Editing Snakebite (section)

== Treatment ==
It may be difficult to determine if a bite by any species of snake is life-threatening. A bite by a North American [[Agkistrodon contortrix|copperhead]] on the ankle is usually a moderate injury to a healthy adult, but a bite to a child's abdomen or face by the same snake may be fatal. The outcome of all snakebites depends on a multitude of factors: the type of snake, the size, physical condition, and temperature of the snake, the age and physical condition of the person, the area and tissue bitten (e.g., foot, torso, vein or muscle), the amount of venom injected, the time it takes for the person to find treatment, and finally the quality of that treatment.<ref name="Gold2002" /><ref name="Gold1994" /> An overview of systematic reviews on different aspects of snakebite management found that the evidence base from majority of treatment modalities is low quality.<ref name="Interventions for the management of">{{cite journal | vauthors = Bhaumik S, Beri D, Lassi ZS, Jagnoor J | title = Interventions for the management of snakebite envenoming: An overview of systematic reviews | journal = PLOS Neglected Tropical Diseases | volume = 14 | issue = 10 | pages = e0008727 | date = October 2020 | pmid = 33048936 | pmc = 7584233 | doi = 10.1371/journal.pntd.0008727 | doi-access = free}}</ref> An analysis of World Health Organization guidelines found that they are of low quality, with inadequate stakeholder involvement and poor methodological rigour.<ref>{{cite journal | vauthors = Bhaumik S, Jagadesh S, Lassi Z | title = Quality of WHO guidelines on snakebite: the neglect continues | journal = BMJ Global Health | volume = 3 | issue = 2 | pages = e000783 | date = 2018-04-01 | pmid = 29662699 | pmc = 5898301 | doi = 10.1136/bmjgh-2018-000783}}</ref> In addition, access to effective treatment modalities is a major challenge in some regions, particularly in most African countries.<ref name=":0">{{Cite journal |last1=Berg |first1=Philipp |last2=Theart |first2=Francois |last3=van Driel |first3=Marcel |last4=Saaiman |first4=Esta L. |last5=Mavoungou |first5=Lise-Bethy |date=2024-11-06 |title=Snakebite envenoming in Africa remains widely neglected and demands multidisciplinary attention |journal=Nature Communications |language=en |volume=15 |issue=1 |pages=9598 |doi=10.1038/s41467-024-54070-y |pmid=39505859 |issn=2041-1723|pmc=11541957 |bibcode=2024NatCo..15.9598B }}</ref>

=== Snake identification ===
Identification of the snake is important in planning treatment in certain areas of the world but is not always possible. Ideally, the dead snake would be brought in with the person, but in areas where snake bite is more common, local knowledge may be sufficient to recognize the snake. However, in regions where polyvalent [[antivenom]]s are available, such as North America, identification of snakes is not a high-priority item. Attempting to catch or kill the offending snake also puts one at risk for re-envenomation or creating a second person bitten, and generally is not recommended.<ref name="auto">{{cite journal |last1=Knudsen |first1=Cecilie |last2=Jürgensen |first2=Jonas A. |last3=Føns |first3=Sofie |last4=Haack |first4=Aleksander M. |last5=Friis |first5=Rasmus U. W. |last6=Dam |first6=Søren H. |last7=Bush |first7=Sean P. |last8=White |first8=Julian |last9=Laustsen |first9=Andreas H. |date=2021 |title=Snakebite Envenoming Diagnosis and Diagnostics |journal=Frontiers in Immunology |volume=12 |page=661457 |doi=10.3389/fimmu.2021.661457 |pmid=33995385 |pmc=8113877 |issn=1664-3224|doi-access=free}}</ref>

The three types of venomous snakes that cause the majority of major clinical problems are [[Viper (animal)|vipers]], [[Bungarus|kraits]], and [[Naja|cobras]]. Knowledge of what species are present locally can be crucial, as is knowledge of typical signs and symptoms of envenomation by each type of snake. A scoring system can be used to try to determine the biting snake based on clinical features,<ref>{{cite journal | vauthors = Pathmeswaran A, Kasturiratne A, Fonseka M, Nandasena S, Lalloo DG, de Silva HJ | title = Identifying the biting species in snakebite by clinical features: an epidemiological tool for community surveys | journal = Transactions of the Royal Society of Tropical Medicine and Hygiene | volume = 100 | issue = 9 | pages = 874–878 | date = September 2006 | pmid = 16412486 | doi = 10.1016/j.trstmh.2005.10.003}}</ref> but these scoring systems are extremely specific to particular geographical areas and might be compromised by the presence of escaped or released non-native species.<ref name="auto"/>

