Snakebite First Aid

1
Reassure the victim
Calm the victim down. Un-necessary panic will only raise the pulse rate
and blood pressure and moves the venom into the system faster. Tell the
victim that 70% of snakebites are from non-poisonous species. Of the
remaining 30%, only half will actually involve injecting venom. The
chances are they are OK!

2
Immobilise the bitten limb without compression.
If the bite is on a hand or arm place it in a sling bandage or use a piece of
cloth to support the arm. In the case of a leg bite, use a splint to support
both legs and bandage them together. Do not tie the bandages tightly, we
are only trying to immobilise not apply any pressure.

3
Get the patient to Hospital as fast as safely possible.
Don’t waste time washing the wound, seeking traditional remedies or
applying any drugs or chemicals to the victim. Science has shown that
traditional remedies do not work and simply waste valuable time.
Snakestones do not absorb venom and many herbal remedies make the
situation worse. Keep the patient as immobile as possible.

4
Tell the Doctor any of the following signs appearing on the way to the
hospital.

The Doctor will want to know if any of the following signs or symptoms
are noticeable on the journey to the hospital:
Difficulty breathing. If the patient stops breathing, give artificial
respiration. In Cobra and Krait bites this will save the victims life.
Drooping eyelids
Bleeding from the gums or any unusual bruising appearing.
Increases in any swelling. Carry a pen and mark the limit of the
swelling every 10 minutes or so
Drowsiness
Difficulty speaking
Bleeding from the wound that does not seem to stop
 Do it R.I.G.H.T.

Common Mistakes
There will be many who wonder where the tourniquet or compression
bandage has gone, surely we must tie a ligature to stop the venom
spreading. Others will be wondering why we don’t cut the wound to let
some of the venom out. It is important in India that we address these two
common actions to see if they benefit or potentially cause harm to the
victim.

Tourniquets and Ties

Tourniquets or compression bandages have the following drawbacks:

1.The majority of the Indian venomous

snakes have venom that contains toxins
that do serious local damage at the bite
site. This is true of all vipers and the
Cobras. This toxin breaks down tissue
and destroys it. Confining this toxin in a
smaller area, by use of compression
techniques creates a greater risk of
serious local damage.

2.Compression bandages are based on

research that was carried out in Australia
in the 1970’s. This research appeared to
show that venom could be slowed down
by the use of a compression bandage
with an integral splint.
The version that gets used in India, without the splint, is a local hybrid.
The problem with the research was it was done on animals, not
humans. Also it is not used currently in the majority of snakebite cases
in Australia. The author also concluded that immobilisation with the
splint alone or compression bandaging alone would be ineffective.

3 When the tourniquet is removed there is the problem of the venom

 . rapidly entering the system and causing respiratory failure in the case
of neurotoxic bites. Unless the doctor is aware of this syndrome and,
more importantly equipped to deal with it, death can occur.

4. In the case of Viper bites, tourniquets are also a risk. The Viper’s
venom contains pro-coagulant enzymes which cause the blood to clot.
In the small space below the tourniquet the venom has a greater
chance of causing a clot. When the tourniquet is released the clot will
rapidly enter the body and can cause embolism and death.

5. Lastly, there has been a great deal of research showing that

tourniquets DO NOT stop venom from entering the body. One study
demonstrated that 33% of victims tested, experienced systemic
symptoms whilst the tourniquet was still in place!
Cutting the Wound

Cutting the wound to let blood and some venom flow out is also a
common practice that is wrong. Cutting and bleeding does not release
venom from the wound, by the time the cut is made the venom is already
mixed.

The more critical problem is that, apart from the risk of infection, bites by
Vipers cause the blood to be incoagulable i.e. it will not clot. Cutting the
victim makes it more likely that the person will bleed to death!

Snakebite
From Wikipedia, the free encyclopedia
Jump to: navigation, search
For other uses, see Snakebite (disambiguation).

Snakebite

Classification and external resources

 Cobra Naja naja

ICD-10 T63.0, T14.1, W59 (nonvenomous), X20

(venomous)

ICD-9 989.5, E905.0, E906.2

DiseasesDB 29733

MedlinePlus 000031

eMedicine med/2143

MeSH D012909

A snakebite is an injury caused by a bite from a snake, often resulting in puncture

wounds inflicted by the animal's fangs and sometimes resulting in envenomation.
Although the majority of snake species are non-venomous and typically kill their prey
with constriction rather than venom, venomous snakes can be found on every continent
except Antarctica.[1] Snakes often bite their prey as a method of hunting, but also for
defensive purposes against predators. Since the physical appearance of snakes may differ,
there is often no practical way to identify a species and professional medical attention
should be sought.[2][3]

The outcome of snake bites depends on numerous factors, including the species of snake,
the area of the body bitten, the amount of venom injected, and the health conditions of the
victim. Feelings of terror and panic are common after a snakebite and can produce a
characteristic set of symptoms mediated by the autonomic nervous system, such as a
racing heart and nausea.[4][5] Bites from non-venomous snakes can also cause injury, often
due to lacerations caused by the snake's teeth, or from a resulting infection. A bite may
also trigger an anaphylactic reaction, which is potentially fatal. First aid
recommendations for bites depend on the snakes inhabiting the region, as effective
treatments for bites inflicted by some species can be ineffective for others.

The number of fatalities attributed to snake bites varies greatly by geographical area.
Although deaths are relatively rare in Australia, Europe and North America,[1][6][7] the
morbidity and mortality associated with snake bites is a serious public health problem in
many regions of the world, particularly in rural areas lacking medical facilities. Further,
while South Asia, Southeast Asia, and sub-Saharan Africa report the highest number of
bites, there is also a high incidence in the Neotropics and other equatorial and subtropical
regions.[1][6][7] Each year tens of thousands of people die from snake bites,[1] yet the risk of
being bitten can be lowered with preventive measures, such as wearing protective
footwear and avoiding areas known to be inhabited by dangerous snakes.
Contents
[hide]

• 1 Signs and symptoms

• 2 Pathophysiology
o 2.1 Snake venom
• 3 Prevention
• 4 Treatment
o 4.1 Snake identification
o 4.2 First aid
o 4.3 Pressure immobilization
o 4.4 Antivenom
o 4.5 Outmoded treatments
• 5 Epidemiology
• 6 Society and culture
• 7 See also
• 8 Footnotes
• 9 References

• 10 External links

[edit] Signs and symptoms

The most common symptoms of any kind of snake envenomation.[8][9][10] However, there
is vast variation in symptoms between bites from different types of snakes.[8]
Severe tissue necrosis following Bothrops asper envenomation. The victim was an 11-
year-old boy, bitten two weeks earlier in Ecuador, but treated only with antibiotics.[11]

The most common symptoms of all snakebites are overwhelming fear, panic, and
emotional instability, which may cause symptoms such as nausea and vomiting, diarrhea,
vertigo, fainting, tachycardia, and cold, clammy skin.[4][5] Television, literature, and
folklore are in part responsible for the hype surrounding snakebites, and a victim may
have unwarranted thoughts of imminent death.

