Snake bites

[wolfy]

Great topic, thanks for all the info. I have often wondered about the isolation thing when I'm out solo either walking or riding my mountain bike. My dad was a doctor who treated several snake bites in Victoria. When he went fly fishing alone he would wear overalls, rubber boots and have a bandage in his pocket.
Cheers.

[sailfish]

Yeh, Fly Fishing streams is all about stealth. The worst possible thing to do in the snakiest places in the country. I should know, when fly fishing solo, I wear heavy work wear trousers and canvas gaiters for wet wading, carry a 1st aid kit with 2 snake bandages and a PLB.

The whole 1st aid strategy is based around the premise of getting the patient to expert medical care. If you fail this, the whole strategy fails regardless of what expertise or equipment you may have. Many people have 1st aid knowledge and kit, snake bite bandages etc but the most important thing of all is obtaining transport to get the patient to hospital.


Regards,
Ken

[WarrenH]

Yesterday, on the Queanbeyan River Fire Trail above the Eastern Foreshore of Googong Dam, I saw two Eastern Brown Snakes ... but one of them saw me first.



I gave the paramedics (000) my GPS location but they weren't able to use it. The first guys couldn't find access to the fire trail, thwarted by a locked gate. 000 rang me back via Newcastle 000, so I then talked the second group of paramedics to my location. Turn by turn and how to lift the gate up to beat the lock.

One fang got me right on the shin bone and the other fang scratched me. The doc told me that only about 20% of those who get bitten are envenomated and then only about 20% of those need an antivenin. I stayed in hospital for a blood test and several hours of observation and prodding. Over a decade's worth of paying for ambulance cover which also includes chopper coverage, was squared up yesterday. I'll go back to the Queanbeyan River Fire Trail today ... and recover my gear.

Warren.

PS, "Ah it's just a flesh wound, come back you cowards" ... I've had worse.

[wayno]

sorry to hear that. were you wearing knee length gaitors or long trousers ?

[buggeriamold]

Well done on keeping calm and talking them in I am sure I would have been shifting my self!

[WarrenH]

Wayno, thank you Mate. I had cargo shorts on and only ankle length gaiters yesterday, in the photo. I was on the top of a hill.

Buggeriamold, I was told not to move by 000. I pressure bandaged the leg immediately and 000 stayed talking to me for a long time, at least 20 minutes the first time. They then switched to Newcastle 000 so I could describe to the second group of paramedics how to find me.

I'm so familiar with this particular region of Googong's Eastern Foreshores. I'm the caretaker of a solar and wind farm that's out there. A summer job that I do. When I'm at the solar farm, I go walking or MTB'ing most days. I obviously dropped my guard yesterday. If I had been envenomated, yesterday I would have died because of the time it took the paramedics to get to me nor could I have made it in the farm's 4x4 to Queanbeyan then on to Canberra Hospital. Access to Googong's Eastern Foreshores isn't like the ease of access on the Western Forshores. Obviously yesterday was a timely and extremely lucky wake-up call for me.

Googong is notorious for Eastern Browns and Black Snakes and the odd Tiger. I've knee high, double woven canvas gaiters made by Wilderness Equipment, which I put on when ever I go near creeks and the farm dams, to the main reservoir, battery sheds and to the pumping shed. I'll wear them today when I go back to recover my gear. The doc thought it was a good move not to go back to the farm last night and to stay with my wife in town. My wife Helen will take me back to the solar farm this morning. I have to make sure the propellers the turbines are running truly and check for snakes in the battery sheds. Helen doesn't like going to Googong because of the snakes and the wild track into the farm. I'll escort her back to the main road when I pick up the farm's 4X4. I stay at the solar farm.

I saw the 30cm long Eastern Brown hiding in leaf litter but trod on a slender 2m Eastern Brown on the edge of a track. I'm usually hyper-vigilant for keeping an eye out for snakes but I wasn't looking in the direction that I was walking, the big no-no of bush walking, even on a fire trail.

