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Forward
Snakebite remains a medical condition of the rural poor in developing countries and yet ironically, western developed countries largely produce textbooks and guidelines for treatment of snakebite. These developed country guidelines are probably effective in a developed country infrastructure with access to advanced facilities but developing countries are different. Solutions proposed must be practical, preferably low cost and should be based on extensive experience of developing country facilities.
As a result of this PMRC has embarked on a programme to develop a set of guidelines for snakebite management for the two key areas of mortality, Asia and Africa. The guidelines are based on extensive study of the problem and needs of developing countries. Recommendations are practical and applicable in the most basic medical facilities.
The core intention of the guidelines are to enable doctors in basic facilities manage snakebite effectively and determine when the patient can be treated locally and when and under what conditions they should be referred to better equipped hospitals. Referral of patients is a reality in developing countries and yet there have been few guides that assist in how this can be most effectively managed.
We hope that these guidelines will be widely disseminated which is why we have made them freely available for doctors to download and use within their own facilities. We hope that Health Departments will assist in circulating the guidelines to all doctors in snakebite prone areas.
Introduction
Snakebite has remained an enduring medical problem for many decades and little progress has been made in reducing mortality. Globally, approximately 50,000 60,000 people die each year as a result of snakebite and more are left permanently impaired. The vast majority are rural agricultural workers engaged in subsistence farming.
Over 90% of these fatalities occur in two continents i.e. Africa and Asia. The influence of Western textbooks on the medical education of these continents is high and as a result doctor confidence and capability in managing snakebite is sub optimal as guidelines are not continent specific or appropriate for the developing world. Ironically however, much of appropriate snakebite treatment is common to all areas.
Too little attention to providing guidelines for physicians has been given by snakebite experts, despite this being regularly identified as an area of concern for many decades. This text is intended to guide doctors in how to deal with snakebite in both Asia and Africa.
Much of snakebite treatment is not based on clinical trials as very few have been carried out by experts in the last four decades, funds have been deployed on conferences and planning meetings! The argument propounded by many experts that guidelines should not be published until trial data is available is both unhelpful and unrealistic. Evidence based medicine has now become the battle cry of those who have delivered little in many decades and wish to inhibit any potential progress.
Doctors are treating snakebite daily and guidelines are urgently required. Victims require our help today and cannot be told that treatment will have to wait for trial data, particularly when we have already been waiting for several decades.
These guidelines are based on practical experience of all levels of medical care in developing countries, mainly in the Government Hospital sector where the majority of snakebites are treated. The guidelines include very practical approaches and improvised solutions that are based on the real environment in which snakebite is treated. Western approaches, based on western hospital profiles or western originated international training courses have been shown to fail to prepare developed world doctors from providing assistance in developing countries.
No guidelines, including these, are perfect. As doctors use these guidelines to treat victims their observations and innovations will lead to further progress in both understanding and treatment of snakebite. Progress in treatment is essential if victims are to be best served by the medical facilities that cater to them.
The guidelines are comprehensive and are targeted at doctors and health officials who administrate health in developing countries. Recommendations concerning how to for prepare for snakebite in natural disasters and how to equip basic health facilities to deal with snakebite are key areas for administrators. If health officials are not familiar with the key drug requirements to deal with snakebite doctors will not be properly equipped. These guidelines present an open and clear indication of some of the key controversies within snakebite management, such as the use of swelling as an indication for administering anti venom.
Where the principles contained within these guidelines have been implemented, direct improvements in treatment, reduced mortality and more efficient use of anti venom has been the result.
Snakebite is not the source for television programmes or conferences, it is a terrible malady of the rural agricultural worker and it is entirely manageable in even the most basic settings if practical guidelines are made available and subject to a cascade process.
Ian D Simpson Snakebite Adviser: Pakistan Medical Research Council. Editorial Advisory Board: Pakistan Journal of Medical Research. Snakebite Adviser: KFBG China Programme. Government Snakebite Task Forces Tamil Nadu, India, West Bengal, India. Editorial Advisory Board: Indian Journal of Emergency Pediatrics. Email ID: iandsimpson@gmail.com
Contents
1.0 Snakes of Medical Significance 1.1 Introduction 1.2 Snakes of Medical Significance 1.3 South Asia 1.4 Asia Central, South East and East 1.5 West Asia 1.6 Africa South Zone 1.7 Africa West Zone 1.8 Africa North East Zone 1.9 Africa Progressive Weakness Species 2.0 Snakebite First Aid 2.1 Introduction 2.2 Inappropriate First Aid 2.3 Tight Tourniquets 2.4 Cutting and Suction 2.5 Pressure Immobilisation Method (PIM) 2.6 Other Pressure Techniques 2.7 Electricity and Ice 2.8 Washing the Wound 2.9 Traditional Remedies 2.10 Traditional Remedies: Snake Stones 2.11 Traditional Remedies: Scarification 2.12 Recommended First Aid 3.0 Patient Arrival 3.1 Introduction 3.2 Asymptomatic Arrival 3.3 Symptomatic patients 3.4 Key Interventions 3.5 Non-Critical Arrival 14 14 14 16 20 22 24 27 28 33 35 35 35 35 37 38 40 41 42 42 45 46 47 49 49 49 49 50 51
4.0 Patient Dialogue 4.1 Introduction 4.2 Time of the Bite 4.3 Snake Seen and/or Killed 4.4 Allopathic Treatment Before Hospital 4.5 Traditional Treatments Before Hospital 4.6 Activity at Time of Bite 5.0 Diagnosis: Signs and Symptoms of Envenoming 5.1 Introduction 5.2 Bleeding 5.3 Progressive Weakness 5.4 Painful Progressive Swelling 6.0 Diagnosis of Envenoming 6.1 Introduction 6.2 Visible Criteria 6.3 Simple Diagnostic Methods 6.4 Technical Diagnostic Methods 6.5 Bite marks 7.0 Anti Snake Venom 7.1 Introduction 7.2 Lyophilised ASV Vs Liquid 7.3 Monovalent Vs Polyvalent ASV 7.4 What Can ASV Do and Not Do 7.5 Swelling and ASV 7.6 ASV Safety
53 53 53 53 53 53 54 56 56 56 57 57 58 58 58 60 61 62 63 63 63 63 65 66 66
8.0 Criteria for Administering ASV 8.1 Introduction 8.2 Bleeding 8.3 Progressive Weakness 8.4 The case for Swelling and Local damage 8.5 Painful Progressive Swelling 8.6 How to Administer ASV 8.7 ASV Administration Period 9.0 ASV Dosage 9.1 Introduction 9.2 Initial Dosing Exceptions 9.3 Maximum Doses 9.4 Late Administration of ASV 9.5 ASV & Pregnancy 9.6 Paediatric ASV Dosing 9.7 Repeat Bites 9.8 South Asia ASVs 9.9 Asia Central, South East and East ASVs 9.11 West Asia ASVs 9.12 Repeat ASV Doses 9.13 Repeat ASV Doses: Bleeding 9.14 Repeat ASV Doses: Progressive Weakness 9.15 Repeat ASV Doses: Painful Progressive Swelling 9.16 Signs of Recovery 10.0 Adverse Anti Snake Venom Reactions 10.1 Introduction 10.2 Mechanism of the Reaction 10.3 Prediction of Adverse Reactions 10.4 Preventing Adverse Reactions 10.5 Treatment of Adverse Reactions 10.6 ASV Reaction Support Drugs
67 67 67 67 68 68 69 69 70 70 70 71 71 72 73 73 75 76 81 83 83 83 84 84 85 85 85 85 86 87 88 10
11.0 Neurotoxic Envenomation and Anticholinesterase Drugs 11.1 Introduction 11.2 Anticholinesterase Drugs 11.3 The Test 11.4 Anticholinesterase Drugs: Tests and Doses 12.0 Airway Support Items 12.1 Introduction 12.2 Developing World Airway Management Context 12.3 Improvised Devices 12.4 Bridging Devices 12.5 Ideal Solution 13.0 Haemotoxic Envenomation, Blood Products and Renal Failure 13.1 Introduction 13.2 Anticoagulants 13.3 Coagulants 13.4 Longer Term Issues 13.5 Renal Failure 14.0 Pain, Wound Management and the Surgical Aspects of Snakebite 14.1 Pain and Wound Management 14.2 Antibiotics 14.3 Snake Venom Ophthalmia 14.4 Surgery and Snakebite 14.5 Snakebite & Life Threatening Conditions Requiring Surgery 14.6 Debridement of Necrotic Tissue 14.7 Compartment Syndrome
90 90 90 91 91 93 93 93 94 95 97 98 98 99 99 99 100
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15.0 Snakebite Management in Basic or Primary Care Facilities 15.1 Introduction 15.2 Patient Arrival & Assessment 15.3 Envenomation: Haemotoxic 15.4 Referral Criteria 15.5 Envenomation: Neurotoxic 15.6 Referral Criteria 15.7 Conditions and Equipment for Neurotoxic Referral 16.0 Equipping a Basic Hospital for Effective Snakebite Management 16.1 Introduction 16.2 Assumptions 16.3 Anti Snake venom 16.4 Other Support Drugs 16.5 Support Equipment 17.0 Snakebite: Risk Activities and Prevention 17.1 Introduction 17.2 Prevention Myths 17.3 The Doctors Role 18.0 Snakebite Management When ASV is Unavailable 18.1 Introduction 18.2 Guiding Principles 18.3 Actions for the Physician 19.0 Snakebite Management in Natural Disasters 19.1 Introduction 19.2 Likely Conditions and Impact 19.3 Doctors and medical Authority Response
110 110 110 111 112 113 114 114 114 115 117 117 117 118 120 120 120 121
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20.0 Preserving and Identifying Snake Specimens 20.1 Introduction 20.2 Method of Preservation 20.3 Taking Snake Photos for Identification 20.4 Referral to an Expert 21.0 Snakebite Epidemiology 21.1 Introduction 21.2 Recent Epidemiology Studies 21.3 A Practical Approach to the Africa Asia Region 21.4 The Doctors Role
126 126 126 126 127 129 129 129 130 132
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The classes are defined as follows: Class I: Commonly cause death or serious disability
Class II: Uncommonly cause bites but are recorded to cause serious effects (death or local necrosis)
Class III: Commonly cause bites but serious effects are very uncommon.
In many countries there are snake species, which are known to be venomous or are suspected of being venomous but their level of threat to humans is not clear. This model allows physicians to carry out studies and determine which species fit into the model categories. For example, many of the pit viper family in Asia and South Asia have not been classified into the model based on
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definitive capability. The model will enable physicians to determine the threat posed by each species. The model also enables producers of ASV to determine whether new species need adding to the current polyvalent mixes based on objective data.
Each of the major regions of Asia, the Middle East and Africa has been detailed below and the following data provided. 1. Species for each region have been identified, 2. A preliminary assessment of Class of Medical significance, 3. The primary venom action of the species i.e. B = Bleeding, PPS = Painful Progressive Swelling and PW = Progressive Weakness. 4. Whether the species is definitively covered with an ASV, not necessarily produced within that region. Section 20 contains guidance on preserving dead snake specimens brought to the hospital and who doctors can send photographs of unknown species for identification by an expert.