Dry snakebites, and those inflicted by a non-venomous species, can still cause severe
injury to the victim. There are several reasons for this: a snakebite which is not treated
properly may become infected (as is often reported by the victims of viper bites whose
fangs are capable of inflicting deep puncture wounds), the bite may cause anaphylaxis in
certain people, and the snake's saliva and fangs may harbor many dangerous microbial
contaminants, including Clostridium tetani. If neglected, an infection may spread and
potentially kill the victim.

Most snakebites, whether by a venomous snake or not, will have some type of local
effect. There is minor pain and redness in over 90% of cases, although this varies
depending on the site.[4] Bites by vipers and some cobras may be extremely painful, with
the local tissue sometimes becoming tender and severely swollen within 5 minutes.[7] This
area may also bleed and blister. Other common initial symptoms of pitviper bites include
lethargy, weakness, nausea, and vomiting.[4][7] Symptoms may become more life-
threatening over time, developing into hypotension, tachypnea, severe tachycardia,
altered sensorium, and respiratory failure.[4][7]

Interestingly, bites caused by the Mojave rattlesnake, coral snake, and the speckled
rattlesnake reportedly cause little or no pain despite being serious injuries.[4] Victims may
also describe a "rubbery," "minty," or "metallic" taste if bitten by certain species of
rattlesnake.[4] Spitting cobras and rinkhalses can spit venom in their victims' eyes. This
results in immediate pain, ophthalmoparesis, and sometimes blindness.[12][13]

Some Australian elapids and most viper envenomations will cause coagulopathy,
sometimes so severe that a person may bleed spontaneously from the mouth, nose, and
even old, seemingly-healed wounds.[7] Internal organs may bleed, including the brain and
intestines and will cause ecchymosis (bruising) of the victim's skin.

Venom emitted from elapids, including cobras, kraits, mambas, sea snakes, and many
Australian species, contain toxins which attack the nervous system, causing
neurotoxicity.[4][7][14] The victim may present with strange disturbances to their vision,
including blurriness. Paresthesia throughout the body, as well as difficulty speaking and
breathing, may be reported.[4] Nervous system problems will cause a huge array of
symptoms, and those provided here are not exhaustive. If the victim is not treated
immediately they may die from respiratory failure.

Venom emitted from some Australian elapids, almost all vipers, and all sea snakes causes
necrosis of muscle tissue.[7] Muscle tissue will begin to die throughout the body, a
condition known as rhabdomyolysis. Dead muscle cells may even clog the kidney which
filters out proteins. This, coupled with hypotension, can lead to acute renal failure, and, if
left untreated, eventually death.[7]

[edit] Pathophysiology

Since envenomation is completely voluntary, all venomous snakes are capable of biting
without injecting venom into their victim. Snakes may deliver such a "dry bite" rather
than waste their venom on a creature too large for them to eat.[15] However, the
percentage of dry bites varies between species: 50% of bites from the normally timid
coral snake do not result in envenomation, whereas only 25% of pitviper bites are dry.[4]
Furthermore, some snake genera, such as rattlesnakes, significantly increase the amount
of venom injected in defensive bites compared to predatory strikes.[16]

Some dry bites may also be the result of imprecise timing on the snake's part, as venom
may be prematurely released before the fangs have penetrated the victim's flesh.[15] Even
without venom, some snakes, particularly large constrictors such as those belonging to
the Boidae and Pythonidae families, can deliver damaging bites; large specimens often
cause severe lacerations as the victim or the snake itself pull away, causing the flesh to be
torn by the needle-sharp recurved teeth embedded in the victim. While not as life-
threatening as a bite from a venomous species, the bite can be at least temporarily
debilitating and could lead to dangerous infections if improperly dealt with.
While most snakes must open their mouths before biting, African and Middle Eastern
snakes belonging to the family Atractaspididae are able to fold their fangs to the side of
their head without opening their mouth and jab at victims.[17]

[edit] Snake venom

Main article: Snake venom

It has been suggested that snakes evolved the mechanisms necessary for venom formation
and delivery sometime during the Miocene epoch.[18] During the mid-Tertiary, most
snakes were large ambush predators belonging to the superfamily Henophidia, which use
constriction to kill their prey. As open grasslands replaced forested areas in parts of the
world, some snake families evolved to become smaller and thus more agile. However,
subduing and killing prey became more difficult for the smaller snakes, leading to the
evolution of snake venom.[18] Other research on Toxicofera, a hypothetical clade thought
to be ancestral to most living reptiles, suggests an earlier time frame for the evolution of
snake venom, possibly to the order of tens of millions of years, during the Late
Cretaceous.[19]

Snake venom is produced in modified parotid glands normally responsible for secreting
saliva. It is stored in structures called alveoli behind the animal's eyes, and ejected
voluntarily through its hollow tubular fangs. Venom is composed of hundreds to
thousands of different proteins and enzymes, all serving a variety of purposes, such as
interfering with a prey's cardiac system or increasing tissue permeability so that venom is
absorbed faster.

Venom in many snakes, such as pitvipers, affects virtually every organ system in the
human body and can be a combination of many toxins, including cytotoxins, hemotoxins,
neurotoxins, and myotoxins, allowing for an enormous variety of symptoms.[4][20] Earlier,
the venom of a particular snake was considered to be one kind only i.e. either hemotoxic
or neurotoxic, and this erroneous belief may still persist wherever the updated literature is
hard to access. Although there is much known about the protein compositions of venoms
from Asian and American snakes, comparatively little is known of Australian snakes.

