blood gas
• Urine test or urinalysis to test for free protein, myoglobin, and hemoglobin levels
• Continuous urine output monitoring is helpful to determine damage to the kidneys, if any
• Electrocardiogram (ECG)
• Kidney function test
• Liver function test
• Neurological studies

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Red Diamond Rattlesnake Bite?

The complications of Red Diamond Rattlesnake Bite may include:

• Multiple bites, causing injection of a large quantity of venom
• Blood clotting defects resulting in severe internal bleeding
• Severe deep tissue and muscle damage of the affected leg or hand, which can result in superimposed infections and gangrene formation
• Increased pressure causing compartment syndrome, which is an urgent medical condition
• Loss of limb function
• The snake toxin can damage the muscle resulting in muscle breakdown known as rhabdomyolysis. Extensive muscle breakdown can lead to a variety of complications including kidney failure
• Severe shock
• Seizures and coma
• Multiple organ failure

Presence of misleading symptoms due to fear and anxiety, which may be also aggravated by those around the individual, such as one’s family members, can sometimes result in inappropriate or over-treatment.

Antivenom reactions:

• Some individuals may develop an allergic reaction, such as anaphylaxis, to the antivenom that may be serious. This may develop within 10 minutes or even after 6 hours, typically starting with itchiness over the scalp and other skin areas
• Life-threatening anaphylactic reactions that require immediate medical treatment may include:
  • Low blood pressure or hypotension
  • Bronchospasm causing narrowing of the airways (bronchi) resulting in breathing difficulties
  • Angioedema: Swelling of skin tissue layers at various locations including the throat, causing speaking and breathing difficulties
• Serum sickness may develop as a complication of antivenom therapy causing fever, nausea, itchy skin, muscle and joint pain, etc. It may develop after 4 days or even 2 weeks (average 7 days) following the administration of antivenom serum

How is Red Diamond Rattlesnake Bite Treated?

All snake bites should be considered as medical emergencies and evaluated by trained medical professionals, as soon as possible; the first 6-8 hours are particularly vital for preventing life-threatening symptoms. Failure to obtain early assessment and management from the highest level of care (available within the community) may potentially result in severe complications and death.

The following measures may be considered in the treatment of Red Diamond Rattlesnake Bite, based on the medical evaluation of a trained healthcare professional:

• Administration of intravenous fluids to keep the patient well-hydrated; pain medication
• Administration of anti-snake venom (ASV) to neutralize the venom through slow intravenous injection or infusion method
• Address any signs or early allergic reaction: A close observation of the patient is necessary for a minimum of 60 minutes immediately following antivenom administration, to detect early allergic reactions, if any
• Periodic blood and urine tests are undertaken for 12-24 hours or more
• Tetanus vaccination is usually required, if it is not up to date
• The patient is generally admitted and placed in an ICU setting and monitored for at least a day following the abatement of symptoms; the patient has to be rested and kept warm
• Strict bed rest to prevent trauma may be advocated in case of hemostatic abnormalities that arises from a hemotoxic/cytotoxic venom (the venom can result in increased bleeding tendencies leading to substantial blood loss even to minor trauma)
• If necessary, blood and plasma transfusions for severe cases
• Intubation and respiratory support
• Providing life support, such as ventilation assistance and treatment for shock, for those with severe symptoms leading to potential organ failure
• Medications to control blood pressure
• Peritoneal dialysis for acute kidney failure
• Pressure management (using appropriate pressure devices) of affected limb for compartment syndrome
• Removal or necrotic tissue through surgical debridement
• Rehabilitation of the affected limb through physical therapy

Note:

• For envenomation involving rattlesnake bites, the use of prophylactic antibiotic therapy is medically not advised
• Consultation with a medical toxicologist is recommended for all cases requiring the administration of anti-snake venom
• Even though antivenom therapy is the key treatment for systemic envenomation; on its own, it may never be adequate enough to completely resolve the condition. Other supportive and symptomatic measures are always necessary to save the patient
• The dose of antivenom does not vary for a child, adult, or even for a pregnant woman, since the snake typically injects the same quantity of venom into an individual
• Gynecological evaluation may be necessary for pregnant women bitten by snakes to evaluate the health of the fetus
• In many instances, the type of venomous snake involved in the bite is unknown; hence, all vital organs and systems should be closely monitored and treated appropriately, as necessary

How can Red Diamond Rattlesnake Bite be Prevented?