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Class
ASV Coverage
Naja naja PW
Hypnale hypnale B
II
Naja oxiana PW Bungarus caeruleus PW Bungarus fasciatus PW Ophiophagus hannah PW Macrovipera lebetina PPS Cryptelytrops albolabris PPS
Hypnale nepa B Eristicophis macmahoni PPS/PW? Bungarus sindanus sindanus PW Bungarus sindanus walli PW Bungarus lividus PW Bungarus niger PW
India, Bangladesh, Pakistan, Sri Lanka, Nepal Note 1. A number of pit vipers are found in the region including the Trimeresurus sp which are believed to be medically significant but no reliable reports are available. This would be a fruitful area of research. Note 2. Indian and Pakistan ASV do not specifically include N. oxiana N. kaouthia or Bungarus fasciatus venom and thus has questionable efficacy against these species.
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Fig 1.3.1 South Asia PW Cobras Top Row Naja naja (India), N. naja (Sri Lanka), N. kaouthia, Paternless N.naja (Pakistan) Bottom Row. Naja naja (India), N.oxiana (Pakistan), Ophiophagus hannah (India)
17
Fig 1.3.2 South Asia PW Kraits Top. Bungarus caeruleus (India). Middle Row. Bungarus caeruleus (Pakistan) Bottom Row. Bungarus sindanus sindanus (India), B. fasciatus (India)
18
Fig 1.3.3. South Asia Bleeding Top Row. Daboia russelii (Sri Lanka), D. russelii (India). Middle Row. Echis carinatus (India), Echis sochureki (Pakistan). Bottom Row. Hypnale hynale (India), H. hypnale (Sri Lanka)
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Daboia siamensis B
Bungarus fasciatus PW
II
Bungarus multicinctus PW Bungarus candidus PW Gloydius brevicaudus PW Naja atra PPS Naja sputatrix PPS Naja philippinensis PW Ophiophagus hannah PW Agkistrodon halys B Deinagkistrodon acutus B Macrovipera lebetina PPS/B Protobothrops flavoviridis PPS Cryptelytrops albolabris PPS Vipera berus PPS Naja sumatrana PW Naja siamensis N
Oxyuranus scutellatus canni PW/B Acanthophis antarcticus/praelongus PW Pseudechis australis B Pseudechis papaunus B/PW
Note 1. A variety of pit vipers Protobothrops, Cryptelytrops and Viridovipera are also found in the region. Some cause a large number of bites but mortality is low and few ASVs are available.
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Fig 1.4.1 Central, South East and East Asia Major Species. Deinagkistrodon acutus, Callesolasma rhodostoma, Naja kaouthia, Oxyuranus scutellatus
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Fig 1.4.2 Central, South East and East Asia Progressive Weakness: Kraits. Top Row. Bungarus candidus, B. fasciatus. Bottom. Bungarus multicinctus, B. flaviceps
22
Echis coloratus B Echis multisquamatus B Echis sochureki B Echis pyramidium PPS/B Vipera palaestinae PPS
II
Pseudocerastes persicus PPS Cerastes vipera PPS/B Macrovipera lebetina PPS/B Bitis arietans PPS Naja haje PW Naja oxiana PW Walterinnesia aegyptia PPS/PW? Vipera ammodytes PPS/B Vipera albicornuta PPS/B
Armenia, Azerbaijan, Bahrain, Cyprus, Georgia, Iraq, Iran, Israel, Jordan, Kuwait, Lebanon, Oman, Palestine, Qatar, Saudi Arabia, Syria, Turkey, U.A.E., Yemen.
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Fig 1.5.1 West Asia Painful Progressive Swelling and Bleeding Top Row. Echis sochureki, Vipera palaestinae. Middle Row. Echis coloratus, Echis pyramidum. Bottom Row. Macrovipera lebetina, Cerastes cerastes
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B. gabonica PPS/B
II
B. nasicornis PPS/B N. pallida PPS Naja melanoleuca PW Naja annulifera PW Naja nivea PW Dendroaspis polylepsis PW Dendroaspis jamesoni PW Dendroaspis augusticeps PW Hemachatus haemachatus PPS PW Dispholidus typus B N. nigricincta PPS N. ashei PPS
Angola Burundi Botswana Congo D.R.C Gabon Kenya Lesotho Malawi Mozambique Namibia Rwanda South Africa Swaziland Tanzania Uganda Zambia Zimbabwe
Note 1. Atheris bush vipers cause a small number of bites and one or two are capable of lethal envenoming e.g. Atheris squamiger. No specific ASV is available. Twig snakes Thelotornis sp occur in the region, bites are rare and there is no ASV.
25
Fig 1.6.1 Southern Zone Painful Progressive Swelling: Cobras Top Row. Naja nigricollis, N. mossambica. Bottom Row. N. pallida, N. ashei
26
Fig 1.6.2 Southern Zone Painful Progressive Swelling: Vipers Top. Bitis arietans, Middle Bitis gabonica, Bottom. Bitis nasicornis
27
Class
ASV Coverage
E. leucogaster B
B. gabonica PPS/B
II
B. nasicornis PPS/B B. rhinoceros PPS/B N. katiensis PPS Dendroaspis viridis PW Dispholidus typus B
Benin, Burkina Faso, Cameroon, Cape Verde, C.A R., Chad, Cote dIvoire, Gambia, Ghana, Guinea, Guinea Bissau, Liberia, Mali, Mauritania, Niger Nigeria, Senegal, Sierra Leone, Togo, Western Sahara. Note 1. Atheris bush vipers cause a small number of bites and one or two are capable of lethal envenoming e.g. Atheris squamiger. No specific ASV is available.
28
Fig 1.7.1 Western Zone Painful Progressive Swelling and Bleeding: Vipers Top Row Bitis gabonica, B. nasicornis, B. rhinoceros Bottom Row. Bitis arietans, Echis ocellatus
29
Class
ASV Coverage
Naja nigricollis PW
Echis leucogaster B
N. pallida PPS
II
N. ashei PPS N. nubiae PPS Naja haje PW Naja melanoleuca PW Echis multisquamatus B Cerastes cerastes PPS/B Dendroaspis polylepsis PW Dispholidus typus B
Algeria, Djibouti, Egypt, Eritrea, Ethiopia, Libya, Morocco, Sudan, Somalia, Tunisia.
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Fig 1.8.1 North Eastern Zone Painful Progressive Swelling: Cobras Top Row. Naja nigricollis, Naja nubiae. Bottom Row. Naja pallida, Naja ashei
31
Fig 1.8.2 North Eastern Zone Painful Progressive Swelling and Bleeding: Vipers Top Row. Echis pyramidum. Middle Row. Echis ocellatus, Cerastes vipera. Bottom Row. Cerastes cerastes
32
Fig 1.9.1 Progressive Weakness: The mambas Top Row. Dendroaspis polylepsis, D. augusticeps .Bottom Row. D. viridis, D. jamesoni
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Fig 1.9.2. Progressive Weakness: The cobras Top Row. Naja haje, N.annulifera. Bottom Row. Naja nivea, Hemachatus haemachatus, N. melanoleuca
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However if the tourniquet is applied correctly, are there any problems with its use? Many authors have argued that correct application of a tourniquet carries significant risks for the patient. Necrotic and Ischaemic Risks A major risk factor is the potential for increased necrotic damage, both as a result of the venom and because of the risk of ischaemia, if the tourniquet remains in place for longer than 40 minutes (Pugh, 1987; Warrell, 1999). Some investigators have argued that in some species the risk of necrosis is low, however this relates to species such as the Philippine cobra (Naja
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philippinensis), which has the least necrotic of any Naja venom and kraits (Watt, 1988). Most of the cobras and the vipers have highly necrotic venom. The risk of ischaemia leading to irreversible gangrene is undisputed.
Risks on Release A further risk identified, is when the tourniquet is released (Watt, 1988). Massive and sudden binding of the venom to neuromuscular junctions can be lethal in cases of neurotoxic envenoming such as by cobras or kraits.
Haemostatic Risks In the case of anti-haemostatic bites, such as the Russells and saw-scaled vipers, pro-coagulant venom activity causes clotting distal to the tourniquet. When the tourniquet is released, these clots may be carried by the venous return to the heart and lungs and cause pulmonary embolism.
Research has also shown that once a tourniquet is removed, the fibrinolytic system is raised for approximately 15 minutes after removal. There is thus the risk that coagulation tests will be compromised during this period and a false indication of coagulopathy may result (Klenerman, 1977b). In addition to ischaemia, it has been pointed out that the release of toxic metabolites upon release of the tourniquet presents a danger (Trevett, 1993). Effectiveness Risks There has been some debate about whether tourniquets do reduce venom spread in practice. Many authors have concluded that the tourniquets actually used in developing countries are ineffective, as they do not reduce systemic absorption of venom (Khin Ohn Lim, 1984; Tun Pe, 1987; Amaral, 1998; Ho., 1986). However, they consider tourniquets as a single entity and do not distinguish between the different ways in which tourniquets are applied.
In most developing countries, the vast majority of tourniquets are applied below the knee or elbow because that is where most bites are inflicted. However, arterial occlusion in the lower portion of the limb is nearly impossible to achieve because the structure, which allows an inter-osseous
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venous drainage, cannot be completely inhibited by compression. Upper limb tourniquets are considerably more effective although painful and require frequent release, which will necessarily negate the effectiveness of preventing venom absorption over time. Most of the debate about efficacy/practicability is explained by the fact that most tourniquets are incorrectly tied around the lower part of the limb. Some authors have argued that this is because nonexperts simply cannot apply a tourniquet effectively (Ismail, 1983). Finally, psychologically, victims with ligatures tend to believe the venom flow has been inhibited. There is a further danger that this confidence in the power of the ligature will lead them to seek medical attention with less urgency.
Most tourniquets tied by lay people are ineffective as they are tied on the wrong portion of the limb and tied too loosely.
Tourniquets should not be applied if there is a danger of necrotic venom activity i.e. virtually all cobras and vipers.
There are great dangers of ischaemia, if you do manage to tie the tourniquet correctly and if it is left in place for greater than 40 minutes
There are significant medical risks when the tourniquet is released if you do tie the tourniquet correctly,
Very few bite victims are sure which kind of snake has bitten them making it implausible to restrict the use tourniquets to people who correctly identify the snake and are familiar with its venom action. Even in those bitten by non-necrotic species, tourniquets in themselves still carry the risk of ischaemia.
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1981). Consumption coagulopathy renders the victims blood incoagulable and cutting the wound leads to potentially serious bleeding.
