Appropriate, effective, and timely response to snake bite

This comment may be worth bringing up to the level of a forum discussion. It concerns our preparedness to handle snake bite while out at the crags. My impression is that few of us are capable of an appropriate, effective, and timely response to snake bite.

I was bouldering at The Millenium Boulder last weekend, near the end of September, and really enjoying the fall evening, flat landings, and nasty hard problems. Initially there were several other people at the crag. As the sun dipped below the hills, the other climbers departed, but I stayed on until dusk, when the temperature started to fall. I hiked out using the climber's access trail. About half way up, I took a step with my foot just about to drop onto a rattlesnake coiled up directly in the path. My readjustment left my foot well within striking range of the snake. Fortunately, he did not even flinch.

Several things struck me about this close encounter. First, the climber's trail winds through very dense vegetation, is very narrow, and provides the only good place for the snake to warm itself. Second, during these warm evenings the snakes will be out and about catching the last rays, just like us. Third, I was completely unprepared to do anything other than wrap a tourniquette above a bite. I had waited to leave until all the others were gone, so no help was immediately available. I had a cell phone, although it was unlikely to bring help in timely fashion. I did not carry a knife.

If you are bitten while significantly far from help how many of us know what do and are in a position to do something? We can all throw the tourniquette. But, how many of us can, or are even capable, of cutting the bite. Do we know how to make the cut? How deep to make it? The chances are high that a bite would occur on the lower leg. Can any of us suck out the venom by ourselves? It would be easy to imagine being stranded as the light is failing and the parks clearing out without the proper recourse or response to a snake bite.

I don't think that this is cause for any great concern. However, I do think that it is important to have an appropriate, effective, and timely plan in mind in the event that you are bitten. Bear in mind that a bite from a western timber rattler will indeed kill you unless you spring into action immediately.

uh, Richard, I wouldn't even think about any of those methods; they are indeed not the proper course of action but merely urban myths as to emergency treatment for envenomization.

Snake venom in this region will not kill rapidly unless there is some sort of allergic reaction; which if the case, that person will more than likely already have that known and carry an epi pen.

I've always wondered about this issue. First of all, don't try to cut and suck out the venom. The quandry to me is:
do you try and hurry out to the trailhead before the venom hits your nervous system (of course, moving will pump it through the blood stream faster); or do you sit and let the venom take over? I'd vote for running to the trailhead in hopes of making it out before the venom sets in big time. What do you all think?

not the right course of action at all!

DO NOT cut.

DO NOT suck.

DO NOT tourniquet

Get on a cell phone for help and get to a hospital as quickly as possible while staying calm.

The vast majority of bites occur while handling the snake. DON'T DO IT!

The three 'T's of rattlesnake bites are:

1.) Tattoo to Teeth ratio
2.) Tequila
3.) Testosterone

If you suffer from any of these three, you are at an elevated risk of a bite.

[post edit: as nobody listens anyway, just run around in circles & inject yourself with the appropriate anti-venom or morphine; either of which you will already have]

What if by yourself and isolated. Assume no cell phone coverage. What do you do? You can't lay there forever....

carry a PLB if you plan on really getting isolated

Pray that you're climbing with MacGyver that day.

Buff Johnson wrote:carry a PLB if you plan on really getting isolated How's your wilderness experience, so far??

Pretty good actually. Never thought of a PLB however, unless it was for avalanche purposes. Good idea. The idea of relying on a cell phone is a bad move, however. They seldom work in the boonies. I've had zero coverage in the Superstitions, just east of metro Phoenix.

Richard,

Let me first off say that I love all of your hard work in both Empire and at Mary's Bust. You must have over a thousand dollars worth up bolts up all over Colorado. With that said, with the medical training I have had, all the above is true.

Typically, no tourniquets, no ice, lay down, keep the extremity still and call for help. Now we can interject reality--which means by yourself, no cell phone service, a decent hike to the car.

Lets take RA at Empire. Know that venom can render a person useless within 20 minutes. (depending on bite location,venom infused, whether or not the venom reached the vessels and a whole slew of other factors.)--so after 20 minutes you might
have no choice but to lay on the trail. So at RA or The Monastery (where I have seen rattlers) I would drop my pack, take the car keys, and slow boogie back. Will a tourniquet help--YES--but the medical world does no want you use it since it will compromise blood flow to that limb. However, the objective is to survive, so I will lose the leg, save the heart and lungs. You can crawl, and drink beer and climb with a plastic leg. Get to your car and find somebody, tell them you need an ambulance and make sure they know you have been bitten and need a helicopter.

Helicopter medical services will typically have Crofab which is the antidote. You will need 8-10 doses at 10-15,000 dollars a pop. SO HAVE INSURANCE! Aside from that, you could roll the dice, since snakes do not use their venom 25% of the time. Up to you.

Have Fun.

The best recourse is to carefully cut into a major artery on the other side of your body and allow the poison to quickly flow through and harmlessly spray into the air from your newly severed artery. Always carry a knife sharp enough to sever an artery, and consider pre-marking some likely candidates. PLBs are unnecessary for snake bites but should be carried in case of a meteor strike, where artery severing will not help and professional rescue will likely be required.

