Correspondence
Bites of Venomous Snakes
N Engl J Med 2002; 347:1804-1805November 28, 2002
- Article
To the Editor:
The review by Gold et al. on bites of venomous snakes (Aug. 1 issue)1 does not mention Sutherland's pressure-immobilization technique for the first-aid treatment of neurotoxic envenomation, despite its sound experimental basis and experience of its clinical efficacy, especially in Australia.2 In controlled trials, epinephrine was effective3 and promethazine, a histamine H1-receptor blocker, was ineffective4 in preventing early anaphylactoid reactions to antivenom.
Recurrence of the effects of venom after an initial response to antivenom was demonstrated in Thailand in 1986,5 so this phenomenon should not have been an “unexpected observation” during trials of Crotalidae Polyvalent Immune Fab (Ovine) (FabAV) antivenom in the United States in 1997. FabAV was licensed in the United States before any randomized trials had been conducted to compare its efficacy and safety with those of the existing Antivenin (Crotalidae) Polyvalent, Wyeth. Its rapid clearance allows recurrent envenomation that demands repeated doses.
Bacterial infections of snakebite wounds may be rare in the United States, but elsewhere in the world — for example, in South America — their incidence may exceed 10 percent.6 The authors recommend elevation of tensely swollen limbs, but this will increase the risk of intracompartmental ischemia by decreasing arterial perfusion pressure.
6 ReferencesDavid A. Warrell, D.M.
University of Oxford, Oxford OX3 9DU, United Kingdom
david.warrell@ndm. ox. ac. uk 1
Gold BS ,Dart RC ,Barish RA . Bites of venomous snakes. N Engl J Med 2002;347:347-356
Full Text | Web of Science | Medline2
Warrell DA . “To search and Studdy out the secrett of Tropical Diseases by way of experiment.“ Lancet 2001;358:1983-1988
CrossRef | Web of Science | Medline3
Premawardhena AP ,de Silva CE ,Fonseka MM ,Gunatilake SB ,de Silva HJ . Low dose subcutaneous adrenaline to prevent acute adverse reactions to antivenom serum in people bitten by snakes: randomised, placebo-controlled trial. BMJ 1999;318:1041-1043
CrossRef | Web of Science | Medline4
Fan HW ,Marcopito LF ,Cardoso JL , et al. Sequential randomised and double blind trial of promethazine prophylaxis against early anaphylactic reactions to antivenom for bothrops snake bites. BMJ 1999;318:1451-1452
CrossRef | Web of Science | Medline5
Ho M ,Warrell DA ,Looareesuwan S , et al. Clinical significance of venom antigen levels in patients envenomed by the Malayan pit viper (Calloselasma rhodostoma). Am J Trop Med Hyg 1986;35:579-587
Web of Science | Medline6
Otero R, Tobón GS, Gómez LF, et al. Accidente ofídico en Antioquia y Chocó: aspectos clínicos y epidemiológicos (Marzo de 1989–Febrero de 1990). Acta Médica Colomb 1992;17:229-49.
Author/Editor Response
The authors reply:
To the Editor: We appreciate the comments of Dr. Warrell, a recognized authority. The use of a pressure-immobilization bandage as a first-aid measure for neurotoxic envenomations remains speculative, finding limited support outside Australia, where it is used in less than 50 percent of cases of snakebite.1 Clinical case reports on its efficacy are few, with no comparative or controlled studies. The method has practical problems related to availability, proper application, and prolonged duration of use.2
We did not discuss the prophylactic use of epinephrine because early anaphylactoid reactions are relatively mild and remarkably infrequent after the administration of FabAV. Our research protocols for FabAV addressed a full range of outcomes, including recurrence. Warrell's opinion regarding FabAV's rapid clearance as a cause of recurrence has not been substantiated; there is also recurrence with antivenoms that contain IgG molecules.3 The mechanism of recurrence has not been established. We maintain that antibiotics should be administered only on the basis of clinical or microbiologic evidence of infection.
We acknowledge that the positioning of the limb in patients with compartment syndrome is controversial. We are not aware of any controlled trial examining this issue in persons who have been bitten by venomous snakes. In our experience, elevation of the limb combined with the administration of additional antivenom and mannitol was effective in reducing compartment pressure caused by a crotaline envenomation.4
4 ReferencesBarry S. Gold, M.D.
University of Maryland School of Medicine, Baltimore, MD 21201Richard C. Dart, M.D., Ph.D.
Rocky Mountain Poison Center, Denver, CO 80230Robert A. Barish, M.D.
University of Maryland School of Medicine, Baltimore, MD 212011
Currie B . Pressure-immobilization first aid for snakebite -- fact and fancy. Toxicon 1993;31:931-932 abstract.
CrossRef2
Meir J, White J, eds. Handbook of clinical toxicology of animal venoms and poisons. Boca Raton, Fla.: CRC Press, 1995:569.
3
Bogdan GM ,Dart RC ,Falbo SC ,McNally J ,Spaite D . Recurrent coagulopathy after antivenom treatment of crotalid snakebite. South Med J 2000;93:562-566
Web of Science | Medline4
Gold BS, Barish RA, Dart RC, et al. Resolution of compartment syndrome following rattlesnake envenomation utilizing non-invasive measures. J Emerg Med (in press).
- Citing Articles (3)
Citing Articles
1
Stephen R. Manock, German Suarez, David Graham, María L. Avila-Aguero, David A. Warrell. (2008) Neurotoxic envenoming by South American coral snake (Micrurus lemniscatus helleri): case report from eastern Ecuador and review. Transactions of the Royal Society of Tropical Medicine and Hygiene 102:11, 1127-1132
CrossRef2
Ian D. Simpson, P.D. Tanwar, Chittaranjan Andrade, D.K. Kochar, Robert L. Norris. (2008) The Ebbinghaus retention curve: training does not increase the ability to apply pressure immobilisation in simulated snake bite—implications for snake bite first aid in the developing world. Transactions of the Royal Society of Tropical Medicine and Hygiene 102:5, 451-459
CrossRef3
David A. Warrell. (2006) Australian toxinology in a global context. Toxicon 48:7, 718-725
CrossRef