I often joke to Helen and say the solar farm should change its name to Snakes'R'Us.

Warren.

[wayno]

good thing you took teh right action, and had the bandage.... look like a perfect first aid treatment helped everything turn out well.

[Tony]

Hi Warren,

Sorry to read that you were bitten by a snake but great news that you are OK, it is a timely reminder that things can easily and quickly go wrong when walking.

I have been reading that because of the few recent good seasons that we have had, it is expected that we will see more snakes around than we have during the drought years.

Thanks for posting your story.

Tony

[photohiker]

Dodged a bullet there Warren! Good to still have you with us.

Are you sure you would be dead today if you had been envenomated? You seem to have taken all the right steps, and I absolutely agree that getting into medical care is the number one priority but unless the venom hits a vein, or you go walking around and pumping the venom about, if you apply an adequate pressure bandage, don't you have significant time to get into care?

Talking of pressure bandages, this is a good time to remind ourselves that specific elastic pressure bandages work better than standard crepe bandages. http://www.ncbi.nlm.nih.gov/pubmed/7830641 Setopress seems like the best option for general use as it has visual indicators for correct tension.

Edit: Pressure bandaging method from AVRU (Australian Venom Research Unit, Melbourne Uni)

[jackhinde]

i doubt you would be dead if envenomated, you did everything correctly and would have bought yourself a few hours at least . you do need to update your snake bandage to a close woven elastic type, the one you have on has been shown to be unreliable.

[dplanet]

Dodged a bullet there Warren! Good to still have you with us.

Are you sure you would be dead today if you had been envenomated? You seem to have taken all the right steps, and I absolutely agree that getting into medical care is the number one priority but unless the venom hits a vein, or you go walking around and pumping the venom about, if you apply an adequate pressure bandage, don't you have significant time to get into care?

Talking of pressure bandages, this is a good time to remind ourselves that specific elastic pressure bandages work better than standard crepe bandages. http://www.ncbi.nlm.nih.gov/pubmed/7830641 Setopress seems like the best option for general use as it has visual indicators for correct tension.

Edit: Pressure bandaging method from AVRU (Australian Venom Research Unit, Melbourne Uni)

Remind me of the fact sheet always left in the first aid kit; but removed before ski trips. Useful movie too. Congratulations and thanks.
According to forecast from BoM's site, it will snow again on Thursday in alpine area; so would be cool enough for the cup weekend walk.

[Lindsay]

Great work under pressure Warren. A bit worrying that the local Ambos could not access the locked gate. Could have been nasty. Anyhow congratulations on a job well done.

[walk2wineries]

"lack of any bite / fang marks does not exclude envenomation" (Primary Clinical Care Manual (PCCM) 7th edition )
Just a reminder that no fang marks doesn't mean no envenomation, and conversely seeing fang marks don't necessarily mean that the person has been envenomated. I wouldn't want to take the risk....... Have seen socks wet from venom after snake fangs went through the side of elastic sided boots and into the socks (person not envenomated) and someone else who had no obvious "bite marks" but ended up quite sick after a good history of probable snakebite.

Just a dumb question ,if the skin is not penetrated how does the venom get into the lymphatic system
corvus

Sensible questions but Corvus is quite right. Australian snakes particularly the brown, remarkable for striking often with a closed mouth (fang stays outside lip) have very concentrated venom with TINY volumes. The brown scratches the skin and that's all that's needed - and you can't always see the scratch. Sometimes you can. On the good side it probably won't get through your jeans.
You do need a hospital test - not just the venom detection kit, but a test to see if your blood is clotting. I recall one lady transferred to a hospital in order to have the tests done- she had maybe a tiny bruise under a toenail, neither of us could see a scratch - and she was a sensible person able to describe what had happened. Same blood group as me - I got asked to donate after her first 25 units (pints in the old terminology)... local blood bank was running low.
Another bloke I recall collapsed and died before coming to hospital. I attended the post-mortem (rural area) at request of CLS to look for the bite and take samples; again had spoken to witnesses who had seen his hand bitten, and I couldn't see a bite mark.
Other elapids leave more obvious bites. Even with an obvious bite though, half the victims won't be envenomated even if its a poisonous snake.

