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Date: Fri, 10 May 2002 21:53:27 -0500
From: lee gladstone <doctorlee@mail.com>
Subject: Re: W-EMED A novel treatment for laryngeal edema?
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I'm somewhat new to this forum so I hope you dont mind input from a new guy.&nbsp;&nbsp;Although I dont know whether phenylephrine would be of benefit in laryngeal edema,&nbsp;I have read reports of racemic epi as an effective treatment for uvular edema.&nbsp; And since theie alpha&nbsp;effects are similar then there should be some benefit.&nbsp; At the least it wouldnt harm (as in rimum non nocere.)<BR><BR>----- Original Message -----<BR>From: JadedMedic@aol.com<BR>Date: Tue, 7 May 2002 13:41:57 EDT<BR>To: wilderness-emergency-medicine@list.pitt.edu<BR>Subject: W-EMED A novel treatment for laryngeal edema?<BR><BR><BR>Content-Type: text/html; charset="US-ASCII"<BR><FONT face=arial,helvetica><FONT size=3><BR>Hi folks,<BR><BR>As some of you know, anaphylaxis is something of a special concern of mine.&nbsp; It is a common medical emergency that often cannot be adequately treated by the traditionally taught "physical" first aid procedures such as the Heimlich maneuver, cardiac c!
ompression, direct pressure, and so forth -- but rather calls for "chemical" intervention (often, of course, in the form of epinephrine) and yet the lore of first aid instruction is generally very reluctant to advocate chemical interventions in addition to physical interventions.&nbsp; There are days when the implications of this reluctance worry me -- a lot.<BR><BR>Anyway, it's pretty well know that laryngeal edema can be the development in anaphylaxis that leads to a fatal outcome, and right now not too much is done to treat laryngeal edema specifically.&nbsp; It's one of the few situations which, in my opinion, resorting to creating a surgical airway might "really" be necessary.<BR><BR>So, how might one treat laryngeal edema?<BR><BR>Well, I notice that many OTC nasal decongestants contain the pure alpha agent phenylephrine as their active agent, and that reduces swelling.&nbsp; So...the question becomes....might a generous spritz of phenylephrine spray into the back of th!
e throat (and into the nose) of a person developing laryngeal edema -- or at risk for developing it -- either prevent such edema from progressing to a life-threatening level and/or delay the speed at which it does so?<BR><BR>"On paper" at least, it would seem that indeed it might.<BR><BR>I note that the National Safety Council's book on Wilderness first aid includes mention of nasal decongestant spray as a possible alternative treatment for anaphylaxis, although I found no info on type of agent, dosage, or administration route.<BR><BR>In other news, I bounced this general thought off the brain of an MD friend of mine and he agreed that, at least in theory, the phenylephrine spray might indeed be useful in such a situation.&nbsp; He further speculated that OTC decongestant sprays containing oxymetazoline (the "12 hour" agent) might also be useful.<BR><BR>Any thoughts?<BR><BR>Regards to all,<BR><BR>Jay Wiseman<BR>FA/CPR Instructor-at-large<BR>Visit my FA/CPR class preview/revi!
ew website: http://hometown.aol.com/safescene/<BR>"If you're gonna play the game, boy, you'd better learn to play it right."&nbsp; -- Kenny Rogers, "The Gambler"</FONT><BR></FONT>
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Date: Tue, 07 May 2002 13:41:57 -0400 (EDT)
From: JadedMedic@aol.com
Subject: W-EMED A novel treatment for laryngeal edema?
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Hi folks,

As some of you know, anaphylaxis is something of a special concern of mine.  
It is a common medical emergency that often cannot be adequately treated by 
the traditionally taught "physical" first aid procedures such as the Heimlich 
maneuver, cardiac compression, direct pressure, and so forth -- but rather 
calls for "chemical" intervention (often, of course, in the form of 
epinephrine) and yet the lore of first aid instruction is generally very 
reluctant to advocate chemical interventions in addition to physical 
interventions.  There are days when the implications of this reluctance worry 
me -- a lot.

Anyway, it's pretty well know that laryngeal edema can be the development in 
anaphylaxis that leads to a fatal outcome, and right now not too much is done 
to treat laryngeal edema specifically.  It's one of the few situations which, 
in my opinion, resorting to creating a surgical airway might "really" be 
necessary.

So, how might one treat laryngeal edema?

Well, I notice that many OTC nasal decongestants contain the pure alpha agent 
phenylephrine as their active agent, and that reduces swelling.  So...the 
question becomes....might a generous spritz of phenylephrine spray into the 
back of the throat (and into the nose) of a person developing laryngeal edema 
-- or at risk for developing it -- either prevent such edema from progressing 
to a life-threatening level and/or delay the speed at which it does so?

"On paper" at least, it would seem that indeed it might.

I note that the National Safety Council's book on Wilderness first aid 
includes mention of nasal decongestant spray as a possible alternative 
treatment for anaphylaxis, although I found no info on type of agent, dosage, 
or administration route.

In other news, I bounced this general thought off the brain of an MD friend 
of mine and he agreed that, at least in theory, the phenylephrine spray might 
indeed be useful in such a situation.  He further speculated that OTC 
decongestant sprays containing oxymetazoline (the "12 hour" agent) might also 
be useful.

Any thoughts?

Regards to all,

Jay Wiseman
FA/CPR Instructor-at-large
Visit my FA/CPR class preview/review website: 
http://hometown.aol.com/safescene/
"If you're gonna play the game, boy, you'd better learn to play it right."  
-- Kenny Rogers, "The Gambler"

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<HTML><FONT FACE=arial,helvetica><FONT  SIZE=3><BR>
Hi folks,<BR>
<BR>
As some of you know, anaphylaxis is something of a special concern of mine.&nbsp; It is a common medical emergency that often cannot be adequately treated by the traditionally taught "physical" first aid procedures such as the Heimlich maneuver, cardiac compression, direct pressure, and so forth -- but rather calls for "chemical" intervention (often, of course, in the form of epinephrine) and yet the lore of first aid instruction is generally very reluctant to advocate chemical interventions in addition to physical interventions.&nbsp; There are days when the implications of this reluctance worry me -- a lot.<BR>
<BR>
Anyway, it's pretty well know that laryngeal edema can be the development in anaphylaxis that leads to a fatal outcome, and right now not too much is done to treat laryngeal edema specifically.&nbsp; It's one of the few situations which, in my opinion, resorting to creating a surgical airway might "really" be necessary.<BR>
<BR>
So, how might one treat laryngeal edema?<BR>
<BR>
Well, I notice that many OTC nasal decongestants contain the pure alpha agent phenylephrine as their active agent, and that reduces swelling.&nbsp; So...the question becomes....might a generous spritz of phenylephrine spray into the back of the throat (and into the nose) of a person developing laryngeal edema -- or at risk for developing it -- either prevent such edema from progressing to a life-threatening level and/or delay the speed at which it does so?<BR>
<BR>
"On paper" at least, it would seem that indeed it might.<BR>
<BR>
I note that the National Safety Council's book on Wilderness first aid includes mention of nasal decongestant spray as a possible alternative treatment for anaphylaxis, although I found no info on type of agent, dosage, or administration route.<BR>
<BR>
In other news, I bounced this general thought off the brain of an MD friend of mine and he agreed that, at least in theory, the phenylephrine spray might indeed be useful in such a situation.&nbsp; He further speculated that OTC decongestant sprays containing oxymetazoline (the "12 hour" agent) might also be useful.<BR>
<BR>
Any thoughts?<BR>
<BR>
Regards to all,<BR>
<BR>
Jay Wiseman<BR>
FA/CPR Instructor-at-large<BR>
Visit my FA/CPR class preview/review website: http://hometown.aol.com/safescene/<BR>
"If you're gonna play the game, boy, you'd better learn to play it right."&nbsp; -- Kenny Rogers, "The Gambler"</FONT><FONT  COLOR="#000000" style="BACKGROUND-COLOR: #ffffff" SIZE=2 FAMILY="SANSSERIF" FACE="Arial" LANG="0"><BR>
</FONT></HTML>
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Date: Mon, 22 Apr 2002 14:24:28 -0600
From: wjgrimes <wjgrimes@u.arizona.edu>
Subject: W-EMED Antivenom
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I E mailed earlier some comments about rattlesnakes. I checked with 
one of our clinicians who treats bite victims here, and who does 
research with the antivenoms. As was said earlier, there are a number 
of snakes with neurotoxin. The Mojave is the most common, and usually 
has the highest concentration. The CroFab preparation used in the 
clinic was made with venom from a number of snakes, including the 
Mojave.
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Date: Mon, 22 Apr 2002 09:13:03 -0700
From: Hal Lillywhite <hall@smtp1.mxim.com>
Subject: Re: W-EMED Patient packaging
In-reply-to: "Your message of Sun, 21 Apr 2002 10:03:50 PDT."
 <KMyNncA2Dvw8EwYh@wildmedic.org>
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In message <KMyNncA2Dvw8EwYh@wildmedic.org>, Jel Coward writes:
>Hi all
>
>Question:
>In a system without vacuum mattresses, what methods have people
>devised/studied/read about for getting a patient, who needs
>immobilisation, into a basket stretcher?