Suction devices came to be viewed as a valuable tool for first aid treatment for snakebite in the United States. Some authors advocated them on the basis that they did no harm (Christensen, 1969). Rather than sucking venom from the wound by mouth, a device was developed that created approximately 1 atmosphere of suction pressure. It was recommended that it should be applied within 3 minutes of the bite. As with electrical shock, this method was initially promoted with little research to support it. Research evidence casts a very different light on the subject.
Studies have shown that suction devices increase the risk of tissue necrosis (Bush et al, 2000; Gelert et al, 1992; Bharati, 2000), do not extract significant amounts of venom from the wound (Alberts 2004; Hardy, 1992) and may reduce the level of normal oozing from the wound and thus increase the level of envenomation (Bush et al, 2000). This device is totally impracticable for use in developing countries. Its cost alone and the need for it to be carried by the potential victim render it useless.
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The method proposed that a firm crepe bandage should be applied to the limb at a pressure of 55mm of mercury, with an accompanying splint (Sutherland, 1979). Further small-scale studies involving one or two subjects were also carried out, which represent the basis for the statement that PIM has been proved both experimentally and clinically often referred to by proponents (Sutherland, 1981; Sutherland and Coulter, 1981; Oxer, 1982; Sutherland, 1995; Winkel and Hawdon, 1999; Grenard, 2000). The method is described as having a good experimental base and present experimental and clinical evidence is strongly in favour (Sutherland, 1983; White 1991). On the basis of these experiments, the Australian National Health and Medical Research Council (NHMRC) adopted PIM with unwise haste although many experts from a number of countries expressed doubts as to the merits of the technique (Edmondson, 1979; Anker and Straffon, 1982; Fisher, 1982; Russell, 1982; Currie, 1992; Blaylock, 1994; Blaylock, 1995; Gray, 2003). A number of case studies were produced which appeared to confirm the method, including one that claimed that PIM actually reduced the requirement for ASV but these were inconclusive (Murrell, 1981; Pearn et al, 1981; Balmain and McClelland, 1982; Simes, 2002). Animal model studies appeared to show effectiveness but again were inconclusive (Burgess et al, 1992; Bush et al, 2004; German et al, 2005).
Other case studies showed that trained individuals who applied the technique rapidly after a bite underwent systemic symptoms in any case (Maiden and White, 2006).
Other research work demonstrated that this technique had very narrow ranges of pressure to be applied; 40-70mm of mercury in the upper limb and 55-70mm of mercury in the lower limb; immobilisation had to be total and walking for more than 10 minutes caused the bandage to be ineffective (Howarth et al, 1994).
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Work examining the capability of people to effectively apply the bandages within the correct pressure range established that both medical personnel and lay people were unable to achieve success even after basic training (Norris et al, 2005). Extensive training given specifically to aid retention of the technique also failed to equip lay people to retain the technique (Simpson et al, 2008). Victims who have the technique properly applied can travel in an Australian ambulance on Australian roads for only 5 minutes before the technique became ineffective (Global Snakebite Initiative, 2008). The bandage that the victim must be carrying should not be crepe but an elasticized sports bandage, which presumably the poor rural worker will carry in their Nike sports bag with their energy drink! (Global Snakebite Initiative, 2008).
The fact that the original PIM study would not pass peer review today has also been noted (Rogers and Winkel, 2005). There is often confusion as to whether to bandage the limb proximally or distally and even to which types of bites it should be administered by the same author (Sutherland, 1994; Warrell, 1995; Warrell, 1999; Warrell, 2003; Warrell, 2005a; Warrell, 2005b; Warrell, 2006; Warrell, 2010).
Due to the lack of any beneficial evidence, the poor nature of the original evidence, the difficulty in applying the technique, the utter confusion as to which type of bites it should apply to and the impracticality of millions of developing world rural workers carrying splints and crepe bandages, PIM is NOT recommended for use in developing countries (Simpson et al, 2008).
Sutherland himself stated that to be effective a first aid technique needed to be Easily reproduced by inexperienced personnel (Sutherland, 1983). PIM does not pass the test and should NOT be used in developing countries.
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et al, 2000). In this approach, a hard pad of rubber or cloth is applied directly to the wound.
In one study, it was suggested that the Monash technique out-performed both the use of air splints and PIM to apply pressure and retard venom flow although the originators of the PIM technique lost no time in decrying the research (Duncan et al, 1982; Anker, 1983). Why this method was not more enthusiastically pursued was certainly asked (Pantanowitza, 1997) but never followed up.
This method should be subjected to further research to assess its efficacy. This method may have particular relevance to the Armed Forces who carry shell dressings as part of their normal equipment, and would thus be ideally equipped to apply effective first aid in difficult geographic settings where the need is great.
Properly constructed studies however showed that: 1. Venom was not denatured by electrical shock (Davis et al, 1992) 2. No beneficial effect was noted from the use of electricity in snakebite (Russell, 1987; Russell, 1987a; Snyder et al, 1987; Dart and Gustafson, 1991; Hardy, 1992)
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During the 1950s the use of ice and cold to slow the movement of venom by constricting capillaries was proposed (Stahnke, 1953, Glass, 1981). Further research showed this method was ineffective and indeed risked increasing necrotic damage.
The key point to remember is that the priority is to avoid anything that increases the systemic absorption of venom via the lymph. Key influences on lymph flow are:
Breathing Muscular contraction Elevating the part A stroking massage towards the heart which stretches the skin
Washing the wound requires rubbing of the skin, which will inevitably involve massaging the tissue, thereby causing more venom to be absorbed. This should not be done as the action of washing increases the flow of venom into the system by stimulating the lymphatic system (Gray, 2003).
There is a key aspect to the mathematics of snakebite that must be understood to place traditional medicine in context. In the case of 100
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snakebites, 70 are likely to result from a non-venomous species. The remaining 30 bites will result from a venomous species. However, approximately 50% of bites from venomous species result in a dry bite where no venom is injected. It is thus likely that in the case of 100 snakebites, 85 victims will have nothing wrong with them and not require any treatment.
This is the mathematics that shows how traditional treatments APPEAR to cure snakebite.
Once the traditional healer realises that the victim has been truly envenomed then the victim is eventually sent to hospital. It is worth remembering that the traditional healer has the least interest in treating an envenomed victim as victims that die under traditional treatment reduce confidence in the healer. One or two specific traditional treatments need examination.
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Fig 2.1 Traditional Treatments Top Row. Scarification of Echis ocellatus bite (Ghana). Middle Row. Use of Snake Stone (India). Bottom Row. Application of Neem leaves (India)
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A justification for the Stones can be found in a small book produced by the Reverend Father Antoninus of Little Flower Dispensary in Calicut, Kerala. Interestingly the first aid section of the book advises the use of a tourniquet but not tied too tightly, presumably to retard venom movement. The book further recommends washing the wound with salt water for 2-3 minutes to wash away the polluted blood after cutting the wound.
The books recommendation is that the above two processes will be enough in the ordinary case.
The book further recommends that the doctor consulted to treat snakebite, should be selected on the basis of whether they use Snake Stones or not. The method for the use of the stone is as follows. When the patient arrives at a location, the wound should be cut in one or two places, washed with water and the stone applied. The stone would adhere to the wound and begin absorbing venom. Although one stone is regarded as sufficient, the use of more than one stone is regarded as being better. Once the stone has absorbed the venom it will drop from the body as frequently as once or twice per hour. In any event, if the stone has been in place for 24 hours it should be removed and placed in a glass of pure, unboiled cow's milk.
Father Antoninus describes how pain at the site of the Snake Stone may increase due to its action in drawing venom away from the head and the heart towards the limb where the stone is applied. This pain is regarded as a good thing.
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There is only one research study on snake stone effectiveness (Chippaux 2006), which concluded that there was no reduction in systemic envenoming with the use of the snakestone. Research therefore has invalidated this enduring remedy.
It is best to leave the last word on Snake Stones to Father Antoninus himself when he perceptibly observes: One who has been bitten by a Cobra feels hardly any difficulty after the application of the Stones, so much so that ordinarily one would wonder if one had been bitten by a snake at all: Quite so! (Antoninus Fr)
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The first aid thats currently recommended to be administered by self or the community volunteer is based around the mnemonic:
Do it R.I.G.H.T.
The letters in the mnemonic stands for:
R. =
I. =
G. H. =
T=
Tell
This method will get the victim to the hospital quickly, without recourse to traditional medical approaches, which can dangerously delay effective treatment and will supply the doctor with the best possible information on arrival (Simpson, 2007).
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The snake, if killed should be carefully taken to the hospital for identification by the doctor. No time should be wasted in attempting to kill or capture the snake. This solely wastes time and can lead to other victims.
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results from a lack of effective treatment. Death due to fright is a convenient reason to account for inadequate treatment.
Patients should be intubated if possible or provided with airway support (See page 83) and ventilated with a resuscitation bag.
In the case of respiratory arrest it is vital to establish from the individuals accompanying the victim on the journey to the hospital when the respiratory impairment commenced. The time will give the physician critical information concerning the likelihood of a successful patient revival. Many victims undertake long journeys to hospital and even if a resuscitation bag is used the efforts are often ineffective due to flaccid paralysis, without support factors such as nasopharyngeal airways, laryngeal mask airways or endotracheal intubation.
If the victim underwent respiratory failure shortly before reaching the hospital, it is likely that a full recovery will be possible. This factor should be communicated to staff responsible for mechanical ventilation of the patient. Often a key decision is whether to continue with mechanical ventilation with a patient who is non responsive for several hours on the ventilator. Patients with neurological envenomation may require many hours or days on a ventilator to achieve recovery, particularly in the case of pre synaptic envenoming. The reality is that in many developing countries ventilators are unavailable in most hospitals and even where present are in short supply. There is thus a
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tendency to ventilate patients for a short period, achieve no response and then discontinue ventilation due to sepsis or some other cause of death.
In the case of pre synaptic envenoming this is disastrous! It is vital that the physician who initially receives the patient fully investigates the timeline of respiratory arrest and informs ventilation staff of the likely outcome. In reality, a patient that underwent respiratory arrest some distance from the hospital will not survive unless good airway support with a resuscitation bag and airway maintenance tools was provided in the interim period.
Items Required 1. A supply of New, Clean, Glass and Dry test tubes 2. A syringe and needle.
Method A few mLs of fresh venous blood is placed into the test tube and left undisturbed for 20 minutes. At that time the tube is gently tilted to 45 degrees and the status of the blood examined.
Results Interpretation 1. If the blood is solid i.e. has clotted the patient has passed the coagulation test and no ASV is required at this stage. The patient is re-
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tested every 30 minutes for the first three hours and then hourly after that for 24 hours.
2. If the blood is still liquid and runny, the patient has failed the coagulation test and consumption coagulopathy is present. ASV is now indicated. The 20WBCT should be repeated 6 hours after ASV administration is complete to assess any requirement for further ASV.
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4.4 Have any allopathic treatments been taken before arrival at the present medical facility?
In many areas of developing countries, smaller medical facilities are often visited before arrival at a larger hospital. These smaller facilities may have already administered a small quantity of ASV before transferring the patient.