Other families particularly the crotolids (rattle snake) found in the USA have large volumes and cause local tissue damage and there is some concern that compression bandaging can make that worse, although it might still be your best hope. But that's why "suck and spit" or suction devices still have adherents in the USA.

[igor]

When I was in the russian army we were taught to suck out the blood and spit it out. So we were required to do the cut in the bite area and then suck out as much blood as possible. This in addition to bandages. The danger only if you have an open wound in your mouth, otherwise it's pretty safe. You can even swallow accidently the poison and nothing happens. Well I suppose after army food there was no poison that would affect you much. I remember one case when a guy was bitten by the caucasian viper and after this treatment was carried on stretches for several hrs. There was no helicopter pad around anyway and I don't think they would fly a helo for such a minor thing as a snake bite. Anyway whats wrong with sucking out the blood? Of course it would only work if ther are two or more people...

[igor]

The Indian guys said it is also how they are told to deal with snake bites in India. And there are a lot of snake over there.

[maddog]

Anyway whats wrong with sucking out the blood?

I understand that sucking out the blood was once common practice in Australia too.

The sucking of blood causes problems if does not remove enough of the venom. After getting bitten by a snake if you visit a doctor, they can take a swab of the wound and reliably determine the type of snake. This information enables the doctor to administer the correct anti-venom. They cannot do this if you have removed the venom from the skin, and for this reason we are told not to wash the wound or suck blood.

I was told about 10 years ago while working in a remote area (while attending a first aid course), that if you bandaged and immobilised the limb, it was ok to sit around and wait until the body destroyed the toxin itself. You just had to relax to minimise the circulation of blood around the body. I do not know how reliable this advice was however, and have not heard it repeated since.

Cheers

[ofuros]

Old, outdated ways, igor.....science marches on, and has given us newer
effective ways to deal with snakebite.

.....via tapatalk.

[Hallu]

You should never suck the blood out. First, it's more efficient to use a pressure bandage and not move the limb : the venom is injected too deep and spreads rapidly in a region where sucking it out won't work. There's an article here : http://www.nejm.org/doi/full/10.1056/NEJMra013477 , I can read it through the University of Melbourne website, but I'm guessing it's not public. Beside, unless you have medical supplies, sucking a wound is dangerous, infection-wise. There was something widespread about 10 years ago, called "aspivenin" in France, which is nothing but a syringe with a suction pad. It was proved useless for snakebites for the reason I mentioned earlier, and proved dangerous for insect darts, since it would blow the venom sack, while removing manually and carefully the dart with the sack attached to it proved more efficient.

And regarding snakes, I've also learned recently that nothing proves that baby snakes are more dangerous than adults (a common legend is that babies don't control the amount of venom they inject) : http://www.livingalongsidewildlife.com/ ... nakes.html

[photohiker]

When I was a lad in the Scouts we were taught (but thankfully never practiced) to cut and suck. I can remember seeing plenty of snakes about, the most thrilling of which was hiking up the Taggerty river in Vic near Marysville and being passed by several snakes swimming the other way.

Medicine has moved on. I can remember news reports of snake bite victims bleeding to death from the first aid, Clearly the pressure bandage, immobilisation and get help fast is the best first aid we have.

I think the King Brown also has lower toxicity venom and higher volumes. I have heard that they tend to hang on when they strike, possibly for that reason but I don't know. There is lots of folklore in the outback of how stroppy that species gets - one bloke told me he watched one strike every tyre of a road train as it rolled slowly by.

[maddog]

You should never suck the blood out... the venom is injected too deep and spreads rapidly in a region where sucking it out won't work.

That sounds like nonsense Hallu.

