Puff Adder (Bitis arietans) Bite Protocol

This section will help you get first aid treatment protocols incase of an envenomation. This includes indigenous and exotic reptiles. Please do not use this forum for photo sharing, etc.

Postby Quintin » Fri Sep 21, 2007 11:01 am

Perhaps they were refering to Anaphylactic shock?!?

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Postby Nasicornis » Fri Sep 21, 2007 11:32 am

Whatever they were referring to I believe that the word "death" should never be mentioned to any snake bite victim.
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Postby Quintin » Fri Sep 21, 2007 12:02 pm

LOL Nasicornis.. i agree!!!
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Postby Bushviper » Fri Sep 21, 2007 12:06 pm

Quinten the body can go into hypovolemic shock as a result of the action of the venom and then death follows rather quickly.

Be careful of describing too many symptoms because often the patient will imagine that they are developing them. The reasoning has been reported as "if I dont show the symptoms they might send me home to die there" and this can confuse matters. Rather ask them what they are feeling and then just confirm that those are symptoms or else tell them that these could be induced by the shock of being bitten. Dry mouth, light headedness, tremors etc are all possibly from the fright they got.
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Postby Nasicornis » Fri Sep 21, 2007 12:49 pm

BV, I totally agree with you on that. What I was referring to was obvious symptoms like severe burning, swelling ect.

I assisted in a snake bite case once involving a red lip herald. A woman in her 40's was bitten and taken to Akasia Hospital. The snake had been caught and placed into a glass jar. I arrived and id'd the snake. The woman was terrified of dying and insisted that I could not possibly know what I was talking about and she started developing all kinds of "symptoms" and insisted that her arm was on fire and that she could not breath.

From a medical point of view, she was fine, just went into a severe panick attack. I took the the herald out of the jar and jammed my finger into its mouth to convince her that she had absolutely nothing to worry about. She watched me in amazement and after about an hour she came to the conclusion that I looked ok and was not going to kill over. She made a miraculous recovery in the following 10 minutes and was discharged about an hour later.

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Postby alexander » Fri Sep 21, 2007 12:49 pm

how exactly do you die from puff adder envenomation, apart from shock?
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Postby Nasicornis » Fri Sep 21, 2007 12:56 pm

I stand corrected,

but death may result from a number of reasons. Cytotoxins cause severe tissue distruction by actually breaking down tissue matter. The broken down tissue can start to circulate into the bloodstream and can cause complications in various organs like the kidneys for instance which may result in kidney failure. In some cases severe fluid loss may also occur.
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Postby s'mee » Fri Sep 21, 2007 3:32 pm

Nasicornis is correct, there are a number of ways Puff adder envenomation can cause death - none of them pleasant.
Early causes of death may be due to anaphylaxis to the venom (vary rarely) or due to the systemic effects of the venom causing circulatory collapse and hypovolemic shock. Coagulopathy (bleeding syndromes) have also been documented in several Bitis arietans bites - the venom may cause desquamation of the epithelium lining the blood vessels (ie the cell membranes of the lining of the blood vessels are broken down) and these broken down pieces of epithelium form the basis for numerous clots in the blood stream. This process may continue until the available circulating clotting factors are used up and than bleeding will begin (similar to the process in heamotoxic venoms). Another danger is that the clots formed may find their way to either the heart or brain - in which case death can result from an embolus - much the same as a heart attack or stroke. Also, do not underestimate the psychosomatic effects of a snakebite - panic kills!

Late (delayed causes of death) are usually due to systemic infection or kidney failure - the breakdown products of the venom collect in the kidneys and cause a blockage. This is why it is important to keep all envenomated patients adequately hydrated as a part of the clinical management.

As Armata said, there is a distinction between emergency first aid measures and clinical (in hospital) management. Very few Doctors are knowledgeable on the subject and Armata mentioned 2 of the best in his post. There are others but they are few and far between.
The most important part of initial field treatment would be to remain calm and immediately proceed to a capable hospital without delay.
I personally would not hesitate to use pressure-immobilization therapy for any venomous snakebite - including cytotoxic bites, providing it is applied immediately. The key however is to apply the pressure bandage correctly - too tight and it will act as a tourniquet, too loose and will not have any effect on lymphatic drainage. If there is a delay in applying a pressure bandage and swelling has already progressed than immobilization of the bitten limb without application of a pressure bandage is recommended (Pantanowitz et al)