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Chilli is ingested to counteract the venom, which can result in abdominal pain in the victim. In areas where abdominal pain may be indicative of envenomation e.g. krait areas, this can mislead the doctor.
4.6 What activity was the victim carrying out at the time of the bite?
There are two principal reasons why this is a critical question:
a) Confirmation of Snakebite/ Species There will be many occasions when victims are not sure whether they have been bitten by a snake or not. They may have experienced a pricking pain while carrying out an activity but they may not be able to confirm that a snake was responsible. The wound may have resulted from a thorn, scorpion, centipede or other insect. In these cases ASV is clearly not required.
Certain activities can help determine if a snake was likely involved. Grass cutting is a high bite risk activity and this may be good evidence that a snake was involved. Feeding chickens or other animals with grain can also indicate snakebite. Grain will attract rats and when feeding of the animal is taking place it is possible that a snake may be present to predate on the rats.
In some cases the activity can cast light on the likely species. Victims that are bitten by a cobra, in South Asia, will exhibit neurotoxic features if envenomed. If the victim was walking through the fields during the day, then neurotoxic symptoms are highly likely to result from a cobra as kraits are strictly nocturnal. However, if the victim is clearing rubbish in a shed or repairing bunding at the edge of rice fields, then it is possible that they have disturbed a krait sleeping during the day.
54
b) Bite Activities and Prevention Advice The prevention section (Page 99) gives details on the advice that doctors can give the local community as to how to reduce their risk of snakebite. The raw data for this exercise comes during this questioning phase. Determine as accurately as possible what precise activity the victim was performing when the bite occurred and note this on the patient record. Once the activities that constitute the majority of bites are identified, strategies to make potential victims aware can be developed.
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It must be remembered that the following are SIGNs and SYMPTOMs of an envenomation at some point in time, not necessarily current, which may be detected. They are NOT in themselves criteria for administering ASV. That is specifically dealt with in Section 8.
5.2 Bleeding
1. Consumption coagulopathy. 2. Visible systemic bleeding from the action of haemorrhagins e.g. gingival bleeding, epistaxis, haemoptysis, continuous bleeding from the bite site, bleeding from pre existing conditions e.g. haemorrhoids, bleeding from freshly healed wounds. 3. Renal failure e.g. declining or no urine output, deteriorating renal signs such as rising serum creatinine, urea or potassium. Some species e.g. Russells viper (Daboia sp) frequently cause renal failure whereas other species such as saw scale vipers (Echis sp) do not (Simpson, 2007). 4. Myoglobinuria i.e. darkening of the urine, complaints of low back pain. 5. Swelling or necrosis may be evident although this is by no means certain; many cases of bites from species causing bleeding will not cause these symptoms. 6. Longer term sequelae e.g. pituitary insufficiency with Russells viper (Daboia sp)
56
57
Others are impractical in many developing world settings as the test equipment is unavailable (Isbister et al, 2006)
1. Visible 2. Simple Diagnostic 3. Technical Diagnostic Examples of each of the techniques are:
58
Fig 5.1 Signs of Haemotoxic Envenomation Top Row. Gingival Bleeding, Ecchymoses on the Trunk Bottom Row. Lateralising Neurological Signs of Intracranial Bleeding, Bleeding from a Pre Existing Condition i.e. Prolapsed Piles.
B. Progressive Weakness
I. Descending paralysis commencing with cranial nerve impairment e.g. ptosis, opthalmoplegia II. Numbness of lips and difficulty speaking and swallowing, pooling of secretions III. Weakness in the neck muscles, inability to lift or support the head IV. Difficulty breathing V. Fasiculations
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Fig 5.2 Local damage from Envenoming Top Row. Blistering from Echis sochureki bite, Necrosis from Echis ocellatus bite Bottom Row. Swelling from Hypnale hypnale bite, Post necrosis from Naja atra bite.
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B. Progressive Weakness
I. Single breath count II. Length of time upward gaze can be maintained III. Basic Grip Tests
B. Progressive Weakness
I. Single breath count II. FEV III. Grip Tests with Equipment
61
62
Lyophilised
Liquid
ASV, the use of monovalent ASVs may actually INCREASE the cost of the final product as batch, testing, distribution & storage costs for specific ASVs may be higher.
It must be remembered that: 1. The majority of victims do not bring the dead snake for identification 2. Doctors are unreliable in making a correct identification even if the snake is brought 3. ELISA testing kits would need to be provided 4. A number of monovalent ASVs would need to be provided to many physicians which has planning, logistical & cost implications 5. Producing a separate batch for each monovalent ASV may well increase the costs of production and testing versus polyvalent ASVs.
Very few countries have ELISA testing despite it being referred to for nearly 30 years; the main example is Australia where it is used to identify biting species NOT level of envenomation (World Health Organisation, 1981).
There are key problems with monovalent ASVs that are often overlooked: 1. The clinical symptoms to administer the ASV must be clear and mutually exclusive. If two species cause the same symptom, monovalent ASVs are not useful. A good example of this is the case of China where both the Chinese cobra (Naja atra and the White-lipped pit viper (Cryptelytrops albolabris) produce significant local swelling. Local doctors have difficulty in determining whether to use SIBP Naja atra ASV or TRC Green pit viper ASV. 2. If ELISA is to be developed: i. It is costly to develop the base product ii. It must be rigorously tested to eliminate false positives and negatives iii. It must be based on local snakes; the kits cannot be imported If your country does not have it now, then it will be many years before it is reliably available.
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7.4 What Can ASV Do and more importantly what can it NOT Do?
It is vital to remember the capabilities and limitations of ASV if it is to be used effectively.
ASV Can: 1) Bind to a venom molecule that it is effective against and neutralise that venom molecule rendering it unable to bind to the target cell but only whilst the venom molecule is circulating in the blood or lymph and is unbound. ASV prevents the patients condition from worsening by neutralising venom that otherwise could have bound and completed its damaging effect on the victim. It does not reverse anything nor does it make the patient better. The latter is the result of the bodys normal functions, such as the liver replacing clotting factors, being able to return to normal by the elimination of the circulating venom.
ASV Cannot: 1) Reverse necrotic action of the venom on tissue 2) Reverse local swelling 3) Reverse renal failure 4) Reverse coagulopathy; the liver does this. 5) Reverse pre synaptic envenoming; the nerve damage is structural and large quantities of ASV are ineffective, the body must regenerate synaptic vesicles 6) Prevent local necrosis; the damage is done too quickly and the venom is in the tissue and therefore not reachable by the ASV (Gutierrez et al, 2007) 7) Prevent local swelling; the damage is done too quickly and the venom is in the tissue and therefore not reachable by the ASV (Gutierrez et al, 2007)
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Some of these points should be obvious and yet they are frequently given as reasons for administering ASV.
Swelling: Control or Reduction? The proposed evidential support for ASV to be able to control swelling comes principally from the U.S.A. A number of studies purport to show that ASV has brought swelling under control (Heard et al, 1999; Thorson et al, 2003; Lavonas et al, 2004). These studies are not robust however, as they link the causal of administering ASV with the outcome of halted swelling: envenoming is a dynamic process and the halting of the swelling may be due to the fact that the oedema-causing portion of the venom is exhausted.
WHOs reluctance to provide clear guidance on the safety issues of production and the cost impact is lamentable.
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The key question for the physician to answer is: Is there evidence of unbound circulating venom currently present in the victims blood stream or lymph NOW which is capable of being neutralised by the ASV at hand?
There is little dispute that the answer YES is indicated in the first two of the below cases:
8.2 Bleeding
Criteria for administering ASV are: 1. Incoagulable blood determined by a 20 Minute Whole Blood Clotting Test in a new, clean glass and dry test tube (Sano-Martins et al, 1994). 2. Systemic bleeding, not local bruising 3. Laboratory evidence of coagulopathy 4. Muscle pain or myoglobinuria clinically detected as dark brown urine (Indonesia East Islands, Papua and West Papua)
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In the above two circumstances ASV should be administered according to the dosage schedules on Pages 71-76.
Swelling requires the doctor to make a decision as to whether they accept either or both the following principles for which there is no evidence and which many authorities reject:
II. ASV can pass the blood tissue barrier III. Swelling is indicative that systemic symptoms will occur and therefore ASV will be required
IF swelling is to be used as a criteria for administering ASV then evidence must be present that the swelling is both CURRENT and SEVERE, simple bite site swelling is NOT grounds for giving ASV.
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ASV is not administered intra muscularly or around the bite site, although intuitively this may seem sensible. ASV has a large molecular size and therefore intra muscular injection results in slow ASV absorption into the blood stream; use of this route may also cause haematoma. The use of ASV around the bite site to reduce local effects such as swelling or necrosis has no evidential support (Offerman et al, 2009).
Lyophilised ASV is reconstituted with saline and gently rolled between the fingers until the powder has dissolved; it should not be shaken. When reconstituted it should be mixed with approximately 250ml of saline in the same way as liquid ASV.
It is often recommended that ASV should be administered for a period after coagulation has been restored or recovery is evidenced in neurotoxic envenomation to prevent recurrence. This practice has largely derived from the U.S. where a smaller antibody is used in the local ASV, which results in a much shorter half-life and thus more rapid clearance from the system. This is not required in ASVs in Africa or Asia and simply wastes resources.
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In an attempt to guide physicians, where possible, maximum dose levels have been provided. The amount of snake venom, injected by the snake is not infinite; it will have an upper range. There is a tendency amongst physicians to believe that more ASV is better, and to continue using ASV past the point where the amount of ASV given is in excess of the maximum amount of venom possible. This is both wasteful of resources and expensive.
Some dosage guidelines are based on manufacturers recommendations and have been marked accordingly. Care must be taken with manufacturers recommendations as such guidelines have been shown to be unreliable previously (Simpson and Norris, 2007)
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The important point to note is that there is always a maximum dose of ASV required as defined above. There is no rationale for administering very large doses of ASV where there is no evidence of currently circulating venom (Agrawal et al, 2001; Sharma et al 2002; Sharma et al, 2006; Harish and Digra, 2007).
PW envenomed patients who wait many hours or days before seeking medical aid will be dead if they are envenomed! It is therefore unlikely that a late arriving patient, bitten by a PW species will require ASV.
Patients bitten by Bleeding species should be assessed by use of the 20 WBCT and if the blood is incoagulable, ASV should be administered. If the blood is coagulable ASV is not required.
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In patients bitten by PPS species, 1. The venom would be already bound and thus unneutralisable 2. The venom is probably unable to be reached by the ASV as we have seen in Section 7.5
It is unclear if snake venom or components or ASV cross the placenta (Seneviratne et al, 2002).
The common expectation that snakebite invariably leads to spontaneous abortion of the foetus is not supported by available data. In one study in Sri Lanka, only 30% of victims aborted (Seneviratne et al, 2002).
In the case of an envenomed victim, ASV is required to neutralise the unbound venom in the normal way.
ASV should be given: 1. In the same dose and 2. Under the same criteria as standard victims.
