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GUIDELINE SUMMARY
KEY PRINCIPLES
Determination of antivenom stock requirements is best done at a regional level, either
for a whole Local Health District (LHD) or important regions within a Local Health
District in collaboration with local Critical Care Clinicians based a review of risks,
facilities, past usage and other practical considerations using the following principles:
Whilst, the definitive management of snake envenoming can only occur in a hospital
with a laboratory that can do an INR/aPTT and there is sufficient nursing care;
antivenom treatment can (and should) be given to obviously envenomed patients in
smaller hospitals without laboratory services prior to retrieval.
Specifically, the guidelines recommended that at a minimum ALL hospitals in NSW
should have:
Two (2) vials of funnel-web spider antivenom should be kept in all hospitals
where the spider occurs.
GL2014_005
Page 1 of 2
GUIDELINE SUMMARY
REVISION HISTORY
Version
March 2014
GL2014_005
May 2007
GL2007_006
Approved by
Chief Health Officer
and Deputy
Director General,
Population and
Public Health
Director General
Amendment notes
Updated guideline
New guideline
ATTACHMENTS
1. Snakebite and Spiderbite Clinical Management Guidelines 2013 Third edition
GL2014_005
Page 2 of 2
Contents
ACKNOWLEDGEMENTS.................................. 2
LIST OF ABBREVIATIONS............................... 3
5. SPIDERBITE
GUIDELINES FOR ASSESSMENT
AND MANAGEMENT................................. 20
Introduction..............................................................................20
1. INTRODUCTION.......................................... 5
Relevant history.......................................................................20
RED-BACK SPIDER BITE...........................................................21
Management.....................................................................21
3. SNAKEBITE
KEY PRINCIPLES........................................ 7
Antivenom treatment......................................................22
4. SNAKEBITE
GUIDELINES FOR ASSESSMENT
AND MANAGEMENT................................... 8
First aid................................................................................22
Supportive care.................................................................23
Introduction................................................................................8
Antivenom administration..............................................24
Epidemiology.............................................................................8
Clinical effects............................................................................8
Clinical assessment..................................................................10
Australian snakes cause distinct clinical syndromes..........11
Brown snakes.....................................................................11
Scorpions...................................................................................26
Tiger snakes........................................................................11
Ticks............................................................................................26
Rough-scaled snakes........................................................11
Centipedes................................................................................26
Hoplocephalus spp...........................................................11
Black snakes.......................................................................11
APPENDICES
Taipans................................................................................13
Death adders.....................................................................13
and ENVENOMING...........................................................27
First Aid......................................................................................14
Treatment..................................................................................14
Diagnostic process............................................................14
Exclusion of envenoming................................................16
Antivenom treatment......................................................16
Treatment of complications............................................18
LABORATORY STAFF........................................................28
GLOSSARY OF TERMS................................. 41
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 1
Acknowledgements
NSW Health, Health System Planning and Investment
Branch would like to thank the expert review panel for
their time, expertise and contribution to the review of the
New South Wales Health Snakebite and Spiderbite
Previous contributors
(2007 edition)
n
Newcastle.
Australia.
Review coordination
Mr Bart Cavalletto and Ms Christine Frew, Specialty
Service and Technology Evaluation Unit, Health System
Planning and Investment Branch, NSW Ministry of Health.
PAGE 2 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
List of Abbreviations
AMRS
AV Antivenom
aPTT
CK
Creatinine Kinase
CSL
EUC
FBC
FDP
FFP
INR
LDH
Lactate Dehydrogenase
LHD
LFT
NETS
NSAIDS
PIB
PIC
SVDK
VICC
WBCT
WCC
XDP
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 3
Figures
Figure 1. Flow chart for the management of snake bite..................................................................................15
Figure 2. Ptosis following Tiger Snake Bite......................................................................................................27
Figure 3. Myoglobinuria..................................................................................................................................27
Figure 4. Local effects of a red-bellied black snake bite on finger...................................................................27
PAGE 4 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
ONE
Introduction
These Guidelines provide information to assist clinicians
administer antivenom.
of standard analgesics.
advice.
n
further information.
TWO
Medical retrieval
(modern spiders)
http://www.xs4all.nl/~ednieuw/australian/Spidaus.html
http://www.ecinsw.com.au/node/183
http://www.toxinology.com/
Agency for Clinical Innovation
PAGE 6 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
THREE
Snakebite
Key Principles
n
Snakebite is a potential medical emergency and should always receive high priority assessment and
treatment, even if the patient appears initially well.
