roxkaw,1%7, VoL 4. pp . 283-289. Pereamon Pmr Ltd.

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SPECIAL COMMUNICATION

FIRST-AID FOR SNAKE VENOM POISONING'

FINDLAY E . RussEix.
Univeaaity of Southern California School of Medicine, Los Angeles County General Hospital,
Los Angeles, California, U.S .A.

(.Acceptedfor publication 20 Judy 1966)

SNAKE venom poisoning is an emergency requiring immediate attention and the exercise of
considerable judgment . Delayed or inadequate treatment may result in tragic consequences.
On the other hand, failure to differentiate between the bite of a venomous and a non-
venomous snake may lead to the use of measures that cannot only cause discomfort to the
victim but may produce deleterious results. It is essential that a diagnosis be established
before any treatment is instituted . In making the diagnosis it must be remembered that a
venomous snake may bite a person without injecting venom, and that such bites are best
treated as simple puncture wounds . It should also be borne in mind that some persons
bitten by non-venomous snakes become excited and even hysterical, and that these emotions
may give rise to disorientation, faintness, dizziness, rapid respirations or hyperventilation, a
rapid pulse and even primary shock.
The person charged with the responsibility of instituting first-aid treatment will first
need to determine whether or not envenomation has occurred. Secondly, he will need to
decide, among other things, upon the kind of treatment to be used, and then how to initiate
it with the greatest possible speed. Above all, he must keep cool and consider each move
thoroughly. Any treatment, to be effective, must be instituted immediately following the
bite and must include measures (1) to retard absorption of the venom ; (2) to remove as much
venom as possible from the wound ; (3) to neutralize the venom ; (4) to mitigate the effects
produced by the venom ; and (5) to prevent complications, including secondary infection.

STEP ONE
Capture the snake and kill it
Make every effort to identify the snake before initiating treatment. If identification is not
established at the time of the bite, make an effort to find the snake. Most snakes will remain
in the immediate area of the accident and can be found quickly without too much difficulty .
If a second person is present, send him in search of the snake while the victim remains at
rest. Exercise extreme caution in hunting for the offending snake. A reptile that has bitten
once is just as likely to bite again as not. The snake can be killed by a sharp blow on the head .
Do not handle the snake. Carry it on a stick or in a cloth bag if it cannot be positively
identified .

'Presented before the Fort Worth Zoological Association, Fort Worth, Texas, June 24, 1966.
285
286 FINDLAY S RUSSELL

Ifthe snake is a venomous one proceed with the first-aid measures as outlined . Do not
depend on the amount of pain or absence of pain as a symptom on which to base your
decision on whether or not the offending snake was venomous .

STEP TWO
Apply a constriction bandor tourniquet
In cases of envenomation by most Crotalidae, a constriction band should be placed
above the first joint proximal, or 2 to 4 in. proximal to the bite. It should be applied im-
mediately following the bite andtight enough to occlude the superficial venous and lymphatic
return but not the arterial flow. It should be released for 90 sec every 10 min. The con-
striction band can be moved in advance of the progressive swelling. It should be removed
as soon as antivenin has been started or suction discontinued . In no case of viper venom
poisoning should a constriction band be used for more than 2 hr. It is of little value if
applied later than 30 min following the bite. It should be used in conjunction with incision
and suction in viper bites.
In envenomation by elapids, the constriction band or tourniquet is of questionable
value. However, in cases of severe envenomation by cobras, kraits, mambas, tiger snakes,
death adders and taipans, a tight tourniquet should be applied immediately proximal to the
bite and left in place until antivenin is given. It should be released for 90 sec every 10 min.

