snake bite

[dplanet]

... almost there aussies aussies! http://getup.to/vQnNUVaziYmEUZN5

[Overlandman]

From the Mercury
A US tourist has been flown to the Royal Hobart Hospital after being bitten by a tiger snake on Maria Island, off Tasmania’s East Coast.

Tasmania Police Search and Rescue was advised of the incident at 10.45am today.

The victim was a 30-year-old man visiting the national park from the United States.

He was taken by the Westpac Rescue Helicopter to the RHH, with his condition described as stable.

Tasmania’s three species of snake are all found on the island — the tiger snake, copperhead and white-lipped snake.

[north-north-west]

And it's going to be a very busy snake season. I had ten over the last five days, all tigers and mostly reluctant to share the bush with me.
Except the one near my camp. We got to be quite friendly.

[Overlandman]

And it's going to be a very busy snake season. I had ten over the last five days, all tigers and mostly reluctant to share the bush with me.
Except the one near my camp. We got to be quite friendly.

On my last walk in, 2 hours I saw 10 & caught 6, only one tiger, the rest were copperheads, all were around 4 feet long, all in good condition but there were a few sheep ticks in between the scales, let them all go. Also saw a ginger cat, 2 rabbits, heaps of black swans & cygnets, & the large green & gold bell frog
Looking forward to taking Corvus to my favourite spot.
Regards Overlandman

[GPSGuided]

Caught 6? Is that a hobby of your?

[Overlandman]

From ABC

A man has died after being bitten by a snake in north Queensland.

Ambulance crews were called to a property near Townsville at about 8:30am.

A 62-year-old was in cardiac arrest when they arrived.

Paramedic Michael Grainger said the man's partner had applied a compression bandage, but that the man died at the scene.

"The snake possibly could have been a brown or a taipan because it actually caused the patient to deteriorate into a cardiac arrest," Mr Grainger said.

"Despite ambulance resuscitation, we were unsuccessful and the patient unfortunately deteriorated and died on scene."

[Overlandman]

Non venomous

From ABC

A Cairns woman has been released from hospital after being bitten by a snake which had slithered into her car.

Debbie Ritchie, 46, thought it was her daughter's cat that brushed against her leg and bit her while driving in Edmonton, south of Cairns, in Queensland's far north on Sunday night.

But when her daughter, Kellie Roe, confirmed her cat was at home, Ms Ritchie realised it must have been a snake.

Ms Roe and her friends met Ms Ritchie and searched the car for the snake but when they could not find it, Ms Ritchie again began driving home.

That is when the snake reappeared.

"I wouldn't get back into the car after that," she said.

"I jumped out and walked home.

"I did not think too much about it.

"I was not sick but about half an hour later I started feeling sick."

A snake catcher came to remove the snake, and initially thought it was the deadly eastern brown snake.

It is believed it had climbed into the car through the engine.

An ambulance was called and Ms Ritchie was taken to the Cairns Base Hospital.

Three series of blood tests showed the snake was not venomous.

Ms Ritchie, a mother of three, was released from hospital this morning, however her leg still aches.

"You see snakes all the time on TV, but you don't think it will ever happen to you," she said.

The bite comes after a 62-year-old man died north of Townsville on Sunday after being bitten on the hand.

The snake was unidentified, but paramedics said it was most likely a brown snake or a taipan.

[Overlandman]

From ABC

Girl, 4, bitten by 'brown' snake while watching TV at home on western Queensland property

An unidentified "brown" snake has bitten a four-year-old girl while she was watching television at home near Cloncurry in Queensland's north-west.

The snake appeared from under a cabinet in the lounge room and bit Ellen Gordon on her toe, the child's mother Lee Gordon told ABC Local Radio.

Ellen was airlifted to Mount Isa in a stable condition.

"She was sitting down watching TV and then started screaming there was a snake," Ms Gordon said.

"She backpedalled to the couch and climbed on top of me. I thought she was maybe just being silly or had seen something on TV but when I looked back and saw a brown tail going back under the TV, I thought, 'oh my God'.

"I took her younger brother out of the lounge room and put him on the kitchen table and put her on there as well."

She said snakes were a part of life for the family who live on a property 50 kilometres outside Cloncurry.