Manage cases only in hospitals with laboratory facilities on-site and antivenom. (Point of care pathology
testing is not sufficient).
Admit all cases of probable snakebite for at least 12 hours after the bite to a suitable clinical unit such as
an emergency department observation or short stay ward, high dependency unit or other clinical unit
where close observation can be maintained. Patients should have serial blood testing (aPTT, INR, CK) and
serial neurological examinations.
Antivenom should be given as soon as there is clear evidence of envenoming. Evidence for systemic
envenoming includes history of sudden collapse, venom induced consumption coagulopathy,
neurotoxicity, myotoxicity, systemic symptoms and renal impairment.
Although the definitive care of patients with snake envenoming cannot occur in small hospitals without
laboratory facilities or sufficient medical or nursing care to allow close observation, antivenom treatment
can be given. In patients with clear evidence of clinical envenoming or sufficient concern by the treating
clinicians, antivenom should be administered in smaller hospitals prior to retrieval.
Each venomous snake group causes a characteristic clinical syndrome which can be used with local
geographical distribution information to determine the likely snake. Either one or more monovalent
antivenom(s) that cover possible snakes or polyvalent antivenom can be used with equal effect.
One vial of the correct antivenom is sufficient to neutralise all circulating venom, however recovery may
be delayed as many clinical effects of venom are not immediately reversible.
The majority of snakebites will not result in significant envenoming and will not require antivenom.
For expert advice on envenoming contact the NSW Poisons Information Centre (13 11 26).
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 7
FOUR
Snakebite
Guidelines for Assessment and Management
Introduction
Clinical effects
Epidemiology
Most bites occur in the warmer months and in regional
and rural areas. Brown snakes are the most common
cause of severe envenoming and make up the majority of
confirmed envenomings in NSW. Antivenoms that cover
the important local snakes should be held in most
hospitals. Snake collectors may have uncommon snakes in
captivity that rarely bite or do not occur in the wild in
that part of NSW (e.g. Colletts snake, death adders and
taipans) in which case the monovalent antivenom may
not be immediately available and polyvalent antivenom
should be used. Snake handlers may be reluctant to have
antivenom as there is a myth that they are more likely to
have a reaction to antivenom. There is no evidence to
suggest they are at greater risk of anaphylaxis to
antivenom. They are at risk of anaphylaxis to venom and
this should be considered in the differential diagnosis.
PAGE 8 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
CHARACTERISTICS
Sudden collapse
Collapse/syncope that occurs within an hour of the bite and often before patients present to
hospital. The collapse is associated with hypotension and loss of consciousness. Spontaneous
recovery usually occurs within minutes but in some cases patients have a cardiac arrest or
seizure.
Venom-induced consumption
coagulopathy (VICC)
Activation of the clotting pathway and consumption of important clotting factors, including
fibrinogen, factor V and factor VIII leads to a consumptive coagulopathy. The INR and aPTT
are raised or unrecordable, fibrinogen is low or undetectable and very high D-Dimer.
Complete or severe VICC is defined as an undetectable fibrinogen, unrecordable INR and
aPTT, and very high d-Dimer (10 to 1000 times the assay cut-off).
Less severe changes are referred to as Partial VICC (detectable fibrinogen, and INR <3.0)
Neurotoxicity
A descending flaccid paralysis which classically first involves the eye muscles (ptosis, diplopia
and blurred vision), followed by bulbar muscles, respiratory muscle paralysis and limb
paralysis.
Myotoxicity
Local or generalised myalgia and/or muscle tenderness. The CK is usually normal on admission
and then rapidly rises over 24-48 hours (CK ranges from 1000 U/L in mild cases to >100,000
U/L in severe cases).
Anticoagulant coagulopathy
The aPTT is moderately raised (1.5 to 2.5 x normal) with or without a mild elevation in the INR
and a normal D-Dimer. This coagulopathy provides a good marker of envenoming by black
snakes but is not clinically important.
Thrombotic microangiopathy
(TMA)
Systemic symptoms
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 9
Clinical assessment
focus on:
envenoming.
renal impairment/failure.