The strength of venom differs markedly between species and even more so between
families, as measured by LD50 in mice.[1] Subcutaneous LD50 varies by over 140-fold
within elapids and by more than 100-fold in vipers [2]. The amount of venom produced
also differs among species, with the Gaboon viper able to potentially deliver from 5–7 ml
(450–600 mg) of venom in a single bite, the most of any snake. [21] Opisthoglyphous
colubrids have venom ranging from life-threatening (in the case of the boomslang) to
barely noticable (as in Tantilla).
[edit] Prevention

Sign at Sylvan Rodriguez Park in Houston, Texas warning of the presence of snakes.

Snakes are most likely to bite when they feel threatened, are startled, are provoked, or
have no means of escape when cornered. Encountering a snake is always considered
dangerous and it is recommended to leave the vicinity. There is no practical way to safely
identify any snake species as appearances may vary dramatically.

Snakes are likely to approach residential areas when attracted by prey, such as rodents.
Practicing regular pest control can reduce the threat of snakes considerably. It is
beneficial to know the species of snake that are common in local areas, or while traveling
or hiking. Areas of the world such as Africa, Australia, the Neotropics, and southern Asia
are inhabited by many highly dangerous species. Being wary of snake presence and
ultimately avoiding it when known is strongly recommended.

When in the wilderness, treading heavily creates ground vibrations and noise, which will
often cause snakes to flee from the area. However, this generally only applies to North
America as some larger and more aggressive snakes in other parts of the world, such as
king cobras and black mambas, will protect their territory. When dealing with direct
encounters it is best to remain silent and motionless. If the snake has not yet fled it is
important to step away slowly and cautiously.

The use of a flashlight when engaged in camping activities, such as gathering firewood at
night, can be helpful. Snakes may also be unusually active during especially warm nights
when ambient temperatures exceed 21 °C (70 °F). It is advised not to reach blindly into
hollow logs, flip over large rocks, and enter old cabins or other potential snake hiding-
places. When rock climbing, it is not safe to grab ledges or crevices without examining
them first, as snakes are cold-blooded and often sunbathe atop rock ledges.
Pet owners of domestic animals or snakes should be aware that a snake is capable of
causing injury and that is necessary to always act with caution. When handling snakes it
is never wise to consume alcoholic beverages. In the United States more than 40% of
snakebite victims intentionally put themselves in harm's way by attempting to capture
wild snakes or by carelessly handling their dangerous pets—40% of that number had a
blood alcohol level of 0.1 percent or more.[22]

It is also important to avoid snakes that appear to be dead, as some species will actually
roll over on their backs and stick out their tongue to fool potential threats. A snake's
detached head can immediately act by reflex and potentially bite. The induced bite can be
just as severe as that of a live snake.[4][23] Dead snakes are also incapable of regulating the
venom they inject, so a bite from a dead snake can often contain large amounts of venom.
[24]

[edit] Treatment

It is not an easy task determining whether or not a bite by any species of snake is life-
threatening. A bite by a North American copperhead on the ankle is usually a moderate
injury to a healthy adult, but a bite to a child's abdomen or face by the same snake may be
fatal. The outcome of all snakebites depends on a multitude of factors: the size, physical
condition, and temperature of the snake, the age and physical condition of the victim, the
area and tissue bitten (e.g., foot, torso, vein or muscle), the amount of venom injected, the
time it takes for the patient to find treatment, and finally the quality of that treatment.[4][25]
Promptly securing qualified medical treatment is the best course of action, and
conservative management in the meantime is recommended.

[edit] Snake identification

Identification of the snake is important in planning treatment in certain areas of the

world, but is not always possible. Ideally the dead snake would be brought in with the
patient, but in areas where snake bite is more common, local knowledge may be
sufficient to recognize the snake. However, in regions where polyvalent antivenoms are
available, such as North America, identification of snake is not a high priority item.

The three types of venomous snakes that cause the majority of major clinical problems
are vipers, kraits, and cobras. Knowledge of what species are present locally can be
crucial, as is knowledge of typical signs and symptoms of envenomation by each type of
snake. A scoring systems can be used to try and determine the biting snake based on
clinical features,[26] but these scoring systems are extremely specific to particular
geographical areas.

[edit] First aid

Snakebite first aid recommendations vary, in part because different snakes have different
types of venom. Some have little local effect, but life-threatening systemic effects, in
which case containing the venom in the region of the bite by pressure immobilization is
highly desirable. Other venoms instigate localized tissue damage around the bitten area,
and immobilization may increase the severity of the damage in this area, but also reduce
the total area affected; whether this trade-off is desirable remains a point of controversy.

Because snakes vary from one country to another, first aid methods also vary. As always,
this article is not a legitimate substitute for professional medical advice. Readers are
strongly advised to obtain guidelines from a reputable first aid organization in their own
region, and to be wary of homegrown or anecdotal remedies.

However, most first aid guidelines agree on the following:

1. Protect the patient (and others, including yourself) from further bites. While
identifying the species is desirable in certain regions, do not risk further bites or
delay proper medical treatment by attempting to capture or kill the snake. If the
snake has not already fled, carefully remove the victim from the immediate area.
2. Keep the victim calm. Acute stress reaction increases blood flow and endangers
the patient. Keep people near the patient calm. Panic is infectious and
compromises judgment.
3. Call for help to arrange for transport to the nearest hospital emergency room,
where antivenom for snakes common to the area will often be available.
4. Make sure to keep the bitten limb in a functional position and below the victim's
heart level so as to minimize blood returning to the heart and other organs of the
body.
5. Do not give the patient anything to eat or drink. This is especially important with
consumable alcohol, a known vasodilator which will speed up the absorption of
venom. Do not administer stimulants or pain medications to the victim, unless
specifically directed to do so by a physician.
6. Remove any items or clothing which may constrict the bitten limb if it swells
(rings, bracelets, watches, footwear, etc.)
7. Keep the victim as still as possible.
8. Do not incise the bitten site.

Many organizations, including the American Medical Association and American Red
Cross, recommend washing the bite with soap and water. However, do not attempt to
clean the area with any type of chemical. Australian recommendations for snake bite
treatment strongly recommend against cleaning the wound. Traces of venom left on the
skin/bandages from the strike can be used in combination with a snake bite identification
kit to identify the species of snake. This speeds determination of which antivenom to
administer in the emergency room.[27]
[edit] Pressure immobilization

A Russell's viper is being "milked". Laboratories use extracted snake venom to produce
antivenom, which is often the only effective treatment for potentially fatal snakebites.

