snakebite first aid
TRANSCRIPT
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Snakebite First Aid
1
Reassure the victim
Calm the victim down. Un-necessary panic will only raise the pulse rateand blood pressure and moves the venom into the system faster. Tell thevictim that 70% of snakebites are from non-poisonous species. Of theremaining 30%, only half will actually involve injecting venom. Thechances are they are OK!
2 Immobilise the bitten limb without compression.
If the bite is on a hand or arm place it in a sling bandage or use a piece of cloth to support the arm. In the case of a leg bite, use a splint to supportboth legs and bandage them together. Do not tie the bandages tightly, weare only trying to immobilise not apply any pressure.
3 G et the patient to Hospital as fast as safely possible.
Don’t waste time washing the wound, seeking traditional remedies or applying any drugs or chemicals to the victim. Science has shown thattraditional remedies do not work and simply waste valuable time.Snakestones do not absorb venom and many herbal remedies make thesituation worse. Keep the patient as immobile as possible.
4 Tell the Doctor any of the following signs appearing on the way to thehospital.
The Doctor will want to know if any of the following signs or symptomsare noticeable on the journey to the hospital:
Difficulty breathing. If the patient stops breathing, give artificialrespiration. In Cobra and Krait bites this will save the victims life.
Drooping eyelids
Bleeding from the gums or any unusual bruising appearing.
Increases in any swelling. Carry a pen and mark the limit of theswelling every 10 minutes or so
Drowsiness
Difficulty speaking
Bleeding from the wound that does not seem to stop
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Do it R.I.G.H.T.
Common Mistakes
There will be many who wonder where the tourniquet or compression
bandage has gone, surely we must tie a ligature to stop the venomspreading. Others will be wondering why we don’t cut the wound to letsome of the venom out. It is important in India that we address these twocommon actions to see if they benefit or potentially cause harm to thevictim.
Tourniquets and Ties
Tourniquets or compression bandages have the following drawbacks:
1. The majority of the Indian venomoussnakes have venom that contains toxinsthat do serious local damage at the bitesite. This is true of all vipers and theCobras. This toxin breaks down tissueand destroys it. Confining this toxin in asmaller area, by use of compressiontechniques creates a greater risk of serious local damage.
2. Compression bandages are based onresearch that was carried out in Australiain the 1970’s. This research appeared toshow that venom could be slowed downby the use of a compression bandagewith an integral splint.The version that gets used in India, without the splint, is a local hybrid.The problem with the research was it was done on animals, nothumans. Also it is not used currently in the majority of snakebite casesin Australia. The author also concluded that immobilisation with thesplint alone or compression bandaging alone would be ineffective.
3 When the tourniquet is removed there is the problem of the venom
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. rapidly entering the system and causing respiratory failure in the caseof neurotoxic bites. Unless the doctor is aware of this syndrome and,more importantly equipped to deal with it, death can occur.
4. In the case of Viper bites, tourniquets are also a risk. The Viper’svenom contains pro-coagulant enzymes which cause the blood to clot.In the small space below the tourniquet the venom has a greater chance of causing a clot. When the tourniquet is released the clot willrapidly enter the body and can cause embolism and death.
5. Lastly, there has been a great deal of research showing thattourniquets DO NOT stop venom from entering the body. One studydemonstrated that 33% of victims tested, experienced systemicsymptoms whilst the tourniquet was still in place!
Cutting the Wound
Cutting the wound to let blood and some venom flow out is also acommon practice that is wrong. Cutting and bleeding does not releasevenom from the wound, by the time the cut is made the venom is alreadymixed.
The more critical problem is that, apart from the risk of infection, bites byVipers cause the blood to be incoagulable i.e. it will not clot. Cutting thevictim makes it more likely that the person will bleed to death!
SnakebiteFrom Wikipedia, the free encyclopediaJump to: navigation , search
For other uses, see Snakebite (disambiguation) .
Snakebite
Classification and external resources
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Cobra Naja naja
ICD -10 T63.0 , T14.1, W59 (nonvenomous), X20
(venomous)
ICD -9 989.5 , E905.0 , E906.2
DiseasesDB 29733
MedlinePlus 000031
eMedicine med/2143
MeSH D012909
A snakebite is an injury caused by a bite from a snake , often resulting in puncturewounds inflicted by the animal's fangs and sometimes resulting in envenomation .Although the majority of snake species are non-venomous and typically kill their preywith constriction rather than venom , venomous snakes can be found on every continentexcept Antarctica .[1] Snakes often bite their prey as a method of hunting, but also for defensive purposes against predators. Since the physical appearance of snakes may differ,
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there is often no practical way to identify a species and professional medical attentionshould be sought. [2][ 3]
The outcome of snake bites depends on numerous factors, including the species of snake,the area of the body bitten, the amount of venom injected, and the health conditions of the
victim. Feelings of terror and panic are common after a snakebite and can produce acharacteristic set of symptoms mediated by the autonomic nervous system , such as aracing heart and nausea .[4] [5] Bites from non-venomous snakes can also cause injury, oftendue to lacerations caused by the snake's teeth, or from a resulting infection. A bite mayalso trigger an anaphylactic reaction, which is potentially fatal. First aidrecommendations for bites depend on the snakes inhabiting the region, as effectivetreatments for bites inflicted by some species can be ineffective for others.
The number of fatalities attributed to snake bites varies greatly by geographical area.Although deaths are relatively rare in Australia , Europe and North America ,[1][ 6][7] themorbidity and mortality associated with snake bites is a serious public health problem in
many regions of the world, particularly in rural areas lacking medical facilities. Further,while South Asia , Southeast Asia , and sub-Saharan Africa report the highest number of bites, there is also a high incidence in the Neotropics and other equatorial and subtropical regions. [1][ 6][7] Each year tens of thousands of people die from snake bites ,[1] yet the risk of
being bitten can be lowered with preventive measures, such as wearing protectivefootwear and avoiding areas known to be inhabited by dangerous snakes.
