I live in a country that boasts 19 of the worlds top 23 most venomous snakes. Deadly slithering hypoderms waiting to sneak up an unguarded trouser leg and inject you with a coctail of neurotoxins, haemolytic and haemorrhagic enzymes, pro and anti coagulants, myotoxic, cytotoxic and nephrotoxic factors, all guaranteed to ruin your day. The Fierce Snake (Oxyuranus microlepidotus) produces the most toxic venom of any land based snake in the world, being around 1,000 times more toxic than the American Rattler. One dose of its venom is powerful enough to kill around 500,000 mice. Luckily, it is a very shy snake and only lives in remote desert regions. The Eastern Brown Snake (Pseudonaja Textillis), on the other hand, lives all along the east coast of Australia. In fact there are bound to be a few within spitting distance of where I sit this very moment. It is the second most venomous land snake in the world and one of the most dangerous. It can be aggressive, fast moving and has been known to follow people home at night, knock on their doors, leap up and then repeatedly attack.

first aid treatment.

  • As soon as possible identify the area bitten.
  • Immobilize the victim.
  • Cut clothing around the bite site rather than removing it, as increased activity only forces more venom into the bloodstream. If possible mark around the bite site with a pen.
  • Do NOT wash or clean the site. Venom is not absorbed through the skin and any residue may be useful in venom identification.
  • Apply a broad pressure bandage. You need to bandage upwards from the lower portion of the bitten limb. Include fingers or toes in the bandage. Make it as firm as you would for a sprained ankle and extend it the entire length of the affected limb. Immobilize the limb (use a splint if possible) and then immobilize the patient. (Bring transport to the patient rather than trying to get them to transport.) Bandages should NOT be removed or loosened until the patient has reached hospital and resuscitation and monitoring equipment is available.
  • Do NOT apply a tourniquet.
  • And do NOT attempt to capture or kill the snake and bring it into the ED and drop it in the face of the Triage nurse. You only increase the risk of getting yourself envenomated by the snake or beaten by the nurse. Probably both.

name your poison.

Once in the ED the patient should be assessed for any immediate threats to their ABC’s. Even though the patient may have been bitten multiple times and have clear bite marks they may not have been envenomated. This will depend on several factors:

  • Fang length. Immature snakes may have short fangs that are unable to penetrate through clothing. Fangs may also have been broken or damaged (snakes don’t floss much).
  • Time of last venom injection. If the snake has recently injected venom whilst obtaining its lunch its venom sacks may not have yet replenished a significant yield.
  • Decision to inject. Snakes make a conscious decision to inject their venom and may make a “dry bite”.

Antivenom is only administered if the patient develops definite systemic symptoms of envenomation. Some indicators may include:

  • Neurological: ptosis, pupillary impairment, motor impairment, decreased GCS, pain, numbness, paraesthesia.
  • Cardiovascular: bradycardia or tachycardia, hypotension or hypertension.
  • Respiratory: bronchospasm’ pulmonary oedema, respirtory muscle impairment.
  • Gastrointesinal: nausea and vomiting, haematemesis.
  • Integumentary: bleeding at bite site, IV site, gingiva and diaphoresis.
  • Musculoskeletal: myalgia.
  • Urinary: haematuria, myoglobinuria, oliguria, anuria.

The Australian Venom Research Unit (AVRU) has a great step by step guide in assesssing symptoms of snakebite envenomation. Correct identification of a snake is a tricky business and even experienced herpetologists (no, nothing to do with herpes) get it wrong. Giving the wrong antivenom is dangerous and can lead to unnecessary death of the patient. Luckily, we are the only country in the world with Snake Venom Detection Kits (SVDKs) which allow the most appropriate and effective antivenom to be given. Instructions on use of our SVDK can be found at the AVRU website. Using one, is kinda like playing with a kids chemistry set, so its useful to familiarize yourself with it so as not to blow yourself up.

antivenom.

Snake antivenom is produced from the serum of horses that have been immunised with sub-clinical doses of specific snake venom. When enough antibodies are detected in the serum it is collected and fractionated and purified into antivenom. Because these antivenom remain essentially a horse protein, they may result in adverse reactions such as anaphylaxis and serum sickness and strong urges to eat hay. Once the snake venom has been identified a corresponding monovalent antivenom is administered IV. A single dose of antivenom is based on the average venom yield of the snake, but because snakes often deliver much higher doses, a patient may require multiple doses of antivenom to neutralize the venom (a case in 2001 required 28 vials of antivenom to neutralize a Brown Snake bite). Before administering antivenom, advanced life support, and experienced staff must be present.

15 Responses to “how to manage a snakebite.”

  1. a helpful thing to do if you are putting on first aid prior to arrival in ed is the mark the area of the bite site ON THE OUTSIDE OF THE BANDAGE, that way when the patient arrives in ed, we can cut a small window in the bandage to swab the bite site rather than removing the whole bandage and rendering 1st aid useless.
    if you’re out in the bush and dont have a pen or lipstick with you even a smear of dirt will do.