Where ASV is given there is good maternal outcome (Seneviratne et al, 2002).
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The period of greatest risk appears to be during the first trimester and with cases of systemic envenoming, particularly with systemic bleeding and coagulopathy (Seneviratne et al, 2002).
This would indicate that wherever possible, patients in the first trimester, with systemic signs of envenomation particularly bleeding, should be referred to a gynaecologist for specialised review. In cases of spontaneous abortion this usually occurred within 7 days of the bite (Seneviratne et al, 2002).
The answer to this question lies in clearly understanding the role of ASV. Its function is to neutralise unbound venom, injected by the venomous snake. Snakes do not vary the amount of venom injected into children or adults and therefore the dose of ASV for children is THE SAME as that for adults.
The dosage schedule for ASV in the event of a second bite is however unchanged. The same starting dose and repeat dose schedule as for a normal bite applies. If there is concern of an adverse reaction due to a second administration of ASV, then a prophylactic regimen of adrenaline can be considered. Any reaction should be handled in the normal way.
It is worth noting that it is fashionable amongst herpetologists with questionable competence to claim that they have been told by a doctor that
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they can not have ASV again as it threatens their life due to previous bites. This seems to be regarded as a macho badge of achievement by some.
This statement should be treated with high suspicion and the doctor should treat the victim and any reactions in the normal way in the normal way (Section 10).
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Vins Bioproducts Bharat Serums Serum Institute of India Haffkine Bengal Chemicals Biological E Polyvalent
8-10
20
30
Pakistan
8-10
20
Daboia russelii
8-10
30
Echis sochureki
12
Notes
1. Indian ASV is manufactured containing venom almost exclusively from snakes captured in Tamil Nadu in South India. The Echis species venom is Echis carinatus 2. NIH ASV is made using venom from Sindh Province. The Echis species is Echis sochureki and the cobra species is largely the paternless Naja naja.
3. Macrovipera lebetina, Bungarus fasciatus and Naja oxiana ASVs are available id
required, see Pages 72 & 74
75
Thailand
5 4 10 10 5 5 10
20
Myanmar China
Cryptelytrops albolabris Naja kaouthia Bungarus fasciatus Bungarus candidus Ophiophagus hannah
20 10 10 20
China
Naja atra
Bungarus multicinctus
10
Deinagkistrodon acutus
Indonesia
10
10 10
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Rhabdophis subminiatus
Myanmar: AntiViper AV
Myanmar
Daboia siamensis
Naja kaouthia
12
Naja philippinensis
10
77
1 1
Central Asia
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8 5 5 5
Bivalent Naja/Walterinasia
2
Iran
Echis
sochureki/ 2* 2* 2*
multisqamatus Naja oxiana Macrovipera lebetina Pseudocerastes persicus Vipera albicornuta Gloydius halys
2*
2* 2*
West Asia
79
Vacera/EgyVac Polyvalent
West Asia
* = Manufacturers recommended dose. Notes 1. Echis species in Saudi Arabia are E. coloratus, E. pyramidum, E. sochureki and E. khosatskii. 2. Echis species described as Echis carinatus are collected from South West Iran and are likely to be Echis sochureki in the main but also E. multisquamatus.
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9.11 Africa
Initial ASV Producer Country Species Dose Vials Maximum Dose Suggestion
Bitis arietans Bitis gabonica Naja melanoleuca Naja nivea Naja annulifera
5 10 8 8 8 20 20 20
Naja mossambica
8 5
20
Monovalent
Echis ocellatus
Monovalent
Dispholidus typhus
Africa
Bitis arietans Bitis gabonica Echis ocellatus Echis leucogaster Naja haje Naja melanoleuca Naja nigricollis Dendroaspis polylepsis Dendroaspis jamesoni Dendroaspis viridis
8 10 10 10 10 10 10 10 10 10 20 20 20 20
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Sub Vacera/EgyVac
1
8 6 10
Saharan Africa
* = Manufacturers recommended dose. Note 1. Vacera/EgyVac also produce a 16 species polyvalent ASV for Egyptian Species including Sub-Saharan species of unknown capability or effectiveness. Dosage recommendations from the manufacturer are 4-6 vials for all species. The number of species included and the fixed initial dose independent of species raises concerns as to its effectiveness.
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After 6 hours, a further 20 WBCT is carried out. If the blood is still incoagulable, then a second dose of ASV is given. It is usual to repeat the same dose of ASV as was given initially. This approach is continued on a 6 hourly basis until coagulation is restored or until the maximum level of ASV is reached if known.
Following the completion of the initial dose a period of 1 hour is allowed to elapse. The patient is reassessed and if the symptoms have worsened, i.e. paralysis has descended further a second dose is given at the same dosage as the initial dose.
If after 1 hour, following completion of the initial dose, symptoms have not worsened, a further hour is allowed to pass. If the patient has not improved or has worsened a second dose is given at this stage, at the same level as the initial dose.
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Following the second dose of ASV, no further ASV is administered. At this stage it is very likely that circulating venom will be neutralised and the patient will either recover or proceed to respiratory failure. Supportive measures should be taken in line with the guidelines in Section 12.0.
It therefore makes little sense to give a second dose in such cases, as there will be no unbound venom that can be neutralised.
1. Blood coagulation will be restored 2. Systemic bleeding may stop as early as 30 minutes after the first dose is given 3. Hypotension may be controlled in 30 minutes to 1 hour. 4. Neurological signs may stop descending and gradual recovery in function may be evident
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1. Complement activation directly by the ASV proteins There is some evidence that ASV is able to activate complement in vitro (Sutherland, 1977; Leon et al, 2001; Leon et al, 2005)
Skin tests are widely used in testing for Type I hypersensitivity allergic reactions. They indicate high levels of IgE in the presence of a specific allergen.
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They are of no use in predicting ASV reactions for the following reasons: 1. They are non predictive ASV reactions are complement activated and not mediated by IgG, they are also de novo reactions (Malasit et al, 1986; Gutierrez et al, 2007) 2. They waste time when the patient needs ASV 3. They may pre-sensitise the patient and make a severe reaction more likely when the major amount of ASV is administered.
The prophylactic approach is based largely on two studies in Sri Lanka, which appeared to show that prophylactic doses of adrenaline or hydrocortisone and antihistamine prevented reactions (Premawardenha et al, 1999; Gawarammana et al, 2004). Both these studies were statistically underpowered, with one stopping half way through the study as the results at that stage were regarded as good! Other poorly constructed retrospective studies also appear to support the use of premedication to prevent reactions (Williams et al, 2007). Other studies have shown no benefit to prophylactic regimens (Isbister et al, 2008)
A study in Brazil indicated that antihistamine alone was not effective in preventing reaction (Wen-Fan et al, 1999).
The conclusion with respect to prophylactic regimens to prevent adverse reactions is that they probably do no harm but there is no compelling evidence that they are effective.
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Step 1: Identified Early Many ASV reactions pass unnoticed as the doctor is not actively looking for them. Local experience with the ASV will almost certainly establish an average time to onset of the reaction. For example, with Indian ASVs the average onset time for reactions is 20 minutes (Kochar et al, 2007). This is a key period to examine the patient carefully, particularly across the trunk, as this is where reactions are first evident. A useful technique is to shine a torch across the trunk as this casts the urticaria in shadow.
Step 2: Treated Immediately At the first sign of a reaction, stop the ASV. The first signs include a single patch of urticaria or any itching. Often the patient will become restless just before these signs and symptoms manifest.
Step 3: Drug of Choice The correct drug of choice and the immediate response is adrenaline (Sampson et al, 1992; Project Team of the Resuscitation Council (UK), 2002; McClean-Tooke et al, 2003). Ideally 2 syringes should be drawn up ready if the ASV is known to cause frequent reactions.
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Step 4: Correct Mode of Administration The critical factor in managing ASV reactions is speed! The longer the reaction persists, the longer will be the period the victim is without ASV and the more venom will be permitted to bind to the target cells. Therefore speed of effect of adrenaline is critical.
The mode of administration therefore is intramuscular (IM). The deltoid muscle is the best site (American Association of Allergy, Asthma, and Immunology, 2003; McClean-Tooke et al, 2003; Simons et al, 2001).
The time for adrenaline to reach peak effect is 8 minutes via the IM route and 34 minutes via the subcutaneous route (Simpson, 2007). Despite a preponderance of doctors who would use the subcutaneous route, IM is the first option (Simons et al, 2001; Simpson, 2008).
Step 5: Correct Reassessment Period Once the initial dose of adrenaline is given IM, the patient is closely monitored. Around 3 minutes, the patients pulse rate should begin to increase confirming the drug was correctly administered IM. At 8 minutes, the adrenaline will reach peak levels and at this stage 5-7 minutes are spent examining the patient for signs of improvement. If none are evident or the patients condition has worsened, a second dose is administered IM. In very rare cases, a third dose may be necessary.
The majority of patients will respond to a single dose, the remainder will respond to the second dose. Using the IM route it is possible to administer 2 doses of adrenaline in the same time, as it would take a single dose of subcutaneous adrenaline to reach peak effect.
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Promethazine HCl can be used at 25mg IM, or 10mg chlorpheniramine maleate if available, can be administered IV.
The paediatric dose is of Phenimarine maleate at 0.5mg/kg/ day IV or Promethazine HCl can be used at 0.3-0.5mg/kg IM or 0.2mg/kg of chlorphenimarine maleate IV and 2mg/kg of hydrocortisone IV.
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Neurotoxic snake venom acts in two main ways that leads to mortality, with other specialised effects in some snake species. The key action of the venom is paralysis of muscles concerned in respiration leading to asphyxia and respiratory failure.
Postsynaptic toxins such as those in the cobra species demonstrate a high level of affinity to bind with the acetylcholine receptor of the motor synapses thus preventing neuromuscular transmission (Watt et al, 1986; Yee et al, 2004). A key objective therefore is to increase the time that acetylcholine is available to bind to free receptors, by eliminating cholinesterase.
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They can also include: Intra incisor distance Length of time grip can be maintained Others
The baseline measure is noted and used to assess the efficacy of the anticholinesterase. Once the test drug is administered, repeating the baseline test to identify improvement assesses the results. If no improvement is noted the use of the anticholinesterase is discontinued. There is no role for longerterm administration in a patient that shows no positive response.
The peak plasma effect is at 20 minutes so repeating the baseline test should be carried out at 10-minute intervals.
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Assessment Period = 1 hour In the event of improvement neostigmine is continued every 30 minutes with 0.5 mg administered IM with atropine as required.
Assessment Period = 20 minutes In the event of improvement neostigmine is continued thereafter every 30 minutes with 0.5 mg administered IM with atropine as required.
There is little doubt that anticholinesterase drugs are effective in postsynaptic envenoming (Ramakrishnan et al, 1975). The evidence is much less clear in cases of presynaptic envenoming (Warrell et al, 1983; Akram and Khurshid, 2000; Akram et al, 2002).
