Bushwalk Australia

Recently found myself scrabbling on ground to get to a clearing for bird photography - what is the first aid if a companion is bitten by a snake on the cheekbone? Apply firm hand pressure as that is applying compression?

Recently instructed a companion to just go in amongst trees to relieve themselves when on a long bicycle ride - what is the first aid if my companion is bitten by an elapid on the buttocks? Instruct them to sit on a log (or their bicycle seat), as that is applying compression?

Your goal is reducing lymph return, so keeping them as fully still as possible while getting help is the key. If you cannot apply compression, keep the large muscles from moving at all. Get them as comfortable as you can, get help as fast as you can. The less total movement the better, and from my understanding, you moving them is better than them moving their own muscles. This is just my understanding from my last WFA course.

Gadgetgeek is correct, reduce lymph flow at all cost. Given the area, unlike in the distal limbs, compression of the area may actually promote the release and flow of the venom but depends on how the compression is applied. Sometimes it’s a no win situation. What further I would do is to keep the individual calm and cool. Heating things up would also increase the circulation and metabolism. Would one cut in and try to excise and drain when desperate? That depends on the skill and knowledge of the individual. Not advised on the general public. Fingers crossed to the rest.

Pressure on the bite site and no movement by the victim is the recommended treatment.

"Stop lymphatic spread - bandage firmly, splint and immobilise!

The "pressure-immobilisation" technique is currently recommended by the Australian Resuscitation Council - see their guidelines, the Royal Australasian College of Surgeons and the Australian and New Zealand College of Anaesthetists.

The lymphatic system is responsible for systemic spread of most venoms. This can be reduced by the application of a firm bandage (as firm as you would put on a sprained ankle) over a folded pad placed over the bitten area. While firm, it should not be so tight that it stops blood flow to the limb or to congests the veins. Start bandaging directly over the bitten area, ensuing that the pressure over the bite is firm and even. If you have enough bandage you can extend towards more central parts of the body, to delay spread of any venom that has already started to move centrally. A pressure dressing should be applied even if the bite is on the victims trunk or torso.

Immobility is best attained by application of a splint or sling, using a bandage or whatever to hand to absolutely minimise all limb movement, reassurance and immobilisation (eg, putting the patient on a stretcher). Where possible, bring transportation to the patient (rather then vice versa). Don't allow the victim to walk or move a limb. Walking should be prevented.

The pressure-immobilisation approach is simple, safe and will not cause iatrogenic tissue damage (ie, from incision, injection, freezing or arterial torniquets - all of which are ineffective).

This is an example of a suitable compression bandage.

This poster from thefirstaidshop.com.au is worth keeping.

Bites to the head, neck, and back are a special problem - firm pressure should be applied locally if possible.

Removal of the bandage will be associated with rapid systemic spread. Hence ALWAYS wait until the patient is in a fully-equipped medical treatment area before bandage removal is attempted.

Do NOT cut or excise the area or apply an arterial torniquet! Both these measures are ineffective and may make the situation worse.

http://www.anaesthesia.med.usyd.edu.au/ ... ebite.html

Lindsay wrote:Do NOT cut or excise the area or apply an arterial torniquet! Both these measures are ineffective and may make the situation worse...

There‘ll always be differences b/n general advisory and specific cases with skilled people. Decision depends on a range of factors and ultimate objective.

Most of 'us' will be first aiders - so pressure.

Surgeons and Doctors might do other things depending on circumstances.

The treatment for snake bite is pressure immobilisation and, in hospital, it is monitoring of clotting and the effects on the nervous system.
Cutting the bite site in attempt to drain the venom is not a treatment for Australian snakebite envenomation.

Warin wrote:Most of 'us' will be first aiders - so pressure.

Surgeons and Doctors might do other things depending on circumstances.

That’s absolutely correct.

slparker wrote:The treatment for snake bite is pressure immobilisation and, in hospital, it is monitoring of clotting and the effects on the nervous system.
Cutting the bite site in attempt to drain the venom is not a treatment for Australian snakebite envenomation.

In hospital, there’s already anti-venoms and full resuscitation support amongst others treatments.
Out in the woods where one can gain rescue in the short term, pressure and wait.
Out there when rescue will be delayed or not coming, and when one can be sure it’s a venomous snake, to ensure survival when one is skilled, quick excision of the tissue may be the better way for best chance of survival. Of course, this requires knowledge and judgement, not for most.

Fact is, public advisories are for the public, having to cover all/most circumstances with a single guideline, and kept simple. In specific circumstances, those guidelines may not be the most appropriate. Yes, it may take a doctor/surgeon to know exactly how to do it, but that’s how it is. Being trained under a protocol, an important part is to also know the limit of said protocol.