...

Near ideal method:

Prepare litter with padding etc.  Get straps outside so they don't interfere.  If appropriate put open sleeping bag/tarp in the litter ready to receive the patient.

Have 7 trained people to manage the patient, three for each side and one for the head.  They take posititions and reach hands under the patient at head, sholders, hips and just above, and at knees/feet.

One or two people move the litter in line with the patient's body and below his feet.

On command, the people on the patient gently raise him high enough to clear the litter, being careful to avoid spinal manipulation.  The litter people slide it under the patient.  The on command, the patient is lowered into position in the litter.

The team wraps the patient appropriately, fastens straps etc.


Now, reality sets in:  The patient is not on a convenient place.  Patients always seem to be in awkward locations with rocks, drop-offs etc. which preclude the above.  The patient is not conveniently laid out on his back but is twisted around a rock or tree stump with other obstacles in the way.  The 8 or 9 trained people required for the above are not on the scene.  You do the best you can. 

You use (or improvise) a C-collar.  

If a KED or equivalent is available you use it.  

If feasible you wait for more help but sometimes considerations like hypothermia preclude that.  

You size up the situation and consider your options.  

Then you make a plan to get the patient in the litter with as little manipulation as possible given the situation.

You splint whatever it is appropriate to splint, then go with what you have.  You may have to accept some less than ideal treatment of extremities in order to protect the spine. 

Maybe you scoop from the side after a log roll. 

Maybe 2-3 people lift the head and shoulders (trying to avoid neck manipulation) while somebody works the litter under the patient.

Maybe you figure out some other method.

In wilderness events there are only two certainties:

1.  Conditions, equipment and personnel will be less than ideal, and

2.  This one will be different from the last one, the techniques which worked last time probably won't work (at least without modification) this time.

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Date: Mon, 22 Apr 2002 08:17:10 -0700
From: Hal Lillywhite <hall@smtp1.mxim.com>
Subject: Re: W-EMED Re: : rattle snake bites
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In message <3CC09360.15610.1E2F8AF@localhost>, "Keith Conover, M.D., FACEP" wri
tes:
>The systemic toxicity of pit vipers is generally low, except in 
>children (big dose to size ratio) and those with medical problems.  
>There are solid recommendations against compression in pit viper 
>bites, based on years of experience with them.  I would not use a 
>single unreported case, not subjected to peer review, as an argument 
>to switch to a treatment that we have good reason to think can 
>definitely cause local damage, and can lead to lifelong problems 
>(repeated skin grafts, loss of function, or even amputation).

OK, since I muddied the water with my comment about neurotoxins, here is the quote from the original email I received from Steve Grenard, dated Aug 1997:

   You might be interested in knowing that Mojaves intergrade with all
   species inside and outside their range and Mojave type toxins have even
   been showing up in Timber Rattlesnakes collected in Georgia. I guess 
   this stuff has a way of getting around. Evolution in real time.

He did not explain how Mojaves could intergrade with snakes in Georgia.  That could be interesting.

I don't claim to be a physician, just an erstwhile physicist involved in SAR and trained in a bit of emergency medicine.  As I indicated in an earlier message, I got roped into doing the snake bite FAQ for rec.backcountry and learned a lot in the research for that but of course not to the level of either Keith Connover or Steve Grenard.  That being the case I have to depend on those who know more than I to educate me.  The obvious problem is that the experts don't always agree.  (No surprise, that happens is physics also.)  I get the impression that putting Steve Grenard and Findlay Russell in the same room could be very interesting.  I  would like to have a definitive answer but at present I suspect what I will get is different "definitive" answers depending on who I ask.  That being the case, should I be faced with a potentially envonomated snake bite, I will have to follow approved protocol which today means no Australian wrap in the US.  (Though I wonder if this should be !
modified in the range of the Mojave rattlesnake.)

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Date: Sun, 21 Apr 2002 20:09:12 -0600
From: Donovan Hoggan <dhoggan@memlane.com>
Subject: Re: W-EMED Patient packaging
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References: <KMyNncA2Dvw8EwYh@wildmedic.org>

We found a wonderful invention called the BackRaft.  It is an airmattress
that inflates after the patient is immobilized and fills voids.  In the
short term, it does wonders for comfort.  We haven't tried it for longer
periods (can't find someone willing to lie still for an hour or two!) but we
should.

Anyone else have experience with this?

Donovan

Donovan Hoggan, R.S.W.
Safety Coordinator
South Eastern Alberta Search & Rescue
dhoggan@memlane.com
va6don@rac.ca.


----- Original Message -----
From: "Jel Coward" <jel@wildmedic.org>
To: <wilderness-emergency-medicine@list.pitt.edu>
Sent: Sunday, April 21, 2002 11:03 AM
Subject: W-EMED Patient packaging


> Hi all
>
> Question:
> In a system without vacuum mattresses, what methods have people
> devised/studied/read about for getting a patient, who needs
> immobilisation, into a basket stretcher?
>
> I am aware of a system that uses longboards (aka spine boards) for this
> - and I think they leave the patient on the board.  The latter is
> clearly not ideal if transport times exceed 15-30 minutes
>
> I am trying to assemble a list of different techniques to try to arrive
> at what might be best practice (for the situation without a vacuum
> mattress).  I will post here any conclusions that this produces
>
> Thanks for any input
>
> Cheers :)
> --
> Jel Coward
>
> http://www.wildmedic.org
> http://www.wemsi.org
>
> jel@wildmedic.org
>
> 'There's no such thing as bad weather - just bad  clothing"
>                                                 Anon Norwegian
> Do not reproduce without author's express permission.
> To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine"
> as the body of a message (no subject) To: Majordomo@list.pitt.edu
> Submissions To: wilderness-emergency-medicine@list.pitt.edu

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Date: Sun, 21 Apr 2002 10:03:50 -0700
From: Jel Coward <jel@wildmedic.org>
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Hi all

Question:
In a system without vacuum mattresses, what methods have people
devised/studied/read about for getting a patient, who needs
immobilisation, into a basket stretcher?

