In the event of an actual or probable bite from an Inland Taipan, execute the following first aid measures without delay.

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. (See attached copy from "First Aid for Snakebite" by Dr. S.K. Struan)

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. Have the TAIPAN ANTIVENOM (Commonwealth Serum Laboratories) ready for the emergency crew to take with the victim to the hospital. Give them the following:
   1. the available antivenom (at least 10 vials)
      
   2. the accompanying instruction (Protocol) packet
      
   3. the victim's medical packet (if available)
      DO NOT cut or incise the bite site
      DO NOT apply ice to the bite site

The bite of the Inland Taipan with envenomation can be rapidly fatal (as early as 30 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 (12000 units) of Commonwealth Serum Laboratories Taipan Antivenom 1:10 in Lactated Ringers Solution. Administer the antivenom I.V. piggyback over 30 minutes at a rate of 400 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 (12000 units) increments at a rate of 400 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):

         1-3 vials total for a minor bite with envenomation.

         4-10 vials or more may be necessary for moderate or severe bites.

This person has received a bite and probable envenomation from an Inland Taipan (Oxyuranus microlepidotus). Also referred to as the Fierce Snake or Small-scaled Snake, this extremely venomous and dangerous snake occupies a remote region of central Australia including the southwest corner of Queensland and adjacent areas of New South Wales, South Australia and the Northern Territories; The Taipans as a group have been responsible for a large number of human deaths. The Inland Taipan is the most venomous terrestrial snake known to man; perhaps the most toxic of all snakes in the world. Envenomation signifies a true medical emergency. The venom can cause neurotoxic, hemolytic, and coagulopathic reactions; paralysis or death could 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 Taipan Antivenom are present with the patient. This antivenom contains the appropriate fractions necessary to neutralize the components of Taipan venom.

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
   
   Consultants
   
   References

Signs and Symptoms of Envenomation:

1. Neurological and Neuromuscular: These signs and symptoms have a high degree of variability from case to case, and may come on subtly and progress rapidly. Early recognition is extremely important.
   Eyelid drooping (Ptosis)
   
   Blurred vision or difficulty seeing
   
   Difficulty with Speaking or Swallowing
   
   Headache
   
   Convulsions or Epileptoid Seizures
   
   Drowsiness
   
   Sudden loss of consciousness
   
   Flaccid paralysis
   
   Stumbling gait (Ataxia)
   
   Respiratory arrest or Dyspnea

   Hematological and Vascular:
   

   Profuse bleeding from bite site
   

   Spitting or vomiting blood (Hematemesis)
   

   Coagulation defects
   

   Hypotension
   

   Circulatory collapse

   Renal and Urinary:
   

   Hemoglobinuria
   

   Myoglobinuria
   

   Proteinuria
   

   Acute Renal Failure

   General: These symptoms may manifest very early (usually within 15 - 60 minutes following the bite) presenting as vague complaints; again prompt recognition as indication of clinical envenomation is critical.

   Abdominal Pain
   

   Regional lymph node tenderness
   

   Vomiting
   

   Coughing
   

   Profuse sweating
   

   Swelling, Edema

   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 noticable 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 Taipans have the longest fangs of the venomous Australian and Papuan snakes reaching 13 mm or more in some specimens. The snake strikes with extraordinary speed and accuracy, often snapping its jaws fiercely several times which can result in multiple punctures in the same attack. Multiple bites inflicted by a single snake or by more than one snake are 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 and call the consultant identified by the Poison Control Center.

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 Degredation 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
         
      2. Hemoglobin
         
      3. Myoglobin

   7. Electrocardiogram (Sinus Tachycardia would be expected).

   8. Continuous Urine Output Monitoring (Indwelling Foley Catheter if unconscious). Watch for possible oliguria or anuria.

   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 laboratory 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 Taipan Antivenom (12000 units) in Lactated Ringers Solution (Hartmann's Solution) to a total volume of 400 mls.

   2. Administer the diluted Antivenom intravenously over a period of 30 minutes at a rate of 13 -14 mls per minute (i.e., 1 vial per 30 minutes or 400 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 Taipan envenomation. Many of the symptoms are ameliorated or entirely eliminated by the antivenom alone. Other symptoms will require additional modalities of therapy 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. If breathing becomes impaired, provide respiratory assistance. Secretions may become copious, necessitating suctioning.

   2. Hematological symptoms may present as Desseminated Intravascular Coagulopathy, and are treated as are other DICs.

   3. Renal symptoms may complicate the situation, and if severe (Acute Renal Failure) may necessiate Peritoneal Dialysis.

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 (12000 unit) doses. Dilute one vial in Lactated Ringers Solution to a total volume of 400 mls and deliver I.V piggyback over 30 minutes at a rate of 13-14 mls per minute (i.e., 1 vial per 30 minutes or 400 units per minute). One should anticipate using (including the Initial dose):

   1-3 vials for a minor bite with envenomation.

   4-10 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 necessay 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. Blood replacement SHOULD NOT be started until the circulating venom anticoagulants have been fully neutralized.

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. Morphine is CONTRAINDICATED because of its tendancy to suppress respiration. Alcohol should also be avoided. Diazepam (Valium) may be given, but not in large quantities.

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. The Inland Taipan is an extremely fast and agile snake which can strike instantly with extreme accuracy. It is possible for a Taipan 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 (24000 units) diluted in Lactated Ringers Solution to a total volume of 800 mls, and delivered over 30 minutes at a rate of 26 - 28 mls per minute (i.e., 2 vials per 30 minutes or 800 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, the further antivenom may be delivered at more concentrated (i.e., 1:5) 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 Taipan 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 senstivity 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 10 mls/ minute (i.e., 300 units/min).

      4. Monitor Pulse and Blood Pressure carefully. Be prepared to treat for Anaphylaxis.

4. Clinical Experience with Oxyuranus microlepidotus :
   1. The venom of the Inland Taipan is by far the most toxic land snake venom known to science with strong coagulopathic and neurotoxic effects. Due to its nervous agitated demeanor, the blinding speed of its strike, its ability to bite multiple times in one attack, the extreme toxicity of its venom, and the number of fatalities attributed to it, the Taipan is perhaps the most feared of all the venomous Australian snakes; it is also one of the most dangerous and difficult to handle in captivity. Prior to the introduction of specific antivenom, the envenomation fatality rate was essentually 100%.

   2. There have been two documented cases of envenomation by Oxyuranus microlepidotus. Clinically, evenomation may represent a complex scenario of multiple organ system poisoning with neurotoxic symptoms typically dominating. Acute renal failure, Rhabdomyolysis, and Disseminated Coagulopathy may also complicate the setting, and are controlled with adjuvant support as indicated.

   3. The development of general and/or respiratory paralysis is of paramount concern in that these are often difficult to reverse once established, even with large amounts of antivenom. Prolonged intubation and ventilatory support (perhaps up to 1 week or longer) may be required. Early diagnosis of neurotoxic symptoms with prompt and adequate dosages of antivenom is critical to avoid these complications.

   4. Although the signs and symptoms of Taipan envenomation may resemble those of other Australian elapid snakes, especially Tiger Snakes (Genus Notechis) and Brown Snakes (Genus Pseudonaja), the antivenoms for these other snakes offer little cross-protection and vice versa -- the Antivenom must be specific for Taipans (Genus Oxyuranus).

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. SUTHERLAND, S.K. et al.: Rapid Death of a Child after a Taipan Bite. Med. J. Aust., 1:136, 1980.

3. BRIGDEN, M.C.: Taipan Bite with Myoglobinuria. Med. J. Aust., 2:42, 1981.