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Old 9 May 2012, 18:45
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Aussie Method For Snakebite

I just got this in my ER email. The distinction may be interesting, though I couldn't access the original document. Still may be worth discussion.


"Pressure immobilization in snake envenomation The pressure immobilization technique to delay systemic absorption of snake venom has widespread use in Australia, where Elapid toxin primarily causes neurotoxicity without tissue necrosis and where there may be significant delays in transfer to medical facilities (figure 1). However, in the United States, Crotalinae species (eg, rattle snake, water moccasin, or copperhead) predominate and primarily cause serious local tissue toxicity and coagulopathy (table 1). According to an international consortium of toxicology societies, pressure immobilization for North American Crotalinae snake bites has not been shown to be efficacious in humans, may cause serious adverse effects, and should be avoided [8,9]. (See "Management of Crotalinae (rattlesnake, water moccasin [cottonmouth], or copperhead) bites in the United States", section on 'Pressure immobilization'.)"

http://www.uptodate.com/contents/man...1190#H21171190
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Old 9 May 2012, 23:50
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Starlight or Old Starlight can make a more informed comment that I, but I believe the reason for the Pressure Immobilisation technique working well in Australia is the way the toxin travels through the body?
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Old 10 May 2012, 00:13
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Originally Posted by nofear View Post
Starlight or Old Starlight can make a more informed comment that I, but I believe the reason for the Pressure Immobilisation technique working well in Australia is the way the toxin travels through the body?
Actually, the mechanism for the toxin migrating is the same. From the abstract, it looks like the key factor is the effect the toxin has along the way. It looks like the Down Under snake venom doesn't cause localized necrosis and coagulopathies along the way to body's core. That, and the water in their toilet bowls swirls the other way.

Seriously, though - this is interesting and may have clinical import. When I first heard about the Aussie approach to snake bite, I made a mental note of 'I probably should do that.' Now it looks like, at least while in North America, I maybe shouldn't do that. It bears further learning of the subject. I'm hoping some of the high-speed types here will have already considered the implications and can expand the discussion. (As always, one report or study does not make for practice-changing evidence...)
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Old 10 May 2012, 03:10
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For those of us wwho regularly work overseas, I find it interesting that our "first aid" requirement is for Australian conditions. As such, if I was working on the African continent and was bitten by a snake, I would use the Aussie method.

But would it actually work? I'm ASSuming where I am now in SE Asia the technique would work due to proximity to home, but I really am guessing.

Thanks mate, you've given me yet another reason to be disliked by our training section.
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Old 10 May 2012, 04:45
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Originally Posted by nofear View Post
Starlight or Old Starlight can make a more informed comment that I, but I believe the reason for the Pressure Immobilisation technique working well in Australia is the way the toxin travels through the body?
As mentioned, the method of transport of the venom is the same, however the localised action of the venom is the key.

There are a very few critters in OZ that you don't use PIMS for, the Redback spider being the first one that springs to mind.
Snakebite in OZ? PIMS and transport to higher med facility stat.

Addit: the sole exception that I can think of for envenomation is the ringhal (sp?) or Spitting Cobra, where the envenomation may occur via the skin.
Mind you, that also applies to OZ snakes as well, one of the handlers at Adelaide Zoo got nailed by a Taipan when he got some venom on his skin while milking it for the CSL antivenine project (mid 80's IIRC) and didn't wash it off soon enough. Didn't kill him, but made him a very sick unit for a while.

Paging AJ.
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Last edited by Starlight; 10 May 2012 at 04:53. Reason: addit.
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Old 10 May 2012, 19:58
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AJ's surrounded by skinnies, trying to find someone to have a beer with. May take him a while to comment.
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Old 10 May 2012, 20:51
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Thanks mate, you've given me yet another reason to be disliked by our training section.
My raison d'etre. Happy to help that cause. That's why from second grade on, I spent more time ejected from class than in.
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Old 10 May 2012, 23:29
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AJ's surrounded by skinnies, trying to find someone to have a beer with. May take him a while to comment.
Copy, he'll need that beer first I imagine...
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Old 11 May 2012, 13:13
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is the ringhal (sp?) or Spitting Cobra,
That would be Rinkhals
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Old 11 May 2012, 13:40
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Originally Posted by nofear View Post

But would it actually work? I'm ASSuming where I am now in SE Asia the technique would work due to proximity to home, but I really am guessing.
Negative on this technique in SEA...

I worked with the folks from the Queen Savannohbah Snake Bite Institute in Bangkok quite frequently while I was working in SEA.

Compression wraps from distal to proximal 2-6inches past the envenomation site on the affected limb (in order to restrict the localization of the venom, promote distribution into the lymphatics and its minimize resultant tissue necrosis) was the primary means of initial intervention and aid.

Most anti-venoms made at the institute utilize Tiger serum vs horse serum and there is a higher potency which results in more serious side effects.