The following is from http://activeeducation.com.au/2012/08/3 ... -outdoors/

The correct treatment involves pressure and immobilisation. The immobilisation part cannot be overemphasised because the short fangs deliver the venom through your skin into the lymphatic layer, where it is trapped above your muscle tissue and bloodstream. The lymphatic layer does not have a pump, but movement is the best way to transfer the venom to the lymph glands high up to the armpits and groin area. These lymph glands defend the body against foreign agents such as bacteria, fungal infections, viruses and venom with antibodies that stop infections from spreading into a victim’s system – when that happens they will have systemic problems that cannot be treated with basic first aid.
Once the correct pressure bandage is applied and there is no limb movement, the rate of the venom’s flow and volume entering the victim’s system can be reduced drastically. This doesn’t mean the patient will not be suffering from the effects of the venom – but it does mean they have two things now in their favour. Firstly, more time has been bought to get them to a medical centre, ambulance or RFDS plane. Secondly, the person’s lymph glands have a better chance of battling the now-reduced feed of venom. There is one case of a man being bitten on the hand by a king brown snake and another of one being bitten on their bare foot by a death adder. Both victims had bandages applied immediately and both recovered fully in three and five days respectively.

Cheers

[Hallu]

Nothing that is said here contradict the fact that you shouldn't suck the blood out... The venom is already too spread out for suction to work, but that's compared to the deepness of the wound, whereas when people say you should apply a pressure bandage because the spread would be slowed down, it means that it takes a couple of hours to reach vital organs, which is a huge distance compare to the deepness of the wound. You're just getting mixed up with the different scales. A spread can be fast compared to a reference distance such as the deepness of the wound (about 1 cm probably) but slow compared to the distance between the bite and vital organs (between 100 and 150 cm). Not to mention that you only have several hours if you apply the bandage, it's significantly less if you don't and waste time sucking the venom out.

[Lindsay]

Am I correct in saying that PIB is a uniquely Australian concept that for all its effectiveness has not caught on anywhere else? I was visiting a US site a while ago and among all the snake bite treatments varying from torniquets to cut and suck PIB did not rate a mention. Is the PIB technique particularly suited to the venom of Australian snakes and not as effective elsewhwere?

[Hallu]

It's a grey area, apparently there's no universal treatment for snakebites, the more effective and universal is not moving the bitten limb and getting help as soon as possible. The pressure bandage seems to be officially recommended only in Australia, but there isn't a concrete and fruitful study showing the benefits of this technique. I wouldn't use a tourniquet though, it would cut the blood-flow. Who recommends it ?

[photohiker]

there isn't a concrete and fruitful study showing the benefits of this technique.

You sure about that?

http://www.ncbi.nlm.nih.gov/pubmed/7830641

Med J Aust. 1994 Dec 5-19;161(11-12):695-700.
Lymphatic flow rates and first-aid in simulated peripheral snake or spider envenomation.
Howarth DM, Southee AE, Whyte IM.
John Hunter Hospital, Newcastle, NSW.

RESULTS:

The mean (+/- SEM) periphery-to-systemic circulation transit time after subcutaneous injection was 58 (+/- 7) minutes. The first-aid was found to be very effective when applied with bandage pressures ranging from 40 to 70 mmHg (5.3-9.3 kPa) in the upper limb and 55 to 70 mmHg (7.3-9.3 kPa) in the lower limb. Lower and higher bandage pressures were ineffective. However, despite first-aid measures, egress of radiotracer, even in the upper limbs, was seen in all subjects who walked for 10 minutes or more.

CONCLUSIONS:

Firm pressure bandaging is an effective means of restricting the lymphatic flow of toxins after envenomation, provided the bandage is applied within the defined pressure range. Strict limb immobilisation is necessary to minimise lymphatic flow, and walking after upper or lower limb envenomation will inevitably result in systemic envenomation despite first-aid measures.

[WarrenH]

Tony, photohiker and Lindsay, thank you for your kind words and for waiting for my reply. I don't have an internet connection when I'm at the farm. I go to the farm to relax ... usually.

Are you sure you would be dead today if you had been envenomated?

