ArticlePDF Available

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.
237
© 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
Quick Response Code:
Website:
www.amhsjournal.org
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,
and build upon the work non-commercially, as long as the author is credited and the new
creaons are licensed under the idencal terms.
For reprints contact: reprints@medknow.com
[Downloaded free from http://www.amhsjournal.org on Friday, December 15, 2017, IP: 197.234.36.126]
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
[Downloaded free from http://www.amhsjournal.org on Friday, December 15, 2017, IP: 197.234.36.126]
Michael, et al.: Pre-hospital care practices for venomous snakebites
239
Archives of Medicine and Health Sciences ¦ Volume 5 ¦ Issue 2 ¦ July‑December 2017
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
[Downloaded free from http://www.amhsjournal.org on Friday, December 15, 2017, IP: 197.234.36.126]
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
1. Chippaux JP. Snake‑bites: Appraisal of the global situation. Bull World
Health Organ 1998;76:515‑24.
2. Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK,
Pathmeswaran A, Premaratna R, et al. The global burden of snakebite:
A literature analysis and modelling based on regional estimates of
envenoming and deaths. PLoS Med 2008;5:e218.
3. Harrison RA, Hargreaves A, Wagstaff SC, Faragher B, Lalloo DG. Snake
envenoming: A disease of poverty. PLoS Negl Trop Dis 2009;3:e569.
4. Theakston RD, Warrell DA. Crisis in snake antivenom supply for Africa.
Lancet 2000;356:2104.
5. Gutiérrez JM. Improving antivenom availability and accessibility:
Science, technology, and beyond. Toxicon 2012;60:676‑87.
6. Stock RP, Massougbodji A, Alagón A, Chippaux JP. Bringing
antivenoms to Sub‑Saharan Africa. Nat Biotechnol 2007;25:173‑7.
7. World Health Organization. Rabies and Envenomings: A Neglected
Public Health Issue. Geneva, Switzerland: World Health Organization;
2007.
8. Simpson ID, Blaylock RS. The anti snake venom crisis in Africa:
A suggested manufacturers product guide. Wilderness Environ Med
2009;20:275‑82.
9. Habib AG. Public health aspects of snakebite care in West Africa:
Perspectives from Nigeria. J Venom Anim Toxins Incl Trop Dis
2013;19:27.
10. Michael GC, Thacher TD, Shehu MI. The effect of pre‑hospital care for
venomous snake bite on outcome in Nigeria. Trans R Soc Trop Med Hyg
2011;105:95‑101.
11. Abubakar SB, Habib AG, Mathew J. Amputation and disability
following snakebite in Nigeria. Trop Doct 2010;40:114‑6.
12. Iliyasu G, Tiamiyu AB, Daiyab FM, Tambuwal SH, Habib ZG,
Habib AG, et al. Effect of distance and delay in access to care on
outcome of snakebite in rural North‑Eastern Nigeria. Rural Remote
Health 2015;15:3496.
13. Cheng AC, Currie BJ. Venomous snakebites worldwide with a focus
ontheAustralia-Pacicregion:Currentmanagementandcontroversies.
J Intensive Care Med 2004;19:259‑69.
14. Sánchez A, Coto J, Segura Á, Vargas M, Solano G, Herrera M, et al.
Effect of geographical variation of Echis ocellatus, Naja nigricollis
and Bitis arietans venoms on their neutralization by homologous and
heterologous antivenoms. Toxicon 2015;108:80‑3.
15. Russell FE. When a snake strikes. Emerg Med 1990;22:20‑43.
16. Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med
2002;347:347‑56.
17. Kumar A. Snakebite: Sociocultural anthropological bias. PLoS Med
2006;3:e412.
18. White J. Bites and stings from venomous animals: A global overview.
Ther Drug Monit 2000;22:65‑8.