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Contents[hide ]
• 1 Signs and symptoms• 2 Pathophysiology
o 2.1 Snake venom• 3 Prevention• 4 Treatment
o 4.1 Snake identificationo 4.2 First aido 4.3 Pressure immobilizationo 4.4 Antivenomo 4.5 Outmoded treatments
• 5 Epidemiology• 6 Society and culture• 7 See also• 8 Footnotes• 9 References
• 10 External links
[ edit ] Signs and symptoms
The most common symptoms of any kind of snake envenomation. [8][9][10] However, thereis vast variation in symptoms between bites from different types of snakes. [8]
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Severe tissue necrosis following Bothrops asper envenomation. The victim was an 11-year-old boy, bitten two weeks earlier in Ecuador , but treated only with antibiotics .[11]
The most common symptoms of all snakebites are overwhelming fear, panic, and
emotional instability, which may cause symptoms such as nausea and vomiting , diarrhea ,vertigo , fainting , tachycardia , and cold, clammy skin. [4][ 5] Television, literature, andfolklore are in part responsible for the hype surrounding snakebites, and a victim mayhave unwarranted thoughts of imminent death.
Dry snakebites , and those inflicted by a non-venomous species, can still cause severeinjury to the victim. There are several reasons for this: a snakebite which is not treated
properly may become infected (as is often reported by the victims of viper bites whosefangs are capable of inflicting deep puncture wounds), the bite may cause anaphylaxis incertain people, and the snake's saliva and fangs may harbor many dangerous microbialcontaminants, including Clostridium tetani . If neglected, an infection may spread and
potentially kill the victim.
Most snakebites, whether by a venomous snake or not, will have some type of localeffect. There is minor pain and redness in over 90% of cases, although this variesdepending on the site. [4] Bites by vipers and some cobras may be extremely painful, withthe local tissue sometimes becoming tender and severely swollen within 5 minutes. [7] Thisarea may also bleed and blister. Other common initial symptoms of pitviper bites includelethargy, weakness, nausea, and vomiting .[4][ 7] Symptoms may become more life-
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threatening over time, developing into hypotension , tachypnea , severe tachycardia,altered sensorium , and respiratory failure .[4] [7]
Interestingly, bites caused by the Mojave rattlesnake , coral snake , and the speckledrattlesnake reportedly cause little or no pain despite being serious injuries. [4] Victims may
also describe a "rubbery," "minty," or "metallic" taste if bitten by certain species of rattlesnake. [4] Spitting cobras and rinkhalses can spit venom in their victims' eyes. Thisresults in immediate pain, ophthalmoparesis , and sometimes blindness .[12][ 13]
Some Australian elapids and most viper envenomations will cause coagulopathy , sometimes so severe that a person may bleed spontaneously from the mouth, nose, andeven old, seemingly-healed wounds. [7] Internal organs may bleed, including the brain andintestines and will cause ecchymosis (bruising) of the victim's skin.
Venom emitted from elapids, including cobras , kraits , mambas , sea snakes , and manyAustralian species, contain toxins which attack the nervous system, causing
neurotoxicity .[4] [7][ 14]
The victim may present with strange disturbances to their vision,including blurriness. Paresthesia throughout the body, as well as difficulty speaking and breathing, may be reported. [4] Nervous system problems will cause a huge array of symptoms, and those provided here are not exhaustive. If the victim is not treatedimmediately they may die from respiratory failure .
Venom emitted from some Australian elapids, almost all vipers, and all sea snakes causesnecrosis of muscle tissue .[7] Muscle tissue will begin to die throughout the body, acondition known as rhabdomyolysis . Dead muscle cells may even clog the kidney whichfilters out proteins. This, coupled with hypotension , can lead to acute renal failure , and, if left untreated, eventually death .[7]
[ edit ] Pathophysiology
Since envenomation is completely voluntary, all venomous snakes are capable of bitingwithout injecting venom into their victim. Snakes may deliver such a " dry bite " rather than waste their venom on a creature too large for them to eat. [15] However, the
percentage of dry bites varies between species: 50% of bites from the normally timidcoral snake do not result in envenomation, whereas only 25% of pitviper bites are dry. [4]
Furthermore, some snake genera , such as rattlesnakes , significantly increase the amountof venom injected in defensive bites compared to predatory strikes .[16]
Some dry bites may also be the result of imprecise timing on the snake's part, as venommay be prematurely released before the fangs have penetrated the victim's flesh. [15] Evenwithout venom, some snakes, particularly large constrictors such as those belonging tothe Boidae and Pythonidae families, can deliver damaging bites; large specimens oftencause severe lacerations as the victim or the snake itself pull away, causing the flesh to betorn by the needle-sharp recurved teeth embedded in the victim. While not as life-threatening as a bite from a venomous species, the bite can be at least temporarilydebilitating and could lead to dangerous infections if improperly dealt with.
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While most snakes must open their mouths before biting, African and Middle Easternsnakes belonging to the family Atractaspididae are able to fold their fangs to the side of their head without opening their mouth and jab at victims .[17]
[edit ] Snake venom
Main article: Snake venom
It has been suggested that snakes evolved the mechanisms necessary for venom formationand delivery sometime during the Miocene epoch. [18] During the mid- Tertiary , mostsnakes were large ambush predators belonging to the superfamily Henophidia , which useconstriction to kill their prey. As open grasslands replaced forested areas in parts of theworld, some snake families evolved to become smaller and thus more agile. However,subduing and killing prey became more difficult for the smaller snakes, leading to theevolution of snake venom. [18] Other research on Toxicofera , a hypothetical clade thoughtto be ancestral to most living reptiles, suggests an earlier time frame for the evolution of snake venom, possibly to the order of tens of millions of years, during the Late
Cretaceous .[19]
Snake venom is produced in modified parotid glands normally responsible for secretingsaliva. It is stored in structures called alveoli behind the animal's eyes, and ejectedvoluntarily through its hollow tubular fangs . Venom is composed of hundreds tothousands of different proteins and enzymes , all serving a variety of purposes, such asinterfering with a prey's cardiac system or increasing tissue permeability so that venom isabsorbed faster.
Venom in many snakes, such as pitvipers, affects virtually every organ system in thehuman body and can be a combination of many toxins, including cytotoxins , hemotoxins ,
neurotoxins , and myotoxins , allowing for an enormous variety of symptoms.[4] [20]
Earlier,the venom of a particular snake was considered to be one kind only i.e. either hemotoxicor neurotoxic, and this erroneous belief may still persist wherever the updated literature ishard to access. Although there is much known about the protein compositions of venomsfrom Asian and American snakes, comparatively little is known of Australian snakes.