PAGE 10 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
Rough-scaled snake
Brown snakes
Brown snakes are the most common cause of severe
Broad-headed snakes
(Hoplocephalus spp.)
both arid and wetter areas, adapt well to human land use
snake antivenom.
Black snakes
snake antivenom.
Tiger snakes
or polyvalent antivenom.
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 11
PAGE 12 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
VICC
Brown Snake
VICC
Rough-scale snake
Anti-coagulant
Anti-coagulant
VICC
VICC
Mulga snake
Hoplocephalus spp.
Death adder
Taipan
Black snakes
VICC
Tiger snake
COAGULOPATHY
SNAKE
Common
Common
Uncommon
Uncommon
NEUROTOXICITY
Rare
Uncommon
Uncommon
Uncommon
Uncommon
MYOTOXICITY
Common
Common
< 50%
Common
Common
Common
Common
<50%
SYSTEMIC
SYMPTOMS
Rare
<5%
<5%
5%
Uncommon
THROMBOTIC
MICROANGIOPATHY
Uncommon
Rare
Rare
Collapse (33%)
CARDIOVASCULAR
EFFECTS
Taipans
systemic envenoming.
n
antivenom.
Death adders
Death adders occur across most of mainland Australia
(except the south-east i.e. Victoria) and have a distinctive
polyvalent antivenom.
Other elapids
Investigations
envenoming:
using a swab from the bite site, although urine can also
n
geographical region.
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 13
First aid
Treatment
Diagnostic process
PAGE 14 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 15
Exclusion of envenoming
observed for 12 hours after the time of the bite with the
neurological examination
neurological examination
bite may roughly coincide and only one set will need to
Antivenom treatment
snake envenomings.
PBI removal.
suspected snakebites.
PAGE 16 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
bnormal INR
A
History of sudden collapse, seizure or cardiac arrest
n Any evidence of paralysis with ptosis and/or ophthalmoplegia
being the earliest signs
n
n
Relative indications:
corticosteroids.
are all large volume (> 10 ml) and all of these snakes
antivenom.
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 17
Treatment of complications
1.
Major bleeding: except for antivenom, the treatment
of major bleeding following snake envenoming is the
be done:
bleeding.
2.
Thrombotic microangiopathy: no specific
HUS/TTP).
3. Rhabdomyolysis and acute renal failure:
clinical features.
PAGE 18 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 19
FIVE
Spiderbite
Guidelines for Assessment and Management
Introduction
Red-back spider envenoming or latrodectism is
systemic envenoming.
Clinical assessment
definite bite.
Relevant history
Newcastle.
occurred?
patient has not been bitten. Most patients will recall the
pain of the bite and often see or catch the spider after
Timing and type of first aid and activity after the bite
conscious state
PAGE 20 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
clinical pathways:
being bitten.
2-5 days.
priapism.
will occur.
neoplastic aetiologies.
Management
First aid
There is no definitive first aid for latrodectism. Cold packs
Further management
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 21
First aid
The first aid for Funnel Web Spider bites is the same as
analgesics.
Antivenom treatment
Administration
administered.
protocols.
not required.
2. If incomplete resolution of symptoms seek expert
PAGE 22 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
CHARACTERISTICS
n
n
n
n
n
n
n
n
n
Non-specific systemic
symptoms
n
n
n
n
rowsiness or coma rare and typically occurs late or in association with severe envenoming
D
Multiorgan failure occurs late in life-threatening cases if antivenom has not been administered
gitation/anxiety
A
Abdominal pain
Nausea, vomiting
Headache
Clinical management of
funnel web spider bite
Supportive care
Respiratory failure is usually due to pulmonary oedema
n S
eek
initial antivenom.
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 23
Antivenom administration
n
Clinical management
of other common spiders
spider bites.
and bites cause local pain and redness and often occur
PAGE 24 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
Table 5. An approach to the investigation and diagnosis of necrotic skin ulcers, presenting as a suspected spider bite
1. Establish whether or not there is a history of spider bite
n
3. Investigation
n
Skin biopsy:
M
icrobiology (with appropriate transport media): contact microbiology laboratory prior to collecting specimens so that appropriate
material and transport conditions are used for organisms such as Mycobacterium spp., fungi and unusual bacterial.
