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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 237-241

Prehospital care practices for venomous snakebites in resource-limited settings: A narrative review


1 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Family Medicine, Federal Medical Centre, Makurdi, Benue State, Nigeria

Date of Web Publication15-Dec-2017

Correspondence Address:
Godpower Chinedu Michael
Department of Family Medicine, Aminu Kano Teaching Hospital, Zaria Road, P.M.B. 3452, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_93_17

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  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.

Keywords: First aid, prehospital care, rural, snakebite, traditional care


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

How to cite this URL:
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 [serial online] 2017 [cited 2018 Sep 22];5:237-41. Available from: http://www.amhsjournal.org/text.asp?2017/5/2/237/220838




  Introduction Top


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],[5],[6],[7],[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 field/ first aid measures,[10] long delays before receiving proper treatment,[1],[11],[12] and ineffective snakebite prevention programs [1],[4],[9] have been identified 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 ( first 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 justified 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 first aid and those who care for snakebite victims.


  Materials and Methods Top


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 first aid, traditional care for snakebite, and prehospital care of snakebite. Articles used were mainly from affected areas such as Africa, Asia, and the United States.


  Discussion Top


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 five 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 first 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],[22],[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 first aid or definitive 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 justification 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 first 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 efficacy 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 benefits following artificial envenoming and application of the extractor; there is also a potential for local skin necrosis if applied for too long.[27],[28],[29],[30] However, some reports have advanced some benefits 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 first 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 indefinitely 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 scientific demonstration of black stones efficacy.[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 efficacy 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 efficacy against snakebite envenoming.[38] However, later studies showed that some fractions of Aristolochia species neutralizes Naja naja venom and reduces hemorrhage from Trimeresurus flavoviridis and Vipera russellii venoms.[39],[40] A 4-year retrospective prevalence study in a hospital in northeast Nigeria reported the use of unidentified herbs by victims; however, 2.9% of those who ingested herbs had jaundice.[21] Furthermore, Michael et al. reported the use of unidentified 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 efficacy.

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 flow have been reported by many workers.[10],[42],[43],[44],[45],[46] Its use as first 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 first 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 five 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 flow into the body.[62] The intent of using of these constricting bands is to occlude lymphatic flow, 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 finger 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 difficult.[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 finger 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 flow 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 identification 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 field should be irrigation of the eyes with copious amount of tap water or any other fluid (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 justified the use of intramuscular injection of antivenom for Russell's viper bites as first aid on the field 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 first 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 terrified, 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 Top


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 conflicts of interest.



 
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