Venomous Snakebite in Mountainous Terrain: Prevention and Management
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1 Venomous Snakebite in Mountainous Terrain: Prevention and Management Jeff J. Boyd MBBS UIAGM, Giancelso Agazzi MD, Dario Svajda MD, Arthur J. Morgan MBBCh, Silvia Ferrandis MD, Robert Norris MD Official Recommendations of the ICAR and UIAA MedComs
2 Wilderness & Environmental Medicine Volume 18, Number 3.
3
4 Epidemiology Viperids Old World Vipers European asp (Vipera aspis) Common adder (Vipera berus) Nose-horned viper (Vipera ammodytes) Russell s viper (Daboia russelii) Saw-scaled viper (Echis carinatus & sochureki) Pit Vipers Rattlesnakes (Crotalids) Himalayan pit viper (Gloydius himalayanus) Elapids Cobras (eg.naja naja) Spitting cobras and Rinkhals (Hemachatus hemachatus)
5 European asp (Vipera aspis)
6 Common adder (Vipera berus)
7 Nose-horned viper (Vipera ammodytes)
8 Russell s viper (Daboia russelii)
9 Saw-scaled viper (Echis carinatus & sochureki)
10 Rattlesnakes (Crotalids)
11 Himalayan pit viper (Gloydius himalayanus)
12 Cobras (eg.naja naja)
13 Spitting cobras and Rinkhals (Hemachatus hemachatus)
14 Epidemiology - hazard of snakebite only 15% of 3000 species dangerous pit viper bites - only 80% envenomation some elapids - only 20% envenomation case fatality rate s % - critical medical care - 2.6% - antivenom - 0.3% - Nepal - 27%
15 Toxicity and Symptoms/Signs Vipers (cellular and clotting toxins) - Local effects - Pain - Swelling - Bleeding, bruising - Tissue destruction - Systemic effects - Generalized bleeding - Shock - Cessation breathing - Early collapse
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18 Toxicity and Symptoms/Signs Elapids (nervous system toxins) - Systemic effects - Eyelid drooping - Difficulty speaking - Cessation breathing - (Generalized bleeding) - Local effects (Cobras) - Tissue destruction - Spitting cobras & rinkhals - Irritation eye - Permanent loss vision
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20 Prevention - Prepare - Learn before - References & photos - Management plans (logistics, antivenom) - Clothing - Baggy ( bloused ) - Boots/gaitors - Gloves
21 Prevention - Look - Ahead - Torch/flashlight - Care cliffs and water - Probe - Sleeping - Closed space - Above floor - Check bed
22 Prevention - Snakes - Leave them alone - Dead snakes can envenomate - If bite -? Need identify - Identify safely (strike 1/2 length) - Zoom photo - Thick bag if killed
23
24 On-Site Treatment - First Aid Safety, Victim Comfort Basic Life Support - CPR early - Prolonged rescue breathing Identify (?) Evaluate bite - Bite - Mark leading edge with time Remove constrictions - Rings, watches, constricting clothing Splint
25 On-Site Treatment - First Aid DO NO HARM - NO incisions, excision, heat, cold, electrical shocks, alcohol or stimulants, (no strychnine!) No constriction bands or tourniquets No mechanical suction - Does not extract venom - May impair natural oozing of venom - May increase tissue damage
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28 On-Site Treatment - First Aid Pressure immobilization - Elapid bites only - (Best not true cobras (local toxicity)) - Reduces absorption and toxicity - Elastic bandage or stretchy clothing - Fingers/toes up limb, over bite, to top - Correct pressure (like sprained ankle) - Splint/sling - Second wrap over splint - Leave in place
29 On-Site Treatment - First Aid Pain control - Paracetamol/acetaminophen - Not aspirin or ibuprofen Fluid (Food) - Clear fluids - Best no solid food Logistics - Mobilize & transport!early! - Expert advice (Poison Centre, Emergency Departments) - Adequate team (Rescue breathing hours - days)
30 On-Site Treatment - Advanced Medical Monitoring - Vital signs - ECG and oximetry monitoring Intravenous fluids - Shock resuscitation - Intraosseous access Oxygen Analgesia - Opiates - Ketamine Advanced life support - Shock, anaphylaxis, cardiac dysrhythmias Airway intervention - RSI & endotracheal intubation
31 On-Site Treatment - Advanced Medical Antivenom - Field administration (esp. remote/delayed or Elapids) - Prepared shock, airway intervention - Intravenous or intraosseous - No skin pre-testing Anticholinesterase Trial - Post-synaptic blockers (Cobras, Tiger Snake,? Others) - Neostigmine or edrophonium - Preload atropine Observation - Expert advice - Minimum 24 hours if Elapid, even if asymptomatic
32 Conservation
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