|Year : 2017 | Volume
| Issue : 2 | Page : 237-241
Prehospital care practices for venomous snakebites in resource-limited settings: A narrative review
Godpower Chinedu Michael1, Ibrahim Aliyu2, Bukar Alhaji Grema1, Niongun Lawrence Paul De-Kaa3
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 Publication||15-Dec-2017|
Godpower Chinedu Michael
Department of Family Medicine, Aminu Kano Teaching Hospital, Zaria Road, P.M.B. 3452, Kano
Source of Support: None, Conflict of Interest: None
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 2019 Sep 17];5:237-41. Available from: http://www.amhsjournal.org/text.asp?2017/5/2/237/220838
| Introduction|| |
Snakebite is a common and neglected public health problem worldwide and an important cause of injury and death in developing countries. 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. The most affected communities are usually ravaged by poverty and deprivation. The challenges of antivenom scarcity,,,,, poor health services, lack of rapid access to healthcare, poor training of health workers on snakebite management,,, utilization of inappropriate field/ first aid measures, long delays before receiving proper treatment,,, and ineffective snakebite prevention programs ,, 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. 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. 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|| |
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|| |
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., Based on their morphological characteristics including arrangement of scales, dentition, osteology, myology, and sensory organs, venomous snakes are categorized into families. There are five main families of venomous snakes, namely, Elapidae, Viperidae, Colubridae, Hydrophiidae, and Atractaspididae.,
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., 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. E. ocellatus alone accounts for 90% of the bites and 60% of the deaths in Nigerian savanna. 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. 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. Snakebite occurs in all sexes and age groups, but young active males are most vulnerable.,,
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., 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.
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. Similarly, among some inhabitants in rural North-central Nigerian communities, there is the belief that “izuwa” (the local name for carpet vipers) 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. 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.,,, 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;, 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.
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. 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. 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. 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.
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. 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. Early studies on some plants/herbs that have been used as snakebite antidotes by Knowles showed no efficacy against snakebite envenoming. However, later studies showed that some fractions of Aristolochia species neutralizes Naja naja venom and reduces hemorrhage from Trimeresurus flavoviridis and Vipera russellii venoms., 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. 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. Other materials that have been used in combination with herbs include scrapings from crocodile teeth or saliva of a fasting man, 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.,,,,, Its use as first aid is controversial. Some reports have recommended its use only when prompt medical treatment is >30 min away  or based on experimental and anecdotal experiences; others have shown that the practice was ineffective and associated with potential tissue damage and infection.
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. 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.
There are reports on the use of electric shock therapy for snakebite as far back as 1899 but became popular again after it was successfully used on the Waorani Indians of Ecuador., 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. However, the use of electric shock therapy has been shown to be ineffective in both animal models and humans., Shock therapy is currently being discouraged for its potential hazards such as cardiac arrhythmias, tissue damages, and exacerbation of snakebite pain.,
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. 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. 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.
Tight ligatures/tourniquet/pressure immobilization
Traditionally, tight ligatures, and tourniquets , 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. 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., 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. This practice is also strongly discouraged in areas where viper bites predominate, because of the resulting local venom necrotic effect. 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. 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. The use of pressure immobilization remains very controversial and experts are generally not inclined to recommending this intervention for the aforementioned reasons.
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., 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. 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.
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. 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.
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. However, it suggested that the victim must be taken to hospital for appropriate intravenous antivenom. 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. 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:
- Removing the victim from snake territory to avoid repeated bites to victims or rescuers ,
- Reassuring the victim. 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
- 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 ,
- Removing tight clothing, shoes, bracelets, rings, etc., before the bitten limb gets swollen and can potentially become tourniquets
- Attempting to identify the snake, without endangering victim or rescuer
- 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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chippaux JP. Snake-bites: Appraisal of the global situation. Bull World Health Organ 1998;76:515-24.
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.
Harrison RA, Hargreaves A, Wagstaff SC, Faragher B, Lalloo DG. Snake envenoming: A disease of poverty. PLoS Negl Trop Dis 2009;3:e569.