"DO NOTs" from Loma Linda UMC

*Info. in italics is what I've heard from other sources in the past.

•DO NOT allow the person to become over-exerted. If necessary, carry the person to safety.
Also, the affected limb should be used as little as possible to delay the absorption of the venom.
•DO NOT apply a tourniquet.
Can cause tissue damage, and loss of limb.
•DO NOT apply cold compresses to a snake bite.
Can cause tissue damage, and/or frostbite
•DO NOT cut into a snake bite with a knife or razor.
•DO NOT try to suck out the venom by mouth.
Sucking, and/or cutting into the bite site can damage underlying organs, increase the risk of infection, and does not result in venom removal.
•DO NOT give the person stimulants or pain medications unless a doctor tells you to do so.
•DO NOT give the person anything by mouth.
•DO NOT raise the site of the bite above the level of the person's heart.

First Aid
1. Keep the person calm, reassuring them that bites can be effectively treated in an emergency room. Restrict movement, and keep the affected area below heart level to reduce the flow of venom.

2. If you have a pump suction device (such as that made by Sawyer), follow the manufacturer's directions.

I've heard that these are practically useless for venomous snakebites, as a sufficient amount of venom can't be extracted by this method, and can cause more tissue damage, but if it'll make your snakebite victim, or yourself feel better. ; )

3. Remove any rings or constricting items because the affected area may swell. Create a loose splint to help restrict movement of the area.

4. If the area of the bite begins to swell and change color, the snake was probably poisonous.

5. Monitor the person's vital signs -- temperature, pulse, rate of breathing, and blood pressure -- if possible. If there are signs of shock (such as paleness), lay the person flat, raise the feet about a foot, and cover the person with a blanket.

6. Get medical help right away.

I've also heard it's a good idea to call the ER you are en route to ahead of time, and let them know you are a (venomous) snakebite victim. You can also call the National Poison Control Center, or Rocky Mountain Poison Control, and Drug Center in your (Richard's) neck of the woods to talk to experts, and to get further instructions.

RE: rattlesnake bites.
"US mortality with administration of antivenin is approximately 0.28%. Without antivenin being administered, mortality is approximately 2.6%."

Info from author: Sean P Bush, MD, FACEP, Professor of Emergency Medicine, Loma Linda University School of Medicine; Consulting Staff, Envenomation Specialist, Department of Emergency Medicine, Loma Linda University Medical Center

The biggest tip of the day.

Do NOT use alcohol. Alcohol may deaden the pain, but it also makes the local blood vessels bigger, which can increase venom absorption.

As a professional herpetologist who works almost exclusively with venomous snakes, I am pretty up to date on this topic. No offense to the doc and medics on here, but probably more familiar with issues of envenomation.
THE ONLY TREATMENT FOR SNAKEBITE IS ANTIVENOM!!!!!

Never tourniquet. Never use those over the counter snake bite kits to "suck out the venom." Those will only remove about 5% if applied within about 20 seconds of the bite. By the time you have it out, the venom isn't leaving. Both of these treatment will only mildly to dramatically increase local tissue damage.

Washing the site won't hurt, but I personally wouldn't waste my time.

If possible, splint the extremity to reduce movement. Try to stay calm. Walk quickly, but don't run. Call 911!

There is one trick to reducing the spread of venom to the system to buy you time if you truly are hours from help. As always though, time is THE factor. It is called the "sutherland wrap." It is regularly used on cobra family bites (which spread via lymph system), but has been used in the field with success on viper bites. I have personally discussed this with a South African who has used them on puff adder bites successfully. The thing is you better know how to do it right or you may do more harm than good. It involves using an elastic bandage and wrapping similar to a sprained ankle. You tighten it as much as humanly possible and if there are no twists it will not create a tourniquet, but should prevent/slow the venom from going systemic and making you incompacitated. You must do this within minutes of the bite, wrapping from just distal of the bite toward the core as far as you have material to wrap or you hit the torso. This should buy you time.

I would only do this if you know you are many hours from help and you have 0% doubt of doing it correctly. Only about 5% of N.A. rattlesnake bites are fatal WITHOUT antivenom. You probably won't die. What you are trying to do is prevent permanent disability. Any of the "so called" first aids will likely INCREASE the chance of this.

jbarnum is right on what it costs. Of the several people I know who have been bitten by rattlesnakes, the average hospital bill is around $150,000! Think about that next time you want to mess with a rattlesnake. I however would be surprised if they had CroFab on the heli?! To my knowledge they will only administer antivenom inside the hospital due to the possibility of anaphylaxis.

If you ARE allergic.... if a heli isn't there in 10 minutes you are probably toast!!!! 15 if you have an epi pen!

Wow, great info. Tim!!

Edit:
Struan Sutherland??
And are these the "Sutherland Wraps" you speak of in the photos at the bottom of the linked web page?

Pete Hickman wrote:The best recourse is to carefully cut into a major artery on the other side of your body and allow the poison to quickly flow through and harmlessly spray into the air from your newly severed artery. Always carry a knife sharp enough to sever an artery, and consider pre-marking some likely candidates. PLBs are unnecessary for snake bites but should be carried in case of a meteor strike, where artery severing will not help and professional rescue will likely be required.