Ms Lee said she was educated in snake-bite first aid.

"I knew how to wrap it. I couldn't find a bandage so I grabbed a muslin wrap that I've got for my youngest so I used that to wrap it as tight as I could.

"Then my husband had gotten back with bandages."

The air ambulance arrived about half an hour after paramedics from Cloncurry turned up at the property.

"She sat there quite happily while everyone poked and prodded her," Ms Lee said.

"She's a fairly well adjusted little kid, so I think she is going to be fine - but certainly more wary of snakes now."

[Lindsay]

It's looking to be a bumper season for snake bites.

[Overlandman]

From ABC
Hopefully they didn't apply a tourniquet

Perth woman bitten by tiger snake suffers rare delayed reaction

A Perth woman who was bitten by a tiger snake has questioned why she was not given anti-venom after suffering a rare delayed reaction to the wound.

Jorji Harper, 20, was bitten on the leg at Yellagonga Regional Park in the northern Perth suburb of Kingsley last month
Ms Harper, who is training to be a teacher, was at the park to work on a proposal for a school excursion.

"We think we accidentally cornered a tiger snake against one of the historical plaques and I think I was closest to it," she said.

"Everyone else sort of screamed 'Snake!', jumped backwards, I didn't jump back as fast as I could've. I'd jumped towards the fence instead and had to run around, but by then it'd already bitten me twice."

After the culprit was identified as a tiger snake, a tourniquet was applied to Ms Harper's leg and an ambulance was called.

But Ms Harper said after arriving at Joondalup Health Campus, the medical staff did not give her anti-venom.

"There was venom in my blood, but not enough, so they said I didn't need anti-venom," she said.

"Because they said they called up the people who were specialised in this, and they said 'no, it's not enough to be given any anti-venom', so they didn't give me any."

Her leg was kept wrapped in a splint for an overnight stay, and she was released from hospital the following day.

'It just kept getting worse'

It was in the days that followed that Ms Harper suffered a delayed reaction to the snake bite.

The only way to know if there was a delayed reaction was the progression of time, but the incidence of that is quite rare.
Simon Wood, Joondalup Health Campus director of medical services
Her ankle became swollen, her pain worsened and she was in and out of Fiona Stanley Hospital for treatment.

"I was a bit confused. I thought the muscle pain would go away, like if you were going to work out and it goes away in a few days, and it just kept getting worse, I kept getting weaker," she said.

"I wasn't able to get out of bed myself or lift my head up or move my arms above a certain height."

Ms Harper's kidneys were affected and she was losing muscle mass. She couldn't go to work and found it hard to return to studies.

"Apparently my age, height, weight, it all sort of [combined]," she said.

"I was fighting it off as hard as I could and then it kicked in later."

Delayed reactions not common, hospital says

Anti-venom is only used in the first 12 hours after a bite, when it is clear a snake has injected its venom into a victim.

The director of medical services at Joondalup Health Campus, Simon Wood, said there was a risk associated with unnecessary use of anti-venoms, due to possible allergic reactions.

A bite wound on the leg of Jorji Harper after she was bitten by a tiger snake.
PHOTO: Jorji Harper has agreed to be used as a case study after her delayed reaction to the bite. (Supplied: Jorji Harper)
While he was unwilling to comment on the specifics of Ms Harper's case, Dr Wood said delayed reactions from snake bites were described in medical literature.

"They're not common, [but] the initial approach to the patient nevertheless would be the same," he said.

"An initial assessment in the emergency department, usually while they have the first aid measures in place, [we] look and see if there's any clinical evidence of envenomation, so we look at a neurological examination and blood tests."

Dr Wood said patients were discharged if those examinations and subsequent blood tests failed to raise concerns, with subsequent delayed reactions difficult to predict.

"The only way to know if there was a delayed reaction was the progression of time, but the incidence of that is quite rare," he said.

"That's the recommendation of all of the toxicology experts that I know of in Australia - if there's not signs of envenomation requiring anti-venom within those 12 hours, then it's very unlikely that there's going to be any significant envenomation that requires treatment.

"[Delayed reactions are] very rare, so rare that it's difficult to get the data on those to give us any clear understanding why it might happen."