Mention of anticholinesterase drugs being used, as a substitute for ASV should only be considered if no ASV is available (Bomb et al, 1996). The more venom that can be neutralised before it binds to target receptors reduces the severity of the envenomation.
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the aftermath of Cyclone Nargis who concentrated on mechanical ventilation and intubation in the snakebite guidelines, demonstrates the lack of understanding of airway support conditions in developing countries.
Solutions therefore range from the improvised, which are most likely to be used, to the bridging solution and then ultimately the ideal.
However, in cases of neurotoxic envenomation, if respiratory failure occurs it will be due to flaccid paralysis and there is a strong likelihood that the tongue will fall back and obstruct the airway. The effective functioning of a resuscitation bag in these circumstances will be highly limited. Nasopharyngeal airway (NPA) support is an excellent emergency measure in these situations (Bajaj et al, 2008). If available, NPAs should be inserted before transportation to the referral hospital, which will dramatically increase the probability of effective respiratory support during the journey.
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It is possible however to improvise nasopharyngeal tubes (NT) from endotracheal tubes (ET), which are usually readily available or can be obtained easily. Two rubber or plastic size 6.5 ET tubes for females, size 7 for males or size 5 for either can be adapted to provide NT (Roberts et al, 2005). The tubes are cut to the distance between the nostril and the tragus, lubricated and inserted into the nostrils of a conscious or unconscious patient (Quraishi et al, 2008; Simpson and Jacobsen, 2009).
Cut to the correct length they will not trigger the gagging reflex and thus can be used when a patient is conscious (Simpson and Jacobsen, 2009). In the event that a patient cannot perform a neck lift and is to be transferred to a better-equipped hospital, the tubes can be inserted and the individuals accompanying the victim instructed to use the resuscitation bag if the victim stops breathing (Simpson and Jacobsen, 2009).
Use of such airways by accompanying laypersons has not been studied, but it is very possible that the lay provider can adequately ventilate the unconscious victim during transfer using a properly placed laryngeal tube. The creation of a better seal makes the use of an LT tube more preferable over rough journeys experienced when transporting snakebite victims in many developing countries (Ocker et al, 2002; Gaitini et al, 2008)
Use of the LMA requires greater skill in maintaining proper positioning, making it a less optimal choice for use by untrained individuals.
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Fig 12.1 Top Row, Resuscitation Bag, LT Tube, LMA, Nasopharyngeal Tubes Bottom Row, How to measure and fit improvised nasopharyngeal Tubes.
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The endpoint therapy will be a mechanical ventilator to provide long-term respiratory support. In presynaptic envenoming, the period of ventilation may be extensive whilst the body restores synaptic vesicles (Harris and Goonetilleke, 2005).
However, in developing countries, where such facilities are limited, an improvised or bridging solution is necessary to ensure the victim survives the inevitable journey. Developed world derived protocols advising endotracheal intubation or tracheostomy, once loss of the gag reflex or pooling of secretions occurs is simply impractical in most developing world facilities (Warrell, 1999; Simpson and Jacobsen, 2009).
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Hypotension, severe reductions in haemoglobin concentration, platelet reductions i.e. thrombocytopenia, or frank bleeding can increase the pressure to administer blood related products.
Hypotension due to action of the venom can have a number of causes in snakebite, ranging from loss of circulating volume due to haemorrhaging, vasodilation due to the action of the venom or direct venom effects on the heart.
In the majority of cases the timely use of ASV will stop systemic bleeding. However in some cases the bleeding may continue to a point where further treatment should be considered.
Test for hypovolaemia by examining the blood pressure lying down and sitting up, to establish a postural drop.
Treatment is by means of plasma expanders and raising the foot of the bed. There is no conclusive trial evidence to support a preference for colloids or crystalloids. In addition fresh frozen plasma or factors present a possibility in order to boost volume and restore factors. In many areas, particularly in developing countries, the only available alternative will be fresh blood.
In cases where generalised capillary permeability has been established a vasoconstrictor such as dopamine can be used. Dosing is 2.5- 5 /kg/minute.
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The major point to note is that clotting must have been re-established before additional measures are taken. Adding clotting factors, FFP, cryoprecipitate or whole blood in the presence of un-neutralised venom will increase the amount of degradation products with the accompanying risk to the renal function (White, 2005).
13.2 Anticoagulants
Other drugs such as heparin have been intuitively thought to be beneficial in snakebite induced coagulation and DIC and apparently supported but by very weak research (Paul et al, 2003; Paul et al, 2008). However, like much of what is intuitively recommended in snakebite, heparin is contraindicated. Venom induced thrombin is resistant to Heparin, the effects of heparin on antithrombin III are negated due to the elimination of ATIII by the time heparin is administered and in itself heparin can cause bleeding. In the case of trial evidence, heparin has been shown to have no beneficial effect (Myint-Lwin et al, 1992; White, 2005).
13.3 Coagulants
When there are signs of current bleeding such as bleeding from the gums, there is the intuitive thought that coagulants can play a role in inhibiting bleeding. For example, drugs such as Botropase, a coagulant, are sometimes used in response to visible bleeding. It is however, a compound derived from the venom of one of two South American pit vipers both of which cause coagulation by activating the clotting cascade. It uses the same means to achieve coagulation as the snake concerned in the envenomation and should not be used in viper bites as it simply prolongs the coagulation abnormality by causing consumption coagulopathy in the same way.
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ensure that no long-term pituitary sequelae are evident. In known Russells viper areas, patients who present with symptoms such as reduced secondary hair growth or lethargy or reduced libido should be asked if they have suffered snakebite in the past.
nephrotoxicity and hypotension and rhabdomyolysis (Chugh et al, 1975, Shastry et al, 1977; Than-Than et al, 1989).
Renal damage can develop very early and even when the patient arrives at hospital soon after the bite, the damage may already have been done (TheinThan et al, 1991). Studies have shown that even when ASV is administered within 1-2 hours after the bite, it was incapable of preventing Acute Renal Failure. A victim in renal failure is evidence of the previous action of venom either directly on the kidney or by fibrin deposition. It is not evidence that the victim has currently has un-neutralised venom in the system and therefore requires ASV (Warrell, 1999).
Declining or no urine output although not all cases of renal failure exhibits oliguria
Blood Bio-Chemistry Serum Creatinine > 5mg/dl or rise of > 1mg / day. Urea > 200mg/dl Potassium > 5.6 mmol/l Confirm hyperkalaemia with ECG.
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Declining renal parameters require referral to a specialist nephrologist with access to dialysis equipment. Peritoneal dialysis could be performed in secondary care centres. Haemodialysis is preferable in cases of hypotension or hyperkalaemia (Shastry et al, 1977).
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The drug of choice is Paracetamol, Adult dose of 500-1000mg 4-6 hourly. Paediatric dose 10mg/kg every 4-6 hourly orally.
If available, mild opiates such as Tramadol, 50 mg can be used orally for relief of severe pain. In cases of severe pain at a tertiary centre, Tramadol can be given IV. Aspirin should not be used due to its adverse impact on haemostasis due to inhibition of platelet aggregation. Do not use non-steroidal anti-inflammatory drugs (NSAIDs) as they can cause bleeding. This can be particularly dangerous in a patient already having coagulopathy.
Routine use of antibiotics in snakebite is unnecessary. However In specific snake species, e,g, Malayan pit viper (Callesolasma rhodostoma) and Chinese cobra (Naja atra) routine use is advised.
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In cases where the victim has cut the wound or in cases of necrosis, antibiotic use is advised (Blaylock, 1999). Where wound infection is suspected a regimen of oral levofloxacin and amoxicillin/clavulanate should be administered.
Tetanus booster doses should be given although these can be delayed until coagulation is restored in cases with incoagulable blood. In many areas tetanus inoculation will not be thorough and tetanus toxoid should thus be given.
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place coagulation must be restored rapidly and thus a very larger initial dose of ASV is given in excess of the normal dosage levels in order to ensure restoration of coagulation within a 6-hour period.
It is recognised that this large initial dose may be in excess of the required amount to achieve neutralisation of the venom. The critical point here is that coagulation must be definitively restored in the shortest period i.e. 6 hours, and thus the risk of exceeding the required amount is acceptable to ensure life saving surgery can take place.
In most rural settings the victim will need referral to a facility that can perform surgery and is equipped with a surgeon.
It is worth waiting 5-7 days before commencing a debridement of necrotic tissue in order that the line of demarcation between viable and non-viable tissue can be specified (Blaylock, 2005)
1. Pain on passive stretching 2. Pain out of proportion 3. Pulselessness 4. Pallor 5. Parasthesia 6. Paralysis
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will often lead to a fasciotomy to release the pressure and enable arterial perfusion to the limb (Joseph, 2003). However, this approach must be used with caution in developing countries. Visual impression is a highly unreliable guide to estimating intra-compartmental pressure.
In a small case study in India, using a Stryker monitor, despite grossly swollen limbs, which matched the 6Ps, only one case from 12 achieved an intracompartmental pressure where fasciotomy would be considered. By the time coagulation was restored in the victim, the intracompartmental pressure had reduced to normal levels.
What is important is that the intra-compartmental pressure should be measured objectively using saline manometers or newer specialised equipment such as the Stryker Intra-compartmental Pressure Monitoring Equipment (Anindhya et al, 2004).
The patient should be referred to a surgical specialist but it is worth the treating clinician ensuring that objective criteria are used to assess the actual intracompartmental pressure in the limb.
The limb can be raised in the initial stages to see if swelling is reduced. However, this is controversial as there is no trial evidence to support its effectiveness.
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Evidence suggests that even when equipped with anti snake venom, PCF/BCF doctors lack the confidence to treat snakebite due to the absence of a protocol tailored to their needs and outlining how they should proceed within their context and setting. The following summarizes a sequence of activities to be carried out in these settings for optimal response.
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appear, ASV is temporarily suspended while the reaction is dealt with and then recommenced.
The 6-hour rule ensures that a six-hour window is now available in which to transport the patient.
Adrenaline is made ready in two syringes of 0.5mg 1:1000 for IM administration if symptoms of any adverse reaction appear. If symptoms do appear, ASV is temporarily suspended while the reaction is dealt with and then recommenced (see Section 10).
A neostigmine test is administered using 1.5-2.0mg of neostigmine IM plus 0.6mg of atropine IV. An objective measure such as single breath count is used to assess the improvement or lack of improvement given by the neostigmine over 1 hour. If there is no improvement in the objective measure the neostigmine is stopped. If there is improvement 0.5mg neostigmine is given IM every 30 minutes with atropine until recovery. Usually this recovery is very rapid.
If after 1 hour from the end of the first dose of ASV, the patients symptoms have not worsened i.e. paralysis has not descended further, a second full dose of ASV is given over 1 hour. ASV is then completed for this patient.
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If after 2 hours the patient has not shown worsening symptoms, but has not improved, a second dose of ASV is given over 1 hour. ASV administration is now complete for this patient.
BCF/PCF and even many referral hospitals are not equipped with mechanical ventilators. The most important factor therefore is when to refer a patient to a hospital with a ventilator and under what conditions.