STEP THREE
Incision and suction
Incision and suction are of definite value when applied immediately following bites by the
vipers, particularly the pit vipers of North America. They are of lesser value following bites
by the South American vipers and Asiatic vipers, and probably of little value subsequent to
envenomation by the elapids and sea snakes . This advice is based on clinical and experi-
mental data which reflect upon the differences in the kind and depth of bites inflicted by the
various venomous snakes, the rate and route of absorption of the venom, and the bio-
chemical and physiopharmacological properties of the different snake venoms .
In viper bites, excluding those by small European vipers and small copperheads of North
America, cruciate or longitudinal incisions of one-eighth to one-quarter in. in length should
be made through the fang marks, except in those cases where there is an abnormal amount
of bleeding or an obvious defect in coagulation. The incisions should be made as deep as
the fang penetration, which in most rattlesnake bites is just through the skin. The direction
ofthe animal's strike andthe curvature ofthe fang should be borne in mind when determining
the plane ofincision . Suction should then be applied and continuedforthe first hour following
the bite. Oral suction should not be used if other means of suction are available. Multiple
incisions over the involved extremity or in advance of progressive edema are not advised.
To be effective, suction must be applied within the first few minutes following the bite. It
is of little value if delayed for 30 min or more. Incisions through the fang marks without
subsequent suction are of questionable value and should be avoided.
In pit viper bites the proper application of the constriction band or tourniquet, and
incision and suction have been found to be of definite value as first-aid measures [1-6].
Their misapplication or late application have resulted in appraisals which do not always
reflect a ready knowledge of the problem. In treating 104 rattlesnake bites over a period of
12 years, most of which arrived at the hospital following the initiation of some first-aid
measures, the author has observed that those patients who properly applied a constriction
 First-aid for Snake Venom Poisoning 28 7

band and incised the fang marks and applied suction fared better than seemingly similar
cases where these measures were not used. In several patients we have been able to remove
the exudate from the suction cups, and in a controlled experiment have demonstrated that
the material was lethal to mice. In 30 cases of envenomation by elapids and African and
Asian vipers we have observed that incision and suction were probably valueless as first-aid
measures . These findings support the clinical observations of RECD [7] and CKAPMAN [8] .

STEP FOUR
Immobilize the injuredpart
This can be done by splinting as for a broken leg. The immobilized part should then be
kept below the level of the heart but not in a completely dependent position . If the wound is
on the body, keep the victim in a sitting or lying position, depending on the location of the
bite. The victim should always be kept warm . He should not be allowed to walk. He should
not be given alcohol . He may be given water, coffee or tea. Any manifestations of fear or
excitement should be alleviated by reassurance with encouraging words and actions.

STEP FIVE
Transport thepatient to a doctor or hospital
This should be done by litter, if at all possible; if not, try to provide some other means of
transportation. Do not let the victim walk if this can be avoided. Be sure to keep him warm,
and the bitten part in a dependent position. If he must walk he should proceed slowly and
rest periodically. Exertion must be avoided. If it appears that a period of more than one
hour will pass before medical treatment can be given, the injured part should be kept cool
with ice bags or cold cloths . This will produce some vasoconstriction and in some cases
reduce pain. It has no effect on the chemistry of the deleterious fractions ofthe venom, nor
should it be used in place of the constriction band and of incision and suction during the
first hour following the bite .

STEP SIX
Antivenin
Under certain conditions antivenin may need to be given as a first-aid measure. Under
no circumstances, however, should it be administered by an untrained person. Deaths have
occurred following injection ofantivenin in persons sensitive to horse serum [9]. Antivenin
might need to be given in those cases where severe symptoms and signs develop early in the
course of the illness, or where a delay of 4 hr or more following viper venom poisoning or
2 hr or more following elapid venom poisoning is foreseen .
In such cases the antivenin should be given intramuscularly following appropriate skin
or conjunctival tests. The antivenin should be given intramuscularly at a site distant from
the wound. The antivenin should never be injected into a finger or toe, and it should be
administered intravenously only by qualified personnel. As the amount of antivenin available
will more than likely be limited, one unit (vial or package) will probably be all that can be
administered . The earlier this is injected the better the results that can be expected. Re-
member, if the victim is in shockthe antivenin will be absorbed slowly from an intramuscular
. site. In such cases the antivenin may need to be given intravenously, but only by a qualified
person.
 288 FINDLAY E. RUS L

STEP SEVEN
Disposition of victim
At the doctor's office or hospital, inform the doctor of the genus of the snake involved
(if known), or turn the dead, unidentified snake over to the doctor . Give approximate
time between bite and arrival, and point out any constriction bands or tourniquets left
in place . Give details on any antivenin or drugs given the patient. Report all unusual
signs and symptoms .