I am aware of a system that uses longboards (aka spine boards) for this
- and I think they leave the patient on the board.  The latter is
clearly not ideal if transport times exceed 15-30 minutes

I am trying to assemble a list of different techniques to try to arrive
at what might be best practice (for the situation without a vacuum
mattress).  I will post here any conclusions that this produces

Thanks for any input

Cheers :)
-- 
Jel Coward

http://www.wildmedic.org
http://www.wemsi.org

jel@wildmedic.org

'There's no such thing as bad weather - just bad  clothing"
                                                Anon Norwegian
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Date: Sat, 20 Apr 2002 10:08:19 -0400
From: "Keith Conover, M.D., FACEP" <kconover+@pitt.edu>
Subject: Re: W-EMED Re: rattle snake bites
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On 20 Apr 2002 at 9:51, Keith Conover, M.D., FACEP wrote:

> The few studies in the medical literature that favored snakebite were
> fatally flawed.

Hmph.  That should have said "favored electric shock for snakebite."  
That's what I get for typing with my eyes closed.  I'm awake now, 
really I am.


--Keith Conover, M.D., FACEP
  http://www.pitt.edu/~kconover
  sent with Pegasus high-security email
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Date: Sat, 20 Apr 2002 09:51:55 -0400
From: "Keith Conover, M.D., FACEP" <kconover+@pitt.edu>
Subject: Re: W-EMED Re: rattle snake bites
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A couple additions for this thread.

There is one report where envenomation signs and symptoms were 
delayed for 10 hour, thus raising into question the "six-hour rule" 
(observe for six hours and then send home):

Swindle GM, Seaman KG, Arthur DC, Almquist TD. The six hour 
observation rule for grade I crotalid envenomation: is it sufficient? 
Case report of delayed envenomation. J Wild Med 1992; 3:168-172.  

> >How about electric discharges?
> Last year I had a look around for an evidence base for acute treatment
> of snake bite.  I could find no evidence for the use of electrical
> devices.  ..Cheers -- Jel Coward

The recent popularity of electric shock for snakebite arose when 
South American cowboys found that, if they shocked themselves with 
their cattle prods after being bitten by a very poisonous snake, they 
did well.  Only problem is that most of them were found to have 
antibodies against the snake venom, likely from bites sustained as a 
child.

The few studies in the medical literature that favored snakebite were 
fatally flawed.

Guderian RH, Mackenzie CD, Williams JF. High voltage shock treatment 
for snake bite. Lancet 1986; 2:229.  

There are now multiple good studies that show electric shock to be 
useless.

Sutherland SK, Coulter AR. Early management of bites by the eastern 
diamondback rattlesnake (Crotalus adamanteus): studies in monkeys 
(Macaca fascicularis). Am J Trop Med Hyg 1981; 30:497-500.  

Davis D, Branch K, Egen NB, Russell FE, Gerrish K, Auerbach PS. The 
effect of an electrical current on snake venom toxicity. J Wild Med 
1992; 3:48-53.  

Howe NR, Meisenheimer JL, Jr. Electric shock does not save 
snakebitten rats. Ann Emerg Med 1988; 17:254-256.   

"Electric shocks were tried on snakebite back when electricity was 
first discovered.  It didn't work then, and it doesn't work now."


--Keith Conover, M.D., FACEP
  http://www.pitt.edu/~kconover
  sent with Pegasus high-security email
  download free from www.pmail.com

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Date: Sat, 20 Apr 2002 08:40:27 -0400
From: Manuel Sotelo <traumamsd@cantv.net>
Subject: Re: W-EMED Re: rattle snake bites
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Jel 
It is a pitty do, it is a practical method if it works.
Thx
Manuel


>How about electric discharges?
Last year I had a look around for an evidence base for acute treatment
of snake bite.  I could find no evidence for the use of electrical
devices.  ..Cheers
-- 
Jel Coward


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Subject: Re: W-EMED Re: : rattle snake bites
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There is one exception to the 'generally low' toxicity of pit vipers that I
know of, the Mojave rattlesnake (aka the Mojave Green or Panamint Red
rattlesnake, same snake, color variation).  Aside from the very small
sidewinders we have locally, this is the most common rattlesnake in our
area, and frequently shows up on lists of the deadliest snakes in the
world.  This pit viper carries a double whammy:  1) 'typical' rattlesnake
hemotoxin;  2) a nuerotoxin.  Severe respiratory distress can commence in as
little as 15 minutes after envenomation, and there are few places where
these snakes are found that are less than an hour from the hospital.  For
more information go to:  http://www.emedicine.com/emerg/topic541.htm

     SNIP:

     Authored by Sean P Bush, MD, FACEP, Associate Professor,
     Department of Emergency Medicine, Loma Linda University School of
     Medicine

     Sean P Bush, MD, FACEP, is a member of the following medical
     societies: American College of Emergency Physicians, Society for
     Academic Emergency Medicine, and Wilderness Medical Society

Dr. Bush is ambiguous about the use of a constrictive bandage, but that
seems based on the question of whether or not the biter has type A venom.
Around here, we KNOW they do (it's where they used to collect them to get
venom for the production of anti-venon).

So, 2 questions:
1)  Compression bandage: Yes or No?  - especially wrt juviniles  (double
especially for asthmatic juviniles, as both my sons are)
2)  CroFab - does it cover the Mojave type A envenomation (or will it in the
future)?

Thanks for letting me add my mud to the water

kit

PS:  yes, I have talked and continue to talk to my sons about these snakes,
the deadly threat they pose, and how snakes usually bite only the people who
just haveto mess with them.  I am confident that as they get older they will
show the same respect for these snakes as teenagers generally show for say,
guns found hidden in a closet.  In other words, educate, educate, educate,
and pray for the best when they get put to the test.



"Keith Conover, M.D., FACEP" wrote:

> The systemic toxicity of pit vipers is generally low, except in
> children (big dose to size ratio) and those with medical problems.
> There are solid recommendations against compression in pit viper
> bites, based on years of experience with them.  I would not use a
> single unreported case, not subjected to peer review, as an argument
> to switch to a treatment that we have good reason to think can
> definitely cause local damage, and can lead to lifelong problems
> (repeated skin grafts, loss of function, or even amputation).
>
> I would suggest that, when trying to decide on issues like this,
> where incomplete information is available, that those with _clinical_
> experience treating patients in general, as well knowledge of the
> literature and basic science of snakebite, would be the best people
> to believe.  In other words, physicians.  And I think most
> physicians, even those who are aware of and even agree with some of
> Grenard's concerns about increasing neurotoxicity, would agree.  It's
> a question of risk-benefit analysis with incomplete information.
>
> Certainly, there are cases of delayed toxicity documented at least up
> to 6-8 hours, and such a period of observation should always occur.
> And, if someone develops problems from a neurotoxin in the urban or
> near-urban setting, intubation and respiratory support, sedation if
> needed, and basic supportive care will almost always get someone
> through it.
>
> On 19 Apr 2002 at 17:00, Hal Lillywhite wrote:
>
> > In message <3CC07031.13250.15983B1@localhost>, "Keith Conover, M.D.,
> > FACEP" wri tes: >There is a way to resolve this, at least in my mind.
> >
> > >If the type of snake venom is known to primarily toxic to local
> > >tissue, and the systemic toxicity is low, compression techniques are
> > >more likely to worsen local tissue damage than prevent systemic
> > >toxicity.
> >
> > I would agree except that the "if" may cover a multitude of sins.
> >
> > >If on the other hand, the main problem is systemic toxicity rather
> > >than local tissue damage, then the compression techniques make sense.
> >
> > >Luckily, all native poisonous snakes in North America are pretty much
> > > local-tissue-toxin types, except for a few like the coral snake that
> > > don't pack much of a systemic wallop anyway.  Which means the
> > >compression technique doesn't make sense in the backcountry, unless
> > >you routinely backpack with your pet Russell's Viper.  Only exception
> > > would be multiple envenomated bites to a limb, especially to someone
> > > already in bad shape...
> >
> > Steve Grenard claims to have evidence that North American rattlesnake
> > venom has undergone some changes in the last few decades, probably due
> > to intergrading.  He claims that we can no longer assume that pit
> > viper venom is lacking in neurotoxins and high in hemotoxins.  If true
> > that would certainly put a different light on this.  (It might also
> > explain a case we discussed at some length with no resolution years
> > ago on rec.backcountry.  Bill Johnson, who had been involved in SAR in
> > New Mexico, knew of a case near Roswell in which a child was bitten by
> > a rattler.  That was a long way from the range of the Mojave or other
> > rattler known for neurotoxins.   The ER doc found no evidence of
> > envenomation and sent the child home.  Systemic reaction set in and
> > the child died.  Of course due to patient privacy we could not find
> > any definitive information so it was left a mystery.  Like all such
> > stories it may even have not been true but Bill was rather confident
> > that the main points were correct.)
> >
> > How about this:  If a patient is bitten by a pit viper and shows signs
> > of hemotoxin (edema etc.) do not use the wrap.  If there is a chance
> > of envenomation but no signs of hemotoxin, assume that either there
> > was no envenomation (no real harm from the wrap) or the venom was high
> > in neurotoxin.  In this case and wrap it till you reach the hospital?
> >
> > (Of course, even better is don't cause the snake to bite you in the
> > first place.  However some of us might be in a position to treat
> > someone not so informed and who did get bitten.)
> >
> >
>
> --Keith Conover, M.D., FACEP
>   http://www.pitt.edu/~kconover
>   sent with Pegasus high-security email
>   download free from www.pmail.com
>
> Do not reproduce without author's express permission.
> To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine"
> as the body of a message (no subject) To: Majordomo@list.pitt.edu
> Submissions To: wilderness-emergency-medicine@list.pitt.edu

--------------34487CCC1A3F2D1DF7CD6038
Content-Type: text/html; charset=us-ascii
Content-Transfer-Encoding: 7bit

<!doctype html public "-//w3c//dtd html 4.0 transitional//en">
<html>
There is one exception to the 'generally low' toxicity of pit vipers that
I know of, the Mojave rattlesnake (aka the Mojave Green or Panamint Red
rattlesnake, same snake, color variation).&nbsp; Aside from the very small
sidewinders we have locally, this is the most common rattlesnake in our
area, and frequently shows up on lists of the deadliest snakes in the world.&nbsp;
This pit viper carries a double whammy:&nbsp; 1) 'typical' rattlesnake
hemotoxin;&nbsp; 2) a nuerotoxin.&nbsp; Severe respiratory distress can
commence in as little as 15 minutes after envenomation, and there are few
places where these snakes are found that are less than an hour from the
hospital.&nbsp; For more information go to:&nbsp; <A HREF="http://www.emedicine.com/emerg/topic541.htm">http://www.emedicine.com/emerg/topic541.htm</A>
<blockquote>SNIP:</blockquote>

<blockquote>Authored by Sean P Bush, MD, FACEP, Associate Professor, Department
of Emergency Medicine, Loma Linda University School of Medicine
<p>Sean P Bush, MD, FACEP, is a member of the following medical societies:
American College of Emergency Physicians, Society for
<br>Academic Emergency Medicine, and Wilderness Medical Society</blockquote>

<p><br>Dr. Bush is ambiguous about the use of a constrictive bandage, but
that seems based on the question of whether or not the biter has type A
venom.&nbsp; Around here, we KNOW they do (it's where they used to collect
them to get venom for the production of anti-venon).
<p>So, 2 questions:
<br>1)&nbsp; Compression bandage: Yes or No?&nbsp; - especially wrt juviniles&nbsp;
(double especially for asthmatic juviniles, as both my sons are)
<br>2)&nbsp; CroFab - does it cover the Mojave type A envenomation (or
will it in the future)?
<p>Thanks for letting me add my mud to the water
<p>kit
<p>PS:&nbsp; yes, I have talked and continue to talk to my sons about these
snakes, the deadly threat they pose, and how snakes usually bite only the
people who just <i>have</i>to mess with them.&nbsp; I am confident that
as they get older they will show the same respect for these snakes as teenagers
generally show for say, guns found hidden in a closet.&nbsp; In other words,
educate, educate, educate, and pray for the best when they get put to the
test.
<br>&nbsp;
<br>&nbsp;
<p>"Keith Conover, M.D., FACEP" wrote:
<blockquote TYPE=CITE>The systemic toxicity of pit vipers is generally
low, except in
<br>children (big dose to size ratio) and those with medical problems.
<br>There are solid recommendations against compression in pit viper
<br>bites, based on years of experience with them.&nbsp; I would not use
a
<br>single unreported case, not subjected to peer review, as an argument
<br>to switch to a treatment that we have good reason to think can
<br>definitely cause local damage, and can lead to lifelong problems
<br>(repeated skin grafts, loss of function, or even amputation).
<p>I would suggest that, when trying to decide on issues like this,
<br>where incomplete information is available, that those with _clinical_
<br>experience treating patients in general, as well knowledge of the
<br>literature and basic science of snakebite, would be the best people
<br>to believe.&nbsp; In other words, physicians.&nbsp; And I think most
<br>physicians, even those who are aware of and even agree with some of
<br>Grenard's concerns about increasing neurotoxicity, would agree.&nbsp;
It's
<br>a question of risk-benefit analysis with incomplete information.
<p>Certainly, there are cases of delayed toxicity documented at least up
<br>to 6-8 hours, and such a period of observation should always occur.
<br>And, if someone develops problems from a neurotoxin in the urban or
<br>near-urban setting, intubation and respiratory support, sedation if
<br>needed, and basic supportive care will almost always get someone
<br>through it.
<p>On 19 Apr 2002 at 17:00, Hal Lillywhite wrote:
<p>> In message &lt;3CC07031.13250.15983B1@localhost>, "Keith Conover,
M.D.,
<br>> FACEP" wri tes: >There is a way to resolve this, at least in my mind.
<br>>
<br>> >If the type of snake venom is known to primarily toxic to local
<br>> >tissue, and the systemic toxicity is low, compression techniques
are
<br>> >more likely to worsen local tissue damage than prevent systemic
<br>> >toxicity.
<br>>
<br>> I would agree except that the "if" may cover a multitude of sins.
<br>>
<br>> >If on the other hand, the main problem is systemic toxicity rather
<br>> >than local tissue damage, then the compression techniques make sense.
<br>>
<br>> >Luckily, all native poisonous snakes in North America are pretty
much
<br>> > local-tissue-toxin types, except for a few like the coral snake
that
<br>> > don't pack much of a systemic wallop anyway.&nbsp; Which means
the
<br>> >compression technique doesn't make sense in the backcountry, unless
<br>> >you routinely backpack with your pet Russell's Viper.&nbsp; Only
exception
<br>> > would be multiple envenomated bites to a limb, especially to someone
<br>> > already in bad shape...
<br>>
<br>> Steve Grenard claims to have evidence that North American rattlesnake
<br>> venom has undergone some changes in the last few decades, probably
due
<br>> to intergrading.&nbsp; He claims that we can no longer assume that
pit
<br>> viper venom is lacking in neurotoxins and high in hemotoxins.&nbsp;
If true
<br>> that would certainly put a different light on this.&nbsp; (It might
also
<br>> explain a case we discussed at some length with no resolution years
<br>> ago on rec.backcountry.&nbsp; Bill Johnson, who had been involved
in SAR in
<br>> New Mexico, knew of a case near Roswell in which a child was bitten
by
<br>> a rattler.&nbsp; That was a long way from the range of the Mojave
or other
<br>> rattler known for neurotoxins.&nbsp;&nbsp; The ER doc found no evidence
of
<br>> envenomation and sent the child home.&nbsp; Systemic reaction set
in and
<br>> the child died.&nbsp; Of course due to patient privacy we could not
find
<br>> any definitive information so it was left a mystery.&nbsp; Like all
such
<br>> stories it may even have not been true but Bill was rather confident
<br>> that the main points were correct.)
<br>>
<br>> How about this:&nbsp; If a patient is bitten by a pit viper and shows
signs
<br>> of hemotoxin (edema etc.) do not use the wrap.&nbsp; If there is
a chance
<br>> of envenomation but no signs of hemotoxin, assume that either there
<br>> was no envenomation (no real harm from the wrap) or the venom was
high
<br>> in neurotoxin.&nbsp; In this case and wrap it till you reach the
hospital?
<br>>
<br>> (Of course, even better is don't cause the snake to bite you in the
<br>> first place.&nbsp; However some of us might be in a position to treat
<br>> someone not so informed and who did get bitten.)
<br>>
<br>>
<p>--Keith Conover, M.D., FACEP
<br>&nbsp; <a href="http://www.pitt.edu/~kconover">http://www.pitt.edu/~kconover</a>
<br>&nbsp; sent with Pegasus high-security email
<br>&nbsp; download free from www.pmail.com
<p>Do not reproduce without author's express permission.
<br>To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine"
<br>as the body of a message (no subject) To: Majordomo@list.pitt.edu
<br>Submissions To: wilderness-emergency-medicine@list.pitt.edu</blockquote>
</html>