Ms Harper is still undergoing tests and has agreed to be used as a case study.

[jackhinde]

If the above article is correct in its description of the aid given then this is yet another case of snake bite mismanagement by hospital staff, and by the first aiders if they did apply a tourniquet. Delayed reaction ...pffft

[devoswitch]

I think you'll find it's merely careless misuse of wording as I'm sure the hospitals would treat a snakebite correctly

[jackhinde]

I suspect 'tourniquet' is a misuse by the journalist, the other statements regarding the treatment in hospital are concerning.
There have been many instances of incorrect hospital treatment of snake bite, this is likely another.
The so called delayed reaction is a result of the removal of the pressure bandage many hours after admission- thus allowing the venom captured in the bite site to migrate; there is never a point in which it is too late to administer antivenom- if venom is detected in the blood, then the antibodies in the antivenom will neutralise it; and the danger of reaction to antivenom is real but manageable and also lesser than the danger posed by the tiger snake venom.

[taipan821]

interesting read, is there a link to the original story? I would like to post it onto a paramedic student forum as a head's up for them

[MickyB]

interesting read, is there a link to the original story? I would like to post it onto a paramedic student forum as a head's up for them

http://www.abc.net.au/news/2015-11-02/p ... on/6906454

[slparker]

I suspect 'tourniquet' is a misuse by the journalist, the other statements regarding the treatment in hospital are concerning.
There have been many instances of incorrect hospital treatment of snake bite, this is likely another.
The so called delayed reaction is a result of the removal of the pressure bandage many hours after admission- thus allowing the venom captured in the bite site to migrate; there is never a point in which it is too late to administer antivenom- if venom is detected in the blood, then the antibodies in the antivenom will neutralise it; and the danger of reaction to antivenom is real but manageable and also lesser than the danger posed by the tiger snake venom.

Jack i disagree that the newspaper report infers that treatment was incorrect.
The initial treatment for snakebite in hospital is to leave the pressure - immobilisation bandage on. serial blood tests are taken to assess the degree (if any) of coagulation problems. The most immediate concern is the anticoagulation properties of the snake venom.
All being well the bandage is released and the coagulation monitored (as is the patients vital signs). If the coags are altered sufficiently (or the patient shows serious signs of envenomation)than antivenene is administered but this is risky, as reaction (sometimes life threatening) to the antivenene is a regular phenomenon.
50% of bites are 'dry' and many snakes do not inject much venom so a blanket administration of antivenene for every bite would be statistically risky (and expensive).

The delayed reaction that the patient suffered was, I presume, from the toxic effects on the muscle. This takes place 24-48 hours after the bite and is far less common than the bleeding problems associated with envenomation. If the snake was indeed a tiger snake than this reaction is rare and clinical staff would be right to discharge the patient without further treatment the next day.

The action by medical staff seems reasonable, if the newspaper report is to be believed. It seems to fit with the clinicla guidelines for treatment of snakebite.

http://www0.health.nsw.gov.au/policies/ ... 14_005.pdf

because the person bitten suffered rare complications post-treatment does not mean that treatment during the stay was 'concerning'.

[slparker]

duplicate post

[jackhinde]

I fail to understand why you are trying to argue with me, when the correct procedure that you describe does not match the description of the treatment given?

The hospital left the limb splinted, thus I assume bandaged, overnight. They also detected venom but did not administer antivenom.

In regards to dry bites, I'd suggest that it varies greatly with species, with death adders almost never giving a dry bite and brown snakes nearly always giving a dry bite. Tiger snakes somewhere in between.

That one of the worlds foremost snake venom experts has publicly blasted the hospital regarding the treatment on his Facebook page lends a little creedence to my concerns

[slparker]

I fail to understand why you are trying to argue with me, when the correct procedure that you describe does not match the description of the treatment given?

The hospital left the limb splinted, thus I assume bandaged, overnight. They also detected venom but did not administer antivenom.

In regards to dry bites, I'd suggest that it varies greatly with species, with death adders almost never giving a dry bite and brown snakes nearly always giving a dry bite. Tiger snakes somewhere in between.