The strength of venom differs markedly between species and even more so betweenfamilies, as measured by LD 50 in mice. [1] Subcutaneous LD 50 varies by over 140-foldwithin elapids and by more than 100-fold in vipers [2] . The amount of venom producedalso differs among species, with the Gaboon viper able to potentially deliver from 5–7 ml(450–600 mg) of venom in a single bite, the most of any snake. [21] Opisthoglyphous
colubrids have venom ranging from life-threatening (in the case of the boomslang) to barely noticable (as in Tantilla ).
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[ edit ] Prevention
Sign at Sylvan Rodriguez Park in Houston, Texas warning of the presence of snakes.
Snakes are most likely to bite when they feel threatened, are startled, are provoked, or have no means of escape when cornered. Encountering a snake is always considereddangerous and it is recommended to leave the vicinity. There is no practical way to safelyidentify any snake species as appearances may vary dramatically.
Snakes are likely to approach residential areas when attracted by prey, such as rodents .Practicing regular pest control can reduce the threat of snakes considerably. It is
beneficial to know the species of snake that are common in local areas, or while travelingor hiking. Areas of the world such as Africa , Australia , the Neotropics , and southern Asia are inhabited by many highly dangerous species. Being wary of snake presence andultimately avoiding it when known is strongly recommended.
When in the wilderness, treading heavily creates ground vibrations and noise, which willoften cause snakes to flee from the area. However, this generally only applies to NorthAmerica as some larger and more aggressive snakes in other parts of the world, such asking cobras and black mambas , will protect their territory. When dealing with directencounters it is best to remain silent and motionless. If the snake has not yet fled it isimportant to step away slowly and cautiously.
The use of a flashlight when engaged in camping activities, such as gathering firewood atnight, can be helpful. Snakes may also be unusually active during especially warm nightswhen ambient temperatures exceed 21 °C (70 °F). It is advised not to reach blindly intohollow logs, flip over large rocks, and enter old cabins or other potential snake hiding-
places. When rock climbing , it is not safe to grab ledges or crevices without examiningthem first, as snakes are cold-blooded and often sunbathe atop rock ledges.
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Pet owners of domestic animals or snakes should be aware that a snake is capable of causing injury and that is necessary to always act with caution. When handling snakes itis never wise to consume alcoholic beverages . In the United States more than 40% of snakebite victims intentionally put themselves in harm's way by attempting to capturewild snakes or by carelessly handling their dangerous pets—40% of that number had a
blood alcohol level of 0.1 percent or more.[22]
It is also important to avoid snakes that appear to be dead , as some species will actuallyroll over on their backs and stick out their tongue to fool potential threats. A snake'sdetached head can immediately act by reflex and potentially bite. The induced bite can be
just as severe as that of a live snake .[4][23] Dead snakes are also incapable of regulating thevenom they inject, so a bite from a dead snake can often contain large amounts of venom.[24]
[ edit ] Treatment
It is not an easy task determining whether or not a bite by any species of snake is life-threatening. A bite by a North American copperhead on the ankle is usually a moderateinjury to a healthy adult, but a bite to a child's abdomen or face by the same snake may befatal. The outcome of all snakebites depends on a multitude of factors: the size, physicalcondition, and temperature of the snake, the age and physical condition of the victim, thearea and tissue bitten (e.g., foot, torso, vein or muscle), the amount of venom injected, thetime it takes for the patient to find treatment, and finally the quality of that treatment. [4][25]
Promptly securing qualified medical treatment is the best course of action, andconservative management in the meantime is recommended.
[edit ] Snake identification
Identification of the snake is important in planning treatment in certain areas of theworld, but is not always possible. Ideally the dead snake would be brought in with the
patient, but in areas where snake bite is more common, local knowledge may besufficient to recognize the snake. However, in regions where polyvalent antivenoms areavailable, such as North America, identification of snake is not a high priority item.
The three types of venomous snakes that cause the majority of major clinical problemsare vipers , kraits , and cobras . Knowledge of what species are present locally can becrucial, as is knowledge of typical signs and symptoms of envenomation by each type of snake. A scoring systems can be used to try and determine the biting snake based on
clinical features,[26]
but these scoring systems are extremely specific to particular geographical areas.
[edit ] First aid
Snakebite first aid recommendations vary, in part because different snakes have differenttypes of venom. Some have little local effect, but life-threatening systemic effects, inwhich case containing the venom in the region of the bite by pressure immobilization is
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highly desirable. Other venoms instigate localized tissue damage around the bitten area,and immobilization may increase the severity of the damage in this area, but also reducethe total area affected; whether this trade-off is desirable remains a point of controversy.
Because snakes vary from one country to another, first aid methods also vary. As always,
this article is not a legitimate substitute for professional medical advice. Readers arestrongly advised to obtain guidelines from a reputable first aid organization in their ownregion, and to be wary of homegrown or anecdotal remedies.
However, most first aid guidelines agree on the following:
1. Protect the patient (and others, including yourself) from further bites. Whileidentifying the species is desirable in certain regions, do not risk further bites or delay proper medical treatment by attempting to capture or kill the snake. If thesnake has not already fled, carefully remove the victim from the immediate area.
2. Keep the victim calm. Acute stress reaction increases blood flow and endangers
the patient. Keep people near the patient calm. Panic is infectious andcompromises judgment.3. Call for help to arrange for transport to the nearest hospital emergency room ,
where antivenom for snakes common to the area will often be available.4. Make sure to keep the bitten limb in a functional position and below the victim's
heart level so as to minimize blood returning to the heart and other organs of the body.
5. Do not give the patient anything to eat or drink. This is especially important withconsumable alcohol, a known vasodilator which will speed up the absorption of venom. Do not administer stimulants or pain medications to the victim, unlessspecifically directed to do so by a physician.
6. Remove any items or clothing which may constrict the bitten limb if it swells(rings, bracelets, watches, footwear, etc.)7. Keep the victim as still as possible.8. Do not incise the bitten site.
Many organizations, including the American Medical Association and American RedCross , recommend washing the bite with soap and water. However, do not attempt toclean the area with any type of chemical. Australian recommendations for snake bitetreatment strongly recommend against cleaning the wound. Traces of venom left on theskin/bandages from the strike can be used in combination with a snake bite identificationkit to identify the species of snake. This speeds determination of which antivenom toadminister in the emergency room .[27]
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[edit ] Pressure immobilization
A Russell's viper is being "milked". Laboratories use extracted snake venom to produceantivenom , which is often the only effective treatment for potentially fatal snakebites.