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Date: Fri, 19 Apr 2002 22:00:00 -0400
From: "Keith Conover, M.D., FACEP" <kconover+@pitt.edu>
Subject: Re: W-EMED Re: : rattle snake bites
In-reply-to: <20020420000028.41BD91B014@mail.mxim.com>
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References: "Your message of Fri, 19 Apr 2002 19:29:53 EDT."
 <3CC07031.13250.15983B1@localhost>

The systemic toxicity of pit vipers is generally low, except in 
children (big dose to size ratio) and those with medical problems.  
There are solid recommendations against compression in pit viper 
bites, based on years of experience with them.  I would not use a 
single unreported case, not subjected to peer review, as an argument 
to switch to a treatment that we have good reason to think can 
definitely cause local damage, and can lead to lifelong problems 
(repeated skin grafts, loss of function, or even amputation).

I would suggest that, when trying to decide on issues like this, 
where incomplete information is available, that those with _clinical_ 
experience treating patients in general, as well knowledge of the 
literature and basic science of snakebite, would be the best people 
to believe.  In other words, physicians.  And I think most 
physicians, even those who are aware of and even agree with some of 
Grenard's concerns about increasing neurotoxicity, would agree.  It's 
a question of risk-benefit analysis with incomplete information.

Certainly, there are cases of delayed toxicity documented at least up 
to 6-8 hours, and such a period of observation should always occur.  
And, if someone develops problems from a neurotoxin in the urban or 
near-urban setting, intubation and respiratory support, sedation if 
needed, and basic supportive care will almost always get someone 
through it.  

On 19 Apr 2002 at 17:00, Hal Lillywhite wrote:

> In message <3CC07031.13250.15983B1@localhost>, "Keith Conover, M.D.,
> FACEP" wri tes: >There is a way to resolve this, at least in my mind.
> 
> >If the type of snake venom is known to primarily toxic to local
> >tissue, and the systemic toxicity is low, compression techniques are
> >more likely to worsen local tissue damage than prevent systemic
> >toxicity.
> 
> I would agree except that the "if" may cover a multitude of sins.
> 
> >If on the other hand, the main problem is systemic toxicity rather
> >than local tissue damage, then the compression techniques make sense.
> 
> >Luckily, all native poisonous snakes in North America are pretty much
> > local-tissue-toxin types, except for a few like the coral snake that
> > don't pack much of a systemic wallop anyway.  Which means the
> >compression technique doesn't make sense in the backcountry, unless
> >you routinely backpack with your pet Russell's Viper.  Only exception
> > would be multiple envenomated bites to a limb, especially to someone
> > already in bad shape...
> 
> Steve Grenard claims to have evidence that North American rattlesnake
> venom has undergone some changes in the last few decades, probably due
> to intergrading.  He claims that we can no longer assume that pit
> viper venom is lacking in neurotoxins and high in hemotoxins.  If true
> that would certainly put a different light on this.  (It might also
> explain a case we discussed at some length with no resolution years
> ago on rec.backcountry.  Bill Johnson, who had been involved in SAR in
> New Mexico, knew of a case near Roswell in which a child was bitten by
> a rattler.  That was a long way from the range of the Mojave or other
> rattler known for neurotoxins.   The ER doc found no evidence of
> envenomation and sent the child home.  Systemic reaction set in and
> the child died.  Of course due to patient privacy we could not find
> any definitive information so it was left a mystery.  Like all such
> stories it may even have not been true but Bill was rather confident
> that the main points were correct.)
> 
> How about this:  If a patient is bitten by a pit viper and shows signs
> of hemotoxin (edema etc.) do not use the wrap.  If there is a chance
> of envenomation but no signs of hemotoxin, assume that either there
> was no envenomation (no real harm from the wrap) or the venom was high
> in neurotoxin.  In this case and wrap it till you reach the hospital?
> 
> (Of course, even better is don't cause the snake to bite you in the
> first place.  However some of us might be in a position to treat
> someone not so informed and who did get bitten.)
> 
> 


--Keith Conover, M.D., FACEP
  http://www.pitt.edu/~kconover
  sent with Pegasus high-security email
  download free from www.pmail.com

Do not reproduce without author's express permission.
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Subject: Re: W-EMED Re: : rattle snake bites
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Date: Fri, 19 Apr 2002 21:59:57 -0400

The systemic toxicity of pit vipers is generally low, except in 
children (big dose to size ratio) and those with medical problems.  
There are solid recommendations against compression in pit viper 
bites, based on years of experience with them.  I would not use a 
single unreported case, not subjected to peer review, as an argument 
to switch to a treatment that we have good reason to think can 
definitely cause local damage, and can lead to lifelong problems 
(repeated skin grafts, loss of function, or even amputation).

