IMMEDIATE FIRST AID
for bites by
Death Adder
(Acanthophis acanthophis laevis, Acanthophis antarcitcus
antarcticus, Acanthophis pyrrhus)

In the event of an actual or probable bite from a Death Adder, execute the following first aid measures expeditiously.

Snake:

1. Make sure that the responsible snake or snakes have been appropriately and safely contained, and are out of danger of inflicting any additional bites.

Transportation:

1. Immediately call for transportation.
   Telephone:

Victim:

1. Keep the victim calm and reassured. Allow him or her to lie flat and avoid as much movement as possible. If possible, allow the bitten limb to rest at a level lower than the victim's heart.
2. Immediately wrap a large crepe bandage snugly around the bitten limb starting at the site of the bite and working proximally up the limb (the full length if possible). The bandage should be as tight as one might bind a sprained ankle. Figure 3 are the steps redrawn from the Commonwealth Serum Laboratory first aid recommendations of S.K. Sutherland.
3. Secure the splint to the bandaged limb to keep the limb as rigid and unmoving as possible. Avoid bending or moving the limb excessively while applying the splint.
4. DO NOT remove the splint or bandages until the victim has reached the hospital and is receiving Antivenom.
5. If available have DEATH ADDER ANTIVENOM (Commonwealth Serum Laboratories) ready for the emergency crew to take with the victim to the hospital. The Commonwealth Serum Laboratory Polyvalent Antivenom is also effective and can be used if the death adder specific antivenom is unavailable or if the snake identification is uncertain. Give them the following:
1. the available antivenom (at least 10 vials)
2. the accompanying instruction (Protocol) packet
3. the victim's medical history (if available)

DO NOT cut or incise the bite site
DO NOT apply ice to the bite site

Summary for Human Bite
by
Death Adder
(Acanthophis antarcticus laevis, Acanthophis antarcticus)
antarcticus, Acanthophis pyrrhus)

The bite of the Death Adder with envenomation can be rapidly fatal (as early as 60 minutes). Please read the attached Medical Management Protocol and respond appropriately.

1. First Aid:
1. Bandage and Immobilize the bitten limb with crepe bandages and splint as described in the Immediate First Aid section. Rest this extremity below the level of the patient's heart (if practical).
2. Transport to a medical center emergency or trauma service.
2. Medical Management:
1. Call your local Poison Control Center or the San Diego Regional Poison Control Center (800 876-4766). They should locate a consultant to help you treat this patient.
2. Observe for Signs and Symptoms of Envenomation.
3. If signs or symptoms are present, perform the following:
1. Administer Lactated Ringers Solution at 200 to 250 mls per hour.
2. Draw samples and collect initial laboratory data
3. Dilute the contents of 1 vial (6000 units) of Commonwealth Serum Laboratories Death Adder Antivenom 1:10 in Lactated Ringers Solution. The Commonwealth Serum Laboratory Polyvalent Antivenom is also effective and can be used with the same dilution and vial instructions as the death adder specific antivenom or if the snake identification is uncertain. Administer the antivenom I.V piggyback over 30 minutes at a rate of 200 units per minute.
4. Remove the splints and crepe bandage slowly over a period of 10 minutes. If symptoms progress rapidly, reapply the bandage, and administer an additional vial of antivenom. Again attempt to remove the bandage.
5. Allergic or untoward reactions to the antivenom should be treated with Corticosteroids, Epinephrine, Benadryl, Atarax and/or Antihistamines as appropriate.
6. Monitor Signs, Symptoms, and Laboratory data, and administer additional antivenom in 1 vial (6000 units) increments at a rate of 200 units per minute as necessary to control the progression of symptoms.
7. The required amount of antivenom will vary with the severity of envenomation. One should anticipate using (including the initial dose):

2-3 vials total for a minor bite with envenomation.

3-6 vials or more may be necessary for moderate or severe bites.

MEDICAL MANAGEMENT
for bites by
Death Adder
(Acanthophis antarcticus laevis, Acanthophis antarcticus
antarcticus, Acanthophis pyrrhus)

This person has received a bite and probable envenomation from a death adder, genus Acanthophis. This is a very venomous and dangerous snake, the species of which are distributed in Australia and New Guinea. The snake has caused several human fatalities. The venom principally causes neurotoxic symptoms; paralysis or death can ensue rapidly.