Effective dosing with anti-venom for the Asian King Cobra actually requires being placed on a vent secondary to limited / moderate paralysis of the diaphragm.

My information is from 2002-2005, so it may have changed / been updated since then.
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Old 13 May 2012, 08:17
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Quote:
Originally Posted by ussfpa View Post
Negative on this technique in SEA...

I worked with the folks from the Queen Savannohbah Snake Bite Institute in Bangkok quite frequently while I was working in SEA.

Compression wraps from distal to proximal 2-6inches past the envenomation site on the affected limb (in order to restrict the localization of the venom, promote distribution into the lymphatics and its minimize resultant tissue necrosis) was the primary means of initial intervention and aid.

Most anti-venoms made at the institute utilize Tiger serum vs horse serum and there is a higher potency which results in more serious side effects.

Effective dosing with anti-venom for the Asian King Cobra actually requires being placed on a vent secondary to limited / moderate paralysis of the diaphragm.

My information is from 2002-2005, so it may have changed / been updated since then.
Bold is Mine.

Sir, this is a modification of PIM. The overall concept of Rx works everywhere in that it is designed to do exactly what you said as well as slowing down the transmission through the lymphatic system to nodes closer to the heart thereby prolonging the patient's Rx window from minutes in some cases (Taipan, Tiger, Funnelweb, Blue Ringed Octopus) to hours.

We do have Oz snakes who's venom causes necrosis rather than CNS issues, and then of course the critters who take advantage of venom that works both ways.

The PIM is not the cure. It is simply the First Aid Rx to enable a victim of snakebite to be transported long distances to definitive medical Rx as experienced in Australia.

(For those who don't know, whilst Australia is an Island, it is also a continent with the same landmass as continental US give or take a couple of hundred square miles with less than 1/10th the population of the US....distances between civilised areas are looooong!)

Herein lies the issue with those who argue for or against ... often the protagonists lose sight of the difference between first aid and definitive Rx.

Is the PIM the definitive Rx for ANY type of venom?

Definitely not!

Can it critically affect survival when applied in a timely manner with correct amount of tension?

Most Definitely!

PIM is the First Response of choice for snake envenomation as well as some other nasty critters.

PIM is not the magic cure for ANYTHING at all.

Sir, your note on Tiger venom based Rx are all correct to date.

I will add that PIM works when coupled with effective splinting as well as placing the casuality in a supine position for transport with minimal stress...in other words...keep the Cas' Calm!

Do not elevate the affected limb. If bite to chest/abdo, there is an argument that a semi reclined position may have some use...but I don't believe there is any definitive research has been made to cover the argument other than to say that mortality rates for torso strikes are higher than limbs ... especially in species that can deliver rapid multiple strikes with effective venom delivery.

Regardless of who you are, learning the PIM technique is easy enough from the literature. Let me cover a couple of points.

The tension should be tight enough to inhibit lymphatic transmission without shutting down the circulation. Always leave a finger or toe nail visible to assess cap refil. It should be slower but not absent.

If administering this technique in civilisation (1st or 2nd World Countries), always mark the bandage over the bite site with a broad or large "X". This enables the trauma folk to simply cut a square out of the bandage to inspect the bite site. Also, in Australia, we do NOT need the snake for identification. We simply swab the site and assess the venom.

Under NO circumstances when in Australia or its Territories should you wash, cut, suck or otherwise tamper with the bite site because of the way we assess venom.

To sum up...PIM is not dependent on whether you are trying to avoid CNS or localised necrosis. In Australia, we'd rather deal with the necrotic tissue (even if it means amputation) rather than funeral arrangements.

Of course, there are going to be people out there with better info than I, so take me for what I am worth...words on a screen in a forum.

I always teach and use PIM Myself regardless of LOCSTAT/AO. I do however educate myself on local species and the AO. For instances, if one of my team is envenomated in this AO, I would expect it would be a fight to keep them alive during the CASEVAC to Nairobi.

Any of my medics I caught trying to vary the above would end up looking like lumberjacks from pushing so much....that's how much faith I have in it all.

I have a mate who survived 13 hrs without definitive Rx post Coastal Taipan strike because of the PIM technique. I have seen it work and more than once.

Any questions on what I have just covered? Ask Starlight

Cheers,
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Old 13 May 2012, 08:25
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Quote:
Originally Posted by Medic09 View Post
Actually, the mechanism for the toxin migrating is the same. From the abstract, it looks like the key factor is the effect the toxin has along the way. It looks like the Down Under snake venom doesn't cause localized necrosis and coagulopathies along the way to body's core. That, and the water in their toilet bowls swirls the other way.