Red Diamond Rattlesnake Bite may be avoided by:

• Learning to recognize red diamond rattlesnakes using the following tips:
  • The dull red/brown color body of the snake with rhombus or diamond-shaped patterns along its length, and the black and white ringed band before the rattle (end of the tail)
  • The snake stays perfectly still and tries to blend more into the surrounding, until approached very closely or disturbed
  • Rattlesnakes provide clear warning signs of hissing and slightly expanding their body when approached
  • The unmistakable back and forth shaking of tail producing a rattle sound
  • Before striking, the snake continuously coils in a serpentine manner
• If you spot a rattlesnake, step back slowly and keep a safe distance of at least 8-10 feet or more (between yourself and the snake)

Outdoors:

• Being alert, if you are in snake-infested regions, particularly containing dangerous species of snakes
• Be on the lookout for snakes and other animals while trekking or hiking; also, if you are with a pet, do not allow the pet to wander away
• Always allow snakes crossing your path the right of way
• Always stay on established paths and clearings, while walking in the woods, grasslands, or through thick undergrowths
• Avoid picking up firewood sticks, stones, or rocks without checking the area for any concealed creatures
• Always step on top of large rocks and fallen trunks; never place one’s foot by the side of big rocks and rotting tree stumps. Some snake species are known to take shelter or warm themselves on the sides, during the day
• Always check before sitting on dead tree logs, stumps, or a pile of rocks; use a stick to stir or probe around the area
• Do not reach out to move or hold bushes or tree branches without properly examining them for any camouflaged creatures such as snakes
• Watch where you place your hands while climbing a ledge, trees, rocky slopes, or mountains
• Avoiding being outdoors at night in forested areas; be careful while camping outdoors
• Avoid tall grassy areas or thick bushes; if you plan to explore the area, use heavy boots and thick pants
• While walking through areas with thick undergrowth, pay attention to the sound of birds that may warn of potential dangers such as snakes
• While walking outdoors at night, use a flashlight or lamp and make constant noise (singing or talking to others) or large stomping sounds that may alert the snake to move away from the region
• While walking through tall grass or undergrowth, try to walk one behind the other in a single file
• Avoid snake-infested regions or even walking on cleared forest paths and roads during nights, immediately after heavy rains that may flush snakes out to the open, due to flooding of their burrows and holes
• Wildlife explorers, amateur adventurers, and others are requested to carry first aid kit, especially when traveling through areas containing highly venomous snake species

Residential settlements:

• Keep homes and surrounding areas clean and clear of rubbish or leafy piles, termite mounds, even building materials (like bricks and large stones)
• Cut tall and unkempt grass or low-lying shrubs and bushes around dwelling areas that provides hiding places for snakes and other rodents
• In regions where snakes are regular home visitors, always switch on the lights before entering one’s shed or garages (and try to stand clear of exits that may serve as possible escape routes for the snakes)
• Natural disasters, such as floods and forest fires, are known to drive out snakes and other creatures into homes seeking shelter. Hence, always remain vigilant when returning home following such situations
• Never intentionally run over snakes on the road while on a vehicle (cycle, other 2-wheeler, or 4-wheeler); the injured snake lying on the road may strike other pedestrians, or get entangled in the vehicle and be carried to the parking lot or even inside one’s garage

Other points to consider:

• Exercise vigilance while working in farms, particularly during the harvest season or after flooding
• Avoid playing with or teasing snakes such as by touching their tails
• Do not pick up dead snakes - they may be poisonous and still bite through a reflex action
• Do not reach into dark nooks/corners/recesses with your bare hands/foot
• Teach and educate children about the dangers and importance of snakes
• Take steps to educate the members of a community to identify venomous snakes, recognize bite symptoms, and how to avoid encounter with snakes
• Completely avoid any form of native or traditional treatment for snake bites

Both large and small snakes have the potential for severe envenomation; hence, all snake bites should be treated promptly and appropriately.

What is the Prognosis of Red Diamond Rattlesnake Bite? (Outcomes/Resolutions)

• The prognosis of Red Diamond Rattlesnake Bite is dependent on the size of the snake, site of bite, overall health of the individual, promptness of medical response, and continued observance and treatment of complications following admission of the patient. In many cases, the prognosis is good with immediate treatment and administration of antivenom
• With prompt administration of antivenom, the coagulation defects and associated symptoms are known to improve. However, the swelling of the limb and tissue necrosis, may take over a week to resolve. Without adequate treatment or access to proper healthcare, deaths have been reported

Additional and Relevant Useful Information for Red Diamond Rattlesnake Bite:

• According to some reports, in the US, only 5% of the snake bite deaths are attributed to red diamond rattlesnakes
• A single bite of a fully-grown red diamond rattlesnake can inject enough venom to potentially kill 3 adults
• In some cases, the snake bite may be a ‘dry bite’, meaning that even though there is a bite mark, no venom injection occurs. However, even for dry bites, the patient must be placed under observation and monitored closely for a period ranging anywhere from 12-24 hours, prior to discharge

Depending on the geographical region, either monovalent antivenom or polyvalent antivenom may be administered for systemic envenomation. Monovalent antivenom neutralizes venom of a single snake species only, whereas polyvalent antivenom can neutralize the venom of several snake species.

The snake venom is a highly complex mix of several proteins, enzymes, amino acids, peptide chains, fats, and even certain metals. The bite causing venom injection into the body may be categorized as:

• Intramuscular injection: Long-fanged snakes have a potential for injecting venom directly into the muscles (this is highly infrequent though)
• Intraperitoneal injection: When the snake bite involves the stomach or abdomen region
• Intravenous injection: In very rare cases, the snake fangs may inject venom directly into a blood vessel, releasing venom directly into blood (posing an even greater danger than normal snake bites)
• Subcutaneous injection: A majority of snake bites involve the subcutaneous skin layers (venom is injected just below the skin surface)