Theakston RD, Warrell DA. Crisis in snake antivenom supply for Africa. Lancet 2000;356:2104.
Gutiérrez JM. Improving antivenom availability and accessibility: Science, technology, and beyond. Toxicon 2012;60:676-87.
Stock RP, Massougbodji A, Alagón A, Chippaux JP. Bringing antivenoms to Sub-Saharan Africa. Nat Biotechnol 2007;25:173-7.
World Health Organization. Rabies and Envenomings: A Neglected Public Health Issue. Geneva, Switzerland: World Health Organization; 2007.
Simpson ID, Blaylock RS. The anti snake venom crisis in Africa: A suggested manufacturers product guide. Wilderness Environ Med 2009;20:275-82.
Habib AG. Public health aspects of snakebite care in West Africa: Perspectives from Nigeria. J Venom Anim Toxins Incl Trop Dis 2013;19:27.
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.
Abubakar SB, Habib AG, Mathew J. Amputation and disability following snakebite in Nigeria. Trop Doct 2010;40:114-6.
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.
Cheng AC, Currie BJ. Venomous snakebites worldwide with a focus on the Australia-Pacific region: Current management and controversies. J Intensive Care Med 2004;19:259-69.
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.
Russell FE. When a snake strikes. Emerg Med 1990;22:20-43.
Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med 2002;347:347-56.
Kumar A. Snakebite: Sociocultural anthropological bias. PLoS Med 2006;3:e412.
White J. Bites and stings from venomous animals: A global overview. Ther Drug Monit 2000;22:65-8.
World Health Organization: Guidelines for the Prevention and Clinical Management of Snakebite in Africa. World Health Organization Regional Office for Africa, Brazzaville; 2010. Available from: www.who.int/snakebites/resources/9789290231684/en/ \l. [Last accessed on 2017 Nov 01].
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].
Mustapha SK. Snake bite in Gombe. Highland Med Res J 2003;1:22-7.
Opadijo OG, Omotosho AB. Snake bite in Ilorin: A review of 115 cases. Niger Med Pract 1996;32:30-2.
Omogbai EK, Nworgu ZA, Imhafidon 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.
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.
Blackman JR, Dillon S. Venomous snakebite: Past, present, and future treatment options. J Am Board Fam Pract 1992;5:399-405.
Bhetwal BB, O'Shea M, Warrell DA. Snakes and snake bite in Nepal. Trop Doct 1998;28:193-5.
Alberts MB, Shalit M, LoGalbo F. Suction for venomous snakebite. Ann Emerg Med 2004;43:181-6.
Warrell DA. Snake bite in Sub-Saharan Africa. Afr Health 1999;21:5-9.
Bush SP, Hegewald KG, Green SM, Cardwell MD, Hayes WK. Effects of a negative pressure venom extraction device (Extractor) on local tissue injury after artificial rattlesnake envenomation in a porcine model. Wilderness Environ Med 2000;11:180-8.
Ertem K. Venomous snakes bite in Turkey. Eur J Gen Med 2004;1:1-6.
Bronstein AC, Russell FE, Sullivan JB, Egen NB, Rumack BH. Negative pressure suction in field treatment of rattlesnake bite. Vet Hum Toxico1 1985;28:297.
Hall EL. Role of surgical intervention in the management of crotaline snake envenomation. Ann Emerg Med 2001;37:175-80.
Riggs BS, Smilkstein MJ, Kulig KW. Rattlesnake Envenomation with Massive Oropharyngeal Edema. Emergency Snakebite Information. Toxicol 1987; 29:320.
Baldwin M. The snakestone experiments. An early modern medical debate. Isis 1995;86:394-418.
Rasquinha D. Snake stone for snake envenomization. Am J Emerg Med 1996;14:112-3.
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.
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.
Knowles R. The mechanism & treatment of snake bite in India. Trans R Soc Trop Med Hyg 1921;15:72.
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.