=== First aid ===
Snakebite [[first aid]] recommendations vary, in part because different snakes have different types of venom. Some have little local effect, but life-threatening systemic effects, in which case containing the venom in the region of the bite by pressure immobilization is desirable. Other venoms instigate localized tissue damage around the bitten area, and immobilization may increase the severity of the damage in this area, but also reduce the total area affected; whether this trade-off is desirable remains a point of controversy. Because snakes vary from one country to another, first aid methods also vary.{{citation needed|date=March 2023}}

Many organizations, including the [[American Medical Association]] and [[American Red Cross]], recommend washing the bite with soap and water. Australian recommendations for snake bite treatment are against cleaning the wound. Traces of venom left on the skin/bandages from the strike can be used in combination with a snake bite identification kit to identify the species of snake. This speeds the determination of which antivenom to administer in the emergency room.<ref>{{cite web|url=http://www.usyd.edu.au/anaes/venom/snakebite.html |title=Treatment of Australian Snake Bites |author=Chris Thompson |website=Australian anaesthetists' website |archive-url=https://web.archive.org/web/20070323132545/http://www.usyd.edu.au/anaes/venom/snakebite.html |archive-date=23 March 2007}}</ref>

=== Pressure immobilization ===
{{Further|Pressure immobilization technique}}
[[File:Bundesarchiv Bild 135-KA-01-019, Tibetexpedition, Melken einer Schlange.jpg|thumb|right|A [[Russell's viper]] is being "milked". Laboratories use extracted snake venom to produce [[antivenom]], which is often the only effective treatment for potentially fatal snakebites.]]

As of 2008, clinical evidence for [[pressure immobilization]] via the use of an [[elastic bandage]] is limited.<ref name="Currie2008">{{cite journal | vauthors = Currie BJ, Canale E, Isbister GK | title = Effectiveness of pressure-immobilization first aid for snakebite requires further study | journal = Emergency Medicine Australasia | volume = 20 | issue = 3 | pages = 267–270 | date = June 2008 | pmid = 18549384 | doi = 10.1111/j.1742-6723.2008.01093.x | s2cid = 40768561}}</ref> It is recommended for snakebites that have occurred in Australia (due to [[elapids]] which are neurotoxic).<ref name="Walker2013">{{cite journal | vauthors = Patrick Walker J, Morrison R, Stewart R, Gore D | title = Venomous bites and stings | journal = Current Problems in Surgery | volume = 50 | issue = 1 | pages = 9–44 | date = January 2013 | pmid = 23244230 | doi = 10.1067/j.cpsurg.2012.09.003}}</ref> It is not recommended for bites from non-neurotoxic snakes such as those found in North America and other regions of the world.<ref name="Walker2013" /><ref name="ACM2011" /> The British military recommends pressure immobilization in all cases where the type of snake is unknown.<ref>{{cite journal | vauthors = Wall C | title = British Military snake-bite guidelines: pressure immobilisation | journal = Journal of the Royal Army Medical Corps | volume = 158 | issue = 3 | pages = 194–198 | date = September 2012 | pmid = 23472565 | doi = 10.1136/jramc-158-03-09 | s2cid = 22415445}}</ref>

The object of pressure immobilization is to contain venom within a bitten limb and prevent it from moving through the [[lymphatic system]] to the vital organs. This therapy has two components: pressure to prevent lymphatic drainage, and immobilization of the bitten limb to prevent the pumping action of the [[skeletal muscle]]s.{{citation needed|date=March 2023}}

=== Antivenom ===
Until the advent of [[antivenom]], bites from some species of snake were almost universally fatal.<ref name="INCHEM">{{cite web | vauthors = White J  |title=Oxyuranus microlepidotus |url=http://www.inchem.org/documents/pims/animal/taipan.htm |date=November 1991 |publisher=Chemical Safety Information from Intergovernmental Organizations |quote=Without appropriate antivenom treatment up to 75% of taipan bites will be fatal. Indeed, in the era before specific antivenom therapy, virtually no survivors of taipan bite were recorded. |access-date=24 July 2009 |url-status=live |archive-url=https://web.archive.org/web/20090803070213/http://www.inchem.org/documents/pims/animal/taipan.htm |archive-date=3 August 2009}}</ref> Despite huge advances in emergency therapy, antivenom is often still the only effective treatment for envenomation. The first antivenom was developed in 1895 by French physician [[Albert Calmette]] for the treatment of [[Indian cobra]] bites. Antivenom is made by injecting a small amount of venom into an animal (usually a horse or sheep) to initiate an immune system response. The resulting [[antibodies]] are then harvested from the animal's blood.{{citation needed|date=March 2023}}