Histopathology
Laboratory: other supportive investigations may be important for underlying conditions (autoimmune conditions, vasculitis and
pyoderma gangrenosum). These may include, but not be limited to:
full blood count
coagulation studies
biochemistry (including liver and renal function tests)
autoimmune screening tests
cryoglobulins
chest radiography
colonoscopy
vascular function studies of lower limbs
4. Treatment
n
n
n
Source: From Isbister GK and Whyte IM, 2004, Suspected white-tail spider bite and necrotic ulcers,
Internal Medicine Journal Volume 34, Issue 1-2, 3844, January 2004
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 25
SIX
ticks but all focus on removing all parts and not leaving
The pain usually lasts for a few hours. Other local effects
human use.
Centipedes
The first pair of centipede legs are modified into biting
Ticks
analgesia.
PAGE 26 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
APPENDIX 1
Renal damage
microangiopathy.
Collapse
General symptoms
Include headache, nausea, vomiting, abdominal pain,
diarrhoea, generalised diaphoresis.
Local symptoms
Vary from minimal to obvious bite marks, local pain,
swelling, or bruising. A trivial looking bite site does
not mean trivial envenoming.
Coagulopathy
Myolysis
Caused by generalised destruction of skeletal muscle with
high serum CK (creatine kinase) and myoglobinuria (red
to brown urine testing positive for blood; can be
confused with true haematuria). Signs include: muscle
movement pain or weakness, and red or brown urine.
Figure 3. Myoglobinuria
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 27
APPENDIX 2
Coagulation studies:
PT/INR, aPTT, fibrinogen level,
d-dimer/FDP, platelet count.
thrombotic microangiopathy.
Muscle damage
[creatinine kinase (CK)]
clinical grounds.
and is expensive.
PAGE 28 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
APPENDIX 3
Preparation prior to
commencing antivenom
ventilation as required.
iii. Rapid infusion of 1L Normal Saline (20 mL/kg in
management.
needed.
Management of a reaction
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 29
APPENDIX 4
of standard analgesics.
retrieval.
following principles:
hospitals
stocks.
regional facilities.
administer antivenom.
PAGE 30 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
affect potency.
individual hospitals.
Drug/Pharmacy Service.
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 31
APPENDIX 5
Goodoga
Delegate
Bega
Bombala
Pambula
Murwillumbah
Tweed Heads
Kyogle
Mullumbimby
Bonalbo
Nimbin
Byron Bay
Tenterfield
Casino
Lismore
Moree Warialda Vegetable Creek Coraki
Collarenabri
Tibooburra
Lightning
Ballina
Ridge
Maclean
Inverell
Walgett
Bingara
Brewarrina
Glen
Grafton
Innes
Wee Waa
Bundarra
Bourke
Dorrigo
Barraba
Narrabri
Armidale
Coffs Harbour
Boggabri Manilla
Bellingen
Coonamble
Baradine
Macksville
Tamworth
Gunnedah
Walcha
Gulargambone Coonabarabran
Kempsey
Cobar
Werris Creek
Wilcannia
Wauchope
Warren Gilgandra
Binnaway
Nyngan
Quirindi
Port Macaquarie
Coolah
Murrurindi
Broken Hill
Trangie
Dunedoo
Scone Gloucester
Dubbo
Taree
Tottenham
Gulgong Muswellbrook
Forster
Dungog
Narromine Wellington
Mudgee Singleton
Buladelah