I would suggest that, when trying to decide on issues like this, 
where incomplete information is available, that those with _clinical_ 
experience treating patients in general, as well knowledge of the 
literature and basic science of snakebite, would be the best people 
to believe.  In other words, physicians.  And I think most 
physicians, even those who are aware of and even agree with some of 
Grenard's concerns about increasing neurotoxicity, would agree.  It's 
a question of risk-benefit analysis with incomplete information.

Certainly, there are cases of delayed toxicity documented at least up 
to 6-8 hours, and such a period of observation should always occur.  
And, if someone develops problems from a neurotoxin in the urban or 
near-urban setting, intubation and respiratory support, sedation if 
needed, and basic supportive care will almost always get someone 
through it.  

On 19 Apr 2002 at 17:00, Hal Lillywhite wrote:

> In message <3CC07031.13250.15983B1@localhost>, "Keith Conover, M.D.,
> FACEP" wri tes: >There is a way to resolve this, at least in my mind.
> 
> >If the type of snake venom is known to primarily toxic to local
> >tissue, and the systemic toxicity is low, compression techniques are
> >more likely to worsen local tissue damage than prevent systemic
> >toxicity.
> 
> I would agree except that the "if" may cover a multitude of sins.
> 
> >If on the other hand, the main problem is systemic toxicity rather
> >than local tissue damage, then the compression techniques make sense.
> 
> >Luckily, all native poisonous snakes in North America are pretty much
> > local-tissue-toxin types, except for a few like the coral snake that
> > don't pack much of a systemic wallop anyway.  Which means the
> >compression technique doesn't make sense in the backcountry, unless
> >you routinely backpack with your pet Russell's Viper.  Only exception
> > would be multiple envenomated bites to a limb, especially to someone
> > already in bad shape...
> 
> Steve Grenard claims to have evidence that North American rattlesnake
> venom has undergone some changes in the last few decades, probably due
> to intergrading.  He claims that we can no longer assume that pit
> viper venom is lacking in neurotoxins and high in hemotoxins.  If true
> that would certainly put a different light on this.  (It might also
> explain a case we discussed at some length with no resolution years
> ago on rec.backcountry.  Bill Johnson, who had been involved in SAR in
> New Mexico, knew of a case near Roswell in which a child was bitten by
> a rattler.  That was a long way from the range of the Mojave or other
> rattler known for neurotoxins.   The ER doc found no evidence of
> envenomation and sent the child home.  Systemic reaction set in and
> the child died.  Of course due to patient privacy we could not find
> any definitive information so it was left a mystery.  Like all such
> stories it may even have not been true but Bill was rather confident
> that the main points were correct.)
> 
> How about this:  If a patient is bitten by a pit viper and shows signs
> of hemotoxin (edema etc.) do not use the wrap.  If there is a chance
> of envenomation but no signs of hemotoxin, assume that either there
> was no envenomation (no real harm from the wrap) or the venom was high
> in neurotoxin.  In this case and wrap it till you reach the hospital?
> 
> (Of course, even better is don't cause the snake to bite you in the
> first place.  However some of us might be in a position to treat
> someone not so informed and who did get bitten.)
> 
> 



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Date: Fri, 19 Apr 2002 17:00:28 -0700
From: Hal Lillywhite <hall@smtp1.mxim.com>
Subject: Re: W-EMED Re: : rattle snake bites
In-reply-to: "Your message of Fri, 19 Apr 2002 19:29:53 EDT."
 <3CC07031.13250.15983B1@localhost>
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In message <3CC07031.13250.15983B1@localhost>, "Keith Conover, M.D., =
FACEP" wri
tes:
>There is a way to resolve this, at least in my mind.

>If the type of snake venom is known to primarily toxic to local=20
>tissue, and the systemic toxicity is low, compression techniques are=
=20
>more likely to worsen local tissue damage than prevent systemic=20
>toxicity.

I would agree except that the "if" may cover a multitude of sins.

>If on the other hand, the main problem is systemic toxicity rather=
=20
>than local tissue damage, then the compression techniques make sense=
.

>Luckily, all native poisonous snakes in North America are pretty muc=
h=20
>local-tissue-toxin types, except for a few like the coral snake that=
=20
>don't pack much of a systemic wallop anyway.  Which means the=20
>compression technique doesn't make sense in the backcountry, unless=
=20
>you routinely backpack with your pet Russell's Viper.  Only exceptio=
n=20
>would be multiple envenomated bites to a limb, especially to someone=
=20
>already in bad shape...

Steve Grenard claims to have evidence that North American rattlesnake=
 venom has undergone some changes in the last few decades, probably d=
ue to intergrading.  He claims that we can no longer assume that pit =
viper venom is lacking in neurotoxins and high in hemotoxins.  If tru=
e that would certainly put a different light on this.  (It might also=
 explain a case we discussed at some length with no resolution years =
ago on rec.backcountry.  Bill Johnson, who had been involved in SAR i=
n New Mexico, knew of a case near Roswell in which a child was bitten=
 by a rattler.  That was a long way from the range of the Mojave or o=
ther rattler known for neurotoxins.   The ER doc found no evidence of=
 envenomation and sent the child home.  Systemic reaction set in and =
the child died.  Of course due to patient privacy we could not find a=
ny definitive information so it was left a mystery.  Like all such st=
ories it may even have not been true but Bill was rather confident th=
at the main points were correct.)

How about this:  If a patient is bitten by a pit viper and shows sign=
s of hemotoxin (edema etc.) do not use the wrap.  If there is a chanc=
e of envenomation but no signs of hemotoxin, assume that either there=
 was no envenomation (no real harm from the wrap) or the venom was hi=
gh in neurotoxin.  In this case and wrap it till you reach the hospit=
al?

(Of course, even better is don't cause the snake to bite you in the f=
irst place.  However some of us might be in a position to treat someo=
ne not so informed and who did get bitten.)



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To: Hal Lillywhite <hall@smtp1.mxim.com>, wilderness-emergency-medicine@list.pitt.edu
Subject: Re: W-EMED Re: rattle snake bites
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Date: Fri, 19 Apr 2002 19:29:33 -0400

Hal's posts on the subject were right on target.

When teaching courses I point out that "Franz Anton Mesmer [1734-
1815] tried electric shock for snakebite, and found it didn't work.  
It still doesn't."