  2. @Belle:
    You would want to be careful with that snake head. There are documented cases of people being envenomated whilst handling a snakes head that has then ‘bitten’ them as a reflex action.
    That would be an embarrassing way to go.

  3. @ wannabe….up shite creek. You’d get it and then be tx’d for anaphylaxis concurrently and hopefully you’d live through it all.

  4. At one hospital I worked at, the patient brought the brown snake ( a big one) to the triage nurse in a bucket along with the snakes head!!!! which had been chopped off. After the patient had been treated, there was a delema on where to dispose of the snake’s head as it was a ‘sharp’ with those fangs. I am so glad I was not the triage nurse that day…………

  5. Ah, the infamous drop bears, GSG. :) A national legend!

  6. Just a question from someone who is curious – ‘Snake antivenom is produced from the serum of horses that have been immunised with sub-clinical doses of specific snake venom.
    Where does this leave someone with an allergy to horses, such as myself? Is the serum likely to cause an adverse reaction?

  7. It’s the drop bears you need to be worried about, Herman. ;)

  8. Man I’d love to visit Australia, but I’d be lying if i said the snake thing didn’t have me quite a bit concerned.

  9. I am getting a cobra. For safety I need its venom sacks removed. How much will this procedure cost me?

  10. Had my first the other day….the first aid was a new learning point (properly rendered on my pt), but I also learned that whilist patho is dinking around b/c the “bloods not clotting” (duh) to fill a red top and in 10-15 min if it is not clotted, give the antivenom…. gud stuff

  11. Pulp Fiction

    Newspapers are a accurate source of information!

    Wrong!

    Sometimes working in hospitals one can have the inside details on a sensational story published in the newspapers.

    I can remember a snake bite story which made media headlines around the country.

    I was reading the story in the paper and if it wasn’t for the names, I would have thought that it was a totally different story about another person being bitten by a snake.

    The only part of the published story which matched with the details I knew were the names, virtually all other details about the snake bite published in the media did not match any of the details contained in the ambulance officers notes or the patient’s hospital history.

    Now I see our investigative journalists as little for than pulp fiction writers and certain incidences since then where journalists have been caught out, just confirms this view much more strongly.

  12. If someone says they have been bitten by a snake, believe them until proven otherwise.

    Many moons before Ian decided to impress a ward sister with his bedpan etiquette, a young girl woke her parents saying she had been bitten by a snake inside the house.

    The parents after examining and not finding any puncture marks sent her back to bed, a while later she started vomiting and I cant remember what else, they decided to bring her to hospital.

    The young girl has a scratch on her leg which was enough to envenomate her.

    And yes it was a brown snake.

    The other day I had a bloke visit our A&E clutching his thumb, like he had just hit with a hammer real bad.

    He walked straight past me, even though I was in uniform asking for one of the nurses he knew.

    It must have been telepathy or it could have been the look on his face of someone trying to be cool whilst desperately clutching his thumb that lead me to surmise that he had been bitten by a snake.

    Sometimes first aid skills come in handy in A&E.

    What had happened is that he was gardening only about 50 metres from the hospital when he killed a snake, cut into pieces and being a tidy type of chap, he picked the pieces up and put them into a plastic bag, so when he picked the head up, it bit him.

    This one was a tiger snake. Being a small hospital we dont have an intenive care unit, so he was transferred out, now at the next center of excellence according the reliable witnesses, the ambulance officers who transferred him.

    The doctor did not beleive that the patient had been envomated, so removed the compression bandage I had diligently applied.

    “He got crook real quick” was the ambos medical description. Patient managed to survive the snake and the doctor.

    Snakes like Blunstones.

    Now very little can get the heart pumping fast like someone rushing another person into A&E saying that they had been bitten by a snake.

    Now what happened is that a young lady decided to put her blunstones on without any socks and as she put her boot on she felt a sting on her foot. Initially she didn’t worry about it and after a while decided to take her boot off and shake it out.

    Out fell the snake. (species unidentified possibly a copperhead).

    The bite detection did not show any vemon.

    Moral always wear socks.

  13. I can remember an encounter with a red bellied black… It had its head high until it met with the sharp end of a spade. I dont know who was the more stupid.. my father or the snake.

  14. “They may result in adverse reactions such as anaphylaxis and serum sickness and strong urges to eat hay.”

    LOL, just as long as the patients don’t start trying to kick the nurses or thwack the doctors with their heads. Let’s not even talk about rubbing out catheters.

    Horses, being curious creatures, are apt to go exploring with their noses, sometimes meeting such unfriendly creatures as snakes. It is helpful to have something, such as a piece of garden hose (although really I think that’s pretty small for a horse — garden hose is more the size of a large NG tube) for an emergency field intubation of sorts to keep the airway patent should they get bitten on the muzzle.

  15. Here where I live we see several rattlesnake envenomations a year. Over the years all that I have seen except one, some yahoo picked the snake up. Duh. One intrepid soul decided to kiss the snake to impress friends. Very bad idea. As you may have guessed, alcohol is always involved.

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