Adder bite in the British Army 1979-1988: a decade of experience

A Guide to the Clinical Management of Vipera Snakebite in Italy

The genus Vipera encompasses most species of medically significant venomous snakes of Europe, with Italy harbouring four of them. Envenomation by European vipers can result in severe consequences, but underreporting and the absence of standardised clinical protocols hinder effective snakebite management. This study provides an updated, detailed set of guidelines for the management and treatment of Vipera snakebite tailored for Italian clinicians. It includes taxonomic keys for snake identification, insights into viper venom composition, and recommendations for clinical management. Emphasis is placed on quick and reliable identification of medically relevant snake species, along with appropriate first aid measures. Criteria for antivenom administration are outlined, as well as indications on managing potential side effects. While the protocol is specific to Italy, its methodology can potentially be adapted for other European countries, depending on local resources. The promotion of comprehensive data collection and collaboration among Poison Control Centres is advocated to optimise envenomation management protocols and improve the reporting of epidemiological data concerning snakebite at the country level.

Vipers of Major clinical relevance in Europe: Taxonomy, venom composition, toxicology and clinical management of human bites

Snakebites in Europe are mostly due to bites from Viperidae species of the genus Vipera. This represents a neglected public health hazard with poorly defined incidence, morbidity and mortality. In Europe, fourteen species of "true vipers" (subfamily Viperinae) are present, eleven of which belong to the genus Vipera. Amongst these, the main medically relevant species due to their greater diffusion across Europe and the highest number of registered snakebites are six, namely: Vipera ammodytes, V. aspis, V. berus, V. latastei, V. seoanei and V. ursinii. Generally speaking, viper venom composition is characterised by many different toxin families, like phospholipases A2, snake venom serine proteases, snake venom metalloproteases, cysteine-rich secretory proteins, C-type lectins, disintegrins, haemorrhagic factors and coagulation inhibitors. A suspected snakebite is often associated with severe pain, erythema, oedema and, subsequently, the onset of an ecchymotic area around one or two visible fang marks. In the field, the affected limb should be immobilised and mildly compressed with a bandage, which can then be removed once the patient is being treated in hospital. The clinician should advise the patient to remain calm to reduce blood circulation and, therefore, decrease the spread of the toxins. In the case of pain, an analgesic therapy can be administered, the affected area can be treated with hydrogen peroxide or clean water. However, anti-inflammatory drugs and disinfection with alcohol or alcoholic substances should be avoided. For each patient, clinical chemistry and ECG are always a pre-requisite as well as the evaluation of the tetanus immunisation status and for which immunisation may be provided if needed. The treatment of any clinical complication, due to the envenomation, does not differ from treatments of emergency nature. Antivenom is recommended when signs of systemic envenomation exist or in case of advanced local or systemic progressive symptoms. Recommendations for future work concludes. The aim of this review is to support clinicians for the clinical management of viper envenomation, through taxonomic keys for main species identification, description of venom composition and mode of action of known toxins and provide a standardised clinical protocol and antivenom administration.

Snakebite enquiries to the UK National Poisons Information Service: 2004-2010

OBJECTIVE

To describe trends regarding snakebite enquiries to the UK National Poisons Information Service (NPIS) from 2004 to 2010.

METHODS

The NPIS telephone enquiry database, the UK Poisons Information Database, was interrogated for enquiries to the four NPIS units from 2004 to 2010. Search terms used were 'snake' and 'snakebite'. Information from the national dataset was available from Cardiff and Edinburgh units from 2004 onwards, Birmingham from June 2005 and Newcastle from September 2006.

RESULTS

Five hundred and ten cases were identified, of which 69% were male and 31% female. Average age of cases was 32 years (±1 95% CI). The snake was identified as follows: British Adder in 52% of cases, an exotic species in 26%, unknown in 18% and another UK snake in 4%. 82% of cases occurred between the months of April and September. Cases peaked during August (19%). Forty-two per cent of enquiries involved features of envenoming. Eighty-five cases were assessed as requiring antivenom. Eighty-four cases received treatment with antivenom. No adverse reactions to the antivenom were reported and resolution of clinical features was reported in all treated cases. Advice to use an antidote was followed in 98.8% of cases.

CONCLUSIONS

Snakebites account for one to two NPIS cases per week. Adder bites account for over half of cases. A quarter of cases were due to non-UK snakes kept in captivity within the UK. Envenoming was said to have occurred in just under half of all cases. Advice given by the NPIS appears to closely reflect national practice guidelines.

Incidence, pathology, and treatment of adder (Vipera berus L.) bites in man

A review of published reports on the incidence, pathology, and treatment of adder (Vipera berus) bites in man in the United Kingdom and Europe produced numerous case studies but little information about the impact od adders as a threat to public health. Adder bites in man are not uncommon (at least 44/year and probably more than 90/year in the United Kingdom) and, although they have been recorded for every month of the year between February and October, envenoming is most likely to occur during June, July, and August. Most adder bites are on the hand (51.6%) or foot (38.2%). The effects of adder bite envenoming are now know. Effective treatment protocols can reduce both the length of time victims spend in hospital and the morbidity in the affected areas: they have resulted in a decline in the death rate over the last 30 years, so that deaths are now rare.

Antivenom treatment in Vipera berus envenoming--report of 30 cases

OBJECTIVES

To assess efficacy and safety of two equine F(ab')2 antivenoms currently used to treat envenoming by European vipers.

DESIGN

Retrospective case review study.

SETTING

Case records collected by the Swedish Poison Information Centre concerning patients treated in Swedish hospitals for bites by the common European adder, Vipera berus.

SUBJECTS

Patients presenting with V. berus envenoming treated with antivenom (n = 30) and two groups of patients not given antivenom (n = 16 and n = 38).

MAIN OUTCOME MEASURES

Clinical course and time in hospital were retrospectively studied and compared in patients treated or not treated with antivenom.

RESULTS

There was a significantly lower incidence of extensive oedema (23 vs. 88%) and anaemia (10 vs. 50%) in the antivenom-treated group, and the hospital stay was shorter (median: 3 vs. 6 days). Antivenom treatment also resulted in prompt clinical improvement in the acute phase. Adverse effects consisting of urticaria and serum sickness occurred in 10% of the patients given antivenom.

CONCLUSIONS

Antivenom treatment was associated with a reduced morbidity in severe V. berus envenoming. However, the occurrence of allergic side-effects is not negligible with this type of antivenom.

Adder (Vipera berus) bites: a case report and review of the management for emergency medical personnel

Few doctors working in the accident and emergency (A&E) department will have had experience in the management of adder (Vipera Berus) bites. While such events are uncommon, and rarely fatal, prompt correct management undoubtedly helps in reducing mortality and morbidity. Various isolated case reports (Watson & Harland, 1977; Gerard & Pugh, 1982; Jones & Clegg, 1985) and larger reviews (Reid, 1976; Pesson & Irestedt 1981; Hawley, 1988, 1990) have appeared in non A&E related journals. Following our own recent experience we felt it timely to report our case and review the management.