A 36-year old male felt a sharp ‘slapping feeling’ on his right foot while passing urine around the back of a sheering shed in Western Australia. He did not see a snake and did not think of snakebite. Ten minutes later, while helping a friend load a motorcycle onto the back of a trailer, he abruptly felt unwell with nausea, dizziness, weakness and a mild headache. He collapsed to the ground but does not think he lost consciousness. His wife thought he might have bitten by a snake and put a pressure immobilisation bandage (PIB) on his leg.
He arrived at a peripheral urban hospital by ambulance 70 minutes later. He appeared pale and sweaty. His vital signs were normal and there was no evidence of abnormal bleeding or neurotoxicity. The PIB was reinforced and IV access obtained.
Blood test results showed INR > 10, APTT > 180, Fibrinogen < 0.3, CK 275, normal renal function and normal full blood picture (Hb 148, platelets 178). Venom detection kit (VDK) undertaken on urine was strongly positive for Brown snake. The hospital has limited after hours laboratory support and 5 ampoules of Brown snake antivenom.
A 25 year old male snake handler was bitten on the left middle finger by a captive Ingram’s Brown snake during routine cage maintenance. He had a history of three previous snake bites; twice by Death Adders, once requiring antivenom and a Tiger snake. After being bitten the patient flicked the snake onto the floor, sucked the bite site and recaptured the snake. He then felt nauseated and generally unwell with a severe headache. A compression bandage was applied and the limb splinted.
On arrival at hospital thirty minutes later he had photophobia, nausea and a headache. Blood tests 1 hour after being bitten showed INR > 10, APTT > 160, creatinine 100, Hb 147 and platelets of 112.
Case adapted from Brimacombe J, Murray A. Envenomation by Ingram’s Brown snake (Pseudonaja Ingrami). Anaesth Intens Care 1995; 23: 231-233.
A peripheral hospital is expecting a herpetologist who has been bitten by a snake. The herpetologist believes he has been bitten by his Inland Taipan. There is no information about symptoms or first aid undertaken. The Hospital only has 2 ampoules of polyvalent antivenom and are seeking advice on initial management.
1. What do you advise?
2. What investigations are indicated?
3. Under what situations would you recommend the administration of polyvalent antivenom and what initial dose would you advise?
Further information is made available after the patient arrives at the hospital. The 33-year-old male herpetologist bitten by a presumed Taipan presented at 1730 hours. He was bitten on the right thumb at approximately 1700 hours and immediately applied a pressure immobilisation bandage but did not splint the limb. The patient complained of pain in the right axilla. He felt flushed and complained of mildly heavy eyes.
There were no objective neurological signs and the patient’s physical examination was normal. Coagulation profile showed INR of 1.0 and APTT of 27. Fibrinogen is not yet available. The VDK was strongly positive for taipan at the bite site.
At 2030 hours the patient was asymptomatic. Repeat blood tests show an INR of 20.8 and APTT of 150 secs. There is evidence of haemolysis with bilirubin of 34. Fibrinogen is pending. CK is 134. The hospital has sourced three ampoules of taipan antivenom and six ampoules of polyvalent antivenom. A haematologist has been consulted and recommended 10 units of cryoprecipitate be administered.
4. What further clinical information would assist in this assessment?
5. Is antivenom indicated; if so how much of which one?
6. What do you think of the advice from the Haematologist?
7. At 0330 the patient remained asymptomatic Repeat blood tests showed an INR of 2.1, APTT of 15 and fibrinogen less then 0.3 g/L.
8. Is antivenom indicated?
9. The peripheral hospital is 20 minutes by road from a tertiary hospital. Should the patient have been transferred?
10. If the patient receives antivenom should prophylactic steroids be commenced?
A 28 yr old woman presents following a single bite to her hand from a 1.6m Taipan she had just purchased. She applied no first aid and was severely inebriated at the time of the bite. She is uncooperative, then lapses into unconsciousness.
A 44 year old male was bitten by a snake on his finger at approximately midnight. The patient breeds tiger snakes. The patient apparently collapsed shortly after being bitten but the exact details of the collapse are not known. A pressure immobilisation bandage was placed on the arm and the patient was transported to hospital by ambulance, arriving one hour after being bitten. On arrival at hospital he is drowsy and is mildly disorientated. Vital signs are normal. There are multiple petechiae on the face and limbs.