Antivenom is injected into the person [[Intravenous therapy|intravenously]], and works by binding to and neutralizing venom enzymes. It cannot undo the damage already caused by venom, so antivenom treatment should be sought as soon as possible. Modern antivenoms are usually polyvalent, making them effective against the venom of numerous snake species. Pharmaceutical companies that produce antivenom target their products against the species native to a particular area. The availability of antivenom is a major concern in some areas, including most of Africa, due to economic reasons (antivenom crisis).<ref name=":0" /> In Sub-Saharan Africa, the efficacy of antivenom is often poorly characterised and some of the few available products have even been found to lack effectiveness.<ref>{{Cite journal |last1=Potet |first1=Julien |last2=Smith |first2=James |last3=McIver |first3=Lachlan |date=2019-06-24 |title=Reviewing evidence of the clinical effectiveness of commercially available antivenoms in sub-Saharan Africa identifies the need for a multi-centre, multi-antivenom clinical trial |journal=PLOS Neglected Tropical Diseases |language=en |volume=13 |issue=6 |pages=e0007551 |doi=10.1371/journal.pntd.0007551 |issn=1935-2735 |pmc=6615628 |pmid=31233536 |doi-access=free}}</ref>

Although some people may develop serious adverse reactions to antivenom, such as [[anaphylaxis]], in emergency situations this is usually treatable in a hospital setting and hence the benefit outweighs the potential consequences of not using antivenom. Giving [[adrenaline]] (epinephrine) to prevent adverse reactions to antivenom before they occur might be reasonable in cases where they occur commonly.<ref name="Nuch2000" /> Antihistamines do not appear to provide any benefit in preventing adverse reactions.<ref name="Nuch2000">{{cite journal | vauthors = Nuchpraryoon I, Garner P | title = Interventions for preventing reactions to snake antivenom | journal = The Cochrane Database of Systematic Reviews | issue = 2 | pages = CD002153 | year = 2000 | volume = 1999 | pmid = 10796682 | pmc = 7017854 | doi = 10.1002/14651858.CD002153}}</ref>

=== Chronic complications ===
Chronic health effects of snakebite include but are not limited to non-healing and chronic ulcers, musculoskeletal disorders, amputations, chronic kidney disease, and other neurological and endocrine complications.<ref>{{cite journal | vauthors = Kasturiratne A, Lalloo DG, Janaka de Silva H | title = Chronic health effects and cost of snakebite | journal = Toxicon | volume = 9-10 | page = 100074 | date = July 2021 | pmid = 34355162 | pmc = 8321925 | doi = 10.1016/j.toxcx.2021.100074| bibcode = 2021TxcnX...900074K }}</ref><ref>{{cite journal | vauthors = Bhaumik S, Gopalakrishnan M, Meena P | title = Mitigating the chronic burden of snakebite: turning the tide for survivors | journal = Lancet | volume = 398 | issue = 10309 | pages = 1389–1390 | date = October 2021 | pmid = 34537105 | doi = 10.1016/S0140-6736(21)01905-X | issn=0140-6736  | s2cid = 237541103}}</ref> The treatment of chronic complications of snakebite has not been well researched and there a systems approach consisting of a multi-component intervention.<ref>{{cite journal | vauthors = Bhaumik S, Gopalakrishnan M, Meena P | title = Mitigating the chronic burden of snakebite: turning the tide for survivors | journal = Lancet | volume = 398 | issue = 10309 | pages = 1389–1390 | date = October 2021 | pmid = 34537105 | doi = 10.1016/S0140-6736(21)01905-X| issn=0140-6736 | s2cid = 237541103}}</ref><ref name="Interventions for the management of" />