That was the Doctor's comment to me. You know what some Docs are like, having tact isn't in their bedside manner but supposedly only 28gms of Eastern Brown Snake venom can kill 14,000 adult males. Shock horror.

Talking of pressure bandages, this is a good time to remind ourselves that specific elastic pressure bandages work better than standard crepe bandages.

You do need to update your snake bandage to a close woven elastic type, the one you have on has been shown to be unreliable.

That wasn't my pressure bandage. The crepe bandages were put on by the paramedics after removing my bandage. My bandage was one leg of a ladies pantyhose several sizes too small (for me) and the other leg was wound back down the leg. The best pressure bandage that I know that can be put on within seconds. I also have two wide elasticized pressure bandages in my wilderness first aid kit.

Because like all bush walkers our legs get scratched and often the bite site from an Eastern Brown can be hard to locate because it can be so fine, when the paramedics removed my pressure bandage they couldn't know which injury was the actual bite. In the hospital when they removed the several crepe bandages I was asked to identify where the bite was then the nurse kept his finger on the bite site while the doc slowly took the bandages off.

... and as if by magic, this is what they found.




The blood spot is surrounded by a faint pencil line drawn by the nurse. A venom test kit could have been used on the bandage if the snake had not been identified, likewise swabbing my leg for venom. I only had blood clotting tests because I knew the type of snake and 5 hours later when I was finally examined by a doctor, I was as fit as a fiddle.

walk2wineries, thank you for the detailed comments. Having such deadly snakes here, it is a credit to our thinking and medical practices and not just a wondrous bit of luck that we lead the world in snake bite recovery. Cheers Mate.

The Indian guys said it is also how they are told to deal with snake bites in India. And there are a lot of snake over there.

When I did a Wilderness First Aid course with Wilderness First Aid Consultants, there was one statistic that I've not forgotten. Over 24,000 Indians die each year from snake bite. Most bitten at night when they're going to the toilet.

At least most of us, we negligent victims here in Oz, get to see what bit us.

Warren.

[Peaksnik]

The PIM seems to be quite difficult to get right, according to the paper 'Physicians and Lay People Are Unable to Apply Pressure Immobilization Properly in a Simulated Snakebite Scenario' - published in Wilderness & Environmental Medicine (2005). Here is the abstract:

Objective
To determine whether volunteers (with or without prior medical training) can correctly apply pressure immobilization (PI) in a simulated snakebite scenario after receiving standard instructions describing the technique.

Methods
Twenty emergency medicine physicians (residents and attendings) and 20 lay volunteers without prior formal medical training were given standard printed instructions describing the application of PI for field management of snakebite. They were then supplied with appropriate materials and asked to apply the technique five separate times (twice to another individual [one upper and one lower extremity] and three times to themselves [nondominant upper extremity, dominant upper extremity, and one lower extremity]). Successful application was defined a priori by four criteria previously published in the literature: wrap begins at the bite site, entire extremity is wrapped, splint or sling is applied, and pressures under the dressing are between 40 and 70mm Hg in upper-extremity application and between 55 and 70mm Hg in lower-extremity use. Pressures were determined using a specially designed skin interface pressure-measuring device placed at the simulated bite site.

Results
The technique was correctly applied as judged by the preset criteria in only 13 out of 100 applications by emergency medicine physicians and in only 5 out of 100 applications by lay people. There was no significant difference in success rates between physicians and lay volunteers. Likewise, there was no significant difference in success based on which extremity was being wrapped. More detailed analysis revealed that the major contributor to failure was inability to achieve recommended target pressures.

Conclusions
Volunteers in a simulated snakebite scenario have difficulty applying PI correctly, as defined in the literature. The major source of failure is an inability to achieve recommended pressure levels under the dressing. New methods of instructing people in the proper use of PI or new technologies to guide or automate application are needed if this technique is to be used consistently in an effective manner for field management of bites by venomous snakes not known to cause significant local wound necrosis.

http://www.wemjournal.org/article/PIIS1080603205703422/abstract

[Hallu]

there isn't a concrete and fruitful study showing the benefits of this technique.