On 19 Apr 2002 at 7:59, Hal Lillywhite wrote:

> 
> [I've tried to post several articles here on this subject but haven't
> seen any of them appear.  I suspect that our IS folks again changed
> our system so I show as posting from a different address and the list
> server no longer recognized me as a legitimate poster.  I've signed up
> again so maybe this will work.]
> 
> In message <SnYajXAIc6v8EwQq@wildmedic.org>, Jel Coward writes:
> >In article <006001c1e66a$df444640$4ab42fc8@supercable.net.ve>, Manuel
> >Sotelo <traumamsd@cantv.net> writes
> >>
> >>How about electric discharges?
> >
> >Last year I had a look around for an evidence base for acute
> >treatment of snake bite.  I could find no evidence for the use of
> >electrical devices.  I did find  a huge amount of ignorance
> >however...
> 
> Par for the course.  I can't think of a subject related to this group
> likely to generate more nonsense than snake bite.
> 
> Here is a quote from the rec.backcountry Snake Bite FAQ:
> 
>    Electrical shock
> 
>    Don't use it. Electrical shock was tried experimentally for a time,
>    and several portable devices were developed. These still turn up in
>    use from time to time at rattlesnake roundups and the like. No
>    research data ever emerged that supported the use of electric
>    shock. (There was, however, an Ignobel Prize awarded to a victim
>    who insisted on this treatment.  This prize is given by the the
>    Annals of Improbable Research and, as the name implies, is not
>    necessarily any great honor.  The ceremony is a spoof, aimed at
>    research which "cannot or should not be repeated.")
> 
> That FAQ runs to over 2,000 lines so I'm not going to post the whole
> thing here (unless I get a lot of requests and Keith personally
> approves).  I could email it to a few people if they request it.  By
> the way, one of the people quoted therein is Keith Connover.  That
> doesn't mean he is responsible for any errors we may have made, he is
> not.  It just means that he helped and provided valuable information. 
> Here is the summary found at the beginning of the FAQ:
> 
> SUMMARY
> 
> Poisonous snakebite is a potentially serious accident.  It can
> lead to severe pain or other problems, and in the rare instance
> even death. In some cases it can cause long term organ damage
> without death.  However in North America it is not nearly as
> dangerous as most believe. Snakes seldom bite humans and even
> when they do so, their bites are seldom fatal.  There is no
> need to allow fear of snakes to ruin your enjoyment of the
> outdoors.  However snake bite is quite serious and can have long
> term complications if not properly treated.  Anybody bitten by a
> venomous snake (or one suspected of being venomous) should seek
> treatment immediately at a hospital.  Modern antivenom can
> eliminate the long term problems and avoid the small possibility
> of death.  Better yet, don't get bitten in the first place.
> 
> Snakes will usually avoid you if you give them a chance.  Try to
> be sure they know you are coming. Don't reach into places they
> might hide. Be careful turning over rock and boards in snake
> country.  Leave snakes alone; there is no simple rule to identify
> which are poisonous.  The same advice applies to dead snakes and
> detached heads - reflex bites are as dangerous as bites from live
> snakes.
> 
> 
> At least half of all bites are caused by foolish behavior:
> handling or taunting venomous snakes, or failing to move away
> from a venomous snake once it has been sighted.  The other half
> are nearly all caused by carelessness or lack of knowledge.  As
> indicated in the data below, a few simple precautions can be
> nearly 100% effective in preventing snake bite.
> 
> If someone is bitten:
> 
> The following treatment protocol is provided by Jeff Isaac and
> Peter Goth in The Outward Bound Wilderness First Aid Handbook,
> Lyons and Burford, 1991.
> 
> "Transport the patient as quickly as possible to antivenom
> (antidote).  Although local discomfort may be severe, systemic
> signs and symptoms may be delayed for two to six hours following
> the bite. Walking your patient out is reasonably safe unless
> severe signs and symptoms occur. It is also significantly faster
> than trying a carry. Splint the affected part if possible.  While it
> is preferable to keep the patient quiet, the benefits of a quicker
> trip to the hospital usually outweigh the disadvantages of physical
> activity.
> 
> 
> Expect swelling. Remove constricting items such as rings, bracelets,
> and clothing from the bitten extremity. A relatively new device called
> the Sawyer extractor can be moderately effective in removing venom if
> applied quickly and properly.  It is worth carrying one of these, not
> because of snake bite (which is rare) but because it is also effective
> on more common problems like bee sting.
> 
> Do not delay. Immediately following the bite of a snake thought to be
> poisonous, evacuation should be started. It can always be slowed down
> or canceled if it becomes obvious that envenomation did not occur, or
> the snake is not poisonous.
> 
> Most medical experts agree that traditional field treatments such as
> tourniquets, pressure dressing, ice packs, and "cut and suck"
> snakebite kits are generally ineffective and dangerous. Poisonous
> snakebite is difficult to treat in the field.  Don't waste valuable
> time trying.
> 
> If it is going to be more than one hour to transport, you should
> consider field treatment.  This should be limited to:
> 
> If it is going to be more than one hour to transport, you should
> consider field treatment.  This should be limited to:
> 
> 1.  A quick cleansing and disinfection of the wound.
> 
> 2.  Application of the extractor if available.
> 
> 3.  Removal of rings, bracelets and other potentially constricting
> items.
> 
> The above should take a total of no more than three minutes.
> Remember the more important treatment is evacuation to definitive
> care.
> 
> (A new field treatment developed in Australia is now being tried in
> the US.  This "Australian wrap" technique is widely accepted in areas
> where elapids are common.  It is controversial here because we have a
> different type of snake.  Some authorities now recommend it while
> others recommend against it.  It may become the recommended treatment
> but at present I cannot recommend it for the average first aid
> situation in the US.)
> 
>       [End of Summary]
> 
> 
> 
> Do not reproduce without author's express permission.
> To unsubscribe, send the text "unsubscribe
> wilderness-emergency-medicine" as the body of a message (no subject)
> To: Majordomo@list.pitt.edu Submissions To:
> wilderness-emergency-medicine@list.pitt.edu



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Date: Fri, 19 Apr 2002 19:29:53 -0400
From: "Keith Conover, M.D., FACEP" <kconover+@pitt.edu>
Subject: Re: W-EMED Re: : rattle snake bites
In-reply-to: <20020419182626.101DC1B014@mail.mxim.com>
To: Hal Lillywhite <hall@smtp1.mxim.com>,
        wilderness-emergency-medicine@list.pitt.edu,
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References: "Your message of Fri, 19 Apr 2002 17:28:08 -0000."
 <F174gZe0J64TBU25JJz00000c09@hotmail.com>

There is a way to resolve this, at least in my mind.

If the type of snake venom is known to primarily toxic to local 
tissue, and the systemic toxicity is low, compression techniques are 
more likely to worsen local tissue damage than prevent systemic 
toxicity.

If on the other hand, the main problem is systemic toxicity rather 
than local tissue damage, then the compression techniques make sense.

Luckily, all native poisonous snakes in North America are pretty much 
local-tissue-toxin types, except for a few like the coral snake that 
don't pack much of a systemic wallop anyway.  Which means the 
compression technique doesn't make sense in the backcountry, unless 
you routinely backpack with your pet Russell's Viper.  Only exception 
would be multiple envenomated bites to a limb, especially to someone 
already in bad shape.

But when dealing with exotic snakes in U.S. urban areas, or in other 
areas, especially in Australia -- compression makes sense.

Hope this helps those who haven't been able to make up their own 
decisions yet.  I'd point out that Grenard is more interested in 
exotic bites whereas Findlay Russell works in Tucson where there are 
lots of native pit viper bites.  Does that help you understand their 
positions?