Peak Hill
Tullamore
Ivanhoe
Maitland
Rylstone
Yeoval
Trundle
Cessnock
Condobolin
Molong
Newcastle (Mater and John Hunter)
Parkes
Orange Portland
Cudal
Hilston
Forbes
Bathurst
Gosford
Blue Mountains/Katoomba
West Eugowra
Canowindra Blayney
Wyalong
Grenfell
Lithgow
Wentworth
Cowra Oberon
Sydney (metropolitan hospitals)
Griffith Barellan
Quiandalla
Young
Mildura
Bulli
Temora
Hay
BooroowaCrookwell Bowral
Balranald
Leeton
Harden
Wollongong
Narrandera
Goulburn
Junee Cootamundra
Coolamon
Yass
Gundagai
Lockhart
Wagga
Canberra
Jerilderie Urana
Henty
Tumut
Barham Deniliquin
Milton/Ulladulla
Berrigan
Braidwood
Batlow
Queanbeyan
Finlay
Culcairn
Batemans Bay
Corowa
Holbrook
Tocumwal
Tumbarumbra
Moruya
Cooma
Albury
Urbanville
Goodoga
Delegate
Bega
Bombala
PAGE 32 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
Pambula
Goodoga
Delegate
Bega
Bombala
Pambula
Goodoga
Tenterfield
Delegate
Bega
Bombala
Pambula
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 33
Goodoga
Delegate
Bega
Bombala
Pambula
Murwillumbah
Tweed Heads
Kyogle
Mullumbimby
Bonalbo
Nimbin
Byron Bay
Casino
Lismore
Moree Warialda Vegetable Creek Coraki
Collarenabri
Tibooburra
Lightning
Ballina
Ridge
Maclean
Walgett
Bingara Inverell
Brewarrina
Glen
Grafton
Innes
Wee Waa
Bundarra
Bourke
Dorrigo
Barraba
Narrabri
Armidale
Coffs Harbour
Boggabri Manilla
Bellingen
Coonamble
Baradine
Macksville
Tamworth
Gunnedah
Walcha
Gulargambone Coonabarabran
Kempsey
Cobar
Werris Creek
Wilcannia
Wauchope
Warren Gilgandra
Binnaway
Nyngan
Quirindi
Port Macaquarie
Coolah
Murrurindi
Broken Hill
Trangie
Dunedoo
Gloucester
Scone
Dubbo
Taree
Tottenham
Gulgong Muswellbrook
Forster
Dungog
Narromine Wellington
Mudgee Singleton
Buladelah
Peak Hill
Tullamore
Ivanhoe
Maitland
Rylstone
Yeoval
Trundle
Cessnock
Condobolin
Molong
Newcastle (Mater and John Hunter)
Parkes
Orange Portland
Cudal
Hilston
Forbes
Bathurst
Gosford
Blue Mountains/Katoomba
West Eugowra
Canowindra Blayney
Wyalong
Grenfell
Lithgow
Wentworth
Cowra Oberon
Sydney (metropolitan hospitals)
Griffith Barellan
Quiandalla
Mildura
Bulli
Temora YoungBooroowaCrookwell Bowral
Hay
Balranald
Leeton
Harden
Wollongong
Narrandera
Goulburn
Junee Cootamundra
Coolamon
Yass
Gundagai
Lockhart
Wagga
Canberra
Jerilderie Urana
Henty
Tumut
Barham Deniliquin
Milton/Ulladulla
Berrigan
Braidwood
Batlow
Queanbeyan
Finlay
Culcairn
Batemans Bay
Corowa
Holbrook
Tocumwal
Tumbarumbra
Moruya
Cooma
Albury
Urbanville
Goodoga
Tenterfield
Delegate
Bega
Bombala
Pambula
Murwillumbah
Tweed Heads
Kyogle
Mullumbimby
Bonalbo
Nimbin
Byron Bay
Casino
Lismore
Moree
Collarenabri
Tibooburra
Lightning
Warialda Vegetable Creek Coraki
Ballina
Ridge
Maclean
Walgett
Bingara Inverell
Brewarrina
Glen
Grafton
Innes
Wee Waa
Bundarra
Bourke
Dorrigo
Barraba
Narrabri
Armidale
Coffs Harbour
Boggabri Manilla
Bellingen
Coonamble
Baradine
Macksville
Tamworth
Gunnedah
Walcha
Gulargambone Coonabarabran
Kempsey
Cobar
Werris Creek
Wilcannia
Wauchope
Warren Gilgandra
Binnaway
Nyngan
Quirindi
Port Macaquarie
Coolah
Murrurindi
Broken Hill
Trangie
Dunedoo
Scone Gloucester
Dubbo
Taree
Tottenham
Gulgong Muswellbrook
Forster
Dungog
Narromine Wellington
Mudgee Singleton
Buladelah
Peak Hill