In 1979, Australia's National Health and Medical Research Council formally adopted pressure immobilization as the preferred method of first aid treatment for snakebites inAustralia. [28] As of 2009, clinical evidence for pressure immobilization remains limited,with current evidence based almost entirely on anecdotal case reports. [28] This has ledmost international authorities to question its efficacy .[28] Despite this, all reputable firstaid organizations in Australia recommend pressure immobilization treatment; however, it
is not widely adhered to, with one study showing that only a third of snakebite patientsattempt pressure immobilization. [28]
Pressure immobilization is not appropriate for cytotoxic bites such as those inflicted bymost vipers ,[29][ 30] [31] but may be effective against neurotoxic venoms such as those of most elapids .[32] [33][ 34] Developed by medical researcher Struan Sutherland in 1978, [35] theobject of pressure immobilization is to contain venom within a bitten limb and prevent itfrom moving through the lymphatic system to the vital organs. This therapy has twocomponents: pressure to prevent lymphatic drainage, and immobilization of the bittenlimb to prevent the pumping action of the skeletal muscles .
Pressure is preferably applied with an elastic bandage, but any cloth will do in anemergency. Bandaging begins two to four inches above the bite (i.e. between the bite andthe heart), winding around in overlapping turns and moving up towards the heart, then
back down over the bite and past it towards the hand or foot. Then the limb must be heldimmobile: not used, and if possible held with a splint or sling. The bandage should beabout as tight as when strapping a sprained ankle. It must not cut off blood flow, or even
be uncomfortable; if it is uncomfortable, the patient will unconsciously flex the limb,defeating the immobilization portion of the therapy. The location of the bite should be
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clearly marked on the outside of the bandages. Some peripheral edema is an expectedconsequence of this process.
Apply pressure immobilization as quickly as possible; if you wait until symptoms become noticeable you will have missed the best time for treatment. Once a pressure
bandage has been applied, it should not be removed until the patient has reached amedical professional. The combination of pressure and immobilization may containvenom so effectively that no symptoms are visible for more than 24 hours, giving theillusion of a dry bite. But this is only a delay; removing the bandage releases that venominto the patient's system with rapid and possibly fatal consequences.
[edit ] AntivenomMain article: Antivenom
Until the advent of antivenom, bites from some species of snake were almost universallyfatal. [36] Despite huge advances in emergency therapy, antivenom is often still the only
effective treatment for envenomation. The first antivenom was developed in 1895 byFrench physician Albert Calmette for the treatment of Indian cobra bites. Antivenom ismade by injecting a small amount of venom into an animal (usually a horse or sheep) toinitiate an immune system response. The resulting antibodies are then harvested from theanimal's blood.
Antivenom is injected into the patient intravenously , and works by binding to andneutralizing venom enzymes. It cannot undo damage already caused by venom, soantivenom treatment should be sought as soon as possible. Modern antivenoms areusually polyvalent, making them effective against the venom of numerous snake species.Pharmaceutical companies which produce antivenom target their products against the
species native to a particular area. Although some people may develop serious adversereactions to antivenom, such as anaphylaxis , in emergency situations this is usuallytreatable and hence the benefit outweighs the potential consequences of not usingantivenom.
[edit ] Outmoded treatments
Old style snake bite kit that should NOT be used.
The following treatments have all been recommended at one time or another, but are nowconsidered to be ineffective or outright dangerous. Many cases in which such treatmentsappear to work are in fact the result of dry bites .
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• Application of a tourniquet to the bitten limb is generally not recommended.There is no convincing evidence that it is an effective first aid tool as ordinarilyapplied. [37] Tourniquets have been found to be completely ineffective in thetreatment of Crotalus durissus bites, [38] but some positive results have been seenwith properly applied tourniquets for cobra venom in the Philippines .[39]
Uninformed tourniquet use is dangerous, since reducing or cutting off circulationcan lead to gangrene , which can be fatal .[37] The use of a compression bandage isgenerally as effective, and much safer.
• Cutting open the bitten area, an action often taken prior to suction, is notrecommended since it causes further damage and increases the risk of infection.
• Sucking out venom, either by mouth or with a pump, does not work and mayharm the affected area directly .[40] Suction started after 3 minutes removes aclinically insignificant quantity—less than one thousandth of the venom injected
—as shown in a human study. [41] In a study with pigs, suction not only caused noimprovement but led to necrosis in the suctioned area .[42] Suctioning by mouth
presents a risk of further poisoning through the mouth's mucous tissues .[43] The
well-meaning family member or friend may also release bacteria into the victim'swound, leading to infection.• Immersion in warm water or sour milk, followed by the application of snake-
stones (also known as la Pierre Noire ), which are believed to draw off the poisonin much the way a sponge soaks up water.
• Application of potassium permanganate .• Use of electroshock therapy. Although still advocated by some, animal testing has
shown this treatment to be useless and potentially dangerous .[44][ 45] [46][ 47]
In extreme cases, where the victims were in remote areas, all of these misguided attemptsat treatment have resulted in injuries far worse than an otherwise mild to moderate
snakebite. In worst case scenarios, thoroughly constricting tourniquets have been appliedto bitten limbs, completely shutting off blood flow to the area. By the time the victimsfinally reached appropriate medical facilities their limbs had to be amputated .
[ edit ] Epidemiology
Map showing the approximate world distribution of snakes.
Map showing the global distribution of snakebite morbidity.