Seriously, though - this is interesting and may have clinical import. When I first heard about the Aussie approach to snake bite, I made a mental note of 'I probably should do that.' Now it looks like, at least while in North America, I maybe shouldn't do that. It bears further learning of the subject. I'm hoping some of the high-speed types here will have already considered the implications and can expand the discussion. (As always, one report or study does not make for practice-changing evidence...)
Ahh the joys of generalisations. Several of our critters (not just snakes) do in fact rely on venom that acts in exactly this way and in fact are using venoms that are neuro-toxins as well as causing "localized necrosis and coagulopathies along the way to body's core.".

Cheers,
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Old 13 May 2012, 09:55
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Originally Posted by Old_Starlight View Post
Ahh the joys of generalisations. Several of our critters (not just snakes) do in fact rely on venom that acts in exactly this way and in fact are using venoms that are neuro-toxins as well as causing "localized necrosis and coagulopathies along the way to body's core.".

Cheers,
Mea culpa. I took that generalization from the authors of the abstract I received. I should have known not to do that without reading and verifying the information more directly - like reading any other study.
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Old 13 May 2012, 10:33
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Well written and good info.
Thank you for the clarification!
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Old 13 May 2012, 10:51
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Mea culpa. I took that generalization from the authors of the abstract I received. I should have known not to do that without reading and verifying the information more directly - like reading any other study.
Mate I meant the article's authors being general. I realise you're quoting them and you came looking for more info...no mea culpa required.

The only dumb question is the one you didn't ask

Without seeing the article, my response was also necessarily general in its direction. I tried not to answer questions posed that I had not really seen, but rather talk to the Pressure ImMobilisation Technique itself and the background of why it's been developed and used on our continent.

If you want to pass along the links etc. I'd be happy to read through and learn some more because depending on the author's direction in their comments, they may be generalising for a good reason.

Happy to field a PM if you're not sure about the links being kosher for SOCNET or check with the Boss...USSFPA.

Cheers,
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Old 13 May 2012, 10:52
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Well written and good info.
Thank you for the clarification!
Thank you Sir and a pleasure to share. Although I learn more here than I feel I pass on. I do my best either way.

Cheers,
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Old 13 June 2012, 13:35
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Any opinions on "The extractor" device? It applies strong suction to the bite wounds. I was in Central and South America with a herpetologist who recommended it based on some anecdotal cases. Only works if applied immediately and probably only attenuates the effects --may help "tip the scales". Don't know if it has been used much in areas with predominantly elapid snakes.
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Old 14 June 2012, 02:45
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Any opinions on "The extractor" device? It applies strong suction to the bite wounds. I was in Central and South America with a herpetologist who recommended it based on some anecdotal cases. Only works if applied immediately and probably only attenuates the effects --may help "tip the scales". Don't know if it has been used much in areas with predominantly elapid snakes.
I'll have an opinion when I see the research, but it was thrown out decades ago at home. That's not anecdotal
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Old 14 June 2012, 04:48
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Any opinions on "The extractor" device? It applies strong suction to the bite wounds. I was in Central and South America with a herpetologist who recommended it based on some anecdotal cases. Only works if applied immediately and probably only attenuates the effects --may help "tip the scales". Don't know if it has been used much in areas with predominantly elapid snakes.
Given that approx 90% (according to several articles in OZ at least) of bites are 'dry strikes' I suspect those anecdotal cases might not be that relevent to the issue.
It is, after all, easy to say that XYZ works when the puncture marks are present but no envenomation has occured.

PIMS and evac to higher, stat.

Although, we did have one instance while OS where one of the guys was bitten by "a small black cloured snake". Sadly for him, he managed that during the middle of a thunderstorm and heavy rain with 10/10 clouds that lasted for approx 2 days. No AME and no surface transport due to location.

PIMS stat and then monitor.
Onset of breathing difficulty at about 1.5 hours post envenomation, bagged with mask. LOC at approx 2 hrs.

Continue Rx until Pt recovered conc and ability to breath unassisted, approx 24 hrs post bite.

Pt casevac to higher approx 48 hrs post bite.

Pt was bitten by a Krait, quite common in that area.

Turns out (according to a tropical medical specialist attached to the Med support unit) that the body can counter the Krait venom if you simply keep the Pt breathing the whole time and will generally be none the worse for the wear.

PIMS and evac stat. Treat the symptoms as they occur. Don't give up.
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Old 14 June 2012, 06:50
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This is gonna sound crazy, but I remember reading somewhere that when a dog is bitten by a venomous snake they will instinctively move to a protected spot like dense brush where they will lay down and go to sleep. IIRC this allows them to survive in most cases due to sleep slowing down the heart rate etc and giving the dogs body a chance to deal with the venom slowly.

What are the chances that the same thing could be successful for a human? Although I admit it would be hard to relax and sleep immediately after being bitten. Just a curious dumb question but maybe worth a shot if you are bitten, alone, no comms, and no chance of evac. ie trying to walk out would probably kill you quicker due to an increased heart rate.
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