Table of Contents |
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1 Preface |
1 |
1.1 |
Names and addresses of the international panel of experts who contributed to the Guidelines |
3 |
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2 Introduction |
5 |
2.1 |
Venomous snakes of Southeast Asia |
5 |
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2.1.1 |
The venom apparatus |
5 |
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2.1.2 |
Classification |
5 |
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2.1.3 |
How to identify venomous snakes |
19 |
2.2 |
Snake venoms |
19 |
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2.2.1 |
Composition of venom |
19 |
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2.2.2 |
Quantity of venom injected at a bite |
20 |
2.3 |
How common are snake bites? |
21 |
2.4 |
How do snake bites happen? |
23 |
2.5 |
How can snake bites be avoided? |
23 |
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3 Symptoms and signs of snake bite |
24 |
3.1 |
When venom has not been injected |
24 |
3.2 |
When venom has been injected |
25 |
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3.2.1 |
Early symptoms and signs |
25 |
3.3 |
Clinical pattern of envenoming by snakes in Southeast Asia |
25 |
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3.3.1 |
Local symptoms and signs in the bitten part |
25 |
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3.3.2 |
Generalised (systemic) symptoms and signs |
29 |
3.4 |
Clinical syndromes of snake bite in Southeast Asia |
33 |
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3.4.1 |
Limitations of the syndromic approach |
33 |
3.5 |
Long term complications (sequelae) of snake bite |
34 |
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4 Symptoms and signs of cobra-spit ophthalmia |
35 |
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5 Management of snake bites in Southeast Asia |
36 |
5.1 |
First-aid treatment |
36 |
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5.1.1 |
The special danger of rapidly developing paralytic envenoming after bites by some elapid snakes : use of pressure-immobilisation |
38 |
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5.1.2 |
Tight (arterial) tourniquets are not recommended! |
39 |
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5.1.3 |
Viper and cobra bites |
39 |
5.2 |
Transport to hospital |
40 |
5.3 |
Treatment in the dispensary or hospital |
40 |
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5.3.1 |
Rapid clinical assessment and resuscitation |
40 |
5.4 |
Detailed clinical assessment and species diagnosis |
40 |
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5.4.1 |
History |
40 |
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5.4.2 |
Physical examination |
41 |
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5.4.2.1 |
Examination of the bitten part |
42 |
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5.4.2.2 |
General examination |
42 |
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5.4.2.3 |
Neurotoxic envenoming |
42 |
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5.4.2.4 |
Bulbar and respiratory paralysis |
42 |
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5.4.2.5 |
Generalised rhabdomyolysis |
44 |
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5.4.2.6 |
Examination of pregnant women |
44 |
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5.4.3 |
Species diagnosis |
44 |
5.5 |
Investigations/laboratory tests |
45 |
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5.5.1 |
20 minute whole blood clotting test (20WBCT) |
45 |
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5.5.2 |
Other tests |
45 |
5.6 |
Antivenom treatment 5.6.1 What is antive |
47 |
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5.6.1 |
What is antivenom? |
47 |
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5.6.2 |
Indications for antivenom treatmen |
47 |
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5.6.3 |
Inappropriate use of antivenom |
49 |
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5.6.4 |
How long afterthe bite can antivenom be expected to be effective? |
49 |
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5.6.5 |
Prediction of antivenom reactions |
49 |
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5.6.6 |
Contraindications to antivenom |
49 |
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5.6.6.1 |
Prevention of antivenom reactions |
49 |
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5.6.7 |
Selection of antivenom |
50 |
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5.6.8 |
Administration of antivenom |
50 |
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5.6.8.1 |
Local administration of antivenom at the site of the bite is not recommended! |
51 |
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5.6.8.2 |
Intramuscular injection of antivenom |
51 |
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5.6.9 |
Dose of antivenom |
52 |
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5.6.10 |
Antivenom reactions |
52 |
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5.6.11 |
Treatment of early anaphylactic and pyrogenic antivenom reactions |
53 |
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5.6.11.1 |
Addition treatment |
54 |
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5.6.12 |
Treatment of late (serum sickness) reactions |
54 |
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5.6.13 |
Observation of the response to antivenom |
54 |
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5.6.14 |
Recurrence of systemic envenoming |
55 |
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5.6.15 |
Criteria for repeating the initial dose of antivenom |
55 |
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5.6.16 |
Conservative treatment when no antivenom is available |
56 |
5.7 |
Supportive/ancillary treatment |
56 |
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5.7.1 |
Dangers of venepuncture in patients with haemostatic ab- normalities |
57 |
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5.7.2 |
Neurotoxic envenoming |
57 |
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5.7.2.1 |
Trial of anticholinesterase |
58 |
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5.7.3 |
Hypotension and shock |
59 |
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5.7.4 |
Oliguria and renal failure |
60 |
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5.7.4.1 |
Oliguric phase of renal failure |
60 |
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5.7.4.2 |
Prevention of renal damage in patients with myoglobinuria or haemoglobinuria |
63 |
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5.7.4.3 |
Diuretic phase of renal failure |
63 |
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5.7.4.4 |
Renal recovery phase |
63 |
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5.7.4.5 |
Persisting renal dysfunction |
63 |
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5.7.5 |
Haemostatic disturbances |
63 |
5.8 |
Treatment of the bitten part |
64 |
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5.8.1 |
Bacterial infections |
64 |
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5.8.2 |
Necrosis (gangrene) |
64 |
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5.8.3 |
Compartment syndromes and fasciotomy |
64 |
5.9 |
Rehabilitation |
67 |
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6 Management of cobra spit ophthalmia |
67 |
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7 Conclusions and main recommendations |
67 |
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8 Further reading |
71 |
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Annex 1 Algorithm 1 : Antivenom treatment of snake bite cases |
76 |
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Annex 2 Algorithm 2 : Differentiating major Asian snake species by clinical syndrome |
77 |
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Annex 3 Antivenoms for treating bites by Southeast Asian snakes |
78 |
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Annex 4 Measurement of central venous pressure |
82 |
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Annex 5 Measurement of intracompartmental pressure |
84 |
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