You sure about that?

http://www.ncbi.nlm.nih.gov/pubmed/7830641

Med J Aust. 1994 Dec 5-19;161(11-12):695-700.
Lymphatic flow rates and first-aid in simulated peripheral snake or spider envenomation.
Howarth DM, Southee AE, Whyte IM.
John Hunter Hospital, Newcastle, NSW.

RESULTS:

The mean (+/- SEM) periphery-to-systemic circulation transit time after subcutaneous injection was 58 (+/- 7) minutes. The first-aid was found to be very effective when applied with bandage pressures ranging from 40 to 70 mmHg (5.3-9.3 kPa) in the upper limb and 55 to 70 mmHg (7.3-9.3 kPa) in the lower limb. Lower and higher bandage pressures were ineffective. However, despite first-aid measures, egress of radiotracer, even in the upper limbs, was seen in all subjects who walked for 10 minutes or more.

CONCLUSIONS:

Firm pressure bandaging is an effective means of restricting the lymphatic flow of toxins after envenomation, provided the bandage is applied within the defined pressure range. Strict limb immobilisation is necessary to minimise lymphatic flow, and walking after upper or lower limb envenomation will inevitably result in systemic envenomation despite first-aid measures.

I meant an international study. The fact that this study could only be published in an Aussie paper isn't helping the seriousness (if any, I have no idea about that subject I'm no expert) of the method.

[Strider]

there isn't a concrete and fruitful study showing the benefits of this technique.

You sure about that?

http://www.ncbi.nlm.nih.gov/pubmed/7830641

Med J Aust. 1994 Dec 5-19;161(11-12):695-700.
Lymphatic flow rates and first-aid in simulated peripheral snake or spider envenomation.
Howarth DM, Southee AE, Whyte IM.
John Hunter Hospital, Newcastle, NSW.

RESULTS:

The mean (+/- SEM) periphery-to-systemic circulation transit time after subcutaneous injection was 58 (+/- 7) minutes. The first-aid was found to be very effective when applied with bandage pressures ranging from 40 to 70 mmHg (5.3-9.3 kPa) in the upper limb and 55 to 70 mmHg (7.3-9.3 kPa) in the lower limb. Lower and higher bandage pressures were ineffective. However, despite first-aid measures, egress of radiotracer, even in the upper limbs, was seen in all subjects who walked for 10 minutes or more.

CONCLUSIONS:

Firm pressure bandaging is an effective means of restricting the lymphatic flow of toxins after envenomation, provided the bandage is applied within the defined pressure range. Strict limb immobilisation is necessary to minimise lymphatic flow, and walking after upper or lower limb envenomation will inevitably result in systemic envenomation despite first-aid measures.

I meant an international study.

What do you mean international study? Good science doesn't rely on where its produced.

[ALD]

I thought the PIB technique was only used in Australia because of the difference in treating hemotoxic vs neurotoxic venoms. As in the bandage wouldn't have much effect on snakes with neurotoxic venom. I could be wrong.

[Rob A]

The fact that this study could only be published in an Aussie paper isn't helping the seriousness (if any, I have no idea about that subject I'm no expert) of the method.

Wot? You found it in NCBI Glasses on.

Without wasting much more space,

1994 pressure bandaging is an effective means of restricting the lymphatic flow of toxins after envenomation (http://www.ncbi.nlm.nih.gov/pubmed/7830641)
Mar 2005 physicians and lay people are generally unlikely to apply pressure bandages correctly (http://www.wemjournal.org/article/PIIS1 ... 2/abstract)

Which is where I thought Warren deserves credit (and maybe thinking outside the box) acnowledging people might not have their head in the game after something traumatic, had something in place that he could work with, the stockings. Hats off.

I take two heavy elasticised tubes (arm, knee sized), and figure on a pad beneath over a bite site, which would go on quick, followed by the full arm full leg bandage, tape up a splint. I dont know whether this is sensible. And never had to do it.