Most snakebites are caused by non-venomous snakes. Of the roughly 3,000 knownspecies of snake found worldwide, only 15 percent are considered dangerous to humans.[1] [4][ 48] Snakes are found on every continent except Antarctica .[1] The most diverse andwidely distributed snake family, the colubrids , has approximately 700 venomous species,[49] but only five genera — boomslangs , twig snakes , keelback snakes , green snakes , andslender snakes —have caused human fatalities. [49]
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Since reporting is not mandatory in many regions of the world, [1] snakebites often gounreported. Consequently, no accurate study has ever been conducted to determine thefrequency of snakebites on the international level. However, some estimates put thenumber at 5.4 million snakebites, 2.5 million envenomings, resulting in perhaps 125,000deaths. [1] Others estimate 1.2 to 5.5 million snakebites, 421,000 to 1.8 million
envenomings, and 20,000 to 94,000 deaths.[1]
Many people who survive bitesnevertheless suffer from permanent tissue damage caused by venom, leading to disability.[7]
Most snake envenomings and fatalities occur in South Asia , Southeast Asia , and sub-Saharan Africa , with India reporting the most snakebite deaths of any country. [1] In India almost all of these deaths are caused by the Big Four , consisting of the Russell's viper ,Indian cobra , saw-scaled viper , and the common krait . In Burma 80 percent of theapproximately 1000 deaths each year from snake bite are caused by the Russell's Viper .In the Neotropics , the lance-headed vipers inflict the majority of fatal bites, although of the many known species, only two, the common lancehead and terciopelo , are
responsible for most cases.[7][ 50]
The tropical rattlesnake is another important species.
In Africa, the puff adder is responsible for most fatalities, [51] although there are regionaldifferences, with the saw-scaled viper inflicting more bites in Northern Africa , where the
puff adder is not normally found. [50] Most bites occur in industrial plantations , whichattract many types of snake prey. Banana plantations are associated with vipers such asnight adders , while rubber and palm tree plantations attract elapids, including cobras and
black mambas .[6] There are also highly venomous colubrids in Africa, such as the boomslang .
In the Middle East, the snakes responsible for most bites tend to be more venomous than
European species, but deaths are rare, with some estimating perhaps 100 fatal bitesannually. [6] The coastal viper , Palestine viper , and Lebetine viper are the species involvedin most bites. [6] Larger and more venomous elapids, such as the Egyptian cobra , can also
be found throughout the Middle East.
In Europe, nearly all of the snakes responsible for venomous bites belong to the viper family, and of these, the nose-horned viper , asp viper , and Lataste's viper inflict themajority of bites. [6] Although Europe has a population of some 731 million people, snake
bites only kill about 30 people each year, largely due to wide access to health careservices and antivenom , as well as the relatively mild potency of many native species'venom. [6]
In Australia , the only continent where venomous snakes constitute the majority of species, [52] the Taipans , tiger snake and Eastern brown snake inflict virtually all reportedvenomous bites, [6] [52] with the latter responsible for perhaps 60% of deaths caused bysnakebite. [52] Although Australian snakes are highly venomous, wide access to antivenomhas made deaths exceedingly rare, with only a few fatalities each year.
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Most of the Pacific Islands are free of terrestrial snakes; [6] however, sea snakes arecommon in the Indian Ocean and tropical Pacific Ocean , but are not found in the AtlanticOcean or the Caribbean , Mediterranean or Red Seas .[14] While the majority of species liveclose to shorelines or coral reefs , the yellow-bellied sea snake can be found in the openocean. [14] Over 50% of bites inflicted by sea snakes, which are generally not aggressive,
occur when fishermen attempt to remove snakes which have become tangled in fishingnets. [14] [53] Symptoms may appear in as little as 5 minutes or take 8 hours to develop,depending on the species and region of the body bitten. [14] Although sea snakes are highlyvenomous, about 80% of reported bites end up being dry .[14][ 54] The advent of antivenomand advances in emergency medicine have reduced fatalities to about 3% of snakebitecases. [14]
Of the 120 known indigenous snake species in North America, only 20 are venomous tohuman beings, all belonging to the families Viperidae and Elapidae .[4] However, in theUnited States , every state except Maine , Alaska , and Hawaii is home to at least one of 20venomous snake species. [4] Most snakebite related deaths in the United States are
attributed to Eastern and Western diamondback rattlesnake bites.[4]
Further, the majorityof bites in the United States occur in the southwestern part of the country, in part becauserattlesnake populations in the eastern states are much lower. [55] The state of NorthCarolina has the highest frequency of reported snakebites, averaging approximately 19
bites per 100,000 persons. [20] The national average is roughly 4 bites per 100,000 persons.[20]
Worldwide, snakebites occur most frequently in the summer season when snakes areactive and humans are outdoors. [1][56] Agricultural and tropical regions report moresnakebites than anywhere else. [1] [50] Victims are typically male and between 17 and 27years of age. [4] [56][ 57] Children and the elderly are most likely to die. [4][25]
Bites by the European adder ,which is widespread and foundthroughout much of Europe andRussia , are relatively common;however, fatalities are very rare.
Startled snakes oftentake a defensive
posture, such as thiscottonmouth , and may hiss and bear their fangs in a threateningmanner. The yellow-lipped sea krait is a
timid but highly venomous seasnake common throughout Indo-Pacific oceanic waters.
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[ edit ] Society and cultureSee also: Serpent (symbolism)
According to tradition, Cleopatra VII famously committed suicide by snakebite to her left breast, as seen in this 1911 painting by Hungarian artist Gyula Benczúr .
Snakes were both revered and worshipped and feared by early civilizations. The ancientEgyptians recorded prescribed treatments for snakebites as early as the Thirteenthdynasty in the Brooklyn Papyrus , which includes at least seven venomous species
common to the region today, such as the horned vipers .[58]
In Judaism , the Nehushtan wasa pole with a snake made of copper wrapped around it, similar in appearance to the Rodof Asclepius . The object was considered sacred with the power to heal bites caused by thesnakes which had infested the desert, with victims merely having to touch it in order tosave themselves from imminent death.
Historically, snakebites were seen as a means of execution in some cultures. In medievalEurope , a form of capital punishment was to throw people into snake pits , leaving victimsto die from multiple venomous bites. A similar form of punishment was common inSouthern Han during China 's Five Dynasties and Ten Kingdoms Period and in India .[59]
Snakebites were also used as a form of suicide, most notably by Egyptian queenCleopatra VII , who reportedly died from the bite of an asp —likely an Egyptian cobra [58] [60] —after hearing of Mark Antony 's death.