Please read and execute the following procedures without delay.

1. A crepe bandage and splint have been applied as immediate first aid adjuncts to retard the absorption of the venom. DO NOT remove until the patient has arrived at the hospital and is receiving the antivenom.
2. Make sure that at least 10 vials of Death Adder Antivenom are present with the patient.
3. If the patient has been envenomated, the treatment is 3 to 10 vials of intravenous antivenom. Envenomation is diagnosed by the presence of characteristic signs and symptoms. Necessary information follows and is organized in sections:

Signs and Symptoms of Envenomation

Medical Management

General Considerations

Special Considerations

References

Signs and Symptoms of Envenomation:

1. Neurological and Neuromuscular: The onset of these symptoms is subtle and highly variable. Blurring of Vision and Ptosis are often the first indications of neurotoxicity. Generalized paralysis of voluntary musculature can develop.

Eyelid drooping (Ptosis)

Blurred vision or difficulty seeing

Difficulty Speaking or Swallowing (Dysarthria, Dysphasia)

Dyspnea

Respiratory paralysis

Headache

Drowsiness

Sudden loss of consciousness

Flaccid paralysis

Stumbling gait (Ataxia)

2. Hematological and Vascular: These symptoms are minimal in most cases

Bleeding from bite site (typically stops early after the bite)

Very mild Coagulopathy (may develop early in course indicating systemic poisoning)

Hypotension

3. Renal and Urinary: Albuminuria
4. General: These symptoms typically develop earliest often within one hour following the bite. Not all of these will necessarily develop.

Pain at bite site (usually mild)

Regional lymph node tenderness (pain can be severe)

Regional Lymphadenopathy

Vomiting

Coughing

Profuse sweating

Swelling, Edema (tends to be slight around the bite site)

5. Fang Marks: Fang marks may be present as one or more well defined punctures, as a series of small lacerations or scratches, or there may not be any noticeable or obvious markings where the bite occurred. The absence of fang marks does not preclude the possibility of a bite (especially if a juvenile snake is involved). The Death Adder characteristically lies motionless until the strike at which time it darts instantly and accurately at the target; often it will hold on after biting. Multiple bites inflicted by a single snake or by more than one snake are also possible, and should be noted if present (See Special Considerations below). The presence of fang marks does not always imply that the injection or deposition of venom into the bite wound (envenomation) actually occurred.

Medical Management:

1. Admit patient to an emergency or trauma service.
2. Begin a peripheral intravenous infusion (16 gauge catheter) of Lactated Ringers Solution at a rate of 250 cc/hour.
3. Draw blood from the contralateral arm, and collect urine for the following laboratory tests. Mark STAT.
1. Type and Cross Match TWO units of Whole blood.
2. CBC with differential and platelets.
3. Coagulation Parameters:
1. Prothrombin Time (PT)
2. Partial Thromboplastin Time (PTT)
3. Fibrinogen levels
4. Fibrin Degradation Products
4. Serum Electrolytes, BUN/Creatinine, Calcium, Phosphorus.
5. Lactate Dehydrogenase (with Isoenzyme analysis). Isoenzyme analysis may indicate multiple targets of the venom components which may dictate further management.
6. Urinalysis (Macroscopic and Microscopic Analysis). Must include analysis for:
1. Free Protein (Albumin)
2. Hemoglobin
7. Electrocardiogram (Sinus Tachycardia would be expected).
8. Continuous Urine Output Monitoring (Indwelling Foley Catheter if unconscious). Keep Urine Output brisk.
9. Additional Tests as needed or indicated by patient's hospital course.
10. It may be necessary or practical to repeat some of the above serum and urine tests periodically over the hospital course to monitor the effects of antivenom therapy or to detect late changes in parametric values previously normal or slightly abnormal.
4. OBSERVE PATIENT CLOSELY for signs and symptoms of envenomation which usually manifest between 15 minutes and two hours after the bite occurred.
1. If NONE of the signs or symptoms have been noted after TWO hours, there is the possibility that the patient received a dry bite (no venom injected).
1. VERY SLOWLY begin to remove the bandages and splint watching carefully for any changes in the patient's status. If any changes occur, assume the patient has been envenomed and prepare to give antivenom immediately (as directed below).
2. If signs and symptoms still fail to manifest, continue CLOSE observation of the patient for an additional 12 to 24 hours.
5. IF ANY SIGN OR SYMPTOM becomes apparent or has been noted during the course of treatment, begin Antivenom Therapy as follows:
1. Dilute the contents of One Vial of Commonwealth Serum Laboratory Death Adder Antivenom (6000 units) in Lactated Ringers Solution (Hartmann's Solution) to a total volume of 60 mls. If the Adder Specific
   Antivenom is unavailable use Commonwealth Serum
   Laboratory Polyvalent Antivenom. Instructions for
   dilution, administration and titration are the same as
   for Adder Specific Antivenom.
2. Administer the diluted Antivenom intravenously over a period of 30 minutes at a rate of 2 mls per minute (i.e., 1 vial per 30 minutes or 200 units per minute).
3. Should any signs of ALLERGY/ANAPHYLAXIS (e.g., coughing, dyspnea, urticaria, itching, increased oral secretions, etc.) develop, immediately discontinue the administration of antivenom, and treat symptoms with Epinephrine, Steroids and Antihistamines. As soon as the patient is stabilized, continue the antivenom infusion at a slower rate.
4. After 15 minutes of antivenom administration, the splint and the bandages may be removed. This should be done VERY SLOWLY over a period of FIVE minutes to prevent a bolus release of venom. If the patient's condition worsens, reapply the crepe bandage, wait 10 minutes and release the bandage again slowly over 10 minutes while antivenom administration is continuing.
6. Antivenom Therapy is the mainstay of treatment for Death Adder envenomation. Many of the symptoms are ameliorated or entirely eliminated by the antivenom alone. Other symptoms will require additional therapeutic modalities to correct.
1. Neurological Symptoms (especially respiratory obstruction or failure) are usually the most immediate cause of dangerous problems. Many may be improved by the antivenom. Complete reversal of paralysis has been seen on administration of Death Adder antivenom. If breathing becomes impaired, provide respiratory assistance. Secretions may become copious necessitating suctioning and possibly intubation.
2. Death Adder venom lacks the coagulant action seen in other Australian elapid venoms. Disseminated Intravascular Coagulopathy should not be an anticipated complication, and coagulation parameters should remain normal. The venom may, however, have a mild hemolytic action. Treat these symptoms appropriately.
3. Death Adder venom also lacks myelitic and nephrotoxic actions. Myoglobinuria and renal failure have not been reported in Death Adder bite.
7. It is important to keep venom neutralization current and continuous. The best method to accomplish this is to keep a close watch on the patient's status. If the present condition does not improve, or should it worsen for any reason, additional antivenom should be administered. Give all additional antivenom in 1 vial (6000 unit) doses. Dilute one vial in Lactated Ringers Solution to a total volume of 60 mls and deliver I.V piggyback over 30 minutes at a rate of 2 mls per minute (i.e., 1 vial per 30 minutes or 200 units per minute). One should anticipate using (including the initial dose):

2-3 vials for a minor bite with envenomation.
3-6 or more vials may be necessary for moderate or severe bites.

8. It is advisable to perform periodic serum and urine analyses during therapy (as outlined above).
9. It is always best to keep the patient in an Intensive Care setting until free of major symptoms for 24 hours. The patient should be observed in the hospital for at least 24 hours after all symptoms abate.

General Considerations:

1. It is important that the patient be placed at rest, kept warm, and avoid unnecessary movement.
2. The onset of dangerous Neurotoxic symptoms can be rapid and subtle. In addition, they are more rapidly reversed in their early stages than when fully developed. It may be necessary to wake the patient and perform a brief neurologic check every hour or so to assure that breathing and other vital functions are not impaired. Carefully note the progress of any paralysis which may be present.
3. Respiratory obstruction and failure are the greatest immediate concerns. Should the patient develop difficulties in breathing or airway impairment, respiratory support will be required. If the tongue, jaw or pharynx become paralyzed, insert an oral airway. Make sure adequate suction equipment is available and operative.
4. Fluid management is very important in snake bite cases. The patient should be well hydrated, and a brisk urine output maintained.
5. If any signs of Oropharyngeal paralysis or impaired swallowing exist, give NOTHING BY MOUTH, and keep patient on his side with head down. Watch for airway compromise and aspiration.
6. Narcotics are CONTRAINDICATED because of their tendency to suppress respiration. Diazepam (Valium) may be given, but not in large doses.
7. In cases in which Circulatory Shock remains uncorrected by antivenom therapy, Plasma volume expanders and/or vasopressor agents may be given with appropriate considerations.
8. Tetanus prophylaxis should be current.
9. Antibiotics are NOT recommended prophylactically.