19. World Health Organization: Guidelines for the Prevention and Clinical
Management of Snakebite in Africa. World Health Organization
[Downloaded free from http://www.amhsjournal.org on Friday, December 15, 2017, IP: 197.234.36.126]
Michael, et al.: Pre-hospital care practices for venomous snakebites
241
Archives of Medicine and Health Sciences ¦ Volume 5 ¦ Issue 2 ¦ July‑December 2017
Regional Ofce for Africa, Brazzaville;2010. Available from: www.
who.int/snakebites/resources/9789290231684/en/ \l. [Last accessed on
2017 Nov 01].
20. Nasidi A. Snakebite as a Serious Public Health Problem for Nigeria
and Africa. Presentation to WHO Consultative Meeting on Rabies
and Envenomings: By Director, Special Duties, Federal Ministry of
Health, Project – Coordinator EchiTAb Study Group, UK/Nigeria on
10 January, 2007. Available from: http://www.who.int/bloodproducts/
animal_sera/A.Nasidi.pdf. [Last accessed on 2016 June 03].
21. Mustapha SK. Snake bite in Gombe. Highland Med Res J 2003;1:22‑7.
22. Opadijo OG, Omotosho AB. Snake bite in Ilorin: A review of 115 cases.
Niger Med Pract 1996;32:30‑2.
23. Omogbai EK, Nworgu ZA, Imhadon MA, Ikpeme AA, Ojo DO,
Nwako CN. Snake bites in Nigeria. A study of the prevalence and
treatment in Benin City. Trop J Pharm Res 2002;1:39‑44.
24. Warrell DA. WHO/SEARO guidelines for the clinical management of
snake bites in the Southeast Asian region. Southeast Asian J Trop Med
Public Health 1999;30:1‑85.
25. Blackman JR, Dillon S. Venomous snakebite: Past, present, and future
treatment options. J Am Board Fam Pract 1992;5:399‑405.
26. Bhetwal BB, O’Shea M, Warrell DA. Snakes and snake bite in Nepal.
Trop Doct 1998;28:193‑5.
27. Alberts MB, Shalit M, LoGalbo F. Suction for venomous snakebite. Ann
Emerg Med 2004;43:181‑6.
28. Warrell DA. Snake bite in Sub‑Saharan Africa. Afr Health 1999;21:5‑9.
29. Bush SP, Hegewald KG, Green SM, Cardwell MD, Hayes WK. Effects
of a negative pressure venom extraction device (Extractor) on local
tissueinjuryafterarticialrattlesnakeenvenomationinaporcinemodel.
Wilderness Environ Med 2000;11:180‑8.
30. Ertem K. Venomous snakes bite in Turkey. Eur J Gen Med 2004;1:1‑6.
31. Bronstein AC, Russell FE, Sullivan JB, Egen NB, Rumack BH.
Negativepressuresuctionineldtreatmentofrattlesnakebite.VetHum
Toxico1 1985;28:297.
32. Hall EL. Role of surgical intervention in the management of crotaline
snake envenomation. Ann Emerg Med 2001;37:175‑80.
33. Riggs BS, Smilkstein MJ, Kulig KW. Rattlesnake Envenomation with
Massive Oropharyngeal Edema. Emergency Snakebite Information.
Toxicol 1987; 29:320.
34. Baldwin M. The snakestone experiments. An early modern medical
debate. Isis 1995;86:394‑418.
35. Rasquinha D. Snake stone for snake envenomization. Am J Emerg Med
1996;14:112‑3.
36. Chippaux JP, Diédhiou I, Stock R. Study of the action of black
stone (also known as snakestone or serpent stone) on experimental
envenomation. Cah Sante 2007;17:127‑31.
37. Gomes A, Das R, Sarkhel S, Mishra R, Mukherjee S, Bhattacharya S,
et al. Herbs and herbal constituents active against snake bite. Indian J
Exp Biol 2010;48:865‑78.
38. Knowles R. The mechanism & treatment of snake bite in India. Trans R
Soc Trop Med Hyg 1921;15:72.
39. Vishwanath BS, Gowda TV. Interaction of aristolochic acid with Vipera
russelli phospholipase A2: Its effect on enzymatic and pathological
activities. Toxicon 1987;25:929‑37.
