Prehospital Care Practices for Venomous Snakebites in Resource‑limited Settings: A Narrative Review

Abstract

Venomous snakebite is a medical emergency encountered worldwide, especially in resource‑limited communities. It usually leaves victims at the mercy of traditional care, whose effectiveness have come under scrutiny over time. Several of these traditional/first aid practices have also been reported over time. Controversies over their efficacy often result in confusion among snakebite victims, their caregivers, and sometimes, among health‑care providers. This narrative review describes reported prehospital interventions for venomous snakebites highlighting their usefulness, dangers, and/or limitations associated with their use and the currently widely recommended prehospital activities for venomous snakebite.

Full text

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© 2017 Archives of Medicine and Health Sciences | Published by Wolters Kluwer ‑ Medknow
Review Article
iNtroductioN
Snakebite is a common and neglected public health problem
worldwide and an important cause of injury and death in
developing countries.[1] Despite the problem of underreporting,
recent estimates suggest that between 1.2 and 5.5 million
snakebites, as high as 1.8 million envenoming and 94,000
deaths occur yearly; most of these events occur in rural tropical
regions of Asia, Sub‑Saharan Africa, and South America.[2] The
most affected communities are usually ravaged by poverty
and deprivation.[3] The challenges of antivenom scarcity,[4‑8]
poor health services,[1] lack of rapid access to healthcare,[1]
poor training of health workers on snakebite management,[1,2,9]
utilizationofinappropriateeld/rstaidmeasures,[10] long
delays before receiving proper treatment,[1,11,12] and ineffective
snakebite prevention programs[1,4,9] have been identied as
contributing to high snakebite morbidity and mortality. First
aid following snakebite is given to delay systemic absorption
and spread of venom while expediting the transport of victim
to an appropriate medical facility.[13]Severalprehospital(rst
aid/traditional) practices for snakebite have been described.
While a majority of these practices have been described as
controversial, ineffective, or dangerous, many including
healthcareprovidershavejustiedtheiruseeveninthepresent
day practice. This confusion may be responsible for the
continuous patronage of many of these practices by snakebite
victims and their caregivers who often have limited care
options at the time of bite to save theimselves or the lives of
their loved ones. In addition, there are different snake families
and species which differ with geography and their venom
components.[14] This makes the use on prehospital or hospital
treatment for all snakebites inappropriate and ineffective. We
therefore reported prehospital practices for snakebite, their
dangers, and their usefulness in resource‑limited settings in
the hope that it could provide useful information resource for
thosewhoteachaboutsnakebiterstaidandthosewhocare
for snakebite victims.
Materials aNd Methods
Google scholar was the major search engine used for research
and review articles up to December 2015. We also searched
Nigerian journals that are not indexed and also contacted
Nigerian experts in snakebite for potential articles. The search
termsusedweresnakebite,snakebiterstaid,traditionalcare
for snakebite, and prehospital care of snakebite. Articles used
Prehospital Care Practices for Venomous Snakebites in
Resource‑limited Settings: A Narrative Review
Godpower Chinedu Michael, Ibrahim Aliyu1, Bukar Alhaji Grema, Niongun Lawrence Paul De‑Kaa2
Department of Family Medicine, Aminu Kano Teaching Hospital, 1Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, 2Department of Family Medicine,
Federal Medical Centre, Makurdi, Benue State, Nigeria
Venomous snakebite is a medical emergency encountered worldwide, especially in resource‑limited communities. It usually leaves victims at the
mercyoftraditionalcare,whoseeffectivenesshavecomeunderscrutinyovertime.Severalofthesetraditional/rstaidpracticeshavealsobeen
reportedovertime.Controversiesovertheirefcacyoftenresultinconfusionamongsnakebitevictims,theircaregivers,andsometimes,among
health‑care providers. This narrative review describes reported prehospital interventions for venomous snakebites highlighting their usefulness,
dangers, and/or limitations associated with their use and the currently widely recommended prehospital activities for venomous snakebite.
Keywords: First aid, prehospital care, rural, snakebite, traditional care
Access this article online
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DOI:
10.4103/amhs.amhs_93_17
Abstract
Address for correspondence: Dr. Godpower Chinedu Michael,
Department of Family Medicine, Aminu Kano Teaching Hospital, Zaria Road,
P.M.B. 3452, Kano, Nigeria.
E‑mail: drgcmichael@gmail.com
How to cite this article: Michael GC, Aliyu I, Grema BA, Paul De‑Kaa NL.
Prehospital care practices for venomous snakebites in resource‑limited
settings: A narrative review. Arch Med Health Sci 2017;5:237‑41.