In 1979, Australia's National Health and Medical Research Council formally adopted
pressure immobilization as the preferred method of first aid treatment for snakebites in
Australia.[28] As of 2009, clinical evidence for pressure immobilization remains limited,
with current evidence based almost entirely on anecdotal case reports.[28] This has led
most international authorities to question its efficacy.[28] Despite this, all reputable first
aid organizations in Australia recommend pressure immobilization treatment; however, it
is not widely adhered to, with one study showing that only a third of snakebite patients
attempt pressure immobilization.[28]

Pressure immobilization is not appropriate for cytotoxic bites such as those inflicted by
most vipers,[29][30][31] but may be effective against neurotoxic venoms such as those of
most elapids.[32][33][34] Developed by medical researcher Struan Sutherland in 1978,[35] the
object of pressure immobilization is to contain venom within a bitten limb and prevent it
from moving through the lymphatic system to the vital organs. This therapy has two
components: pressure to prevent lymphatic drainage, and immobilization of the bitten
limb to prevent the pumping action of the skeletal muscles.

Pressure is preferably applied with an elastic bandage, but any cloth will do in an
emergency. Bandaging begins two to four inches above the bite (i.e. between the bite and
the heart), winding around in overlapping turns and moving up towards the heart, then
back down over the bite and past it towards the hand or foot. Then the limb must be held
immobile: not used, and if possible held with a splint or sling. The bandage should be
about as tight as when strapping a sprained ankle. It must not cut off blood flow, or even
be uncomfortable; if it is uncomfortable, the patient will unconsciously flex the limb,
defeating the immobilization portion of the therapy. The location of the bite should be
clearly marked on the outside of the bandages. Some peripheral edema is an expected
consequence of this process.

Apply pressure immobilization as quickly as possible; if you wait until symptoms

become noticeable you will have missed the best time for treatment. Once a pressure
bandage has been applied, it should not be removed until the patient has reached a
medical professional. The combination of pressure and immobilization may contain
venom so effectively that no symptoms are visible for more than 24 hours, giving the
illusion of a dry bite. But this is only a delay; removing the bandage releases that venom
into the patient's system with rapid and possibly fatal consequences.

[edit] Antivenom
Main article: Antivenom

Until the advent of antivenom, bites from some species of snake were almost universally
fatal.[36] Despite huge advances in emergency therapy, antivenom is often still the only
effective treatment for envenomation. The first antivenom was developed in 1895 by
French physician Albert Calmette for the treatment of Indian cobra bites. Antivenom is
made by injecting a small amount of venom into an animal (usually a horse or sheep) to
initiate an immune system response. The resulting antibodies are then harvested from the
animal's blood.

Antivenom is injected into the patient intravenously, and works by binding to and
neutralizing venom enzymes. It cannot undo damage already caused by venom, so
antivenom treatment should be sought as soon as possible. Modern antivenoms are
usually polyvalent, making them effective against the venom of numerous snake species.
Pharmaceutical companies which produce antivenom target their products against the
species native to a particular area. Although some people may develop serious adverse
reactions to antivenom, such as anaphylaxis, in emergency situations this is usually
treatable and hence the benefit outweighs the potential consequences of not using
antivenom.

[edit] Outmoded treatments

Old style snake bite kit that should NOT be used.

The following treatments have all been recommended at one time or another, but are now
considered to be ineffective or outright dangerous. Many cases in which such treatments
appear to work are in fact the result of dry bites.
 • Application of a tourniquet to the bitten limb is generally not recommended.
There is no convincing evidence that it is an effective first aid tool as ordinarily
applied.[37] Tourniquets have been found to be completely ineffective in the
treatment of Crotalus durissus bites,[38] but some positive results have been seen
with properly applied tourniquets for cobra venom in the Philippines.[39]
Uninformed tourniquet use is dangerous, since reducing or cutting off circulation
can lead to gangrene, which can be fatal.[37] The use of a compression bandage is
generally as effective, and much safer.
• Cutting open the bitten area, an action often taken prior to suction, is not
recommended since it causes further damage and increases the risk of infection.
• Sucking out venom, either by mouth or with a pump, does not work and may
harm the affected area directly.[40] Suction started after 3 minutes removes a
clinically insignificant quantity—less than one thousandth of the venom injected
—as shown in a human study.[41] In a study with pigs, suction not only caused no
improvement but led to necrosis in the suctioned area.[42] Suctioning by mouth
presents a risk of further poisoning through the mouth's mucous tissues.[43] The
well-meaning family member or friend may also release bacteria into the victim's
wound, leading to infection.
• Immersion in warm water or sour milk, followed by the application of snake-
stones (also known as la Pierre Noire), which are believed to draw off the poison
in much the way a sponge soaks up water.
• Application of potassium permanganate.
• Use of electroshock therapy. Although still advocated by some, animal testing has
shown this treatment to be useless and potentially dangerous.[44][45][46][47]

In extreme cases, where the victims were in remote areas, all of these misguided attempts
at treatment have resulted in injuries far worse than an otherwise mild to moderate
snakebite. In worst case scenarios, thoroughly constricting tourniquets have been applied
to bitten limbs, completely shutting off blood flow to the area. By the time the victims
finally reached appropriate medical facilities their limbs had to be amputated.

[edit] Epidemiology

Map showing the approximate world distribution of snakes.

Map showing the global distribution of snakebite morbidity.

Most snakebites are caused by non-venomous snakes. Of the roughly 3,000 known
species of snake found worldwide, only 15 percent are considered dangerous to humans.
[1][4][48]
Snakes are found on every continent except Antarctica.[1] The most diverse and
widely distributed snake family, the colubrids, has approximately 700 venomous species,
[49]
but only five genera—boomslangs, twig snakes, keelback snakes, green snakes, and
slender snakes—have caused human fatalities.[49]
Since reporting is not mandatory in many regions of the world,[1] snakebites often go
unreported. Consequently, no accurate study has ever been conducted to determine the
frequency of snakebites on the international level. However, some estimates put the
number at 5.4 million snakebites, 2.5 million envenomings, resulting in perhaps 125,000
deaths.[1] Others estimate 1.2 to 5.5 million snakebites, 421,000 to 1.8 million
envenomings, and 20,000 to 94,000 deaths.[1] Many people who survive bites
nevertheless suffer from permanent tissue damage caused by venom, leading to disability.
[7]

Most snake envenomings and fatalities occur in South Asia, Southeast Asia, and sub-
Saharan Africa, with India reporting the most snakebite deaths of any country.[1] In India
almost all of these deaths are caused by the Big Four, consisting of the Russell's viper,
Indian cobra, saw-scaled viper, and the common krait. In Burma 80 percent of the
approximately 1000 deaths each year from snake bite are caused by the Russell's Viper.
In the Neotropics, the lance-headed vipers inflict the majority of fatal bites, although of
the many known species, only two, the common lancehead and terciopelo, are
responsible for most cases.[7][50] The tropical rattlesnake is another important species.

