Chapter V 



MEDICAL TREATMENT 



GENERAL CONSIDERATIONS 



On arrivul al the aid station or iiospital, an 

 iinnu'diati' evaluation nnist be made of tiie pa- 

 tient's <renerixl condition. Snake venom poisoning 

 is always a medical cnier<jency reqnirinjj immedi- 

 ate attention. .\, delay in institutinji; medical 

 treatment can lead to far more trafjic conse- 

 (piences than one following an ordinary ti'anmatic 

 injury. Tn most cases, fir.st aid measures will 

 already have been instituted by the corpsman. 

 The physician will need to evaluate these meas- 

 ures before determinincr the course of subsequent 

 ti'eatment. Xone of the first aid measures should 

 be regarded as substitutes for antivenin, anti- 

 biotic and antitetanus agents; nor should they he 

 instituted at the possible e.xpense of delaying ad- 

 ministration of the antivenin. Xeedless to say, 

 the physician will have to establish in his own 

 mind whether or not the patient has been poisoned 

 and, if so, to determine which therapeutic meas- 

 ures he can use most effectively. 



If the patient arrives at the medical installation 

 one hour or more following the bite and no first 

 aid measures have been initiated, the physician 

 should put him to bed, inunobilize the affected 

 part, clean the wounds thoroughly, and proceed 

 with the measures outlined below. Incision and 

 suction, excision, et cetera . are of no value after 

 svu'h a delay and should not be attempted. 



Admission Procedures 



A routine history and physical examination 

 should be done. The identity of the offending 

 snake, its size, the time of the bite, and the details 

 of all first aid measures employed, including the 

 time lapse for each, should be recorded. Inquiry 



should be iiiiiiic i'((nrcni iiig previous biles, aller- 

 gies, and \\ hcl hci- (ir iKil llicpalicnl has pri'X'iously 

 been exposed to Ikm'sc serum. If a skin test has 

 already bi'cii done this should be checked. Blood 

 should be drawn for typing, cross-matching, 

 blood clotliiig, and clot retraction studies. A com- 

 plete blood count, hematocrit, and urine analysis 

 are essential. Determinations of the sedimenta- 

 tion rate, prothi-ombin time, carbon dioxide com- 

 bining ))ower. urea nitrogen, sodium, potassium 

 and chloi'ide are ad\ised, if within the limits of 

 personnel, time, and ecpiipment. In severe poison- 

 ings, an electrocardiogram and a blood platelet 

 count should be done. Serum bilirubin, red cell 

 fragility tests, and renal function tests should be 

 done if the condition warrants. Studies of the 

 Iieniatocrit, complete blood covmts, and hemoglo- 

 bin concentration should be carried out several 

 times a day. Urinalyses should be done with par- 

 ticular attention being given to the presence or 

 absence of red cells. This is especially important 

 in all cases of viper venom poisoning. 



In all i)atients, regardless of the snake involved, 

 pvdse, blood pressure, and respirations should be 

 checked periodically. "When available, central 

 venous pressure monitoring devices may be used 

 in order to determine need for and to evaluate 

 resi)onse to anti-shock therapy. Facilities and 

 drugs for shock must l>e readily available, and 

 a tracheostomy set and [)ositive pressure lu-eath- 

 ing apparatus should be held in readiness. A 

 measurement of the circumference of the affected 

 part 4 inches above the bite, and at an additional 

 point proximal to the wound, should be recorded. 



The course of snake venom poisoning is some- 

 times unpredictable, and patients showing steady 

 recovery may on occasions take a turn for the 

 worse. Continued close observation by physi- 



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