Forget my last post. I agree with Pete!
Also, use copious amounts of alcohol.... best if started from the inside and moved outward!

Gigi.
That is the Sutherland i refer to. A couple of notes on it though. The pictures show a splint. The extremities were first wrapped WITHOUT the splint. ONLY AFTER the Sutherland wrap was applied was the splint added to reduce movement. With the splint on the inside of this type of wrap, it negates the purpose.

Also, the article mentions the skepticism (and rightly so) of using this on n.a. rattlesnake bites. Mainly due to the low mortality rates of rattlesnakes and the potential increase in local tissue damage. Based on anecdotal evidence, they do not seem to increase local damage. Probably not constricting enough for that. This is based mostly on its use in treatment of puff adder bites, which are even more necrotic (and way more deadly) than rattlesnake bites. i would only use a wrap in a worst case scenario, where death IS a possibility.

Thanks, Tim! Also, I'm going to PM you for your mailing address. I have a little gift to send you for showing my good friend Sarah, and I around in the snake temple. : )

Thanks again for your expertise!!

Great info Tim! I teach the wilderness medicine classes at the UofUtah medical school- we teach that the only real cure for a rattle snake bite is your car keys. i.e. get to the hospital ASAP. Are you aware of any other papers supporting or contraindicating pressure wrappings for pit viper bites?

Justin,

I do not believe that pressure wraps have ever been formally studied as a treatment for pit viper bites. All the info I have on them are anecdotal from actual field use. Based on the reports I have heard, I would use them in a life/death situation for sure and that is where I have heard them used. The big argument I have heard against them in pit viper bites is that with the swelling it would get too painful and the victim would remove it causing massive "venom shock." According to the South African who has used these multiple time against puff adders, this is not the case.
Without research, probably not warranted in rattlesnake bites. I would like to see some formal research though.
Agreed that car keys or better yet a cell phone are the best remedies!!!!

timt wrote:As a professional herpetologist who works almost exclusively with venomous snakes, I am pretty up to date on this topic. No offense to the doc and medics on here, but probably more familiar with issues of envenomation. THE ONLY TREATMENT FOR SNAKEBITE IS ANTIVENOM!!!!! Never tourniquet. Never use those over the counter snake bite kits to "suck out the venom." Those will only remove about 5% if applied within about 20 seconds of the bite. By the time you have it out, the venom isn't leaving. Both of these treatment will only mildly to dramatically increase local tissue damage. Washing the site won't hurt, but I personally wouldn't waste my time. If possible, splint the extremity to reduce movement. Try to stay calm. Walk quickly, but don't run. Call 911! There is one trick to reducing the spread of venom to the system to buy you time if you truly are hours from help. As always though, time is THE factor. It is called the "sutherland wrap." It is regularly used on cobra family bites (which spread via lymph system), but has been used in the field with success on viper bites. I have personally discussed this with a South African who has used them on puff adder bites successfully. The thing is you better know how to do it right or you may do more harm than good. It involves using an elastic bandage and wrapping similar to a sprained ankle. You tighten it as much as humanly possible and if there are no twists it will not create a tourniquet, but should prevent/slow the venom from going systemic and making you incompacitated. You must do this within minutes of the bite, wrapping from just distal of the bite toward the core as far as you have material to wrap or you hit the torso. This should buy you time. I would only do this if you know you are many hours from help and you have 0% doubt of doing it correctly. Only about 5% of N.A. rattlesnake bites are fatal WITHOUT antivenom. You probably won't die. What you are trying to do is prevent permanent disability. Any of the "so called" first aids will likely INCREASE the chance of this. jbarnum is right on what it costs. Of the several people I know who have been bitten by rattlesnakes, the average hospital bill is around $150,000! Think about that next time you want to mess with a rattlesnake. I however would be surprised if they had CroFab on the heli?! To my knowledge they will only administer antivenom inside the hospital due to the possibility of anaphylaxis. If you ARE allergic.... if a heli isn't there in 10 minutes you are probably toast!!!! 15 if you have an epi pen!

From an emergency medical point the best advice I've seen on this site (although I'm not sure an epi pen will do much)! As a novice treating a snake bite think of your ABC's. DO NOT elevate the extremities (such as a ankle that has been bitten) as this will increase the perfusion of the venom. The last info I got was that the wrap such as an ace wrap or coban (mentioned in the above quote) had been effective in limiting the effects of venom (last article I read was a bit, old around 2004, based out of Australia)It was also noted that no ill effects were found from using these techniques. Treat ABC's, limit exertion and seek medical attention. Also unless I'm mistaken none of the CO snakes are neurotoxic so that generally buys more time.

These are interesting responses. Apparently I'm not the only one who may have made the situation worse. The common mythology, however, seems to be prevalent. I brought the question up to some of the clinical docs at work and most of them were operating with the same tourniquette/cut/suck paradigm, often specifying the exact way to make an incision. None had the fatality statistics correct.