Vishwanath BS, Kini RM, Gowda TV. Characterization of three edema-inducing phospholipase A2 enzymes from habu (Trimeresurus flavoviridis) venom and their interaction with the alkaloid aristolochic acid. Toxicon 1987;25:501-15.
Klauber LM. Rattlesnakes, Their Habits, Life Histories, and Influence on Mankind. Berkeley: University of California Press; 1982.
Hardy DL. A review of first 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.
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.
Habib AG, Abubakar SB. Factors affecting snakebite mortality in North-Eastern Nigeria. Int Health 2011;3:50-5.
Bhat RN. Viperine snake bite poisoning in Jammu. J Indian Med Assoc 1974;63:383-92.
Ralidis PM. Medical treatment of reptile envenomation: A review of the current literature. Top Emerg Med 2000;22:16-36.
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.
Wingert WA, Chan L. Rattlesnake bites in Southern California and rationale for recommended treatment. West J Med 1988;148:37-44.
Morandi N, Williams J. Snakebite injuries: Contributing factors and intentionality of exposure. Wilderness Environ Med 1997;8:152-5.
Guderian RH, Mackenzie CD, Williams JF. High voltage shock treatment for snake bite. Lancet 1986;2:229.
Theakston RD, Reid HA, Larrick JW, Kaplan J, Yost JA. Snake venom antibodies in Ecuadorian Indians. J Trop Med Hyg 1981;84:199-202.
Howe NR, Meisenheimer JL Jr. Electric shock does not save snakebitten rats. Ann Emerg Med 1988;17:254-6.
Snyder CC, Murdock RT, White GL Jr., Kuitu JR. Electric shock treatment for snake bite. Lancet 1989;1:1022.
Dart RC, Gustafson RA. Failure of electric shock treatment for rattlesnake envenomation. Ann Emerg Med 1991;20:659-61.
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.
Kunkel DB, Curry SC, Vance MV, Ryan PJ. Reptile envenomations. J Toxicol Clin Toxicol 1983;21:503-26.
Snyder CC, Knowles RP. Snakebites. Guidelines for practical management. Postgrad Med 1988;83:52-60, 65-8, 71-5.
Rossner F. Letter: Medical writings of Moses Maimonides. Arch Intern Med 1974;133:318-9.
Knoefel PK. Francesco Redi on Vipers. Leiden: EJ Brill; 1988.
Bharati K, Hati AK. Snakebite management in the tropics. Sci Cult 2000;66:302-4.
Pugh RN, Theakston RD. Fatality following use of a tourniquet after viper bite envenoming. Ann Trop Med Parasitol 1987;81:77-8.
Gray S. Pressure immobilization of snakebite. Wilderness Environ Med 2003;14:70-1.
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.
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].
Win A, Tin T, Khin MM, Aye K, Hla P, Tin NS, et al
. Clinical trial of intramuscular anti-snake venom administration as a first aid measure in the field in the management of Russell's viper bite patients. Southeast Asian J Trop Med Public Health 1996;27:494-7.
Win A. DMR research findings on the management of Russell's viper bite patients (I) prophylactic and first aid measures. Myanmar J Curr Med Pract 2001;5:138-45.
Win A, San K, Khin PPK, Aye K, Hla P. Comparison of efficacy of antivenom injected intravenously and intramuscularly on envenomed mice with Russell's viper venom. Snake 1996;27:106-9.
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.
Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F. Snake bite in South Asia: A review. PLoS Negl Trop Dis 2010;4:e603.
|This article has been cited by|
||Knowledge of venomous snakes, snakebite first aid, treatment, and prevention among clinicians in northern Nigeria: a cross-sectional multicentre study
| ||Godpower C Michael,Bukar A Grema,Ibrahim Aliyu,Mohammed A Alhaji,Teslim O Lawal,Haliru Ibrahim,Aminu G Fikin,Fatima S Gyaran,Kennedy N Kane,Thomas D Thacher,Abba K Badamasi,Emmanuel Ogwuche |
| ||Transactions of The Royal Society of Tropical Medicine and Hygiene. 2018; |
|[Pubmed] | [DOI]|