40. Vishwanath BS, Kini RM, Gowda TV. Characterization of three
edema‑inducing phospholipase A2 enzymes from habu (Trimeresurus
avoviridis)venom andtheirinteractionwiththealkaloidaristolochic
acid. Toxicon 1987;25:501‑15.
41. KlauberLM. Rattlesnakes,Their Habits,Life Histories,and Inuence
on Mankind. Berkeley: University of California Press; 1982.
42. Hardy DL.A review of rst aid measures for pitviper bite in North
America with an appraisal of extractor suction and stun gun electroshock.
In: Campbell JA, Brodie ED, editors. Biology of the Pitvipers. Tyler,
TX: Selva Publishing; 1992. p. 405‑41.
43. Mondal RN, Chowdhury FR, Rani M, Mohammad N, Islam MM,
Haque MA, et al. Pre hospital and hospital management practices and
circumstances behind venomous snakebite in northwestern part of
Bangladesh. Asia Pac J Med Toxicol 2012;1:18‑21.
44. Habib AG, Abubakar SB. Factors affecting snakebite mortality in
North‑Eastern Nigeria. Int Health 2011;3:50‑5.
45. Bhat RN. Viperine snake bite poisoning in Jammu. J Indian Med
Assoc 1974;63:383‑92.
46. Ralidis PM. Medical treatment of reptile envenomation: A review of the
current literature. Top Emerg Med 2000;22:16‑36.
47. McCollough NC, Gennaro JR. Evaluation of venomous snake bite
in the Southern United States from parallel clinical and laboratory
investigations: Development of treatment. J Fla Med Assoc
1963;49:959‑67.
48. Wingert WA, Chan L. Rattlesnake bites in Southern California and
rationale for recommended treatment. West J Med 1988;148:37‑44.
49. Henshaw A. Snakebite Treatments: Dos and Don’ts. Available from:
https://www.symptomnd.com/health/snake-bite-treatment/. [Last
accessed on 2017 Apr 19].
50. Morandi N, Williams J. Snakebite injuries: Contributing factors and
intentionality of exposure. Wilderness Environ Med 1997;8:152‑5.
51. Guderian RH, Mackenzie CD, Williams JF. High voltage shock
treatment for snake bite. Lancet 1986;2:229.
52. Theakston RD, Reid HA, Larrick JW, Kaplan J, Yost JA. Snake venom
antibodies in Ecuadorian Indians. J Trop Med Hyg 1981;84:199‑202.
53. Altman LK. The Doctor’s World; New Shock Therapy for Snakebites. The
New York Times; 5 August, 1986. Available from: http://www.nytimes.
com/1986/08/05/science/the‑doctor‑s‑world‑new‑shock‑therapy‑for‑
snakebites.html?pagewanted=all. [Last accessed on 2016 Apr 16].
54. Howe NR, Meisenheimer JL Jr. Electric shock does not save snakebitten
rats. Ann Emerg Med 1988;17:254‑6.
55. Snyder CC, Murdock RT, White GL Jr., Kuitu JR. Electric shock
treatment for snake bite. Lancet 1989;1:1022.
56. Dart RC, Gustafson RA. Failure of electric shock treatment for
rattlesnake envenomation. Ann Emerg Med 1991;20:659‑61.
57. Stoud C, Amon H, Wagner T, Falk JL. Effect of electric shock therapy
on local tissue reaction to poisonous snake venom injection in rabbits
(abstract). Ann Emerg Med 1989;18:447.
58. Kunkel DB, Curry SC, Vance MV, Ryan PJ. Reptile envenomations.
J Toxicol Clin Toxicol 1983;21:503‑26.
59. Snyder CC, Knowles RP. Snakebites. Guidelines for practical
management. Postgrad Med 1988;83:52‑60, 65‑8, 71‑5.
60. Rossner F. Letter: Medical writings of Moses Maimonides. Arch Intern
Med 1974;133:318‑9.
61. Knoefel PK. Francesco Redi on Vipers. Leiden: EJ Brill; 1988.
62. Bharati K, Hati AK. Snakebite management in the tropics. Sci Cult
2000;66:302‑4.