That one of the worlds foremost snake venom experts has publicly blasted the hospital regarding the treatment on his Facebook page lends a little creedence to my concerns

these are the guidelines for administration of antivenene:
"Antivenom should be given as soon as there is clear evidence of envenoming. Evidence for systemic
envenoming includes history of sudden collapse, venom induced consumption coagulopathy,
neurotoxicity, myotoxicity, systemic symptoms and renal impairment."

and,

"The majority of snakebites will not result in significant envenoming and will not require antivenom."

If the patient had venom detected, but no systemic signs of envenomation, then they followed the guidelines; irrespective of what someone posts on facebook.
I'm not seeking an argument just pointing out that with the information available in the article treatment appears to have been as per the guidelines. Whether the limb was left with a PIM on overnight is not a massive clinical issue.

From the victim involved:
'Fremantle teacher's aide Jorji Harper was bitten on the leg at Yellagonga Regional Park in Kingsley on October 1 but said her blood did not register a venom level high enough to make it safe for Joondalup Health Campus staff to administer anti-venom in the customary 12-hour window.

"Their experts said it would be better if they didn't give the anti-venom," the 20-year-old said.

""They followed the protocol to a T. It was just so unfortunate and rare that my body just fought it off for the first 12 hours while they were doing the tests, and it only began to kick in well after I got out. "

A spokeswoman for Joondalup Health Campus, the original hospital, confirmed that doctors had followed protocol for a snakebite.

http://www.watoday.com.au/wa-news/delay ... kqork.html

[jackhinde]

Great research work Mr Parker. Forgive the tardiness of my reply, I was up the nsw north coast chasing snakes. Now let us consider a most puzzling aspect, that statement that there was venom detected, but it was not at high enough levels for antivenom. The CSL VDK is qualitative and not quantitative, and is not recommended for testing blood. As there is no way a hospital could determine the amount of venom in a blood sample, how could they consult an expert, that then made a decision that the blood venom level was below some safe limit?

[stry]

Getting interesting.

I think I am learning something(s).

I was under the impression that the purpose of the compression bandage was to restrict, but not necessarily prevent 100% the movement of any venom around the body AND to thereby give the body a chance to absorb/defeat/whatever the greatly reduced flow of venom.

if (big if ) this is correct. the removal of the bandage as described would appear simply to give any venom still present a running jump at beating the body in which it is present.

Rather than a delayed "reaction" it reads to me more like exactly what one would expect from venom rather the euphemistic description of "reaction". Would death resulting from envenomation be described as a "reaction" ? We are not talking about an allergy.

Just my observations as someone without formal qualifications

Still watching.

[slparker]

Great research work Mr Parker. Forgive the tardiness of my reply, I was up the nsw north coast chasing snakes. Now let us consider a most puzzling aspect, that statement that there was venom detected, but it was not at high enough levels for antivenom. The CSL VDK is qualitative and not quantitative, and is not recommended for testing blood. As there is no way a hospital could determine the amount of venom in a blood sample, how could they consult an expert, that then made a decision that the blood venom level was below some safe limit?

Certainly, mr Hinde:

The venom works by a number of pathways the immediate and most lethal are neurotoxic (nerve dysfunction) and coagulopthic (clotting problems).

the neurotoxic effects (to my knowledge) are not quantifiable as such but are measured indirectly by clinical neurological deficits (effects on the nervous sytem).
The most obvious way to assess envenomation is indirectly via the coagualopathic effects, that is the degree of envenomation will be reflected proportionally by the degree of disorder in the blood tests measuring blood clotting.

I presume that the patient in question had no, or minimal, neurotoxic effects; +/- minimal, negative or resolved coagulopathy; + a positive VDK swab.

That's how you'd measure minimal envenomation - by clinical effect and indirectly via the numbers in the coag report.

[slparker]

I was under the impression that the purpose of the compression bandage was to restrict, but not necessarily prevent 100% the movement of any venom around the body AND to thereby give the body a chance to absorb/defeat/whatever the greatly reduced flow of venom.

Sort of. it is to restrict the movement of venom from the lymphatic system (small vessels under the skin) into the blood. It is first aid to buy time to enable the patient to get to medical care without severe envenomation. By the way the limb (it's usally a limb) should be splinted as muscular movement also helps the venom dump into the blood.

if (big if ) this is correct. the removal of the bandage as described would appear simply to give any venom still present a running jump at beating the body in which it is present.

