THE SOUTHEAST ASIAN JOURNAL OF TROPICAL MEDICINE AND PUBLIC HEALTH

 


Volume 30
Supplement 1
1999

  CONTENTS
Page

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