While on the topic, those of you that parlez francais can have a browse through these pages:
http://www.pathexo.fr/pages/Bull-somm/2005/2005n4.html and
http://www.pathexo.fr/pages/Bull-somm/2002/2002n3.html
These are the published proceedings of the first two international conferences on Envenomation in Africa. Most of the papers have to do with epidemiology and clinical management, there is nothing on first aid or out of hospital treatment, but a very interesting read nonetheless. The Third Conference on Envenomation in Africa will be held in November this year and there should be some interesting papers coming out from that.
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Postby froot » Fri Sep 21, 2007 9:05 pm

Thanks you for that s'mee. Pity I can't understand French though, looks like some interesting information.
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Postby swazi » Sat Sep 22, 2007 9:37 am

What really concerns me is the fact that so many of us keep venomous reptiles and there is no clear guideline to follow.

What is the opinion regarding the following info I was given?

Pressure Immobilization:
1. Apply a broad bandage and wrap from the distal to the proximal limb to occlude the lymphatic system and trap the venom bolus in the area of injection. It should be wrapped as tight as for a sprained ankle (55 mm Hg), and the limb should be immobilized. Please note that both these conditions need to be met in order for this method to be effective.

2.This is effective treatment for Neurotoxic cobra bites.

3. It is not indicated for Cytotoxic bites, as it may aggravate this type of syndrome.

4. It does not work in the case of a Mamba bite as Mamba venom is transported away from the bite site through the circulation. The venom of a Mamba is absorbed by the capillary bed into the circulation, so restrict movement until proper first aid is in place.

(Flexing & elevation)

This method can also be used for other bites with a mixed syndrome of PPS and PW like Rinkhals, Berg adder, Garter snake and Shield nosed snake.
Mortality will be increased if this measure is used with non-spitting cobras as the venom is transported via the lymphatic system.
Contra-indicated for Mamba bites.
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Postby s'mee » Sat Sep 22, 2007 4:41 pm

Froot,
Although the proceedings are in French, there are English abstracts of all the papers as well. Possibly you could try running them through a translation tool like Google (I haven't) and see what pops out - should make for some interesting (and cumbersome) reading.

Swazi,
Pressure-immobilization was first described by Sutherland, as a first aid measure for Australian elapid envenomation. The idea behind it is that proper application will inhibit lymphatic drainage of the affected limb and thus delay the uptake of the venom into the circulatory system via the lymphatic system. This is effective in most Australian elapids as their venom uptake is primarily via the lymphatic system. It has been shown to be less effective in African elapids and especially, as you mentioned, in the mambas.
There are 2 distinct components to pressure-immobilization therapy: the application of a pressure bandage, which compresses the lymph nodes in the area of application and immobilization of the bitten limb, which limits both passive drainage and localized circlulation. Either one of these on their own will inhibit lymphatic drainage to some degree, whether this will be significant enough to make a difference in an envenomation or not remains undetermined. Pantanowitz in an early paper did recommend the use of immobilization without a pressure bandage in cases of cytotoxic envenomation with early severe swelling. It is important to note that properly applied pressure-immobilization therapy will not completely occlude lymphatic drainage, but will inhibit it significantly.
The corollary to the above is that any movement of the bitten limb will cause an increase in both localized circulation and lymphatic drainage. This would also apply to elevation and flexion of the bitten limb. The theoretical danger with this is that it would accelerate the systemic uptake of the venom and may result in severe (read life-threatening) symptoms earlier. I stress that this is a theoretical danger -this has not been proven, but it may be significant to note that in the study mentioned by BV, conducted by Prof CJ Reitz, the most active group displayed the fastest mortality. This just confirms what we aready know - an increase in circulation results in faster systemic absorbtion of injected venom. I personally remain unconvinced of the safety and efficacy of this method (elevation and flexion) as a first aid measure and will not use it until I see some proof to the contrary. Prof Reitz also published a very interesting study back in the 80's which suggested that applying local trauma to the area of injury in rabbits injected with Naja annulifera venom resulted in a delay in the onset of symptoms and a slight increase in survivabilty over the control group. That does not mean that, based on this study, I will now start beating the cr@p out of any snakebite victim that I come across!