In Africa, the puff adder is responsible for most fatalities,[51] although there are regional
differences, with the saw-scaled viper inflicting more bites in Northern Africa, where the
puff adder is not normally found.[50] Most bites occur in industrial plantations, which
attract many types of snake prey. Banana plantations are associated with vipers such as
night adders, while rubber and palm tree plantations attract elapids, including cobras and
black mambas.[6] There are also highly venomous colubrids in Africa, such as the
boomslang.

In the Middle East, the snakes responsible for most bites tend to be more venomous than
European species, but deaths are rare, with some estimating perhaps 100 fatal bites
annually.[6] The coastal viper, Palestine viper, and Lebetine viper are the species involved
in most bites.[6] Larger and more venomous elapids, such as the Egyptian cobra, can also
be found throughout the Middle East.

In Europe, nearly all of the snakes responsible for venomous bites belong to the viper
family, and of these, the nose-horned viper, asp viper, and Lataste's viper inflict the
majority of bites.[6] Although Europe has a population of some 731 million people, snake
bites only kill about 30 people each year, largely due to wide access to health care
services and antivenom, as well as the relatively mild potency of many native species'
venom.[6]

In Australia, the only continent where venomous snakes constitute the majority of
species,[52] the Taipans, tiger snake and Eastern brown snake inflict virtually all reported
venomous bites,[6][52] with the latter responsible for perhaps 60% of deaths caused by
snakebite.[52] Although Australian snakes are highly venomous, wide access to antivenom
has made deaths exceedingly rare, with only a few fatalities each year.
Most of the Pacific Islands are free of terrestrial snakes;[6] however, sea snakes are
common in the Indian Ocean and tropical Pacific Ocean, but are not found in the Atlantic
Ocean or the Caribbean, Mediterranean or Red Seas.[14] While the majority of species live
close to shorelines or coral reefs, the yellow-bellied sea snake can be found in the open
ocean.[14] Over 50% of bites inflicted by sea snakes, which are generally not aggressive,
occur when fishermen attempt to remove snakes which have become tangled in fishing
nets.[14][53] Symptoms may appear in as little as 5 minutes or take 8 hours to develop,
depending on the species and region of the body bitten.[14] Although sea snakes are highly
venomous, about 80% of reported bites end up being dry.[14][54] The advent of antivenom
and advances in emergency medicine have reduced fatalities to about 3% of snakebite
cases.[14]

Of the 120 known indigenous snake species in North America, only 20 are venomous to
human beings, all belonging to the families Viperidae and Elapidae.[4] However, in the
United States, every state except Maine, Alaska, and Hawaii is home to at least one of 20
venomous snake species.[4] Most snakebite related deaths in the United States are
attributed to Eastern and Western diamondback rattlesnake bites.[4] Further, the majority
of bites in the United States occur in the southwestern part of the country, in part because
rattlesnake populations in the eastern states are much lower.[55] The state of North
Carolina has the highest frequency of reported snakebites, averaging approximately 19
bites per 100,000 persons.[20] The national average is roughly 4 bites per 100,000 persons.
[20]

Worldwide, snakebites occur most frequently in the summer season when snakes are
active and humans are outdoors.[1][56] Agricultural and tropical regions report more
snakebites than anywhere else.[1][50] Victims are typically male and between 17 and 27
years of age.[4][56][57] Children and the elderly are most likely to die.[4][25]

Startled snakes often

Bites by the European adder,
which is widespread and found
throughout much of Europe and
Russia, are relatively common;
however, fatalities are very rare.
take a defensive
posture, such as this
cottonmouth, and may
hiss and bear their
fangs in a threatening
manner. The yellow-lipped sea krait is a
timid but highly venomous sea
snake common throughout Indo-
Pacific oceanic waters.
[edit] Society and culture
See also: Serpent (symbolism)

According to tradition, Cleopatra VII famously committed suicide by snakebite to her left
breast, as seen in this 1911 painting by Hungarian artist Gyula Benczúr.

Snakes were both revered and worshipped and feared by early civilizations. The ancient
Egyptians recorded prescribed treatments for snakebites as early as the Thirteenth
dynasty in the Brooklyn Papyrus, which includes at least seven venomous species
common to the region today, such as the horned vipers.[58] In Judaism, the Nehushtan was
a pole with a snake made of copper wrapped around it, similar in appearance to the Rod
of Asclepius. The object was considered sacred with the power to heal bites caused by the
snakes which had infested the desert, with victims merely having to touch it in order to
save themselves from imminent death.

Historically, snakebites were seen as a means of execution in some cultures. In medieval

Europe, a form of capital punishment was to throw people into snake pits, leaving victims
to die from multiple venomous bites. A similar form of punishment was common in
Southern Han during China's Five Dynasties and Ten Kingdoms Period and in India.[59]
Snakebites were also used as a form of suicide, most notably by Egyptian queen
Cleopatra VII, who reportedly died from the bite of an asp—likely an Egyptian cobra[58]
[60]
—after hearing of Mark Antony's death.

Snakebite as a surreptitious form of murder has been featured in stories such as Sir
Arthur Conan Doyle's The Adventure of the Speckled Band, but actual occurrences are
virtually unheard of, with only a few documented cases.[59][61][62] It has been suggested that
Boris III of Bulgaria, who was allied to Nazi Germany during World War II, may have
been killed with snake venom,[59] although there is no definitive evidence. At least one
attempted suicide by snakebite has been documented in medical literature involving a
puff adder bite to the hand.[63]

[edit] See also

• Antivenom
• List of victims of fatal snake bites in the United States
• Medical emergency
• Ophidiophobia
• Snake attacks in Australia
• Snake-stones
• Snake venom
• Venomous snakes
• Wilderness first aid

Burns and Scalds

A burn is an injury caused by:

a. Dry heat, such as fire, a piece of hot metal or the sun.

b. Contact with any object charged with a high tension electric current; or by lightning.
c. Friction, for example, by contact with a revolving wheel (brush burn) or fast-moving
rope or wire.
d. Corrosive chemicals:
(i) Acids, such as sulphuric, nitric and hydrochloric.
(ii) Alkalis, such as caustic soda, caustic potash, strong ammonia or quicklime.