The key criteria to determine whether respiratory failure, requiring mechanical ventilation is likely, is the neck lift. Neurotoxic patients should be frequently checked on their ability to perform a neck lift. If they are able to carry out the action then treatment should continue until recovery in the BCF/PCF.
If the patient reaches the stage when a neck lift cannot be carried out then the patient should be immediately referred to a hospital with a mechanical ventilator.
The key priority is to transfer the patient with a facemask, resuscitation bag and a person, other than the driver of the vehicle, who is trained of how to use
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these devices. If respiration fails then the victim must be given artificial respiration until arrival at the institution.
Greater success can be achieved with two additional approaches, prior to despatch
In the conscious patient, two Nasopharyngeal Tubes (NP) should be inserted before referral (see Section 12). These will enable effective resuscitation with the resuscitation bag by not allowing the tongue to fall back and block the airway, without triggering the gagging reflex. Improvised Nasopharyngeal tubes can be made by cutting down size 5 endotracheal tubes to the required length i.e. from the tragus to the nostril (see Section 12). NP tubes should be prepared and kept with the snakebite kit in the Basic Medical Facility. This is preferable as the patient may well be unable to perform a neck lift but still remain conscious and breathing. The danger will be that respiratory failure will occur after the patient has left the BCF/PCF and before arriving at the eventual institution. In that case the patient will be pre-prepared for the use of a resuscitation bag by the use of NP tubes.
In the unconscious patient, a Laryngeal Mask Airway or preferably a Laryngeal Tube Airway should be inserted before referral, which will enable more effective ventilatory support to be provided with a resuscitation bag until the patient reaches an institution with the facility of mechanical ventilation.
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However, with a few basic drugs and equipment, it is possible to manage most snakebite in the most primitive settings.
16.2 Assumptions
The assumption in this section is that this is a basic setting i.e. without laboratory analysis capability, mechanical ventilator or renal dialysis capability. In such a situation the following basic principles apply:
1. Victims with coagulopathy will require eventual transfer to a betterequipped hospital, due to the requirement to test for occult bleeding or renal failure. 2. Once the initial dose of ASV is given to a victim with coagulopathy, a six-hour window is available before ASV will require re-administration. 3. Neurotoxically envenomed patients can be treated entirely locally, if there is no evidence of respiratory failure and a need for long-term mechanical ventilation. 4. The trigger to indicate respiratory failure as being imminent is the failure of a patient to be able to perform a neck lift.
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5. If the patient is unable to perform a neck lift, this will require transfer to a better-equipped hospital with a ventilator BUT will crucially require airway support for the journey as described in Section 12. 6. ASV requirement will be limited to a single dose per patient with coagulopathy and two doses for a patient with neurotoxic envenoming.
Holding Quantities of ASV Holding quantity can be established using the following equation:
x =number of envenomings on average per month d = the maximum number of vials likely to be applied at the medical facility to a single patient i.e. 2 doses to a Neurotoxically envenomed patient t = length of time normally experienced for replenishment in months.
Suppose we are dealing with a basic facility with two envenomings per month then x=2: the maximum dose required per patient determines a key part of usage, so for example, if the maximum dose for a patient at a basic facility is 2 doses of 10 vials for a neurotoxic patient, d = 20. 1.2 represents the safety factor to ensure greater than minimal stock is available. The restocking time in months is represented by t. If the restocking period is 2 months for ASV to be replaced the equation would require 2 X 20 X 1.2 X 2 = 96 vials would be the ASV base stock amount.
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Adrenaline Adult dosage of 0.5mg of 1:1000 with a potential of three doses maximum per patient (i.e. stock of a minimum 10 vials)
Hydrocortisone and Antihistamine Adult dosage of antihistamine and hydrocortisone: only one application per patient is normally required before referral (i.e. stock of 10 vials)
Neostigmine and Atropine Adult dosage of 1.5mg for neostigmine and 0.6mg atropine for the test phase of treatment: ongoing support if test shows positive response is 0.5mg neostigmine every 30 minutes. Victims who are responsive usually recover quite rapidly so assume a dosage requirement of 12 hours i.e. 24 x 0.5mg ampoules. Further atropine may also be required @ 1 ampoule of 0.6mg atropine for every 5-6 ampoules of 0.5mg neostigmine.
Dose required per neurotoxic bite would be about 30 ampoules (0.5 mg) of neostigmine and five ampoules of atropine.
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Clean, New GLASS Test Tubes (plastic test tubes or syringes are useless in this setting)
Nasopharyngeal Airways (These can be improvised using size 5-7 Endotracheal Tubes cut to the required length
Oxygen Cylinder Some basic medical facilities already possess oxygen cylinders. For example, many basic medical facilities are equipped with a 40cft cylinder. This can be used not only for application of oxygen to a victim but newer equipment is becoming available that enables the cylinder to power a gas ventilator.
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The recommendation to wear protective footwear, such as boots when rice harvesting, is fine from a western perspective and yet in 45C temperatures impractical. The author witnessed a western multinational company, which insisted that its employees wore snake protective boots when working in the fields. The response from the employees was to cut large holes in the boots to ensure they were cool enough to be able to wear.
Much snake prevention advice is dubious in its effectiveness. For example, it is frequently reported that sleeping on a cot prevents snakebite; it has also been reported that religious groups such as Hindus are more at risk as they sleep on the floor. Muslims that sleep on cots are reported to be at less risk and yet the Islamic Republic of Pakistan has the third highest death toll from snakebite. This risk can also be increased as vegetable products such as
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onions are placed on the cot to repel snakes, yet paradoxically have the effect of attracting rats up onto the cot, swiftly followed by snakes!
Certain periods are also reported to present greater risk but probably for the wrong reasons. Monsoon rains are described as driving snakes from their holes, causing greater numbers of bites and yet this is probably incorrect. Analysis of the snakes that are brought with victims to the hospital during the start of the monsoon rains show they are mainly recently hatched juveniles.
Snakes give birth at the commencement of the rainy season, as food sources such as frogs are abundant. Large numbers of juvenile snakes moving about, looking for food and territories are the much more likely cause of the increase in snakebite. Victims need to be looking not for a large snake seeking refuge, but many small snakes that are more difficult to see!
Physical protection methods such as ditches, chemical and floral repellents are also often recommended. The military still employs ditches around army camps to prevent snake ingress, however snakes cross such ditches easily. There are no chemical or plant repellents that deter snakes; the author has captured snakes resting in plants that allegedly repel them.
When activities involved in snakebite are specifically examined, the outcome usually indicates that 3 or 4 key activities result in 80% plus of the snakebites.
For example, in India, China and Africa, grass cutting is a particularly risky activity.
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The rural practice of cutting grass manually, with a cutting device in the right hand and grasping the grass with the left hand, places the left hand in close proximity with the stationary snake in the long grass. It is a frequent cause of bites on the left hand. Cutting of high-level crops such as millet, particularly by women, often results in walking up and down rows of the crop, with the focus of attention upwards on the crop. The victim will be walking and cutting, but not looking downwards where the snake is resting.
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Dealing with an envenomation without ASV is a difficult activity that requires tough decisions to be taken; it is not for the squeamish!
1. In the vast majority of envenomations from venomous species mortality is not 100% in untreated cases. In some major contributors to snakebite envenomations such as the African carpet viper (Echis ocellatus) and the Indian Russells viper (Daboia russelii) the untreated mortality rate is around 10-20% (Abubakar et al, 2009). 2. In species such as the black mamba (Dendroaspis polylepsis), which does have a high mortality rate, the mode of death is neurotoxic and good preparation to manage respiratory compromise will increase the success rate of managing a bite. 3. The mode of death further reduces the risk of death in an envenomation without ASV. The key modes of death are, spontaneous bleeding, shock, renal failure and respiratory arrest. Not all cases of haemotoxic envenoming result in spontaneous bleeding. A great many simply involve coagulation abnormalities without spontaneous bleeding. In the case of renal failure it is doubtful that ASV has any role
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in preventing it, in any event. Respiratory failure can be managed as a separate event in the absence of ASV. 4. The case for the use of ASV in dealing with swelling is inconclusive and there is thus a strong possibility that a lack of ASV in cases that only cause Painful Progressive Swelling is not a significant problem in any event (Gutierrez et al, 2007; Offerman et al, 2009).
1. Preparations for Managing Respiratory Failure. The first step is to secure a resuscitation bag and ideally an emergency airway support device such as an LMA or LT Tube. In addition, a number of size 5-7 ET tubes should be obtained to create improvised nasopharyngeal tubes if required. Ensure that any support staff are trained in the correct use of the resuscitation bag (See Section 12.3). In many rural areas, basic medical workers are present in villages and small towns, often to cope with maternity and basic inoculation matters. It is essential to ensure that these staff can effectively support respiration with a resuscitation bag. The physician should provide training to ensure that this is the case.
2. Preparing to Manage Life Threatening Spontaneous Bleeding Spontaneous bleeding is a common outcome from snakebite. It is manifest in a variety of symptoms from gingival bleeding, haematemesis, haemoptysis, bleeding from the bite site, ecchymoses and the more serious symptoms such as intra cranial bleed etc. These outcomes become serious if they progress to life threatening conditions, which is by no means inevitable.
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The victim will need life saving surgery in the case of an intracranial bleed and the potential outcome is very poor. Coagulation will need to be restored before any surgery can be contemplated.
In the case of other bleeding, the major risk is hypotension and shock. Maintaining adequate stocks of fluids to increase volume is vital as this will be the first line of response. If whole blood is required, it will be useful if the physician has a list of healthy persons blood groups that can be utilised to provide a transfusion in an emergency.
Patients should be kept as immobile as possible in order to avoid any further cause of bleeding.
3. Preparing to Manage Renal Complications Many species, such as Russells viper (Daboia russelii) are capable of causing renal failure due to the action of the venom. This will need careful monitoring of the patients fluid output and lab tests if available to determine if renal failure is occurring. If renal impairment is suspected the patient should be referred to a facility with dialysis capability.
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1. Snakebites may increase in number particularly in flooding. Snakebite is a seasonal medical issue with peaks coinciding with the rainy season in many areas. Natural disasters such as flooding can cause an additional peak in the number of bites, which can overwhelm local medical capabilities. This can be particularly acute, as other medical conditions will also increase in number due to the natural calamity.
2. ASV supplies will be unavailable or scarce. Many countries with serious snakebite problems either have a strategic shortage of ASV or a tactical shortage in that ASV is located at larger hospitals that may well be inaccessible following the disaster.
3. Power supplies and Road transportation will be disrupted. The main effect in this case will be that victim referral to better equipped hospitals will be seriously reduced or blocked altogether until roads are restored. Victims bitten by species that cause occult bleeding or renal failure will thus be unlikely to be readily transported to a
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hospital that has laboratory facilities to diagnose the problem or equipped with dialysis equipment. Similarly neurotoxic victims will not be able to be referred to a hospital with a mechanical ventilator and any referral, if indeed possible, will be much delayed and take longer and thus require better airway management on the journey.