=== Outmoded ===
[[File:Snakebite kit.jpg|thumb|right|Old-style snake bite kit that should not be used]]
The following treatments, while once recommended, are considered of no use or harmful, including tourniquets, incisions, suction, application of cold, and application of electricity.<ref name="ACM2011">{{cite journal | title = Pressure immobilization after North American Crotalinae snake envenomation | journal = Journal of Medical Toxicology | volume = 7 | issue = 4 | pages = 322–323 | date = December 2011 | pmid = 22065370 | pmc = 3550191 | doi = 10.1007/s13181-011-0174-2 | author1 = American College of Medical Toxicology | author2 = American Academy of Clinical Toxicology | author3 = American Association of Poison Control Centers | author4 = European Association of Poison Control Centres | author5 = International Society of Toxinology | author6 = Asia Pacific Association of Medical Toxicology}}</ref> Cases in which these treatments appear to work may be the result of [[dry bite]]s.
* Application of a [[tourniquet]] to the bitten limb is generally not recommended. There is no convincing evidence that it is an effective first-aid tool as ordinarily applied.<ref name="theak">{{cite journal | vauthors = Theakston RD | title = An objective approach to antivenom therapy and assessment of first-aid measures in snake bite | journal = Annals of Tropical Medicine and Parasitology | volume = 91 | issue = 7 | pages = 857–865 | date = October 1997 | pmid = 9625943 | doi = 10.1080/00034989760626 | url = http://www.kingsnake.com/aho/pdf/menu6/theakston1997.pdf | url-status = live | archive-url = https://web.archive.org/web/20081230093058/http://www.kingsnake.com/aho/pdf/menu6/theakston1997.pdf | archive-date = 30 December 2008}}</ref> Tourniquets have been found to be completely ineffective in the treatment of ''[[Crotalus durissus]]'' bites,<ref>{{cite journal | vauthors = Amaral CF, Campolina D, Dias MB, Bueno CM, Rezende NA | title = Tourniquet ineffectiveness to reduce the severity of envenoming after Crotalus durissus snake bite in Belo Horizonte, Minas Gerais, Brazil | journal = Toxicon | volume = 36 | issue = 5 | pages = 805–808 | date = May 1998 | pmid = 9655642 | doi = 10.1016/S0041-0101(97)00132-3| bibcode = 1998Txcn...36..805A }}</ref> but some positive results have been seen with properly applied tourniquets for cobra venom in the [[Philippines]].<ref>{{cite journal | vauthors = Watt G, Padre L, Tuazon ML, Theakston RD, Laughlin LW | title = Tourniquet application after cobra bite: delay in the onset of neurotoxicity and the dangers of sudden release | journal = The American Journal of Tropical Medicine and Hygiene | volume = 38 | issue = 3 | pages = 618–622 | date = May 1988 | pmid = 3275141 | doi = 10.4269/ajtmh.1988.38.618 | s2cid = 29451180}}</ref> Uninformed tourniquet use is dangerous since reducing or cutting off circulation can lead to [[gangrene]], which can be fatal.<ref name="theak" /> The use of a compression bandage is generally as effective, and much safer.
* Cutting open the bitten area, an action often taken before suction, is not recommended since it causes further damage and increases the risk of infection; the subsequent cauterization of the area with fire or silver nitrate (also known as ''infernal stone'') is also potentially threatening.<ref name="peola">{{cite book | vauthors = Lupano G, Peola P |date=1915 |title=Corso di Scienze Naturali a uso delle Scuole Complementari |trans-title=A Course of Natural Sciences for the Complementary Institutes |language=it |publisher=G.B. Paravia |page=68}}</ref>
* Sucking out venom, either by mouth or with a pump, does not work and may harm the affected area directly.<ref name="pmid16781926">{{cite journal | vauthors = Holstege CP, Singletary EM | title = Images in emergency medicine. Skin damage following application of suction device for snakebite | journal = Annals of Emergency Medicine | volume = 48 | issue = 1 | pages = 105, 113 | date = July 2006 | pmid = 16781926 | doi = 10.1016/j.annemergmed.2005.12.019 | doi-access = free}}</ref> Suction started after three minutes removes a clinically insignificant quantity—less than one-thousandth of the venom injected—as shown in a human study.<ref>{{cite journal | vauthors = Alberts MB, Shalit M, LoGalbo F | title = Suction for venomous snakebite: a study of "mock venom" extraction in a human model | journal = Annals of Emergency Medicine | volume = 43 | issue = 2 | pages = 181–186 | date = February 2004 | pmid = 14747805 | doi = 10.1016/S0196-0644(03)00813-8}}</ref> In a study with pigs, suction not only caused no improvement but led to [[necrosis]] in the suctioned area.<ref name="pmid11055564">{{cite journal | vauthors = Bush SP, Hegewald KG, Green SM, Cardwell MD, Hayes WK | title = Effects of a negative pressure venom extraction device (Extractor) on local tissue injury after artificial rattlesnake envenomation in a porcine model | journal = Wilderness & Environmental Medicine | volume = 11 | issue = 3 | pages = 180–188 | year = 2000 | pmid = 11055564 | doi = 10.1580/1080-6032(2000)011[0180:EOANPV]2.3.CO;2 | doi-access = free}}</ref> Suctioning by mouth presents a risk of further poisoning through the mouth's [[oral mucosa|mucous tissues]].<ref>Riggs BS, Smilkstein MJ, Kulig KW, ''et al.'' Rattlesnake envenomation with massive oropharyngeal edema following incision and suction (Abstract). Presented at the AACT/AAPCC/ABMT/CAPCC Annual Scientific Meeting, Vancouver, Canada, September 27 October 2, 1987.</ref> The helper may also release bacteria into the person's wound, leading to infection.
* Immersion in warm water or sour milk, followed by the application of [[snake-stones]] (also known as ''la Pierre Noire''), which are believed to draw off the poison in much the way a sponge soaks up water.
* Application of a one-percent solution of [[potassium permanganate]] or [[chromic acid]] to the cut, exposed area.<ref name="peola"/> The latter substance is notably toxic and carcinogenic.
* Drinking abundant quantities of alcohol following the cauterization or disinfection of the wound area.<ref name="peola"/>
* Use of electroshock therapy in animal tests has shown this treatment to be useless and potentially dangerous.<ref>{{cite journal | vauthors = Russell FE | title = Another warning about electric shock for snakebite | journal = Postgraduate Medicine | volume = 82 | issue = 5 | page = 32 | date = October 1987 | pmid = 3671201 | doi = 10.1080/00325481.1987.11699990}}</ref><ref>{{cite journal | vauthors = Ryan AJ | title = Don't use electric shock for snakebite | journal = Postgraduate Medicine | volume = 82 | issue = 2 | page = 42 | date = August 1987 | pmid = 3497394 | doi = 10.1080/00325481.1987.11699922 | s2cid = 222260195}}</ref><ref>{{cite journal | vauthors = Howe NR, Meisenheimer JL | title = Electric shock does not save snakebitten rats | journal = Annals of Emergency Medicine | volume = 17 | issue = 3 | pages = 254–256 | date = March 1988 | pmid = 3257850 | doi = 10.1016/S0196-0644(88)80118-5}}</ref><ref>{{cite journal | vauthors = Johnson EK, Kardong KV, Mackessy SP | title = Electric shocks are ineffective in treatment of lethal effects of rattlesnake envenomation in mice | journal = Toxicon | volume = 25 | issue = 12 | pages = 1347–1349 | year = 1987 | pmid = 3438923 | doi = 10.1016/0041-0101(87)90013-4| bibcode = 1987Txcn...25.1347J }}</ref>