63. Pugh RN, Theakston RD. Fatality following use of a tourniquet after
viper bite envenoming. Ann Trop Med Parasitol 1987;81:77‑8.
64. Gray S. Pressure immobilization of snakebite. Wilderness Environ Med
2003;14:70‑1.
65. Chu ER, Weinstein SA, White J, Warrell DA. Venom ophthalmia caused
by venoms of spitting elapid and other snakes: Report of ten cases
with review of epidemiology, clinical features, pathophysiology and
management. Toxicon 2010;56:259‑72.
66. Bal B, Williams DJ. First aid for snakebite in PNG. In: William DJ,
Jensen SD, Winkel KD, editors. Clinical Management of Snakebite in
Papua New Guinea. Port Moresby: Independent Publishing Pty. Limited;
2004. Available from: http://www.kingsnake.com/aho/pngsmc/contents.
html. [Last accessed on 2017 Apr 29].
67. Win A, Tin T , Khin MM ,Aye K, Hla P, Tin NS, et al. Clinical trial of
intramuscularanti-snakevenomadministrationasarstaidmeasurein
theeld inthe managementof Russell’sviperbite patients.Southeast
Asian J Trop Med Public Health 1996;27:494‑7.
68. WinA.DMR researchndings onthemanagement ofRussell’sviper
bitepatients(I) prophylactic and rstaidmeasures. Myanmar JCurr
Med Pract 2001;5:138‑45.
69. WinA, San K, Khin PPK, Aye K, Hla P.Comparison of efcacy of
antivenom injected intravenously and intramuscularly on envenomed
mice with Russell’s viper venom. Snake 1996;27:106‑9.
70. Kanaan NC, Ray J, Stewart M, Russell KW, Fuller M, Bush SP, et al.
Wilderness Medical Society Practice Guidelines for the treatment of
pit viper envenomations in the United States and Canada. Wilderness
Environ Med 2015;26:472‑87.
71. Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F. Snake bite in
South Asia: A review. PLoS Negl Trop Dis 2010;4:e603.
[Downloaded free from http://www.amhsjournal.org on Friday, December 15, 2017, IP: 197.234.36.126]
... Many (including 50%-90% of snakebite victims in sub-Saharan Africa) [82] sought after traditional healers for first-line treatment; these traditional healers offer interventions such as tourniquet application, bite site incision, application of oral and topical concoctions, shock, suction of bite site, and cryotherapy. [17,59,83] Studies have not only questioned the efficacy of these traditional practices but also associated them with increased complications. [17,83] As such, some envenomed victims find their ways to the hospital lately increasing adverse outcomes. ...
... [17,59,83] Studies have not only questioned the efficacy of these traditional practices but also associated them with increased complications. [17,83] As such, some envenomed victims find their ways to the hospital lately increasing adverse outcomes. [47] Unfortunately, many hospitals in rural areas where most snakebite occur are ill equipped to handle snakebite envenoming. ...
Article
Full-text available
Background: Snakebite envenoming is a neglected tropical disease that accounts for preventable morbidity and mortality, especially in resource‑limited settings. This review aimed at examining the snake and human behaviors that facilitate snake‑human encounters and highlighting the primary preventive measures for snakebite and the resultant envenoming. Materials and Methods: Google Scholar, Medline (via PubMed), and African Journal Online were searched from January 1959 to April 2019 for peer‑reviewed studies addressing primary prevention of snakebite. We extended our search to grey literature from conference proceedings, documents from organizations, book chapters, and thesis. Results: We found few studies in medical literature on community knowledge of the intrinsic characteristics of snakes (e.g., its unique venom apparatus for nutrition, defense and competition, and its habitat and activities); however, there is appreciable amount of studies on human activities associated with snakebite envenoming. Deservedly, more studies appear to focus on snakebite management (secondary and tertiary prevention) with inadequate emphasis on primary prevention of snakebite (which may be the only intervention in some resource‑limited settings). Conclusion: Synergy of efforts toward improving community knowledge of human behaviors associated with snakebite and snake behaviors may generate appropriate environmental and behavioral responses to curtail human‑snake encounters. Hence, intensive promotion of primary prevention may be a useful approach toward reducing snakebite burden in resource‑limited settings.