This is an open access arcle distributed under the terms of the Creave Commons
Aribuon-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
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Michael, et al.: Pre-hospital care practices for venomous snakebites
238 Archives of Medicine and Health Sciences ¦ Volume 5 ¦ Issue 2 ¦ July‑December 2017
were mainly from affected areas such as Africa, Asia, and the
United States.
discussioN
Epidemiology of snakebite
Snakes are found all over the globe except in the permanently
frozen Arctic and Antarctic regions. There are about three
thousand species of snakes worldwide, but only about 15%
are poisonous to man.[15,16] Based on their morphological
characteristics including arrangement of scales, dentition,
osteology, myology, and sensory organs, venomous snakes
are categorized into families.[17]Therearevemainfamilies
of venomous snakes, namely, Elapidae, Viperidae, Colubridae,
Hydrophiidae, and Atractaspididae.[16,18]
In Sub‑Saharan Africa, 30 species are responsible for an
estimated one million snakebites annually, resulting in
100,000–500,000 envenoming and 10,000–30,000 deaths;
they belong to four families of venomous snakes, namely,
Viperidae, Elapidae, Colubridae, and Atractaspididae.[2,19]
The highest incidence of snakebite in Africa is in the West
African savanna region. The African situation is replicated
in Nigeria but only three species, the West African carpet
viper (Echis ocellatus), puff adder (Bitis arietans), and spitting
cobra(Najanigricollis), belongingtothe rsttwofamilies,
are the most important snakes associated with envenoming in
the region.[19] E. ocellatus alone accounts for 90% of the bites
and 60% of the deaths in Nigerian savanna.[20] Most bites in
developing countries are “hazardous snakebites” (occurring
when humans encounter a snake accidentally) in contrast
with “illegitimate” bites which occur when humans are bitten
by snakes kept in captivity or during handling, an increasing
scenario in developed nations.[1] However, most snakebites
worldwide occur at peak periods of agricultural activities, but it
is also associated with herding, walking barefooted along bush
paths, hunting, snake charming, and among zoo attendants.[1]
Snakebite occurs in all sexes and age groups, but young active
males are most vulnerable.[21‑23]
Prehospital practices for snakebite
First aid is carried out immediately or very soon after the bite
before the victim reaches medical facility. It can be performed
by the victim or anyone who is present. The aim is to attempt
to delay systemic absorption and spread of toxin, preserve life,
minimize local damage and infection, expedite transport to
medical facility, and above all, do no harm.[13,24] Historically,
severaltraditionalpracticeshavebeengiven as rst aid or
denitivetreatment.Someofthesetraditional interventions
are still in use today in many rural communities of the world
wheresnakebiteisrife.However,therehavebeenjustication
and condemnation of virtually every recorded intervention.[25]
Incantations
The practice of chanting incantations after snakebite has been
tradition in many parts of rural Asia and Africa for the relief of
symptoms. This was documented by Bhetwal et al. in Nepal.[26]
Similarly, among some inhabitants in rural North‑central Nigerian
communities, there is the belief that “izuwa” (the local name
for carpet vipers)[10] are evil spirits sent by the enemy to kill the
victim. Hence, the need to counter the toxin effects using higher
powers. It is only when incantations have been done and found
ineffective that victims are taken to hospital. No study has proved
thatincantationsareeffectiverstaidortreatmentforsnakebite.
Bite site suction
Among the heritage of several folk and traditional practices
for snakebite in India is the use of anal sphincter of chicken
to suck out venom from snakebite wound.[26] The exact mode
of action of this chicken sphincter is not known, and hence,
itsefcacywasonlyleftinthemindsofthosewhopracticed
it. Similarly, suction of venom from the bite wound using
devices such as the Sawyer extractor has been discouraged
becauseofnoprovenbenetsfollowingarticialenvenoming
and application of the extractor; there is also a potential for
local skin necrosis if applied for too long.[27‑30] However, some
reportshaveadvancedsomebenetsifthevenomextractoris
used within 5 min of the bite and left in place for 30 min and
that it is capable of removing up to 35% of venom;[31,32] its
use immediately after a bite precludes their use in many rural
communities where they are not readily available. Similarly,
oral suction has also been reported; this may confer a risk to
the caregiver who can have venom absorption through the
oral mucosa. It may also introduce oral microorganisms into
the bite wound and increase the risk of wound infection.[33]
Blackstone application
BlackorsnakestoneoriginatinginIndiaisawidelyusedrstaid
in Asia and Africa as well as in some Latin American countries.[34]
By traditional instructions, the black stone is applied on the bite
site, where it strongly adheres and believed to extract the venom.