Special Considerations:

1. Multiple Bites:
1. It is possible for a Death Adder to deliver more than one bite in a single attack. If there is evidence that such an attack occurred (i.e., history or multiple bite sites), twice (2X) the INITIAL dose of antivenom should be given: TWO vials (12,000 units) diluted in Lactated Ringers Solution to a total volume of 120 mls, and delivered over 30 minutes at a rate of 4 mls per minute (i.e., 2 vials per 30 minutes or 400 units per minute).
2. Severe Envenomation:
1. If the patient shows severe signs of envenomation, particularly if early after the bite, increase the INITIAL dose of antivenom 2X or 3X. Dilute this volume 1:10 in Lactated Ringers Solution, and deliver over a period of 30 minutes. If the patient is in extreme fluid load, antivenom may be delivered at more concentrated volumes until the patient is in appropriate fluid balance.
3. Testing for Equine Protein Sensitivity:
1. It is NOT ADVISABLE to utilize subcutaneous or intradermal testing for sensitivity to equine products in that such testing may be unreliable, and may unnecessarily delay antivenom therapy which must be used if any signs of Death Adder envenomation are present.
2. If there is reason to believe that the patient may be sensitive to equine protein products (e.g., previous snake bite treated with antivenom in which a sensitivity reaction was noted, multiple previous snake bites):
1. Administer 1 gram of Solumedrol I.V. Push.
2. Wait 15 minutes.
3. Administer the antivenom at a rate as tolerated by the patient, and beginning at a rate of 1.5 mls/minute (i.e., 150 units/min).
4. Monitor Pulse and Blood Pressure carefully. Be prepared to treat for Anaphylaxis with Epinephrine and other vasoactive medications.
4. Clinical Experience with Death Adders:
1. The Death Adders (Genus Acanthophis) are widely distributed throughout the Australian continent, and are also found in most parts of Papua New Guinea and in some regions of Indonesia. Although viper-like in appearance, these snakes (like all venomous terrestrial Australian snakes) are Elapids (Cobra-relatives). This fact is important to the clinician in predicting signs, symptoms and clinical management which is typically a syndrome of neurotoxic and systemic manifestations.
2. The majority of accidents occur at dusk or in the evening; the victim often trods upon the Death Adder without first seeing it.
3. Most envenomated patients will present with vague initial symptoms including brief headaches, nausea, vomiting, regional lymph node pain and enlargement. Ptosis and blurring of vision may herald the onset of neurotoxic signs which can lead to severe generalized paralysis and respiratory insufficiency. This paralysis has been shown to rapidly and impressively reverse following the administration of antivenom even after several hours delay. Early treatment is always indicated with symptomatic envenomations.
4. Clinical differences in envenomation characteristics among the races of Death Adder: Common (Acanthophis antarcticus antarcticus), Eastern (Acanthophis antarcticus laevis), Desert (Acanthophis pyrrhus) have not been reported.

References:

The following references are recommended for further indepth reading. This material includes case histories, guidelines and recent findings in Australian elapid literature. These should be read only after treatment has begun, and the patient is in stable status.

1. COMMONWEALTH SERUM LABORATORIES: Treatment of Snake Bite in Australia and Papua New Guinea using Antivenom (Package Insert with Antivenom). CSL, June 1982.
2. CAMPBELL, C.H.: The Death Adder (Acanthophis antarcticus): The Effect of its Bite and its Treatment. Med J Aust. 2:922, 1966.
3. CURRIE, B.; M. FITZMAURICE; J. OAKLEY. "Resolution of Neurotoxicity with Anticholinesterace Therapy and Death
   Adder Envenomation." Med J Aust. 148:10, 1980.