... The incidence of venomous snakebites is between 1.2 and 5.5 million per year worldwide, resulting in approximately 20 000-94 000 deaths and tens of thousands of disabled people. Most of the above events happen in rural tropical areas of Sub-Saharan Africa, South America and Asia [6,7]. It is estimated that 50% of these snakebites are venomous, resulting in 100 000 deaths per year [8]. ...
Article
Full-text available
Objective: To investigate the prevalence of snakebites and associated epidemiologic factors in Khorram-shahr County, Iran, between 2013 and 2017. Methods: This was a cross-sectional descriptive-analytical study. Information was collected and recorded via questionnaires. Snakebite data included gender, age, occurrence regions, bite site, time of being bitten, month and season. Data were analyzed by Chi-square and t-tests with SPSS version 18. Results: A total of 102 cases of snakebites occurred in Khorram-shahr County of Khuzestan Province, southwestern Iran. There were 75 men (73.5%) and 27 women (26.4%), without significant difference in incidence. The highest frequency of snakebites was observed in the age group of 41-50 years with 28 cases (27.4%). In total, 58 cases (56.9%) occurred in urban areas and 44 cases (43.1%) in rural areas. No statistically significant difference was observed between the age groups or residential areas. Snakebites occurred in May with 19 cases (18.6%), spring with 45 (44.1%) and summer with 45 (44.1%). The results showed significant difference among different seasons and months of the year. Snakebites were in feet in 62 cases (60.8%) and hands in 36 cases (35.3%) which were bitten more than other organs, respectively, with significant difference among different bite sites in the body. The highest and lowest frequencies of snakebites were observed between 18:00 and 24:00 with 43 cases (42.2%) and between 6:00 and 12:00 with 14 cases (13.7%), with a significant difference among different hours of the day. Conclusions: Useful information about snakebites, venomous snakes, their hazards, prevention of bites and the importance of early hospital referral and treatment of victims should be provided to people using different educational tools.
... 7 The economic impact of snakebite on victims (who are mostly farmers, herders and rural dwellers) and their families results in aggravation of poverty in affected communities. [8][9][10] The management challenges of snakebites in low-and middle-income countries includes the frequent use of harmful and time-wasting (traditional healing) pre-hospital measures, 1,11 poor access to effective health care services, lack of affordable and effective snake antivenom (SAV; the mainstay of envenoming treatment), 12 poor patient education, lack of standardized treatment protocols and poor health care provider training. 8,13 Health care workers are important stakeholders in the control of snakebites and their consequences. ...
Article
Full-text available
Background Snakebite envenoming causes considerable morbidity and mortality in northern Nigeria. The clinician’s knowledge of snakebite impacts outcome. We assessed clinicians’ knowledge of snakebite envenoming to highlight knowledge and practice gaps for possible intervention to improve snakebite outcomes. Methods This was a cross-sectional multicentre study of 374 doctors selected from the accident and emergency, internal medicine, family medicine/general outpatient, paediatrics and surgery departments of nine tertiary hospitals in northern Nigeria using a multistage sampling technique. A self-administered questionnaire was used to assess their sociodemographics, knowledge of common venomous snakes, snakebite first aid, snake antivenom treatment and prevention. Results The respondents’ mean age was 35.6±5.8 y. They were predominantly males (70.6%) from urban hospitals (71.9%), from the northwest region (35.3%), in family medicine/general outpatient departments (33.4%), of <10 years working experience (66.3%) and had previous experience in snakebite management (78.3%). Although their mean overall knowledge score was 70.2±12.6%, only 52.9% had an adequate overall knowledge score. Most had adequate knowledge of snakebite clinical features (62.3%), first aid (75.7%) and preventive measures (97.1%), but only 50.8% and 25.1% had adequate knowledge of snake species that caused most injuries/deaths and anti–snake venom treatment, respectively. Overall knowledge predictors were ≥10 y working experience (odd ratio [OR] 1.72 [95% confidence interval {CI} 1.07 to 2.76]), urban hospital setting (OR 0.58 [95% CI 0.35 to 0.96]), surgery department (OR 0.44 [95% CI 0.24 to 0.81]), northwest/north-central region (OR 2.36 [95% CI 1.46 to 3.82]) and previous experience in snakebite management (OR 2.55 [95% CI 1.49 to 4.36]). Conclusions Overall knowledge was low. Improvements in overall knowledge may require clinicians’ exposure to snakebite management and training of accident and emergency clinicians in the region.