Tullamore
Ivanhoe
Maitland
Rylstone
Yeoval
Trundle
Cessnock
Condobolin
Molong
Newcastle (Mater and John Hunter)
Parkes
Orange Portland
Cudal
Hilston
Forbes
Bathurst
Gosford
Blue Mountains/Katoomba
West Eugowra
Canowindra Blayney
Wyalong
Grenfell
Lithgow
Wentworth
Cowra Oberon
Sydney (metropolitan hospitals)
Griffith Barellan
Quiandalla
Mildura
Bulli
Temora YoungBooroowaCrookwell Bowral
Hay
Balranald
Leeton
Harden
Wollongong
Narrandera
Goulburn
Junee Cootamundra
Coolamon
Yass
Gundagai
Lockhart
Wagga
Canberra
Jerilderie Urana
Henty
Tumut
Barham Deniliquin
Milton/Ulladulla
Berrigan
Braidwood
Batlow
Queanbeyan
Finlay
Culcairn
Batemans Bay
Corowa
Holbrook
Tocumwal
Tumbarumbra
Moruya
Cooma
Albury
Urbanville
Goodoga
Tenterfield
Delegate
Bega
Bombala
PAGE 34 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
Pambula
Goodoga
Delegate
Bega
Bombala
Pambula
Murwillumbah
Tweed Heads
Kyogle
Mullumbimby
Bonalbo
Nimbin
Byron Bay
Tenterfield
Casino
Lismore
Moree Warialda Vegetable Creek Coraki
Collarenabri
Tibooburra
Lightning
Ballina
Ridge
Maclean
Inverell
Walgett
Bingara
Brewarrina
Glen
Grafton
Innes
Wee Waa
Bundarra
Bourke
Dorrigo
Barraba
Narrabri
Armidale
Coffs Harbour
Boggabri Manilla
Bellingen
Coonamble
Baradine
Macksville
Tamworth
Gunnedah
Walcha
Gulargambone Coonabarabran
Kempsey
Cobar
Werris Creek
Wilcannia
Wauchope
Warren Gilgandra
Binnaway
Nyngan
Quirindi
Port Macaquarie
Coolah
Murrurindi
Broken Hill
Trangie
Dunedoo
Scone Gloucester
Dubbo
Taree
Tottenham
Gulgong Muswellbrook
Forster
Dungog
Narromine Wellington
Mudgee Singleton
Buladelah
Peak Hill
Tullamore
Ivanhoe
Maitland
Rylstone
Yeoval
Trundle
Cessnock
Condobolin
Molong
Newcastle (Mater and John Hunter)
Parkes
Orange Portland
Cudal
Hilston
Forbes
Bathurst
Gosford
Blue Mountains/Katoomba
West Eugowra
Canowindra Blayney
Wyalong
Grenfell
Lithgow
Wentworth
Cowra Oberon
Sydney (metropolitan hospitals)
Griffith Barellan
Quiandalla
Young
Mildura
Bulli
Temora
Bowral
Hay
BooroowaCrookwell
Balranald
Leeton
Harden
Wollongong
Narrandera
Goulburn
Junee Cootamundra
Coolamon
Yass
Gundagai
Lockhart
Wagga
Canberra
Jerilderie Urana
Henty
Tumut
Barham Deniliquin
Milton/Ulladulla
Berrigan
Braidwood
Batlow
Queanbeyan
Finlay
Culcairn
Batemans Bay
Corowa
Holbrook
Tocumwal
Tumbarumbra
Moruya
Cooma
Albury
Urbanville
Goodoga
Delegate
Bega
Bombala
Pambula
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 35
Goodoga
Tenterfield
Delegate
Bega
Bombala
Pambula
Death adder
Murwillumbah
Tweed Heads
Kyogle
Mullumbimby
Bonalbo
Nimbin
Byron Bay
Tenterfield
Casino
Lismore
Moree Warialda Vegetable Creek Coraki
Collarenabri
Tibooburra
Lightning
Ballina
Ridge
Maclean
Walgett
Bingara Inverell
Brewarrina
Glen
Grafton
Innes
Wee Waa
Bundarra
Bourke
Dorrigo
Barraba
Narrabri
Armidale
Coffs Harbour
Boggabri Manilla
Bellingen
Coonamble
Baradine
Macksville
Tamworth
Gunnedah
Walcha
Gulargambone Coonabarabran
Kempsey
Cobar
Werris Creek
Wilcannia
Wauchope
Warren Gilgandra
Binnaway
Nyngan
Quirindi
Port Macaquarie
Coolah
Murrurindi
Broken Hill
Trangie
Dunedoo
Scone Gloucester
Dubbo
Taree
Tottenham
Gulgong Muswellbrook
Forster
Dungog
Narromine Wellington
Mudgee Singleton
Buladelah
Peak Hill
Tullamore