1. Snakebites may increase in number particularly in flooding. 1.1. Pre Planning In many cases, natural disasters such as flooding are entirely predictable. For example, in Sindh Province in Pakistan, the yearly flooding of the Indus in certain Districts is well known. ASV supplies can be stockpiled and sent to strategic centers before the flood season. The National Institute of Health in Islamabad carries out such a policy. Additional supplies of ASV can be pre-ordered and placed in key locations. Prior notification enables the producer to schedule delivery in good time.
1.2. Protocol Distribution Snakebite management in disaster settings requires that physicians are very well trained in how to manage snakebite in a local setting. Distribution of local protocols for managing snakebites such as those in this guideline, increase doctor confidence and optimal patient outcomes. Refresher guidelines from health officials, circulated to treating physicians can be of enormous assistance and local medical organisations can hold workshops prior to the risk season.
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1.3. Drug Distribution ASV should of course be distributed as widely as possible due to the likely interruption of road transport. It is also essential that support drugs such as anticholinesterases are made widely available in areas where postsynaptic envenoming can be expected. Such drugs are normally reserved for hospitals with operating facilities, as it is believed by health officials that such drugs are only used in an operating theatre environment. In the absence of ASV or in support they can make a critical contribution in the treatment of a postsynaptic envenoming.
2.1. Pre Order for known Risks ASV supplies should be pre-ordered and located in key medical facilities. Attention should be given by health officials to ensuring that the correct ASV is ordered. ASV is species specific and sourcing ASV from countries with different species, albeit with an ASV surplus is counterproductive.
Following Cyclone Nargis W.H.O. considered purchasing Indian ASV for use in Myanmar despite the fact that the Russells viper venom included in Indian ASV is from a different species of Russells viper than that in Myanmar. Health officials should establish potential substitutes for domestically produced ASV, in case of shortage.
2.2. Provide Adverse Conditions ASV Administration Criteria and Dosage Guidelines Shortages of ASV will require tough decisions in order to maximise the number of victims that can be treated and to ensure ASV is used in the most critical cases. There are no empirically determined guidelines for using ASV when shortages exist. The following recommendations however may help in prioritising criteria for administering ASV and dosage impacts under conditions of increased shortage. None of these 122
guidelines are ideal but may give some guidance to the treating physician.
100 %
Normal Operating Criteria Incoagulable Blood Visible Neurological Signs Severe Current Swelling (If in normal use)
Normal Dosage
70%
Adjusted Criteria Incoagulable Blood Visible Neurological Signs Normal Dosage Normal Dosage
50%
30%
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2.3. Emphasise Support Drugs and Equipment In cases where snakebite may rapidly increase, careful consideration and action should be given by health officials to ensuring vital support drugs are provided to all health facilities.
The key drug in this case is the anticholinesterases e.g. neostigmine or edrophonium. The benefit of these drugs in managing postsynaptic envenomings cannot be overstated. However, these drugs are often thought of as the domain of anaesthetists in surgical facilities and are thus not supplied to more basic facilities even when readily available. This is the result of health officials not being briefed on their importance to neurotoxic envenoming.
3.
3.1 Position Airway Management Equipment Neurotoxic snakebite victims represent a significant threat as with serious envenomations long term ventilation will be required to maintain breathing until the victim either clears the post synaptic venom by normal means or generates new synaptic vesicles in the case of pre synaptic envenoming. In the former case, this requires hours, possibly days of ventilation, in the latter often many days of ventilation.
As stated above, access to mechanical ventilation is the best option but this will be unlikely in a disaster situation. Not only will ventilators be inaccessible, but also their usage is likely to be high due to other medical conditions.
The normal method of dealing with patients who require ventilation, in the absence of a ventilator or where a ventilator is unavailable through usage, is for the victims family or friends to provide support with a resuscitation bag until an alternative can be found. This is often the case, even in tertiary hospitals equipped with ventilators. 124
In neurotoxic envenomings. The key consideration is flaccid paralysis during which the tongue falls back and obstructs the airway. Laypersons will be using the bag but the obstruction will prevent the patient from receiving the air being pumped. A simple method of dramatically improving the effectiveness of resuscitation bag support is to provide nasopharyngeal airways which can be readily fitted, do not trigger the gagging reflex if sized correctly and can be simply inserted even by paramedical personnel. In most cases actual NPAs are not available but can be readily improvised using the guidelines in Section 12.
The ET tubes required to improvise the NPAs are very cheap and readily available. They should be supplied to all health facilities with a potential exposure to neurotoxic envenomation. In addition, they will be available to support other instances where airway support will be required and are thus multi functional.
3.2 Provide Improvised Transfusion Facilities Locally In areas with high levels of viperine envenomation where spontaneous bleeding may be a critical issue, access to improvised blood transfusion can be useful. Prior blood testing to establish blood grouping in local people to ensure knowledge of the whereabouts of applicable donors will be very useful.
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Before preparation the snake should be photographed, a digital camera is best, and the images sent to an expert by email. The snake should be kept and cross referenced to the patient in case any further detailed analysis is required.
complex cases it may require an expert carrying out a detailed analysis of the specimen itself.
For photographic identification, the following are the best shots to take of the dead specimen. Grateful thanks for this advice to Ashok Captain, the best herpetologist in the authors experience!
1. A full top shot of the specimen showing body colour and any patterning 2. A close up of the head taken from the side to enable the scales on the face to be seen 3. If the snake DOES NOT have a plain belly then a shot of the belly showing the markings
If the snake has a pit between the nostril and the eye then: 1. A shot of the top of the head from above 2. A shot of the tail area in close up
Asia, North, West, South East, East John C Murphy Email ID: fordonia1@comcast.net
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If new or unusual species are identified then the nature of the envenoming can be studies prospectively and published.
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Source Data
Africa
Asia
Latin America
Total
400 - 1,000
25,00030,000
3,0004,000
30,000 - 40,000
Chippaux 1998
20,000
100,000
5,000
125,000
Kasturiratne et al 2008
3,529 - 32,117
15,38557,636
5402,298
19,886 - 93,945
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The most recent study contains fundamental flaws that also cast doubt on the veracity of the work. For example, the high-end mortality and envenoming numbers for Pakistan, imply a 50% mortality rate from envenomed victims which beggars belief. The untreated mortality rate from Echis species has been reported at 20% and therefore a mortality rate more than double this level is not credible (Kasturiratne et al, 2008; Abubakar et al, 2009). A 2009 WHO SEARO meeting claimed that India had mortality numbers that were widely agreed and yet proceeded to show 3 separate mortality numbers in a 26 page report! (WHO, 2009)
There is still utter confusion between cases i.e. those victims that go to hospital complaining of snakebite and envenomings i.e. those patients with snakebite who ARE envenomed AND require ASV. Cases are often taken as envenomings which increases snakebite morbidity numbers (Global Snakebite Initiative, 2008; Kasturiratne et al, 2008)
It is interesting how when funding justification becomes the rationale, all numbers are higher than would be expected.
Chinas figures are unknown but even if we exclude these figures the mortality number can be estimated with a reasonable degree of accuracy. Assuming a mortality percentage of 10% mortality would be:
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Area or Country Africa India Pakistan Sri Lanka Bangladesh Asia excluding South Asia and China China Assumption Total
4,000 48,152
The mortality percentage is an assumption but not unreasonable. The untreated percentage for Echis species, one of the largest contributors to the bite numbers is approximately 20% (Abubakar et al, 2009).
The numbers for Bangladesh has been taken from the as yet unpublished but reported study by the Bangladesh Ministry of Health, which indicated a snakebite mortality level of 6,000 per annum. However, a recent study of hospital cases reports that the percentage of victims who go to hospital following snakebite but who are NOT in fact envenomed is 60% (Harris et al, 2010). This is one of the key weaknesses of community-based surveys, which rely on lay people diagnosing snakebite and any related mortality. Despite this fact, when funding is the objective, community surveys are the method of choice as they invariably deliver higher numbers (Global Snakebite Initiative, 2008).
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Tom Mazuch Front Cover Dendroaspis viridis Photo 1.5.1 Echis pyrimidium and Cerastes cerastes Photo 1.6.1 Naja nigricollis, Naja ashei and Naja pallida Photo 1.6.2 Bitis arietans Photo 1.7.1 Bitis rhinoceros, Bitis nasicornis and Echis ocellatus Photo 1.8.1 Naja nigricollis, Naja nubiae, Naja pallida and Naja ashei Photo 1.8.2 Echis pyrimidium, Echis ocellatus and Cerastes cerastes Photo 1.9.1 Dendroaspis augusticeps, Dendroaspis polylepsis and Dendroaspis viridis Photo 1.9.2 Naja haje, Naja annulifera and Naja melanoleuca John C Murphy Photo 1.3.1 Naja naja Sri Lanka Photo 1.3.3 Daboia russelii Sri Lanka and Hypnale hypnale Sri Lanka Photo 1.4.1 Deinagkistrodon acutus, Callesolasma rhodostoma, Naja kaouthia, Oxyuranus scutellatus Photo 1.4.2 Bungarus candidus, Bungarus fasciatus and Bungarus flaviceps Photo 1.5.1 Vipera palaestinae, Echis coloratus and Macrovipera lebetina Photo 1.6.2 Bitis nasicornis Photo 1.8.2 Cerastes vipera and Cerastes cerastes Photo 1.9.1 Dendroaspis jamesoni
Earl Hewitt Photo 2.1 Scarification first aid Photo 5.2 Necrosis from Echis ocellatus
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In addition, enormous thanks to many developing world colleagues in India, Pakistan, China and Africa that have enabled this work to be produced. Particularly, the doctors, S. Mahadevan, CK Eapen, Vivek Lal, Mabel Vasnaik, Arvind Mathur, Joseph K Joseph, C. Rajendiran, Soumitra Ghosh, Sharda Peshin, Surjit Singh, Jeffrey Fung, KK Lam and Earl Hewitt.
Political figures worthy of specific mention for their support and encouragement include Dr Surya Kanta Mishra and Mr Narpat Singh Rajvi.
Specific thanks to Dr Huma Qureshi (Executive Director, Pakistan Medical Research Council) whose support in Pakistan was honest, effective and victim orientated. The first review in the Thar Desert was harrowing and no other official of her seniority would have braved the trip. Also to Nasreen Nomani (National Institute of Health, Pakistan) a dedicated champion of anti snake venom production from whom I learned a lot.
To Ashok Captain for reassuring me that not all herpetologists need blond hair, sunglasses, near death experiences or sensational posing in quasimilitary garb to be successful and useful. Also Paul Crow, Michael Lau and Garry Ades of KFBG.
To the many developed world snakebite authorities whose lack of understanding of developing world environments prompts so little success in improving snakebite, thanks for keeping me out of your meetings, it has improved my knowledge enormously.
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24.0 References
Snakes of Medical Significance: South Asia
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