Article
Full-text available
Introduction: Snakebite envenoming is a major cause of morbidity and mortality in rural areas of the tropics. Timely administration of effective antivenom remains the mainstay of management. Methods: The study was a quantitative descriptive study aimed at exploring the causes and effects of delay, distance and time taken to access care on snakebite outcomes in Nigeria. All prospective snakebite victims reporting to Kaltungo General Hospital were enrolled. Data on demography, date and time bitten, date and time admitted, site of bite, circumstances of snakebite, responsible snake, clinical features, 20-minute whole-blood clotting test, antivenom administered and outcome were recorded. Delay arising from use of traditional first aid (TFA), time elapsed from snakebite to presentation and the shortest distance from bite location to the hospital was calculated or obtained using a global positioning system. Results: The association between delay before hospital presentation and poor outcome was not statistically significant, even though there was a 2% higher likelihood of poor outcome among those with a 1-hour delay compared to those without delay (odds ratio 1.02, 95% confidence interval 1.00-1.03). There was no difference in distance from bite location to hospital between those with a poor outcome (74) compared to those with a good outcome (325). Those with a poor outcome had more severe envenomation requiring more antivenoms and longer hospital stays. Given poor access to antivenom therapy at distant locations ≥100 km, victims were more likely to use TFA such as black 'snake' stone, with consequent prolonged delays. Antivenoms should be more readily available at distant places. Conclusions: Community education on avoiding potentially harmful TFA and prompt access to care is recommended. There is a need to provide snakebite care to multiple peripheral, relatively more rural inaccessible areas.
Article
Full-text available
Pitviper envenomations can cause significant morbidity and mortality and must be treated with prompt evidence-based management protocols. Crotaline envenomations often produce local tissue injury and swelling and may result in systemic effects (including coagulopathy, neu-rotoxicity, or hypotension), the progression of which can be halted with prompt administration of antivenom. More severe envenomations feature extensive local effects and life-threatening systemic derangements that require repeated dosing of antivenom and closely monitored supportive care. Frequent patient assessment and diligent tracking of progressive signs and abnormal laboratory results are important for appropriate snakebite management. Consulting a toxinologist or poison control center can greatly assist in patient management. Finally, these guidelines are for crotaline snakes in the United States and Canada, and cannot be safely extrapolated to other snakes species or geographic regions.
Article
Two antivenoms prepared by using Echis ocellatus, Bitis arietans and Naja nigricollis venoms from different locations in sub-Saharan Africa were compared for their neutralizing ability. Both antivenoms were similarly effective in the neutralization of the venoms of the three species from different locations. However in the case of E. ocellatus venom, antivenom prepared using venom from Nigerian specimens was more effective than antivenom prepared with venom from Cameroon specimens in the neutralization of coagulant activity.
Article
The true global incidence of envenomations and their severity remain largely misunderstood, except for a few countries where these accidents are rare or are correctly reported. Nevertheless, this information is essential for drawing up guidelines for dealing with snake-bites, to plan drug supplies, particularly antivenin, and to train medical staff on snake-bite treatments. Since the comprehensive review by Swaroop & Grab in 1954 no global survey has been carried out on snake-bite epidemiology. The present article is an attempt to draw the attention of health authorities to snake envenomations and urges them to prepare therapeutic protocols adapted to their needs.