Doctors and surgeons won't be cutting the site either. It isn't a treatment for snakebite. The Australian guidelines for snakebite use the PIT/PIM because it is has been shown to be effective.

the rationale is that the venom is transported via the lymphatic system. The lymphatic system is like a waste drainage system in the tissues and it is a slow moving circulation of fluid that gets from the bite site to the circulation mainly by squeezing of tiny muscles in the vessels but also somewhat by the pumping action of moving your limbs. The lymph vessels are very small, lie close to the surface and are easily compressible. Lymphatic fluid drains into the central circulation in the trunk and, other than that, it has little further connection to the bloodstream. The blood, obviously, is pumped around quickly by the heart.

The objective of PIM/PIT is to slow or stop the movement of the lymphatic fluid to the trunk where it gets to the blood and where the venom can rapidly circulate, therefore causing the severe general and potentially lethal manifestations of envenomation. The compression exceeds the pressure in the lymphatic system and so slows transport of lymph along the vessels and immobilisation stops the pumping action provided by the limbs. The purpose of snake bite first aid is to give time for evacuation to definitive assessment and treatment and there is also some evidence that some of the venom is broken down in the lymph.


Cutting the bite site, firstly, has never been shown to be an effective treatment for snakebite and, secondly, is more likely to introduce the venom directly to the circulation where it can be distributed more rapidly. Thirdly, it is painful and can cause both complications from infection and, fourthly, there are effects of the venom on open wounds that may be unpredictable (severe tissue loss and severe bleeding has been observed using this practice).
Finally, it has a 50% chance of being an unnecessary surgical intervention as 50% of bites contain no venom.

The misinformation that cutting the site can be effective comes from America where cut and suck kits are available. This method, along with tourniquet, is no longer a recommended treatment for snakebites from american species.

Won’t work if there’s no rescue in sight and there’s real venom injected.

As commented, the public advisory is for general coverage. Even in research papers, it’s by cohort ie. Averaging and statistical comparisons. There’ll always be special cases needing special treatments. #judgement

PS. Never suggested those ‘cut/suck’ are for general recommendations. Emphasis again, in special cases as stated prior.

What are these 'special cases' that you are privy to but expert consensus isn't, GG?

Perhaps you could cite some research or rationale for your assertion, because it runs counter to the evidence in the medical literature.

slparker wrote:What are these 'special cases' that you are privy to but expert consensus isn't, GG?

If you've read above, I already said as an example, if one can confirm there's venom injection when one is well away from help, compression bandage alone will just delay death. A quick excision of the tissue containing the venom may be the only thing that'll save the individual. As said, one can know the textbook but also needs to apply it to the specific circumstance as appropriate. Any treatment has limits and so do broad guidelines. This is just a fact of clinical medicine and not even worth debating... Never say never!

Ideal or close to ideal situation, follow the broad guideline. Outside, know how to think outside the box.

Of course PIM 'delays death' that is the purpose of the treatment.

In the words of the Australian Resuscitation Council:
'Most snake venom reaches the blood stream via the lymphatic system. Research has shown that very little venom reaches the circulation, even after several hours, if the Pressure Immobilisation Technique is applied immediately and maintained.'

Hall (2000) looked at incisional treatments in the US and concluded "All forms of incision should be discouraged. The risk is high and the benefits unproven." Two studies he examined showed an increase in mortality using incisional treatment.


Please show us the evidence that incision is effective and results in decreased mortality after envenomation.

if you can't provide this your comments are unsubstantiated opinion.

Not to butt in here, but can we all agree that asking someone who is not a doctor to speculate on why a doctor might have reason to do something drastic, is at least a little silly? Yeah, there is always the caveat that an expert may act in a way that is outside the norm. They also have to wear the consequences.
Now, would someone decide to do a field amputation to prevent death from a snakebite? I dunno, its probably been done somewhere, and we'll never know what was or was not the right call.
In any case I think we can what-if this to death, but we can do that in a calm, collected sort of tone. (yeah, I know text doesn't convey tone, cue loop of any comedy actor "I AM CALM!")

That's my point, Gadget, a health care professional won't use an incisional treatment for snakebite, nor would they amputate and nor would they use any other treatment than the evidence based treatment.

Only a non-expert would attempt that and that is why I have been diligent in rebutting the message that it is some kind of specialist treatment for snakebite that only if you had special knowledge you could make it work.

The message needs to be very clear - the only treatment shown to be effective in treating Australian snakebite is the PIM. In the heat of the moment do not reach for your knife, reach for your broad compressive bandage.

slparker wrote:That's my point, Gadget, a health care professional won't use an incisional treatment for snakebite, nor would they amputate and nor would they use any other treatment than the evidence based treatment...