It spontaneously detaches after venom extraction is complete. The
blackstonecanberegeneratedandusedindenitelybyboiling
it in milk.[34] Its use is controversial. Earlier clinical arguments
for its use in literature derived mostly from anecdote rather
thanactualscienticdemonstrationofblackstonesefcacy.[35]
However, Chippaux et al. found that local application of black
stone after intramuscular venom injection had no demonstrable
effect on the outcome of envenoming by B. arietans, E. ocellatus,
andN.nigricollisandthereforeconcludedthatnoclinicalefcacy
may be expected of black stone.[36]
Topical application and ingestion of herbs
The topical application and/or ingestion of extracts (mithridates,
lexins, tiriyaq, and latex) from a climbing plant known as the
snake guard have been described in India.[26] Root extract of
Abrus precatorius and leaf paste of Azadirachta indica have
also been used against krait bite and viper bites, respectively,
while extracts from Casearia sylvestris (guacatonga) are
local remedies for snakebite in Columbia and India.[37] Early
studies on some plants/herbs that have been used as snakebite
antidotesbyKnowlesshowednoefcacyagainstsnakebite
envenoming.[38] However, later studies showed that some
fractions of Aristolochia species neutralizes Naja naja venom
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Michael, et al.: Pre-hospital care practices for venomous snakebites
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andreduceshemorrhagefromTrimeresurusavoviridisand
Vipera russellii venoms.[39,40] A 4‑year retrospective prevalence
study in a hospital in northeast Nigeria reported the use of
unidentiedherbsby victims;however,2.9% ofthosewho
ingested herbs had jaundice.[21] Furthermore, Michael et al.
reportedtheuseofunidentiedherbs(eithertopicallyapplied
and/or ingested) by snakebite victims in north central Nigeria;
this was found to be associated with increased risk of dying
or having disability, delayed arrival in hospital, high cost of
hospitalization, and wound infection.[10] Other materials that
have been used in combination with herbs include scrapings
from crocodile teeth or saliva of a fasting man,[41] all of which
havenotbeenproperlystudiedtoascertaintheirefcacy.
Bite site incision
Incisions or tattooing on the bite area with sharp objects (such
as knife and razor) to bleed or enlarge the wound to increase
bloodowhavebeenreportedbymanyworkers.[10,42‑46] Its use
asrstaidiscontroversial.Somereportshaverecommended
its use only when prompt medical treatment is >30 min away[46]
or based on experimental and anecdotal experiences;[47] others
have shown that the practice was ineffective and associated
with potential tissue damage and infection.[48]
Topical application and ingestion of alcohol
The use of alcohol following snakebite has also been reported
in the literature. This is usually intended for calming the nerves
of victims or reducing the pain associated with bite.[49] The
use of alcohol in cleaning the bite wound to reduce wound
infection was earlier considered safe but are now absent in
manysnakebitesrst aid protocols. Furthermore, ingesting
alcohol, caffeine, and others are known to increase heart rate
and thus increase the circulation of the toxins. In addition,
alcohol ingestion is a risk factor for “illegitimate” snakebites.[50]
Shock therapy
There are reports on the use of electric shock therapy for
snakebite as far back as 1899[25] but became popular again
after it was successfully used on the Waorani Indians of
Ecuador.[51,52] The treatment is delivered through the stun guns
thatcomesintheformoffourorvehigh-voltage,low-current
electric shocks. Each is painful and lasts 1–2 s. The shocks are
given about 5–10 s apart and are applied as close as possible
to the bite site.[53] However, the use of electric shock therapy
has been shown to be ineffective in both animal models and
humans.[54,55] Shock therapy is currently being discouraged
for its potential hazards such as cardiac arrhythmias, tissue
damages, and exacerbation of snakebite pain.[56,57]
Cryotherapy
Cryotherapy involves the cleaning of bite site and application
of raw ice, ice packs, cold sprays, or immersion of affected site
in ice water to achieve a theoretical cold‑induced reduction
in venom activity through vasoconstriction and consequent
reduction in tissue damage and venom‑induced pain.[58] Animal
studies had also suggested that cryotherapy was effective in
retaining venom at the bite site but that this could be dramatically
complicated by shock soon after its removal.[59] Similarly,
prolonged application is associated with vasoconstriction of the
already compromised tissues which may result in local tissue
necrosis, gangrene, and the need for amputation.[58]
Tight ligatures/tourniquet/pressure immobilization
Traditionally, tight ligatures, and tourniquets[60,61] in the form
of a ropes, pieces of clothes, rubber bands, and other materials
have been applied around the proximal part of a bitten limb
tostopvenom owintothebody.[62] The intent of using of
theseconstrictingbandsistooccludelymphaticow,butin
practice, tight ligatures and arterial tourniquets are used instead
and are extremely painful and may result in distal avascular
necrosis or gangrene if left beyond 40 min.[24,63] Moreover,
the release of the tourniquet may result in severe systemic
envenoming hence the release should be done in hospital where
antivenom can be given and other facilities for resuscitation
are available.[24] This practice is also strongly discouraged in
areas where viper bites predominate, because of the resulting
local venom necrotic effect.[28] Pressure immobilization on the
other hand has been recommended to be used in neurotoxic
bites as it impedes only lymphatic spread of venom (which
could produce severe systemic symptoms within an hour of
bite). It ideally involves the use of an elastic, stretchy, crepe
bandage, approximately 10 cm wide and at least 4.5 m long
applied around the entire bitten limb.[24] Its application is very
technicalandshouldallowonengerbetweenthelimband
bandage after application. Although pressure immobilization
appears easy in theory, it is not easy in practice. It is only
correctly applied in 18%–53% of cases making its use in rural
anduntrainedpopulationsdifcult.[13] The use of pressure
immobilization remains very controversial and experts are
generally not inclined to recommending this intervention for
the aforementioned reasons.