The patient received antivenom for a Tiger snake bite last year. The hospital has a total of 4 ampoules of tiger snake monovalent antivenom.
A 44 year old man presents following a bite from a captive rough scaled snake, while working in a venom collection facility. Shortly after the bite, despite immediate application of appropriate first aid, he developed a runny nose, red rash, then chest tightness. These are now resolving, but he has a headache and nausea.
A 24 year old amateur snake handler was bitten at the base of the right thumb as he was dropping a Mulga snake into a bag. Immediately after the bite he applied a tight tourniquet around the right arm. He arrived at hospital 30 minutes after the bite complaining of severe pain in the right hand. He appeared pale and apprehensive. The right hand was swollen and tense and the skin was bluish white in colour. Two deep 3 mm long lacerations were present on the palmar aspect at the base of the thumb. The past history is significant for previous bites by P. australis but he had not received antivenom before.
A 64-year-old snake handler was bitten on the right wrist by a Collett’s snake while cleaning out its cage. Immediately after the bite he placed an arterial tourniquet to his right upper arm. A pressure immobilisation bandage was then applied and he was transported to hospital by ambulance. His only symptoms were nausea. In the past he has been envenomated by Tiger and Brown snakes and received antivenom to both without developing an allergic reaction.
On examination he is awake and alert, with stable vital signs. He has no ptosis. Puncture marks are noted to the anterior and posterior aspects of the wrist; they are not bleeding. The right hand is cold and there is no capillary return.
He is given 10 mg of intravenous metoclopramide and develops an urticarial rash within 5 minutes.
A 35 year old bushwalker is flown to hospital by rescue helicopter from a valley in far North Queensland. He gives a history of stepping on a snake that he described as a Death adder. The snake bit him on the dorsum of his right foot penetrating the cloth material of the upper sole of his shoe.
A pressure immobilisation bandage and splint were applied and the patient’s companion left him to climb to higher ground so that he was within mobile phone coverage to call for assistance. Over the next hour the patient developed nausea and a headache. The bite site was painful and swollen but not bleeding.
On returning after two hours the patient’s companion noted that his eyelids were drooping. On arrival of a rescue team by helicopter three hours after the bite the patient described blurring of vision and diplopia. On examination ptosis and opthalmoplegia were noted. Limb strength appeared normal.
You are contacted for medical advice by a hospital in Alice Springs. They have a patient, an 18-year-old boy who was bitten by a snake three hours previously. One of the patient’s friends shot the snake and brought it to hospital with them. The head of the snake is difficult to identify because of the gun shot wound but the Doctor thinks it is a Death Adder. The patient is extremely anxious and is complaining pain at the bite site, and of nausea, a headache, and a sense of impending doom. The bite site shows two puncture marks but is not swollen or bleeding.
The hospital has the complete range of CLS antivenom available.
Biochemistry, haematology and coagulation studies are all within normal limits. Over the next hour the patient is not improving and says he feels he is “going to die” and is short of breath. An arterial blood gas shows:
A 24 year old man presents drunk, some 4 hours after being bitten by his pet death adder. He has not used first aid. He is allergic to antivenom, he says.
You are contacted by Panawonica Hospital in the Pilbara Region, Western Australia. A 58-year old prospector was bitten on the forearm by a 2 metre snake as he was sorting firewood. The snake was aggressive and required considerable effort to remove. The patient washed the bite site with bourbon and presented to the local hospital 40 minutes after the bite without any pressure bandage or attempt to immobilise. He complains of considerable pain and mild swelling at the bite site, abdominal pain and headache. He has vomited several times.
Examination shows fang marks and mild swelling on the forearm. Vital signs are normal. There is no evidence of abnormal bleeding at the bite site, gingiva, or venepuncture site. There is no evidence of neurotoxicity. There are no laboratory facilities in Panawonica and they only have 2 ampoules of polyvalent antivenom. The doctor calls for advice.
A 42 year old man presents following a bite from a forest cobra at the zoo he was working at. This is not his first bite and he has had antivenom previously, though no adverse reaction is recorded.
A 21 year old man is bitten on the lip by a western diamondback rattlesnake while he is cleaning its cage at a zoo. He has not been bitten by a snake before.
A 5 year old child is brought in comatose following a bite from a 50cm long snake thought to be a python by his parents. The snake had been purchased in a pub. The snake is identified by an expert as a Russell’s Viper.