In extreme cases, in remote areas, all of these misguided attempts at treatment have resulted in injuries far worse than an otherwise mild to moderate snakebite. In worst-case scenarios, thoroughly constricting tourniquets have been applied to bitten limbs, completely shutting off blood flow to the area. By the time the person finally reached appropriate medical facilities, their limbs had to be [[amputated]].{{citation needed|date=March 2023}}

=== In development ===
Several new drugs and treatments are under development for snakebite. For instance, the metal chelator [[dimercaprol]] has recently been shown to potently antagonize the activity of Zn<sup>2+</sup>-dependent snake venom [[metalloproteinase]]s ''in vitro''.<ref>{{cite journal | vauthors = Albulescu LO, Hale MS, Ainsworth S, Alsolaiss J, Crittenden E, Calvete JJ, Evans C, Wilkinson MC, Harrison RA, Kool J, Casewell NR | display-authors = 6 | title = Preclinical validation of a repurposed metal chelator as an early-intervention therapeutic for hemotoxic snakebite | journal = Science Translational Medicine | volume = 12 | issue = 542 | pages = eaay8314 | date = May 2020 | pmid = 32376771 | pmc = 7116364 | doi = 10.1126/scitranslmed.aay8314}}</ref> New [[Monoclonal antibody|monoclonal antibodies]], polymer gels and a small molecule inhibitor called [[Varespladib]] are in development.<ref>{{cite web|title=The search for better antivenoms heats up as snakebites get renewed attention|url=https://cen.acs.org/biological-chemistry/biotechnology/search-better-antivenoms-heats-snakebites/97/i4|access-date=2020-10-15|website=Chemical & Engineering News|language=en}}</ref> A core outcome set (minimal list of consensus outcomes that should be used in future intervention research)  for snakebite in South Asia is being developed.<ref>{{cite journal |last1=Bhaumik |first1=Soumyadeep |last2=Beri |first2=Deepti |last3=Tyagi |first3=Jyoti |last4=Clarke |first4=Mike |last5=Sharma |first5=Sanjib Kumar |last6=Williamson |first6=Paula R. |last7=Jagnoor |first7=Jagnoor |date=2022-06-08 |title=Outcomes in intervention research on snakebite envenomation: a systematic review |journal=F1000Research |volume=11 |page=628 |doi=10.12688/f1000research.122116.1 |pmid=36300033 |pmc=9579743 |language=en |doi-access=free}}</ref>