STEP EIGHT
Other supportive measures
Should any of the following sequelae to the bite develop while the victim is being taken to
the doctor, consider these measures :
A. Shock. 1 . Place patient in recumbent or 'sbock' position.
2. Maintain an adequate airway.
3. Keep patient comfortably warm.
4. Control any severe pain . This can usually be done with salicylates or codeine, if
available.
5. Allay apprehension by reassuring words and actions.
6. Give oxygen.
B. Respiratory distress . 1 . Clear airway .
2. Apply artificial respiration. As long as the patient's heart continues to beat he has
a chance to recover, and this may occur even after many hours of artificial respira-
tion . The 'push-pull' methods are most effective in this type of poisoning. How-
ever, use any methods with which you are familiar. Mouth to mouth breathing
with positive pressure to the chest in rhythm can be used. If a mechanical
resuscitator is available, use it ifyou are qualified.
C. Vomiting. Vomiting frequently occurs following certain types of snake venom
poisoning. Precautions should be taken to see that the patient does not aspirate vomitus.
D. Excessive salivation. Place head in a position to permit adequate drainage of
saliva . Keep airway clear.
E. Convulsions . No treatment should be given during the attack except that which will
protect the patient from being injured (e.g. biting his tongue, etc.).
It is not a purpose of this paper to discuss or evaluate all of the first-aid treatments that
have been suggested or advised for snake venom poisoning. Some 217 'cures' for snake
venom poisoning have been described in the literature [9]. Some of the more frequently
suggested are : injecting potassium permanganate, ammonia, vinegar or oil into the wound,
wrapping the liver of the offending snake or of a freshly-killed chicken over the wound,
setting fire to the wound after applying gasoline, cryotherapy, eating various plants or raw
meat, applying mud packs to the wound, soaking the injured part in excrement, washing
the wound with plant juices, indulging in whiskey, taking antihistamatics, etc. These and
the other so-called 'cures' are more than historical curiosities. Whatever the source, they are
hazardous : first, because they often involve dangerous methods; second, because they delay
the use of effective therapeutic procedures . Snake venom poisoning is an accident highly
variable in the gravity of its results. It is one in which the most fantastic remedy may gain its
reputation among credulous people by having cured a malady that required no treatment
whatever.
 First-aid for Snake Venom Poisoning 289

In conclusion it should be noted that there is no single therapeutic standard ofprocedure

for all cases of snake venom poisoning. Rest, immobilization of the injured part and re-
assurance are indicated in every case, and in themselves are valuable therapeutic measures,
but beyond these, few measures can be recommended for all cases of snakebite. Avoid
using any first-aid measure that has not been evaluated; remember, most of the `cures' you
will hear about have been evaluated and found to be useless.

AcknowledgementsThe author is indebted to the Attending Staff Association of the Los Angeles County
Hospital, and the National Institute of Allergy and Infectious Diseases (Grant AC 00273) for the support
of studies upon which certain of the data have been drawn.

REFERENCES
[1] LEOPoLo, R. S. and MERRiAM, T. W., Jr ., The effectiveness of tourniquet, incision and suction in snake
venom removal. U.S. Navy . med. Fiel d Res. Lab. Res. Proj. MR005.09-0020. 1 .3 :211, Nov. 1960.
[2] Rum-L, F. E. and EMERY, J. A., Incision and suction following injection of rattlesnake venom. Am.
J. med. Sei. 241,160,1961 .
[3] GENKARO, J. F., Jr., Observations on the treatment of snakebite in Noi th America. In : Venomous and
Poisonous Animals and Noxious Plants of the Pacific Region . Oxford : Pergamon Press, p. 427, 1963 .
[4] SEELEY, S. F., (For, Ad Hoc Committee on Snakebite Therapy, National Research Council, National
Academy of Sciences .) Interim statement on first-aid therapy for bites by venomous snakes.
Toxicon 1, 81, 1963 .
[5] RUSSELL, F. E., Snake venom poisoning. In : Cyclopedia of Medicine, Surgery and the Specialities.
Volume II . Philadelphia : Davis, p . 197, 1962 .
[6] MCCOLLOUGH, N. C. and GENKARO, J. F., Jr., Evaluation of venomous snake bite in the southern
United States from parallel clinical and laboratory investigations . J. Fla. med. Ass. 49, 959, 1963 .
[7] REm, H. A., Cobra-bites. Br. med. J. 2,540, 1964 .
[8] CHAPMAN, D. S., The clinico-pathology and treatment of snake bite in South and Central Africa.
Presented at the Symposium on Animal Venoms, Silo Paulo, Brazil, July 19, 1966.
[9] RUSSELL, F. E. and SCHARFFENBERG, R. S. : Bibliography ofSnake Venoms and Venomous Snakes . West
Covina, California : Bibliographic Associates, 1964.