A scald is an injury caused by moist heat, such as boiling water, steam, improperly
applied poultice, hot oil or tar. The effects of a burn or scald are the same. There may be
reddening of the skin or blister formation or destruction of the skin or deeper tissues. Pain
is very severe in second degree burns.

Degree of Burns
First degree burns: There is only reddening of skin without damage to deeper tissues.
Second degree burns: Second degree burns often result in vesication and exposure of
nerve endings and are most painful in nature.
Third degree burns: Here even the nerves are burned off. These burns are not painful,
but life threatening as they inevitably cause shock.

The dangers of a burn increase with its surface area (even if it is only superficial) and if
one-third or more of skin area is involved, the condition of the patient can be described as
critical. In small children and especially in infants, even small burns should be regarded
as serious injuries and medical aid sought without delay.
Immediate treatment for a burn patient

1. If a person's clothing catches fire, approach him holding a rug, blanket, coat etc.
and wrap it around him, lay him flat and smother the flames.
2. If a person catches fire, when he is alone, he should roll on the floor, smothering
the flames with the nearest available wrap and call for assistance, on no account
should he rush into the open air.
3. Immerse the affected area in cold water for at least 10 minutes. Alternatively
cover the area with a thick clean cloth soaked in water. Keep it damp.
4. Avoid handling the affected area more than is necessary. See that your hands are
thoroughly washed as burnt area is highly prone to infectious micro-organisms.
5. Do not apply lotions of any kind.
6. Do not remove burned clothing adherent to the burned skin and do not attempt to
break blisters.
7. Cover the burnt area with a clean dry dressing and guard against stock by keeping
the patient warm.
8. Lay the patient down and remove anything which might constrict, if the burnt area
swells.
9. Don't apply any creams or ointment to burnt area.
10. If a limb is burned, keep it elevated to reduce swelling.
11. Burns offer an exception to the general first aid rule of not giving anything by
mouth to the injured person. The burn patient should be give half a glassful of
slightly sweetened tepid water, every 15 or 20 minutes. These liquids helps to
replace body fluids that have been lost as a result of plasma loss caused by the
burn and reduces the risk of development of shock.
12. If there is possibility that medical help will be delayed, give the patient half a
glass of salt and soda solution (half teaspoon table salt + half teaspoon baking
soda per litre/2 pints of water). Give a child about two fluid ounces and an infant
about 1 fluid ounce. Discontinue fluids if vomiting occurs or if the patient
indicates that he does not feel well.
13. Remove the patient to a hospital, as quickly as possible.

Burns by Corrosive Chemicals

When the corrosive is an acid:

1. Thoroughly flood the burnt part with water.

2. Bathe the part freely with an alkaline solution such as two teaspoons of baking
soda or washing soda in one pint of warm water.

When the corrosive is an alkali:

1. Thoroughly flood the part with water.

2. Bathe the part freely with a weak acid solution, such as vinegar or lemon juice
diluted with an equal quantity of water.
Sunburn
Serious discomfort and even superficial burns with blister formation can be caused by
direct rays of the sun. In hot countries even short periods of exposure to the midday sun
can cause quite severe bums. If need be, the general rules for the treatment of burns and
scalds should be applied by the First Aider.

Burns

Published by Bupa's health information team, May 2009.

This factsheet is for people who have been burned, or who would like information about
burns.

A burn is an injury to the skin tissue, usually caused by contact with intense heat,
electricity or chemicals. Recognising different types of burns and having a basic
knowledge of how to treat them can minimise scarring and even save lives.

• About burns
• Symptoms of burns
• Causes of burns
• Diagnosis of burns
• Treatment of burns
• Questions and answers
• Related topics
• Further information
• Sources

About burns

Around 175,000 people every year visit the accident and emergency department for burn
injuries and 16,100 are admitted to hospital. Burns usually affect the skin, but other body
parts can be injured, such as the airways and lungs, from inhaling hot fumes and gases.

Types of burn

The severity of your burn depends on how deeply it has affected the skin tissue (see
illustration). There are three types of burn: superficial, partial-thickness and full-
thickness.
 The layers of skin

Superficial burns

Superficial burns only affect the surface of the skin (epidermis). Your skin will be red
and painful, but not blistered. Mild sunburn is an example of a superficial burn.

Partial-thickness burns

Partial-thickness burns are deeper burns that damage your epidermis and dermis to
varying degrees. If the damage to your dermis is shallow, your skin may be pale pink and
painful, with blisters. Deeper burns to your dermis will cause your skin to become dry or
moist, blotchy and red. Deep partial-thickness burns can be painful or painless and may
blister.

Full-thickness burns

All layers of your skin are damaged by full-thickness burns. Your skin will be white,
brown or black and dry, leathery or waxy. Because the nerves in your skin are destroyed
with full-thickness burns, you won't feel any pain or have blisters.

Symptoms of burns

If you're burned, you may have symptoms such as:

• changes in skin colour - burns can cause pink, red, white, brown and black skin
• blisters
• pain in the burned area - but pain from burns isn't related to severity

Symptoms of an airway burn include:

 • burned nose hairs
• soot in your mouth or nose
• change in your voice
• sore throat
• wheezing

If you have been burned and have any of these symptoms, you should seek advice from
your GP.

Causes of burns

Burns are caused by:

• dry heat (fire)

• wet heat (steam or hot fluids)
• radiation (sun)
• heated objects
• extreme cold
• inhaling smoke or toxic fumes, particularly from chemical explosions or house
fires
• electricity
• chemicals

Diagnosis of burns

Most burns are easily diagnosed - you will know when you have burned yourself.
Determining the cause, size and thickness of your burn, and whether you have inhaled
smoke or chemical fumes, will be your doctor's main concern.

Your doctor will ask you about your symptoms and examine you. He or she may also ask
you about your medical history.