With regard to the application of a pressure bandage aggravating the effects of a cytotoxic envenomation, a study was published by Bush et al which looked at intracompartmental pressure and localized swelling (as measured by limb circumference) following intracompartmental injection of Crotalus atrox venom. The results of this study were that application of a pressure bandage resulted in significantly longer survival times, significantly less swelling and also a significant increase in intracompartmental pressure.
It may be of relevance that no immobilization was applied to the envenomated limb and after the initial anesthesia had worn off following the injection of venom, the study animals (pigs) were returned to cages where they were allowed to ambulate for the duration of the study. The author's conclusions were that application of a pressure bandage in cytotoxic envenomation may be life-saving if there is a delay in transport to hospital, but possibly at the expense of increased local damage. Actual necrosis of tissue in the envenomated muscle compartment was not evaluated in this study.
There seems to be a common misconception among snake keepers that cytotxic bites (and esecially puff adder bites) are not likely to prove lethal very often. This assumption is dangerously incorrect. There are a significant number of fatalities due to these snakes across Africa every year, and a number of well documented cases where death has ocurred very rapidly (within 1 hour) following puff adder bites. How often have you heard "it's only a puff adder bite - you're not gonna die from it but the pain will make you wish that you had!" ?

Sytemic venom absorbtion following a mamba bite is typically very rapid and is only marginally delayed by a pressure bandage. It has been shown that a properly applied arterial tourniquet will delay systemic absorbtion in these cases. Tourniquets are not benign however and can result in significant local tissue damage, including loss of the involved limb. For these reasons, tourniquets are no longer recommended as a first aid measure for neurotoxic snakebite. They do however remain the most effective way of delaying systemic absorbtion of mamba venom.I would however not recommend that anyone apply a tourniquet unless they have a good understanding of the risks and limitations AND have had proper training in the correct application thereof. The little rubber tourniquet that SAVP supply in the "snakebite kit" is probably the most dangerous item in there.
The restriction of movement you mentioned when treating a black mamba bite could be compared to the immobilization part of pressure-immobilization therapy. Seeing as you are going to be splinting the limb anyway, it certainly wouldn't hurt to apply a pressure bandage at the same time.

Maybe now would be a good time to mention that pressure-immobilization therapy is a first aid measure only. It is not intended as long term therapy and pressure bandages should not be left on indefinitely. During clinical management of a snake envenomation, the pressure bandage should be removed as soon as measures are in place to mitigate against a systemic reaction - ie when the patient is in a hospital with adequate resuscitation facilities, has been adequately resucitated and appropriate antivenom is available in adequate quantitites.

As I stated in my previous post, my first aid treatment of choice for ALL venomous snakebites remains pressure-immobilization and rapid transport to a SUITABLE hospital.

The best recommendation that I can give you in your situation is that you collect and review as many published articles and papers as you can on the subject, as well as perhaps discuss it with one or two knowledgeable medical professionals (Prof Muller comes to mind as do a few others) and draw up a protocol that you feel comfortable with based on this and than set up a meeting with the Doctor who is in charge of the emergency department at the hospital you will be using in the event of an envenomation. Present him with your protocol, as well as your research material so that he can see the factual basis behind the protocol and discuss it with him before the time comes when you need to test it for real. It may also be a good idea to discuss it with your local emergency medical service as well if you intend using them in the event of a bite - mainly to ensure that the victim is transported to the correct(appropriate) hospital.

Okay, I'll shut up now...
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Postby Bushviper » Sat Sep 22, 2007 4:56 pm

s'mee thanks for that. No need to shut up if you are partaking in the exchange of critical information.

An occlusive tourniquet can also cause the muscles in the limb to die off if it is left on for an extended period of time. That makes it such a roll of the dice if you get tagged by a mamba.

I do have my doubts that the death from Puff adders in such a short period of time ie one hour was from the venom. It could also be from anaphylaxis. Either that or possibly an intravenous bite which must be hell to go through.
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Postby armata » Sat Sep 22, 2007 5:34 pm

s'mee thanks very much indeed for that.

I would only add do not underestimate the bite from any venomous snake.
You may recall the thread (or maybe on bgf's site) about Vipera berus bites and how they are underestimated - two near fatalities from this species in recent years.

Prof David Warrell is doing (has done) the chapt on clinical management of snakebite for my book; I would not presume to handle that chapter solo.
I will also be in touch with Gerbus Muller; I recently helped him prepare for his presentation at the WHO. I think between us we should WILL produce a good emergency protocol.

Another point; I don't know what s'mee thinks; but dealing with medical staff when arriving as or with a snakebite victim. There are a lot of alternative medical opinions out there. You may remember in Mark O'Shea's black mamba film when he was tagged by the stiletto. The doctor in charge told us that there are two types of stiletto; one is bad and requires antivenom; and the other just has mild symptoms!
One has to be diplomatic - there are instances when people (herpetologists) are 200% sure of what bit them; to be greeted by, 'how do you know? or 'are you sure' or lets see what symptoms develop'.