Guidelines for the PIB in hospital:
"The bandage should only be removed if antivenom is available and after there is no evidence of envenoming based on the admission laboratory tests and clinical examination. If the patient is envenomed the bandage can be removed after antivenom has been administered."

Rather than a delayed "reaction" it reads to me more like exactly what one would expect from venom rather the euphemistic description of "reaction".

Don't know quite what you're getting at here... the person in the report had signs of envenomation that were not severe but then went on to get some myotoxic reactions to the venom - so yes she was envenomated but the patient did not meet the guidelines for antivenene as she did not have in the first few hours any neuro/clotting disorders. The venom that she had on board did cause her subsequent muscle problems and i reckon that antivenene would have prevented it.
They might change the guidelines eventually to give antivenene to prevent the reaction that she had, but i doubt it as it is rare to get these muscle reactions - not worth the risk of giving antivenene more freely, i suspect.

Would death resulting from envenomation be described as a "reaction" ?

Yep. A severe and final reaction.

We are not talking about an allergy.

I haven't heard of an allergy to snakebite but if you get bitten more than once it is a possibility. How bad would that be... envenomated and allergic!

[MickyB]

On The Living Room on channel 10 a week and a half ago they milked a tiger snake and then added the venom to a small glass containing blood. Amazing result .

Here is a link to the whole episode. The snake segment started at approx 16.30 and the milking of the tiger snake started at approx 20.00

http://tenplay.com.au/channel-ten/the-l ... episode-38

[jackhinde]

I presume that the patient in question had no, or minimal, neurotoxic effects; +/- minimal, negative or resolved coagulopathy; + a positive VDK swab.

That's how you'd measure minimal envenomation - by clinical effect and indirectly via the numbers in the coag report.

I agree... but it is not what the article said is it?
A nonsensical statement is made about measuring low venom levels in the blood.

For those that watch the tiger snake venom in blood (a classic demonstration that has been filmed with the venom of many species), it is actually the opposite effect that gets you... the clotting factors are used up in the large blood volume of a human, and your blood cannot clot (VICC- venom induced consumptive coagulopathy)

[slparker]

[
I agree... but it is not what the article said is it?
A nonsensical statement is made about measuring low venom levels in the blood.

That wasn't the issue we were discussing.
You stated: 'There have been many instances of incorrect hospital treatment of snake bite, this is likely another. ' I still disagree and Idon't think that there is anything in the newspaper report or your assertions that supports your claim..

there is no suggestion from any of the reports that they did not follow the guidelines. The hospital probably worked off the clinical presentation and the coags and realised that the patient was not severely envenomed and they released her after 12 hours. As per the guidelines.

That the media misinterpreted the guidelines is peripheral and how you could leap from that to 'incorrect hospital treatment' is baffling to me.

[Lophophaps]

I want to be quite clear about treatment. A compression bandage should be applied (remove clothing first?) and remain on until the patient is under medical care. What if such care is days away? How often and now much of the compression bandage should be removed? Are there any other factors or treatments that apply? TIA.

[slparker]

I want to be quite clear about treatment. A compression bandage should be applied (remove clothing first?) and remain on until the patient is under medical care. What if such care is days away? How often and now much of the compression bandage should be removed? Are there any other factors or treatments that apply? TIA.

In australia the first aid treatment should be the pressure Immobolisation method (compression bandage + splint). The bandage should stay on and the patient should not move, or be moved unduly, except when evacuated (obviously getting the casualty under shelter, etc is appropriate).

if it was me as the treater i would not take the bandage off in the pre-hospital context as there is no danger to the casualty to leave it on if it is applied correctly. I might adjust the splint for pressure area considerations but other than that there is no need to take the bandage off.

There are few examples that I could think of where evac would be delayed by days. If so, the patient, I imagine, will end up envenomed - the process is likely to be over a longer duration and potentially less severe although I have seen no clinical or anecdotal reports of this and it is just my opinion.