Snakebite as a surreptitious form of murder has been featured in stories such as Sir Arthur Conan Doyle 's The Adventure of the Speckled Band , but actual occurrences arevirtually unheard of, with only a few documented cases. [59] [61][ 62] It has been suggested thatBoris III of Bulgaria , who was allied to Nazi Germany during World War II , may have
been killed with snake venom, [59] although there is no definitive evidence. At least one
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attempted suicide by snakebite has been documented in medical literature involving a puff adder bite to the hand. [63]
[ edit ] See also
• Antivenom• List of victims of fatal snake bites in the United States• Medical emergency• Ophidiophobia• Snake attacks in Australia• Snake-stones• Snake venom• Venomous snakes• Wilderness first aid
Burns and Scalds
A burn is an injury caused by:
a. Dry heat, such as fire, a piece of hot metal or the sun.b. Contact with any object charged with a high tension electric current; or by lightning.c. Friction, for example, by contact with a revolving wheel (brush burn) or fast-movingrope or wire.d. Corrosive chemicals:(i) Acids, such as sulphuric, nitric and hydrochloric.(ii) Alkalis, such as caustic soda, caustic potash, strong ammonia or quicklime.
A scald is an injury caused by moist heat, such as boiling water, steam, improperlyapplied poultice, hot oil or tar. The effects of a burn or scald are the same. There may bereddening of the skin or blister formation or destruction of the skin or deeper tissues. Painis very severe in second degree burns.
Degree of BurnsFirst degree burns: There is only reddening of skin without damage to deeper tissues.Second degree burns: Second degree burns often result in vesication and exposure of nerve endings and are most painful in nature.Third degree burns: Here even the nerves are burned off. These burns are not painful,
but life threatening as they inevitably cause shock.
The dangers of a burn increase with its surface area (even if it is only superficial) and if one-third or more of skin area is involved, the condition of the patient can be described ascritical. In small children and especially in infants, even small burns should be regardedas serious injuries and medical aid sought without delay.
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Immediate treatment for a burn patient
1. If a person's clothing catches fire, approach him holding a rug, blanket, coat etc.and wrap it around him, lay him flat and smother the flames.
2. If a person catches fire, when he is alone, he should roll on the floor, smothering
the flames with the nearest available wrap and call for assistance, on no accountshould he rush into the open air.3. Immerse the affected area in cold water for at least 10 minutes. Alternatively
cover the area with a thick clean cloth soaked in water. Keep it damp.4. Avoid handling the affected area more than is necessary. See that your hands are
thoroughly washed as burnt area is highly prone to infectious micro-organisms.5. Do not apply lotions of any kind.6. Do not remove burned clothing adherent to the burned skin and do not attempt to
break blisters.7. Cover the burnt area with a clean dry dressing and guard against stock by keeping
the patient warm.
8. Lay the patient down and remove anything which might constrict, if the burnt areaswells.9. Don't apply any creams or ointment to burnt area.10. If a limb is burned, keep it elevated to reduce swelling.11. Burns offer an exception to the general first aid rule of not giving anything by
mouth to the injured person. The burn patient should be give half a glassful of slightly sweetened tepid water, every 15 or 20 minutes. These liquids helps toreplace body fluids that have been lost as a result of plasma loss caused by the
burn and reduces the risk of development of shock.12. If there is possibility that medical help will be delayed, give the patient half a
glass of salt and soda solution (half teaspoon table salt + half teaspoon baking
soda per litre/2 pints of water). Give a child about two fluid ounces and an infantabout 1 fluid ounce. Discontinue fluids if vomiting occurs or if the patientindicates that he does not feel well.
13. Remove the patient to a hospital, as quickly as possible.
Burns by Corrosive ChemicalsWhen the corrosive is an acid:
1. Thoroughly flood the burnt part with water.2. Bathe the part freely with an alkaline solution such as two teaspoons of baking
soda or washing soda in one pint of warm water.
When the corrosive is an alkali:
1. Thoroughly flood the part with water.2. Bathe the part freely with a weak acid solution, such as vinegar or lemon juice
diluted with an equal quantity of water.
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SunburnSerious discomfort and even superficial burns with blister formation can be caused bydirect rays of the sun. In hot countries even short periods of exposure to the midday suncan cause quite severe bums. If need be, the general rules for the treatment of burns andscalds should be applied by the First Aider.
Burns
Published by Bupa's health information team, May 2009.
This factsheet is for people who have been burned, or who would like information about burns.
A burn is an injury to the skin tissue, usually caused by contact with intense heat,electricity or chemicals. Recognising different types of burns and having a basicknowledge of how to treat them can minimise scarring and even save lives.
• About burns• Symptoms of burns• Causes of burns• Diagnosis of burns• Treatment of burns• Questions and answers• Related topics• Further information• Sources
About burns
Around 175,000 people every year visit the accident and emergency department for burninjuries and 16,100 are admitted to hospital. Burns usually affect the skin, but other body
parts can be injured, such as the airways and lungs, from inhaling hot fumes and gases.
Types of burn
The severity of your burn depends on how deeply it has affected the skin tissue (see
illustration). There are three types of burn: superficial, partial-thickness and full-thickness.
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The layers of skin
Superficial burns
Superficial burns only affect the surface of the skin (epidermis). Your skin will be redand painful, but not blistered. Mild sunburn is an example of a superficial burn.
Partial-thickness burns
Partial-thickness burns are deeper burns that damage your epidermis and dermis tovarying degrees. If the damage to your dermis is shallow, your skin may be pale pink and
painful, with blisters. Deeper burns to your dermis will cause your skin to become dry or moist, blotchy and red. Deep partial-thickness burns can be painful or painless and may
blister.
Full-thickness burns
All layers of your skin are damaged by full-thickness burns. Your skin will be white, brown or black and dry, leathery or waxy. Because the nerves in your skin are destroyedwith full-thickness burns, you won't feel any pain or have blisters.
Symptoms of burns
If you're burned, you may have symptoms such as:
• changes in skin colour - burns can cause pink, red, white, brown and black skin• blisters• pain in the burned area - but pain from burns isn't related to severity
Symptoms of an airway burn include:
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• burned nose hairs• soot in your mouth or nose• change in your voice• sore throat• wheezing
If you have been burned and have any of these symptoms, you should seek advice fromyour GP.
Causes of burns
Burns are caused by:
• dry heat (fire)• wet heat (steam or hot fluids)• radiation (sun)•
heated objects• extreme cold• inhaling smoke or toxic fumes, particularly from chemical explosions or house
fires• electricity• chemicals
Diagnosis of burns
Most burns are easily diagnosed - you will know when you have burned yourself.Determining the cause, size and thickness of your burn, and whether you have inhaled
smoke or chemical fumes, will be your doctor's main concern.