Treatment of burns

Treatment for burns depends on their severity. You can treat superficial and minor
partial-thickness burns caused by heat at home. However, seek medical help:

• all deep partial-thickness and full-thickness burns

• all chemical and electrical burns
• superficial and partial-thickness burns covering an area larger than the palm of
your hand
• burns that cover a joint or are on the face, hands, feet or groin
• all airway or suspected smoke inhalation burns
• advice if you're not sure about the extent of the burn or how to deal with it
For full-thickness burns or burns caused by chemicals or electricity, call for emergency
help. While waiting, valuable treatment can be given.

• For burns caused by heat, carefully remove any restricting clothing or jewellery
that isn't stuck to the burn. Flood the burn with cool (not cold) water until medical
help is available.
• For burns caused by chemicals, remove any affected clothing. Brush the chemical
off your skin if it's a dry powder and flood the burn with cool (not cold) water.
Don't try to neutralise the chemical with another chemical.

Home treatment

Superficial and minor partial-thickness burns can be treated at home. Begin by flooding
your burn with cool (not cold) water for 10 to 30 minutes or until the pain is relieved.

Ointments or creams may help superficial burns like sunburn, but don't apply them to any
deeper burns that have caused a change in your skin colour or blisters. Always ask your
pharmacist for advice before applying ointments or creams.

Don't burst any blisters that form on your burn. Covering a partial-thickness burn with
kitchen clingfilm may reduce pain and speed healing. Ask for advice as soon as you can
from your practice nurse or local accident and emergency department.

Over-the-counter painkillers, such as paracetamol or ibuprofen, may also help. Always

read the patient information that comes with your medicine and if you have any
questions, ask your pharmacist for advice.

Superficial and shallow partial-thickness burns usually heal within three weeks, with
minimal scarring.

Hospital treatment

If you're severely injured over large areas of your body with partial- and full-thickness
burns, you will be admitted to hospital. Your doctors will continue first aid measures and
protect your damaged skin with dressings. They will also give you medicines for any
pain.

Healthy skin prevents loss of fluid from the tissues underneath and is a very effective
barrier to infection. These functions are lost after your skin is severely burned. If
infection is suspected, you will be given antibiotics. If large quantities of fluid are lost
through your burned skin, this can seriously affect your heart and circulation. You will be
closely monitored and may need to have fluids through a drip to help your circulation.

You may be referred to a specialist burn unit. Full-thickness burns tend to result in scars
that can be difficult to treat and you may require skin grafts to minimise scars. Skin grafts
are performed by plastic surgeons. Skin from an unaffected part of your body will be
used to repair any of your burned skin that can't heal itself.

You may need counselling to help deal with the effects of burn scars or physical therapy
to regain movement in your burned areas.

Burns Q&As

See our answers to common questions about burns, including:

• What's the best way to protect my children from being accidentally burned?
• What are the potential complications of being severely burned?
• What are burn clubs and camps?

Related topics

• Sun care

Further information

• British Burn Association

0161 291 6321
www.britishburnassociation.co.uk
• British Red Cross
0844 871 1111
www.redcross.org.uk
• Changing Faces
0845 450 0275
www.changingfaces.org.uk
• Children's Fire and Burn Trust
020 7233 8333
www.childrensfireandburntrust.org.uk

Sources

• Standards and strategy for burn care: a review of burn care in the British Isles.
British Burns Association (National Burn Care Review Committee). 2005.
www.bapras.org.uk
• Burns and scalds. Clinical Knowledge Summaries. http://cks.library.nhs.uk,
accessed 1 September 2008
• Longmore M, Wilkinson IB, Rajagopalan S. Oxford handbook of clinical
medicine. 6th ed. Oxford: Oxford University Press, 2005:834-835
• Simon C, Everitt H, Kendrick T. Oxford handbook of general practice. 2nd ed.
Oxford: Oxford University Press, 2007:1076-1077
• Wasiak J, Cleland H. Burns (minor thermal). BMJ Clinical Evidence.
www.clinicalevidence.com, accessed 1 September 2008
 • McLatchie GR, Leaper DJ. Oxford handbook of clinical surgery. 2nd ed. Oxford:
Oxford University Press, 2002:497-502
• Rehabilitation overview. British Burn Association.
www.britishburnassociation.co.uk, accessed 1 September 2008

This information was published by Bupa's health information team and is based on
reputable sources of medical evidence. It has been peer reviewed by Bupa doctors. The
content is intended for general information only and does not replace the need for
personal advice from a qualified health professional.

Publication date: May 2009

Burns and Scalds

Following a burn or scald, make sure you and the affected person are safe from
further burns or danger - then cool a burnt or scalded area immediately with cool
water (preferably running water) for at least 20 minutes. This leaflet also gives
further advice.

First aid for burns and scalds

Safety first

If possible, or if required:

• Stop the burning process and remove any sources of heat.

• Douse flames with water or smother with a blanket. If the victim's clothing is
burning roll the victim on the ground to smother the flames.
• Remove clothes that are over the burn. Clothing can retain heat, even in a scald
burn, and so should be removed as soon as possible. However, do not pull off
clothing that has stuck to the skin. This may cause skin damage.
• Tar burns should be cooled with water, but do not remove the tar itself.
• For electrical burns - disconnect the victim from the source of electricity before
attempting first aid. If you cannot switch off the electricity:
o If the person has been injured by a low-voltage source (220-240 volts,
domestic electricity supply) then remove the person from the electrical
source using a non-conductive material such as a wooden stick or wooden
chair.
o Do not approach a person connected to a high-voltage source.
• For chemical burns - remove affected clothing. Brush the chemical off the skin if
it is in a dry form. Then wash the burn with lots and lots of water as described
below. Do not attempt to neutralise chemicals.

Cool the burnt area immediately with cool or tepid water

Preferably, use running water, for at least 20 minutes. For example, put the burnt area
under a running tap. A shower or bath is useful for larger areas. Note: do not use very
cold water or ice, as too cold can damage the skin. Ensure the person is otherwise kept
warm to avoid hypothermia. Chemical burns should be irrigated (washed) with lots of of
water and for longer than 20 minutes. (Take advice from a doctor, if possible, as to how
long to keep washing a chemical burn.)

Remove rings, bracelets, watches, etc, from the affected area

These may cause tightness or constriction if any swelling occurs.