Prophylactic amputation
This is another harmful practice recorded in the literature.
Abitten nger or toe is amputatedfollowingsnakebiteto
prevent the spread of venom to other parts of the body.[13,19] This
practice has since been abandoned for its obvious complications.
Washing with soap and water
The usual intention of washing animal bite wound (snakebite
wound inclusive) is to reduce contamination of the wound
and infection. However, washing a snakebite wound requires
rubbing of the skin and most times massaging the tissue,
thereby causing more venom absorption. This is discouraged
astheactionofwashingincreasestheowofvenomintothe
system by stimulating the lymphatic system.[64] In addition,
washing bite wound may limit the use of venom detection
kitsfortheidenticationofsnakespeciesinareaswherethese
kits are available.
Irrigation for spitting elapid bites
For spitting elapids and other snakes that release their venom
towardthehumaneyes,theinitialtreatmentintheeldshould
be irrigation of the eyes with copious amount of tap water or
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Michael, et al.: Pre-hospital care practices for venomous snakebites
240 Archives of Medicine and Health Sciences ¦ Volume 5 ¦ Issue 2 ¦ July‑December 2017
anyotheruid(includingmilk or urine in remoteandarid
environment). This aids in neutralizing and decontaminating
the eyes before reaching medical facility.[65]
Injection with potassium permanganate solution
The injection of potassium permanganate (also referred to as
Condy’s crystals) into snakebite wound was a common practice
during the 20th century.[66] A weak solution of potassium
permanganate injected into the snakebite wounds was
believed to inactivate the venom based on reported laboratory
in vitro experiments. However, absence of clinical evidence
to demonstrate its effectiveness in vivo and the potential
harmful tissue necrotic effects of potassium permanganate
have discouraged its continued use.[66]
Intramuscular injection of snake antivenom
AMyanmarstudyjustiedtheuseofintramuscularinjection
ofantivenomforRussell’sviper bitesasrstaidonthe
eldwhenreachingamedicalfacilitywilltake>2haswas
reported to reduce complications of envenoming.[67] However,
it suggested that the victim must be taken to hospital for
appropriate intravenous antivenom.[68] A 4‑fold increase in
antivenom requirement is required to adequately neutralize
circulating venom through the intramuscular route as a result
of poor absorption of antivenom through the intramuscular
route.[69] The use of intramuscular antivenom injections is not
cost‑effective in many rural resource‑limited settings where
antivenom is expensive and not readily available.
Recommended snakebite first aid
Most experts and guidelines are unanimous in recommending
thefollowingrstaidmeasures:
1. Removing the victim from snake territory to avoid
repeated bites to victims or rescuers[19,70]
2. Reassuring the victim.[19] This is necessary for three
reasons,viz;thevictimsareoften terried, some bites
by venomous snakes are "dry bites" (without injection
ofvenominto victim's body) and should there be
envenoming from the bite, there may be still time to reach
the hospital for treatment
3. Placing victim at rest. Complete immobilization of the
entire body should be maintained to avoid muscular
contraction which aids venom absorption. There should be
immobilization of the affected limb with a makeshift splint
or sling and positioned below the level of the heart[19,71]
4. Removing tight clothing, shoes, bracelets, rings, etc.,[19]
before the bitten limb gets swollen and can potentially
become tourniquets
5. Attempting to identify the snake, without endangering
victim or rescuer
6. Transporting the patient to the nearest medical facility
with antivenom and other resources for treatment.
coNclusioN
Several prehospital practices had been reported for the
treatment of snakebite. Despite their use, the untreated mortality
of snakebite (i.e., without antivenom therapy) remains high.
However, the most widely accepted prehospital intervention
supports the speedy transport of victims to the nearest medical
facility with resources for managing venomous snakebites.
Therefore, concise information materials about prehospital
interventions have the potential of arming healthcare providers
with the right information for targeted counseling of snakebite
victims and their caregivers. This may aid reduction in the
morbidity and mortality associated with inappropriate use of
these interventions.
Financial support and sponsorship
Nil.
Conflicts of interest
Therearenoconictsofinterest.
refereNces
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