IMMEDIATE FIRST AID
for bites by
(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.
- Make sure that the responsible snake or snakes have been appropriately and
safely contained, and are out of danger of inflicting any additional bites.
- Immediately call for transportation.
DO NOT cut or incise the bite site
- 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.
- 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.
- 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.
- DO NOT remove the splint or bandages until the victim has reached the
hospital and is receiving Antivenom.
- 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:
- the available antivenom (at least 10 vials)
- the accompanying instruction (Protocol) packet
- the victim's medical history (if available)
DO NOT apply ice to the bite site
Summary for Human Bite
(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
- First Aid:
- 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).
- Transport to a medical center emergency or trauma service.
- Medical Management:
- 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.
- Observe for Signs and Symptoms of Envenomation.
- If signs or symptoms are present, perform the following:
- Administer Lactated Ringers Solution at 200 to 250 mls per hour.
- Draw samples and collect initial laboratory data
- 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.
- 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.
- Allergic or untoward reactions to the antivenom should be treated with
Corticosteroids, Epinephrine, Benadryl, Atarax and/or Antihistamines as appropriate.
- 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.
- 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.
for bites by
(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.
- 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.
- Make sure that at least 10 vials of Death Adder Antivenom are present with
- 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
Signs and Symptoms of Envenomation:
- 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
- Eyelid drooping (Ptosis)
- Blurred vision or difficulty seeing
- Difficulty Speaking or Swallowing (Dysarthria, Dysphasia)
- Respiratory paralysis
- Sudden loss of consciousness
- Flaccid paralysis
- Stumbling gait (Ataxia)
- 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
- Renal and Urinary: Albuminuria
- 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
- Profuse sweating
- Swelling, Edema (tends to be slight around the bite site)
- 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.
- Admit patient to an emergency or trauma service.
- Begin a peripheral intravenous infusion (16 gauge catheter) of Lactated
Ringers Solution at a rate of 250 cc/hour.
- Draw blood from the contralateral arm, and collect urine for the following
laboratory tests. Mark STAT.
- Type and Cross Match TWO units of Whole blood.
- CBC with differential and platelets.
- Coagulation Parameters:
- Prothrombin Time (PT)
- Partial Thromboplastin Time (PTT)
- Fibrinogen levels
- Fibrin Degradation Products
- Serum Electrolytes, BUN/Creatinine, Calcium, Phosphorus.
- Lactate Dehydrogenase (with Isoenzyme analysis). Isoenzyme analysis may
indicate multiple targets of the venom components which may dictate further
- Urinalysis (Macroscopic and Microscopic Analysis). Must include analysis
- Free Protein (Albumin)
- Electrocardiogram (Sinus Tachycardia would be expected).
- Continuous Urine Output Monitoring (Indwelling Foley Catheter if
unconscious). Keep Urine Output brisk.
- Additional Tests as needed or indicated by patient's hospital course.
- 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.
- OBSERVE PATIENT CLOSELY for signs and symptoms of envenomation which usually
manifest between 15 minutes and two hours after the bite occurred.
- 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).
- 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
- If signs and symptoms still fail to manifest, continue CLOSE observation
of the patient for an additional 12 to 24 hours.
- IF ANY SIGN OR SYMPTOM becomes apparent or has been noted during the course
of treatment, begin Antivenom Therapy as follows:
- 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.
- 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
- 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.
- 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.
- 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
- 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.
- 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
- Death Adder venom also lacks myelitic and nephrotoxic actions.
Myoglobinuria and renal failure have not been reported in Death Adder bite.
- 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.
- It is advisable to perform periodic serum and urine analyses during therapy
(as outlined above).
- 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.
- It is important that the patient be placed at rest, kept warm, and avoid
- 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.
- 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.
- Fluid management is very important in snake bite cases. The patient
should be well hydrated, and a brisk urine output maintained.
- 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.
- Narcotics are CONTRAINDICATED because of their tendency to suppress
respiration. Diazepam (Valium) may be given, but not in large doses.
- In cases in which Circulatory Shock remains uncorrected by antivenom
therapy, Plasma volume expanders and/or vasopressor agents may be given with
- Tetanus prophylaxis should be current.
- Antibiotics are NOT recommended prophylactically.
- Multiple Bites:
- 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).
- Severe Envenomation:
- 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
- Testing for Equine Protein Sensitivity:
- 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.
- 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):
- Administer 1 gram of Solumedrol I.V. Push.
- Wait 15 minutes.
- 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).
- Monitor Pulse and Blood Pressure carefully. Be prepared to treat for
Anaphylaxis with Epinephrine and other vasoactive medications.
- Clinical Experience with Death Adders:
- 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.
- The majority of accidents occur at dusk or in the evening; the victim
often trods upon the Death Adder without first seeing it.
- 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.
- 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.
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.
- COMMONWEALTH SERUM LABORATORIES: Treatment of Snake Bite in Australia and
Papua New Guinea using Antivenom (Package Insert with Antivenom). CSL, June
- CAMPBELL, C.H.: The Death Adder (Acanthophis antarcticus): The Effect of
its Bite and its Treatment. Med J Aust. 2:922, 1966.
- CURRIE, B.; M. FITZMAURICE; J. OAKLEY. "Resolution of Neurotoxicity with
Anticholinesterace Therapy and Death
Adder Envenomation." Med J Aust. 148:10, 1980.
- Sutherland, S.K. First Aid for Snakebite in Australia. Commonwealth
Serum Laboratories : Parkville, 1985.
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