Investigating pressure bandaging for snakebite in a simulated setting: Bandage type, training and the effect of transport

Charles Darwin University, Palmerston, Northern Territory, Australia
Emergency medicine Australasia: EMA (Impact Factor: 1.3). 07/2009; 21(3):184-90. DOI: 10.1111/j.1742-6723.2009.01180.x
Source: PubMed


The clinical evidence base for the use of pressure bandaging in snakebite is limited. We aimed to investigate if pressure bandages (PB) generated and maintained presumptive optimal pressures in a simulated setting.
A total of 96 subjects were recruited, 78 health professionals and 18 from the general public. Participants were asked to apply PB with crepe and with an elasticized bandage without instruction. A paediatric blood pressure cuff attached to a pressure transducer was used to measure the pressure generated. PB application with elasticized bandages was repeated by 36 participants (18 general public and 18 health professionals) with feedback on pressures attained, and reassessment on the sixth subsequent attempt. Pressure was also measured under correctly applied bandages during an ambulance ride.
The median pressure generated under crepe bandages was 28 mmHg (interquartile range [IQR]: 17-42 mmHg) compared with 47 mmHg (IQR 26-83 mmHg) with elasticized bandages, with most subgroups applying the elasticized bandage closer to the estimated optimal pressure (55-70 mmHg). Following training, the median pressure for the 36 participants was 65 mmHg (IQR 56-71 mmHg), closer to the optimal range than initial attempts. On initial bandaging, 5/36 (14%) participants achieved optimal pressure range with elasticized bandages, compared with 18/36 (50%) after training (P = 0.002). Crepe bandages initially correctly applied did not maintain desired pressure during ambulance transport on urban roads over 30 min. Elasticized bandages maintained pressure.
PB was poorly done by the general public and health professionals. Crepe bandages rarely generated optimal pressures compared with elasticized bandages, but training did improve participants' ability to apply elasticized bandages. PB recommendations should be modified to specify appropriate bandage types.

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    • "Norris et al. (2005) noticed difficulties in the application of precise pressure between the bandage and skin, even when applied by health professionals. Canale et al. (2009) reported an improvement in the ability to apply elasticized bandage, after training. To improve the ability to apply recommended methods, the widely used and safer first aid techniques (PIB and LCPI) should be taught in schools and universities in Nepal. "
    Pandey · D. P · Khanal · B.P ·
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    ABSTRACT: In previous studies in Nepal, snakebite victims were found to either not have Pressure Immobilization Bandaging (PIB) or Local Compression Pad Immobilization (LCPI) performed for first aid, or had it performed incorrectly. The goal of this study was to evaluate training texts regarding first aid measures for snakebite and the rates of performance of both methods currently recommended, as well as ineffective or harmful practices. The study was conducted from September, 2009 to November, 2010. It evaluated the venomous snakebite first aid measures recommended in the 31 most recently published and commonly used Nepalese reference works and textbooks aimed at paramedical personnel, primary health care workers, medical undergraduates, and students of class five to bachelor´s degree. It compared the suggestions of these with those of published guidelines for the management of snakebite envenomation. Up to 100% of first aid measures advocated in these materials differed significantly from published guidelines. This included the omission of appropriate activities, misstatements and prescription of inappropriate treatments. Among appropriate recommendations that were missing was the advice to apply PIB or LCPI, and the suggestion to go to a snakebite treatment center. Fifty-five percent of the references did recommend emergency transport. Inclusion of accurate evidence-based information regarding first aid measures for venomous snakebite in commonly used texts could help to reduce the application of ineffective or harmful pre-hospital practices, their associated morbidity and mortality, and increase the use of appropriate methods.
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    • "Moreover, its efficacy remains controversial (Blaylock, 1994). In a recent study in Australia showed that the crepe bandage rarely generated optimal pressures compared with elasticized bandages (Canale et al., 2009). However, WHO has prescribed same first aid techniques till date. "
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    ABSTRACT: A study in Nepal noted that victims did not have pressure immobilization bandage (PIB) and local compression pad immobilization (LCPI) performed or performed incorrectly, despite of public health efforts advocating its use and its inclusion in textbooks. Hence, this study was aimed to determine the reasons why this first aid measure had not been adopted. Sixteen textbooks were analyzed. Between 60 and 100% of first-aid measures advocated differed significantly from published guidelines, including omissions of appropriate activities and commissions of recommending inappropriate treatment. Seven of the errors were felt to be common and serious omissions or misstatements that have the potential to cause harm to patients. The most common failing of the guidelines commonly used in Nepal was the omission of World Health Organization (WHO) recommended first aid measures that include the application of a PIB or LCPI. A simple and cost-effective public health education course given to Community Health Volunteers in Nepal reduced paediatrics fatality rate by 61% over the past decade by promoting mothers to go to nearest health post if their baby gets ill. Similarly, snakebite mortality rate can be reduced by emendation of curriculum in school and universities, rapid transport of snakebite victim to and management at a hospital. The use of accurate published materials in the teaching of snakebite first-aid and subsequent snakebite management would likely further increase the appropriate management of snakebite and reduce its morbidity and mortality.
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    • "La technique de pression-immobilisation, développée par les équipes australiennes, est préconisée pour les élapidés et Bothrops lanceolatus. Elle consiste à poser précocement un bandage comprimant le réseau lymphatique mais respectant les pouls distaux [33] [34]. Elle est à discuter en revanche en cas de syndrome vipérin car elle peut alors favoriser après installation de l'oedème une ischémie du membre et la concentration d'enzymes protéolytiques. "
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    ABSTRACT: Snakebites are an underestimated public health problem, affecting mainly sub-Saharan Africa and South Asia. In France, while the prevalence is low, the keen interest for exotic pets increases the risk of severe envenomation by exotic species. Mostly due to viperidae, viperin syndrome associates haemostasis disorders and local syndrome (pain, swelling and necrosis). The haemostasis disorders are due to venom-induced consumption coagulopathy (VICC) that is different from disseminated intravascular coagulation; and cause local and diffuse bleedings. The elapidae are responsible for cobraïc syndrome, resulting from the action of neurotoxins and respiratory paralysis. Other syndromes include: circulatory failure, acute renal failure, cardiotoxic and myotoxic damage. These syndromes can be associated into a multimodal clnical syndrome. Ophidian envenomation is a real medical emergency, requiring sometimes resuscitation in the field (fluid resuscitation, oro-tracheal intubation and artificial ventilation). Hospital admission must be systematic in order to administer antivenom, the only etiological treatment, that is used according to a severity score. Combination with fresh frozen plasma allows to more rapidly stop VICC. In contrast, heparin is not indicated during the acute phase.
    Le Praticien en Anesthésie Réanimation 09/2010; 14(4):254-263. DOI:10.1016/j.pratan.2010.07.010
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