One has to be a bit of a diplomat I guess. Oh yes, one big no no, don't take a live snake to the hospital!!! (don't laugh its been done).

One answer is to go armed with the contact number of such as Gerbus; any doctor worth his salt will only be too glad to ask for advice and should consult willingly.
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Postby s'mee » Sat Sep 22, 2007 7:22 pm

Bushviper wrote:An occlusive tourniquet can also cause the muscles in the limb to die off if it is left on for an extended period of time.


This is exactly the reason why the use of tourniquets are no longer advocated for the lay public. An arterial tourniquet by definition cuts off all oxygenated blood flow into the limb and will cause the tissue to die off if left in situ for sufficient time.

Death following an intravenous envenomation could still be considered as a death due to the direct effects of the venom as opposed to the indirect effects (as would be the case with anaphylaxis). One of the cases I mentioned was certainly an intravenous bite - both fangs penetrated the popliteal vein (that's the big one that runs behind your knee). Statistically, the chance of this happening (ie both fangs penetrating a major blood vessel) would probably be akin to winning the combined national lotteries of the UK, France, Germany and South Africa on the day of your wedding to the Queen of Sheba - while enduring a snowstorm in hell!
Statistics however, are of little comfort to the victim.
Intravenous bites have, to my knowledge, been documented in Bitis arietans, Naja annulifera, Dendroaspis polylepis and Cotalus adamanteus. I am sure there are others as well. Intravenous bite are extremely rare though - most snakebites, including those from many viperids, result in subcutaneous injection of venom.

Anaphylaxis to snake venom is a subject that has only been researched in detail comparatively recently. Those most at risk are people who are repetitively exposed to large quantities of aerosolized venoms - people who regularly work with spitting cobras as well as people milking snakes regularly and venom researchers. The risk of developing a sensitivity to snake venoms due to one or two previous bites, while possible, is negligible. I still have, somewhere at home, slides of a life-threatening bite from Crotaphopeltis hotamboeia (due to anaphylaxis).

Armata makes some very good points. I have mentioned in another post the danger of underestimating bites from the small arboreal vipers. It is my contention that ANY venomous snake has the potential to cause a life-threatening reaction and should be treated as such.

As I said earlier in this thread, very few doctors have the requisite specialist knowledge to treat a serious snakebite. The biggest problem with a doctor taking medical advice from a non-medically qualified person (even though that person may have the requisite specialized knowledge) is that of liability. In such a situation, the doctor will be held legally and ethically accountable for any and all treatment given. As an example, were you as a lay person to advise the doctor treating your friend for snakebite that he needed to administer antivenom (ie you have just prescribed a drug) and the patient developed an anaphylactic reaction to the antivenom and subsequently died, you would be completely off the hook. Should the victim's family decide to register a malpractice complaint or civil claim against the doctor, that doctor would be wholly accountable.
This example perhaps, illustrates the need to have a properly referenced protocol with recognized subject matter experts as contacts -ie Prof Muller, who is head of the department of Toxicology at the University of Stellenbosch would certainly (objectively) qualify as a recognized subject matter expert. My buddy from down the road who has been breeding snakes for 20 years and has been bitten 5 time this year already, would not!
Your point about the treating doctor being ambivalent when the victim is completely sure of the identification of the snake is valid. So too is your point about diplomacy. If you present to the emergency room with a professional looking, properly referenced protocol and a diplomatic demeanour your are far more likely to have the doctor take your input seriously than would be the case were you to storm into the hospital proclaiming yourself as THE snakebite expert while loudly instructing everyone to get out of your way. To reiterate my advice to Swazi, the gold standard would be to set up a meeting with the hospital emergency department and staff involved to discuss your bite protocol before you needed to use it.

Armata, I am sure that between yourself and Prof Muller you will certainly produce a good emergency protocol. I look forward to seeing this, and also to the outcomes of the conference in November.

Just to end off, with regard to your point about not taking a live snake to hospital, several years ago a friend of mine who was crewing the Flight for Life helicopter in Jhb was called out for a snakebite (it turned out to be a rinkhals). On scene she scooped the dead snake into a bag and flew it to Baragwanath Hospital with the patient for identification. When she handed over to the emergency room staff that it was a rinkhals bite, she was asked how she knew this. She promptly upended the bag and dumped the now very much alive rinkhals into the crowded emergency room! (if you've ever been there you will know what I mean about crowded) It took several hours to find and recapture the snake again!
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Postby rubida » Sun Sep 23, 2007 7:17 pm

What’s the general consensus concerning the use of EpiPen’s by the layman?
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