That is quite incorrect! As said, under specific circumstances, all these are options and tools of the trade. Compression will work in great great majority of the cases, especially in first world countries where rescue in a finite time frame is possible, and as a simple message to the lay public, the advisory is correct and to be supported. But under special situations and where one needs surety, alternate solution can be implemented. That comes down to clinical judgement at the time and having the knowledge and skills. This is just a fact of clinical medicine across the board and not even worth debating. Yes, qualified.

The message needs to be very clear - the only treatment shown to be effective in treating Australian snakebite is the PIM. In the heat of the moment do not reach for your knife, reach for your broad compressive bandage.

Hence the difference b/n a public advisory for general circumstances, but not cover 100% of the situations when there may be knowledgeable individuals around and circumstance that dictates alternative considerations.

Fundamentally and without anti-venom and advanced life support, reducing the quantum of the venom is a logical consideration. Further, venom needs to get into the general circulation to act systemically, so don't mis-quote articles. Some situations the rescuers may be days away...

PS. If you read carefully, never advocated incision. 'Incision and suck' would never be realistic for anyone who has experiences with puncture wounds. In desperate times, bulk excision of tissue to amputation may be needed. Not for the faint hearted of course but also only appropriate under considered circumstances.

PEACE!

This is just a fact of clinical medicine...

But is it a fact, or is it an opinion? Because, when I read what slparker referenced, it looks to me to be a dangerous opinion and not the sort of thing that anyone should be considering under any circumstances, special or otherwise.

PS. Normally I wouldn't say anything, just so we can keep the peace. But I don't like seeing something potentially dangerous being suggested here whatever the circumstances.

@GGuided
Excisional treatments, where subcutaneous tissue down to the muscle fascia was excised, were attempted in the 70s but they are not first aid treatments: they require surgical instrumentation and anaesthesia. They have not been used since safer antivenene was developed and they have a very high complication rate. The reference I have cited above has a nice paragraph on the failure of surgery as a realistic treatment for envenomation.

Interventions of his nature cannot even be attempted in the field, it’s not like the movies - you can’t get the casualty to bite on a stick whilst you wipe the salami off your Swiss Army knife and start digging in. If you have ever assisted with surgical procedures in the field environment you would know the type of equipment it requires to perform these procedures safely and it’s not trivial. This is not first aid and you need anaesthesia and instrumentation.

I spent years in the field environment as an Army medic and it was never contemplated to do more than PIM for snakebite. Even in remotest Australia or overseas. A large enough facility that could carry out excisional surgery is large enough to consider antivenene and or supportive therapies.

What you are also failing to consider is that you have a discredited therapy for a problem that does not even exist. Where are all the bushwalkers here or overseas dying of snakebite after having PIM Applied? The opposite is true, PIM slows envenomation until evacuation to a facility that can infuse antivenom and treat the effects. Even in austere or hostile environments where evacuation is delayed supportive therapy is likely be used over unproven surigical procedure: the abiding ethical principle here is first do no harm.

In all circumstances PIM is the best statistical bet for the casualty. Whilst s an imperfect treatment it is the best one until other treatments on the horizon manifest, which are likely to be pharmaceutical.

The water is being muddied here. Learn how to apply a field splint, Carry two compressive bandages and know how to use them.

I mostly walk solo, and have often pondered this. I carry a PLB and compression bandages, but a venomous snake bite anywhere other than your limbs is going to be problematic. And I have actually come face to face with a snake while climbing an embankment. Thankfully it was only a black, but it could easily have ended badly with a tiger or a brown.

Hughmac wrote:I mostly walk solo, and have often pondered this. I carry a PLB and compression bandages, but a venomous snake bite anywhere other than your limbs is going to be problematic. And I have actually come face to face with a snake while climbing an embankment. Thankfully it was only a black, but it could easily have ended badly with a tiger or a brown.

There have been effective experiments with ring bandages and even ring bandages with elastic bands so that circumferential pressure can be applied if the bite is on the trunk, but at this stage the PIM is still recommended.

I used to walk solo a lot but I was comforted by the stats around snakebite and figured a femur fracture was my biggest risk.

A mate of mine came also came face to face with one searching for a handhold whilst rock climbing and still didn’t get bitten but that could have been nasty, I agree.

Yeah, you'd be seriously unlucky to be bitten at all, much less on the head or body. I've had a lot of close encounters with snakes, but only one where I felt threatened. They mostly just do their best to get away from you if you get too close. As to broken bones, the PLB takes the worry out of that. Gives my wife a lot of peace of mind as well.

Interesting subject
If you get bitten on the *&%$#! you can kiss it goodbye.
Regards OLM