Ivanhoe
Maitland
Rylstone
Yeoval
Trundle
Cessnock
Condobolin
Molong
Newcastle (Mater and John Hunter)
Parkes
Orange Portland
Cudal
Hilston
Forbes
Bathurst
Gosford
Blue Mountains/Katoomba
West Eugowra
Canowindra Blayney
Wyalong
Grenfell
Lithgow
Wentworth
Cowra Oberon
Sydney (metropolitan hospitals)
Griffith Barellan
Quiandalla
Young
Mildura
Bulli
Temora
Bowral
Hay
Booroowa
Crookwell
Balranald
Leeton
Harden
Wollongong
Narrandera
Goulburn
Junee Cootamundra
Coolamon
Yass
Gundagai
Lockhart
Wagga
Canberra
Jerilderie Urana
Henty
Tumut
Barham Deniliquin
Milton/Ulladulla
Berrigan
Braidwood
Batlow
Queanbeyan
Finlay
Culcairn
Batemans Bay
Corowa
Holbrook
Tocumwal
Tumbarumbra
Moruya
Cooma
Albury
Urbanville
Goodoga
Delegate
Bega
Bombala
PAGE 36 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
Pambula
Taipan
Murwillumbah
Tweed Heads
Kyogle
Mullumbimby
Bonalbo
Nimbin
Byron Bay
Casino
Lismore
Moree
Collarenabri
Tibooburra
Lightning
Vegetable Creek Coraki
Warialda
Ballina
Ridge
Maclean
Walgett
Bingara Inverell
Brewarrina
Glen
Grafton
Innes
Wee Waa
Bundarra
Bourke
Dorrigo
Barraba
Narrabri
Armidale
Coffs Harbour
Boggabri Manilla
Bellingen
Coonamble
Baradine
Macksville
Tamworth
Gunnedah
Walcha
Gulargambone Coonabarabran
Kempsey
Cobar
Werris Creek
Wilcannia
Wauchope
Warren Gilgandra
Binnaway
Nyngan
Quirindi
Port Macaquarie
Coolah
Murrurindi
Broken Hill
Trangie
Dunedoo
Scone Gloucester
Dubbo
Taree
Tottenham
Gulgong Muswellbrook
Forster
Dungog
Narromine Wellington
Mudgee Singleton
Buladelah
Peak Hill
Tullamore
Ivanhoe
Maitland
Rylstone
Yeoval
Trundle
Cessnock
Condobolin
Molong
Newcastle (Mater and John Hunter)
Parkes
Orange Portland
Cudal
Hilston
Forbes
Bathurst
Gosford
Blue Mountains/Katoomba
West Eugowra
Canowindra
Blayney
Wyalong
Grenfell
Lithgow
Wentworth
Cowra
Sydney (metropolitan hospitals)
Oberon
Griffith Barellan
Quiandalla
Mildura
Bulli
Temora YoungBooroowaCrookwell Bowral
Hay
Balranald
Leeton
Harden
Wollongong
Narrandera
Goulburn
Junee Cootamundra
Coolamon
Yass
Gundagai
Lockhart
Wagga
Canberra
Jerilderie Urana
Henty
Tumut
Barham Deniliquin
Milton/Ulladulla
Berrigan
Braidwood
Batlow
Queanbeyan
Finlay
Culcairn
Batemans Bay
Corowa
Holbrook
Tocumwal
Tumbarumbra
Moruya
Cooma
Albury
Urbanville
Goodoga
Tenterfield
Delegate
Bega
Bombala
Pambula
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 37
APPENDIX 6
PAGE 38 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
APPENDIX 7
INTERVENTION /OUTCOME
INITIAL
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 39
APPENDIX 8
pp.1606-1620.
pp.125-9.
PAGE 40 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition
Glossary of Terms
Anaphylaxis
Envenoming
Monovalent
Antivenom
Antivenom (or antivenin, or antivenene) is a biological
Myoglobin
renal failure.
Polyvalent
in others.
Coagulopathy
A disorder that prevents normal clotting of the blood.
Priapism
Is a persistent and often painful penile erection that lasts
D-dimer
medical emergency.
Venom
(DIC).
Defibrination
The loss of fibrin from blood.
Snakebite & Spiderbite Clinical Management Guidelines Third Edition NSW HEALTH PAGE 41
PAGE 42 NSW HEALTH Snakebite & Spiderbite Clinical Management Guidelines Third Edition