Your doctor will ask you about your symptoms and examine you. He or she may also ask you about your medical history.
Treatment of burns
Treatment for burns depends on their severity. You can treat superficial and minor partial-thickness burns caused by heat at home. However, seek medical help:
• all deep partial-thickness and full-thickness burns• all chemical and electrical burns• superficial and partial-thickness burns covering an area larger than the palm of
your hand• burns that cover a joint or are on the face, hands, feet or groin• all airway or suspected smoke inhalation burns• advice if you're not sure about the extent of the burn or how to deal with it
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For full-thickness burns or burns caused by chemicals or electricity, call for emergencyhelp. While waiting, valuable treatment can be given.
• For burns caused by heat, carefully remove any restricting clothing or jewellerythat isn't stuck to the burn. Flood the burn with cool (not cold) water until medical
help is available.• For burns caused by chemicals, remove any affected clothing. Brush the chemicaloff your skin if it's a dry powder and flood the burn with cool (not cold) water.Don't try to neutralise the chemical with another chemical.
Home treatment
Superficial and minor partial-thickness burns can be treated at home. Begin by floodingyour burn with cool (not cold) water for 10 to 30 minutes or until the pain is relieved.
Ointments or creams may help superficial burns like sunburn, but don't apply them to any
deeper burns that have caused a change in your skin colour or blisters. Always ask your pharmacist for advice before applying ointments or creams.
Don't burst any blisters that form on your burn. Covering a partial-thickness burn withkitchen clingfilm may reduce pain and speed healing. Ask for advice as soon as you canfrom your practice nurse or local accident and emergency department.
Over-the-counter painkillers, such as paracetamol or ibuprofen, may also help. Alwaysread the patient information that comes with your medicine and if you have anyquestions, ask your pharmacist for advice.
Superficial and shallow partial-thickness burns usually heal within three weeks, withminimal scarring.
Hospital treatment
If you're severely injured over large areas of your body with partial- and full-thickness burns, you will be admitted to hospital. Your doctors will continue first aid measures and protect your damaged skin with dressings. They will also give you medicines for any pain.
Healthy skin prevents loss of fluid from the tissues underneath and is a very effective
barrier to infection. These functions are lost after your skin is severely burned. If infection is suspected, you will be given antibiotics. If large quantities of fluid are lostthrough your burned skin, this can seriously affect your heart and circulation. You will beclosely monitored and may need to have fluids through a drip to help your circulation.
You may be referred to a specialist burn unit. Full-thickness burns tend to result in scarsthat can be difficult to treat and you may require skin grafts to minimise scars. Skin grafts
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are performed by plastic surgeons. Skin from an unaffected part of your body will beused to repair any of your burned skin that can't heal itself.
You may need counselling to help deal with the effects of burn scars or physical therapyto regain movement in your burned areas.
Burns Q&As
See our answers to common questions about burns , including:
• What's the best way to protect my children from being accidentally burned?• What are the potential complications of being severely burned?• What are burn clubs and camps?
Related topics
• Sun care
Further information
• British Burn Association0161 291 6321www.britishburnassociation.co.uk
• British Red Cross0844 871 1111www.redcross.org.uk
• Changing Faces0845 450 0275www.changingfaces.org.uk
• Children's Fire and Burn Trust020 7233 8333www.childrensfireandburntrust.org.uk
Sources
• Standards and strategy for burn care: a review of burn care in the British Isles.British Burns Association (National Burn Care Review Committee). 2005.www.bapras.org.uk
• Burns and scalds. Clinical Knowledge Summaries. http://cks.library.nhs.uk ,accessed 1 September 2008
• Longmore M, Wilkinson IB, Rajagopalan S. Oxford handbook of clinicalmedicine. 6th ed. Oxford: Oxford University Press, 2005:834-835
• Simon C, Everitt H, Kendrick T. Oxford handbook of general practice. 2nd ed.Oxford: Oxford University Press, 2007:1076-1077
• Wasiak J, Cleland H. Burns (minor thermal). BMJ Clinical Evidence.www.clinicalevidence.com , accessed 1 September 2008
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• McLatchie GR, Leaper DJ. Oxford handbook of clinical surgery. 2nd ed. Oxford:Oxford University Press, 2002:497-502
• Rehabilitation overview. British Burn Association.www.britishburnassociation.co.uk , accessed 1 September 2008
This information was published by Bupa's health information team and is based onreputable sources of medical evidence. It has been peer reviewed by Bupa doctors. Thecontent is intended for general information only and does not replace the need for
personal advice from a qualified health professional.
Publication date: May 2009
Burns and Scalds
Following a burn or scald, make sure you and the affected person are safe fromfurther burns or danger - then cool a burnt or scalded area immediately with coolwater (preferably running water) for at least 20 minutes. This leaflet also givesfurther advice.
First aid for burns and scalds
Safety first
If possible, or if required:
• Stop the burning process and remove any sources of heat.• Douse flames with water or smother with a blanket. If the victim's clothing is
burning roll the victim on the ground to smother the flames.• Remove clothes that are over the burn. Clothing can retain heat, even in a scald
burn, and so should be removed as soon as possible. However, do not pull off clothing that has stuck to the skin. This may cause skin damage.
• Tar burns should be cooled with water, but do not remove the tar itself.• For electrical burns - disconnect the victim from the source of electricity before
attempting first aid. If you cannot switch off the electricity:o If the person has been injured by a low-voltage source (220-240 volts,
domestic electricity supply) then remove the person from the electricalsource using a non-conductive material such as a wooden stick or woodenchair.
o Do not approach a person connected to a high-voltage source.• For chemical burns - remove affected clothing. Brush the chemical off the skin if
it is in a dry form. Then wash the burn with lots and lots of water as described below. Do not attempt to neutralise chemicals.
Cool the burnt area immediately with cool or tepid water
Preferably, use running water, for at least 20 minutes. For example, put the burnt areaunder a running tap. A shower or bath is useful for larger areas. Note : do not use very
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cold water or ice, as too cold can damage the skin. Ensure the person is otherwise keptwarm to avoid hypothermia. Chemical burns should be irrigated (washed) with lots of of water and for longer than 20 minutes. (Take advice from a doctor, if possible, as to howlong to keep washing a chemical burn.)