[Lophophaps]

In australia the first aid treatment should be the pressure Immobolisation method (compression bandage + splint). The bandage should stay on and the patient should not move, or be moved unduly, except when evacuated (obviously getting the casualty under shelter, etc is appropriate).

The idea behind this seems to be to keep the pulse rate at a lower level. Is this correct?

if it was me as the treater i would not take the bandage off in the pre-hospital context as there is no danger to the casualty to leave it on if it is applied correctly. I might adjust the splint for pressure area considerations but other than that there is no need to take the bandage off.

Are you saying that a correctly applied compression bandage and splint will allow adequate circulation but tend to stop the blood from the bite area moving around the body? That such a bandage can be left on for some time?

There are few examples that I could think of where evac would be delayed by days. If so, the patient, I imagine, will end up envenomed - the process is likely to be over a longer duration and potentially less severe although I have seen no clinical or anecdotal reports of this and it is just my opinion.

With a PLB and break in the weather there may be, say, 48 hours or so at most before a helicopter or ground evacuation, complete with para-medics or physicians. Can you please explain "envenomed"? Knowing all the possible risks greatly assists, even on anecdotal evidence or an opinion.

[slparker]

In australia the first aid treatment should be the pressure Immobolisation method (compression bandage + splint). The bandage should stay on and the patient should not move, or be moved unduly, except when evacuated (obviously getting the casualty under shelter, etc is appropriate).

The idea behind this seems to be to keep the pulse rate at a lower level. Is this correct?

No, the idea of the compression bandage is to be just firm enough to close the small lymphatic vessels under the skin but not enough to compress the larger blood vessels. This means blood supply can still get to the tissues but the venom (which travels in the lymphatic system) gets trapped. To close of the blood supply requires a tourniquet, which is not appropriate. Because the lymphatic system relies on muscular action of the limbs as one of its mechansims to circulate around the body it is important to keep the patient and the limbs still - which is why the splint is used. The idea is to prevent the lymph from travelling to the point where it drains into the blood stream, and also to prevent any local diffusion into the blood.

if it was me as the treater i would not take the bandage off in the pre-hospital context as there is no danger to the casualty to leave it on if it is applied correctly. I might adjust the splint for pressure area considerations but other than that there is no need to take the bandage off.

Are you saying that a correctly applied compression bandage and splint will allow adequate circulation but tend to stop the blood from the bite area moving around the body? That such a bandage can be left on for some time?
See above, it's not about the blood but the lymphatic fluid in the lymphatic system - a low pressure one way circulation from the tissues back to the main blood circulation. because the compression bandage is only tight enough to restrict lymphatic fluid movement, but not blood circulation, it can be left on for an indeterminate period - just like a sprained ankle bandage or compression hose

There are few examples that I could think of where evac would be delayed by days. If so, the patient, I imagine, will end up envenomed - the process is likely to be over a longer duration and potentially less severe although I have seen no clinical or anecdotal reports of this and it is just my opinion.

With a PLB and break in the weather there may be, say, 48 hours or so at most before a helicopter or ground evacuation, complete with para-medics or physicians. Can you please explain "envenomed"? Knowing all the possible risks greatly assists, even on anecdotal evidence or an opinion.

envenomed means signs of toxicity from venom. There is some evidence that the act of placing effective, early PIM and keeping the venom in situ at the site of envenomation has some effect in total envenomation - which means that it is possible that some of the venom degrades or is neutralised at the site if it is kept there. This research goes back a long way but Ihave seen no studies that reproduce this.
The implications for wilderness first aid is that early, effective first aid may reduce total envenomation - which means that the casualty is less likely to suffer toxic signs of envenomation whilst you are there looking after them. Moreover, the PIM is extremely effective at stopping venom completely if applied effectively and early. If the casualty does show signs of envenomation the most serious short term problems would be respiratory paralysis. theoreticlly you could keep your mate going with some mouth to mouth. Get him to brush his teeth while he can.
I could find no case studies of delayed evacuation for snakebite with PIM applied. But the lesson from this is know how your first aid. Unfortunately the research on this is not good - miost trained first aiders and clinicians can not effectively apply good PIM with t crepe bandage. there is much talk in the literature about using elasticised bandages instead of crepe bandages.