Cover the burn - ideally with cling film

Cling film is ideal to cover a burn as is sterile, as long as the first few centimetres are
thrown away and not used. Also, it also does not stick to skin, a doctor can see through it
to assess the burn, it is protective, and it is soothing. A clear plastic bag is an alternative
if no cling film is available. Leave cling film on until seen by a doctor or nurse.
Important: apply cling film in layers rather than round like a bandage to prevent it
causing pressure if the burnt area swells. So, for example, never wrap cling film round
and round a burt arm or leg. A burnt hand can be put into a loosely fitting clear plastic
bag.

Give painkillers

Paracetamol or ibuprofen may help to ease pain for small burns. A doctor may give
stronger painkillers, if required.

Do not do the following:

• Prick any blisters. (A doctor or nurse may decide to 'de-roof' larger blisters to
assess skin damage, but it is best not to pick smaller blisters unless advised by a
doctor.)
• Apply creams, ointments, oils, grease, etc. (The exception is for mild sunburn. A
moisturiser cream or calamine lotion may help to soothe this.)
• Put on an adhesive, sticky, or fluffy dressing.

Types of burn

• Superficial burns affect the top layer of skin only. The skin looks red and is
mildly painful. The top layer of skin may peel a day or so after the burn, but the
underlying skin is healthy. It does not usually blister or scar. A good example is
mild sunburn.
• Partial thickness burns cause deeper damage. The skin forms blisters and is
painful. However, some of the deeper layer of skin (the dermis) is unharmed. This
means the skin usually heals well, sometimes without scarring if the burn is not
too extensive.
 • Full thickness burns damage all layers of skin. The skin is white or charred black.
There may be little or no pain as the nerve endings are destroyed. These often
require skin grafting.
• Electrical burns can cause damage inside the body even if there is little damage to
the skin.

Note: a single burn from one accident may have various types of burn. For example,
some areas of the burnt skin may be superficial, some partial thickness, and some full
thickness.

Home care, or should I get medical help?

See a doctor or nurse if you are unsure about what to do after a burn. However, you may
be happy to manage small, mild (superficial) burns at home. Mild sunburn, small mild
burns, or mild scalds are best left uncovered. They will heal more quickly if left to the
fresh air. Even a small blister is best left uncovered to heal. If the blister bursts, you can
use a dry, non-adhesive, non-fluffy sterile dressing. This will soak up the weeping blister,
and stop dirt and germs getting into the wound. However:

See a doctor or nurse as soon as possible if:

• The burn becomes infected. Infection causes a spreading redness from the burn,
which becomes more painful.
• You are not up to date with tetanus immunisation.
• Blisters occur. You may be happy to deal with a small burn with a small blister.
However, a blister means a partial thickness burn, and it may be best to see a
doctor or nurse.

Go straight to casualty (after cooling with water and first aid) for the
following:

• Electrical burns.
• Full thickness burns - even small ones. These burns cause white or charred skin.
• Partial thickness burns on the face, hands, arms, feet, legs, or genitals. These are
burns that cause blisters.
• Any burn that is larger than the size of the hand of the person affected.
• If you suspect smoke inhalation (breathing in smoke or fumes). The effects on the
lungs from smoke inhalation may be delayed by a few hours so a person may
appear OK at first. Symptoms such as sore throat, cough, wheeze, singed nasal
hair, facial burns or breathlessness may suggest there may have been smoke
inhalation.

Cover the burn with cling film or a clean plastic bag before going to casualty (as
described earlier).
Common causes of burns

Nearly half of severe burns and scalds occur in children under five years. About half of
these accidents happen in the kitchen, with scalds from hot liquids being the most
common. Many accidents involve the child reaching up and pulling on a mug or cup of
hot drink. Other common causes include children falling or climbing into a bath of very
hot water, and accidents with kettles, teapots, coffee-pots, pans, irons, cookers, fires and
heaters.

Tips on preventing burns - particularly to children

Preventing scalds and burns

• Keep young children out of the kitchen unless they are fully supervised.
• The front of the oven, and even the washing machine, can become hot enough to
burn a young child. Keep them away.
• Use the back rings of cookers when possible. Turn pan handles towards the back
and away from where a child may reach and grab.
• Never drink hot drinks with a baby or child in your lap.
• Never let a child drink a hot drink through a straw.
• Teach older children how to boil kettles and how to use the cooker safely. There
is no right age for this. Every child is different. However, it is important to teach
them correctly when the time is right rather than let them find out for themselves.
• Never heat up a baby's milk in a microwave. It may heat the milk unevenly, and
some parts may become very hot. Stir baby food well if it is heated in a
microwave.
• Put cold water in the bath first, and then bring up the temperature with hot water.
• Do not set the thermostat for hot water too high in case children turn on the hot
tap.

Preventing fires

• Fit smoke alarms in every floor of the home and check them regularly.
• Use fireguards for fires and heaters. Do not dry or air clothes on fireguards.
• Shut all doors at night. This prevents any fire from spreading.
• Store matches away from children. Teach older children how to use matches
correctly and safely. Do not just let them experiment and find out for themselves.
• Have a fire blanket in the kitchen.
• Do not leave chip pans unattended, and they should never be more than a third
full with oil. Some people argue that you should get rid of any chip pans
altogether as they are a major cause of kitchen fires.

Preventing sunburn

• Keep children out of hot sun, particularly between 11 am and 3 pm.

 • When out in the sun, remember: Slip, Slap, Slop - slip on a shirt, slap on a hat,
and slop on some high protection sunscreen.

References

• Burns and Scalds, Clinical Knowledge Summaries (2007)

• Hudspith J, Rayatt S; First aid and treatment of minor burns. BMJ. 2004 Jun
19;328(7454):1487-9.
• Enoch S, Roshan A, Shah M; Emergency and early management of burns and
scalds. BMJ. 2009 Apr 8;338:b1037. doi: 10.1136/bmj.b1037.

Comprehensive patient resources are available at www.patient.co.uk

Disclaimer: This article is for information only and should not be used for the diagnosis
or treatment of medical conditions. EMIS has used all reasonable care in compiling the
information but make no warranty as to its accuracy. Consult a doctor or other health care
professional for diagnosis and treatment of medical conditions. For details see our
conditions.
© EMIS 2009 Reviewed: 23 Jul 2009 DocID: 4419 Version: 38

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