Remove rings, bracelets, watches, etc, from the affected areaThese may cause tightness or constriction if any swelling occurs.
Cover the burn - ideally with cling film
Cling film is ideal to cover a burn as is sterile, as long as the first few centimetres arethrown away and not used. Also, it also does not stick to skin, a doctor can see through itto assess the burn, it is protective, and it is soothing. A clear plastic bag is an alternativeif no cling film is available. Leave cling film on until seen by a doctor or nurse.Important : apply cling film in layers rather than round like a bandage to prevent it
causing pressure if the burnt area swells. So, for example, never wrap cling film roundand round a burt arm or leg. A burnt hand can be put into a loosely fitting clear plastic bag.
Give painkillers
Paracetamol or ibuprofen may help to ease pain for small burns. A doctor may givestronger painkillers, if required.
Do not do the following:
• Prick any blisters. (A doctor or nurse may decide to 'de-roof' larger blisters toassess skin damage, but it is best not to pick smaller blisters unless advised by adoctor.)
• Apply creams, ointments, oils, grease, etc. (The exception is for mild sunburn. Amoisturiser cream or calamine lotion may help to soothe this.)
• Put on an adhesive, sticky, or fluffy dressing.
Types of burn
• Superficial burns affect the top layer of skin only. The skin looks red and ismildly painful. The top layer of skin may peel a day or so after the burn, but theunderlying skin is healthy. It does not usually blister or scar. A good example ismild sunburn.
• Partial thickness burns cause deeper damage. The skin forms blisters and is painful. However, some of the deeper layer of skin (the dermis) is unharmed. Thismeans the skin usually heals well, sometimes without scarring if the burn is nottoo extensive.
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• Full thickness burns damage all layers of skin. The skin is white or charred black.There may be little or no pain as the nerve endings are destroyed. These oftenrequire skin grafting.
• Electrical burns can cause damage inside the body even if there is little damage tothe skin.
Note : a single burn from one accident may have various types of burn. For example,some areas of the burnt skin may be superficial, some partial thickness, and some fullthickness.
Home care, or should I get medical help?
See a doctor or nurse if you are unsure about what to do after a burn. However, you may be happy to manage small, mild (superficial) burns at home. Mild sunburn, small mild burns, or mild scalds are best left uncovered. They will heal more quickly if left to thefresh air. Even a small blister is best left uncovered to heal. If the blister bursts, you can
use a dry, non-adhesive, non-fluffy sterile dressing. This will soak up the weeping blister,and stop dirt and germs getting into the wound. However:
See a doctor or nurse as soon as possible if:
• The burn becomes infected. Infection causes a spreading redness from the burn,which becomes more painful.
• You are not up to date with tetanus immunisation.• Blisters occur. You may be happy to deal with a small burn with a small blister.
However, a blister means a partial thickness burn, and it may be best to see adoctor or nurse.
Go straight to casualty (after cooling with water and first aid) for thefollowing:
• Electrical burns.• Full thickness burns - even small ones. These burns cause white or charred skin.• Partial thickness burns on the face, hands, arms, feet, legs, or genitals. These are
burns that cause blisters.• Any burn that is larger than the size of the hand of the person affected.• If you suspect smoke inhalation (breathing in smoke or fumes). The effects on the
lungs from smoke inhalation may be delayed by a few hours so a person may
appear OK at first. Symptoms such as sore throat, cough, wheeze, singed nasalhair, facial burns or breathlessness may suggest there may have been smokeinhalation.
Cover the burn with cling film or a clean plastic bag before going to casualty (asdescribed earlier).
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Common causes of burns
Nearly half of severe burns and scalds occur in children under five years. About half of these accidents happen in the kitchen, with scalds from hot liquids being the mostcommon. Many accidents involve the child reaching up and pulling on a mug or cup of
hot drink. Other common causes include children falling or climbing into a bath of veryhot water, and accidents with kettles, teapots, coffee-pots, pans, irons, cookers, fires andheaters.
Tips on preventing burns - particularly to children
Preventing scalds and burns
• Keep young children out of the kitchen unless they are fully supervised.• The front of the oven, and even the washing machine, can become hot enough to
burn a young child. Keep them away.• Use the back rings of cookers when possible. Turn pan handles towards the back
and away from where a child may reach and grab.• Never drink hot drinks with a baby or child in your lap.• Never let a child drink a hot drink through a straw.• Teach older children how to boil kettles and how to use the cooker safely. There
is no right age for this. Every child is different. However, it is important to teachthem correctly when the time is right rather than let them find out for themselves.
• Never heat up a baby's milk in a microwave. It may heat the milk unevenly, andsome parts may become very hot. Stir baby food well if it is heated in amicrowave.
• Put cold water in the bath first, and then bring up the temperature with hot water.• Do not set the thermostat for hot water too high in case children turn on the hot
tap.
Preventing fires
• Fit smoke alarms in every floor of the home and check them regularly.• Use fireguards for fires and heaters. Do not dry or air clothes on fireguards.• Shut all doors at night. This prevents any fire from spreading.• Store matches away from children. Teach older children how to use matches
correctly and safely. Do not just let them experiment and find out for themselves.• Have a fire blanket in the kitchen.• Do not leave chip pans unattended, and they should never be more than a third
full with oil. Some people argue that you should get rid of any chip pansaltogether as they are a major cause of kitchen fires.
Preventing sunburn
• Keep children out of hot sun, particularly between 11 am and 3 pm.
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• When out in the sun, remember: Slip, Slap, Slop - slip on a shirt, slap on a hat,and slop on some high protection sunscreen.
References
• Burns and Scalds , Clinical Knowledge Summaries (2007)• Hudspith J, Rayatt S ; First aid and treatment of minor burns. BMJ. 2004 Jun
19;328(7454):1487-9.• Enoch S, Roshan A, Shah M ; Emergency and early management of burns and
scalds. BMJ. 2009 Apr 8;338:b1037. doi: 10.1136/bmj.b1037.
Comprehensive patient resources are available at www.patient.co.uk
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professional for diagnosis and treatment of medical conditions. For details see our conditions .© EMIS 2009 Reviewed: 23 Jul 2009 DocID: 4419 Version: 38
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