On 19 Apr 2002 at 11:26, Hal Lillywhite wrote:

> In message <F174gZe0J64TBU25JJz00000c09@hotmail.com>, "Jonathan
> Silver" writes: >Hi Chris, >Thanks for the reference. I'll check it
> out. There are more knowledgeable= >=20 >people on this list than I so
> if I=92m wrong here, please someone jump in= > and=20 >correct me. I
> have always been under the impression that we apply cold=20
> >compresses to strains, sprains, etc. to reduce circulation to the
> injury = >in=20 >order to reduce swelling and inflammation. 
> 
> I don't think it is that simple.  Speaking as a current sufferer of
> tendonitis, I believe part of the reason for ice packs is to
> *increase* blood flow while decreasing the flow of other fluids.  I
> believe what happens is that the blood system is driven by that engine
> called the heart and controlled by various body systems.  The body
> reacts to localized cooling by sending extra blood to the affected
> part.  Meanwhile, other fluid actions probably are indeed slowed,
> including the movement of fluid outside the blood vessels.  I'm not an
> expert on this so am subject to correction by someone who knows more. 
> I can assure you that when I ice my tendonitis the area turns red,
> indicating enhanced blood flow there.  Of course when a person is
> suffering from hemotoxin from a snake bite, the swelling is induced by
> the chemical happenings, not by physicial trauma such as one would
> have from twisted ankle.  Perhaps that makes a difference.
> 
> Here is the quote from the rec.backcountry FAQ on cold treatment:
> 
>    Ice or Cold Packs
> 
>    Don't use them. Here is what James Wilkerson says in Medicine for
>    Mountaineering (3rd Ed):
> 
>    "Packing an extremity bitten by a poisonous snake in ice or snow
>    probably would not be possible in most wilderness situations
>    because snakes do not inhabit areas where ice and snow are
>    available. However, such therapy for poisonous snake bite has been
>    recommended in the past. The basis of such therapy was the
>    assumption that the active components of snake venom were enzymes,
>    the activity of which would be reduced by cooling. However,
>    subsequent studies have determined that most of the toxins in snake
>    venom are peptides, which are not inactivated by cooling. 
>    Additionally, since snakes are cold blooded animals, their enzymes
>    remain active at temperatures at which a warm blooded human's
>    defenses are immobilized.  Furthermore, some enzymes are driven
>    deeper into warmer tissues by cooling the skin.
> 
>    Few physicians advocate local cold therapy; even fewer would deny
>    that its use outside the hospital as a technique for emergency care
>    has caused the loss of many limbs."
> 
>    Cold causes increased local tissue destruction when applied to
>    North American pit viper bites.  See the following references:
> 
>    Sullivan JB Jr, Wingert WA.  Reptile Bites.  in Auerbach PS, Geehr
>    EC, Ed Management of wilderness and environmental emergencies.  2nd
>    ed.  St.  Louis:  C.V.  Mosby Co., 1989:479-511.
> 
>    Gill KA Jr.  The evaluation of cryotherapy in the treatment of
>    snake envenomation.  So Med J 1968;63:552-6.
> 
>    Durand LS, Rodeheaver GT, Edlich RF.  Poisoning by pit vipers. W Va
>    Med J 1982;78(7):162-7.
> 
> While I'm at it, I might as well throw in the section about
> compression wraps.  Be aware that the FAQ was last updated in 1997 so
> some of this may have changed with advancing knowledge:
> 
>    Compression Wraps
> 
>    Compression wraps, or the Australian wrap was developed to treat
>    the bites of the really potent elapids down under.  Steve Grenard
>    quotes some remarkable information on how effective it can be. 
>    Grenard in fact is pushing its use for all snake bites.  However
>    the technique is still controversial for U.S. snake bites.  At this
>    time we cannot recommend this treatment in the U.S., at least for
>    use by the first aider.  I expect this will change in a few years
>    but that is the situation at present as I see it.  Findlay Russel
>    is opposing its use and has even offered to testify in court in
>    favor of the plaintiff should anybody sue as a result of having a
>    limb damaged by this treatment.  Grenard takes the opposing view. 
>    The prime points of contention are:
> 
>    1.  There is no doubt that this technique is likely to worsen
>    damage to a limb by confining poison to that area.  In extreme
>    cases all or part of the limb might be lost to the local damage
>    caused by hemotoxin.
> 
>    2.  There is also no doubt that compression wraps will reduce the
>    likelihood of systemic and organ damage caused by toxins escaping
>    the region of the bite and reaching heart, kidneys etc.
> 
>    So, which risk do you take?  To whom do you listen?  Unfortunately
>    our legal system is probably not going to recognize the fact that
>    there are risks either way.  If you use this technique at present
>    you can be accused of going beyond your level of training, not a
>    good thing in court.  In addition I think it is still possible for
>    future discoveries to show currently unknown adverse consequences
>    of this treatment on pit viper bites.  Therefore I am forced,
>    somewhat reluctantely, to recommend against its use on pit viper
>    bites in the U.S. at present.
> 
> Do not reproduce without author's express permission.
> To unsubscribe, send the text "unsubscribe
> wilderness-emergency-medicine" as the body of a message (no subject)
> To: Majordomo@list.pitt.edu Submissions To:
> wilderness-emergency-medicine@list.pitt.edu


--Keith Conover, M.D., FACEP
  http://www.pitt.edu/~kconover
  sent with Pegasus high-security email
  download free from www.pmail.com


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Date: Fri, 19 Apr 2002 19:29:53 -0400
From: "Keith Conover, M.D., FACEP" <kconover+@pitt.edu>
Subject: Re: W-EMED Re: : rattle snake bites
In-reply-to: <20020419182626.101DC1B014@mail.mxim.com>
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References: "Your message of Fri, 19 Apr 2002 17:28:08 -0000."
 <F174gZe0J64TBU25JJz00000c09@hotmail.com>

There is a way to resolve this, at least in my mind.

If the type of snake venom is known to primarily toxic to local 
tissue, and the systemic toxicity is low, compression techniques are 
more likely to worsen local tissue damage than prevent systemic 
toxicity.

If on the other hand, the main problem is systemic toxicity rather 
than local tissue damage, then the compression techniques make sense.

Luckily, all native poisonous snakes in North America are pretty much 
local-tissue-toxin types, except for a few like the coral snake that 
don't pack much of a systemic wallop anyway.  Which means the 
compression technique doesn't make sense in the backcountry, unless 
you routinely backpack with your pet Russell's Viper.  Only exception 
would be multiple envenomated bites to a limb, especially to someone 
already in bad shape.

But when dealing with exotic snakes in U.S. urban areas, or in other 
areas, especially in Australia -- compression makes sense.

Hope this helps those who haven't been able to make up their own 
decisions yet.  I'd point out that Grenard is more interested in 
exotic bites whereas Findlay Russell works in Tucson where there are 
lots of native pit viper bites.  Does that help you understand their 
positions?

On 19 Apr 2002 at 11:26, Hal Lillywhite wrote:

> In message <F174gZe0J64TBU25JJz00000c09@hotmail.com>, "Jonathan
> Silver" writes: >Hi Chris, >Thanks for the reference. I'll check it
> out. There are more knowledgeable= >=20 >people on this list than I so
> if I=92m wrong here, please someone jump in= > and=20 >correct me. I
> have always been under the impression that we apply cold=20
> >compresses to strains, sprains, etc. to reduce circulation to the
> injury = >in=20 >order to reduce swelling and inflammation. 
> 
> I don't think it is that simple.  Speaking as a current sufferer of
> tendonitis, I believe part of the reason for ice packs is to
> *increase* blood flow while decreasing the flow of other fluids.  I
> believe what happens is that the blood system is driven by that engine
> called the heart and controlled by various body systems.  The body
> reacts to localized cooling by sending extra blood to the affected
> part.  Meanwhile, other fluid actions probably are indeed slowed,
> including the movement of fluid outside the blood vessels.  I'm not an
> expert on this so am subject to correction by someone who knows more. 
> I can assure you that when I ice my tendonitis the area turns red,
> indicating enhanced blood flow there.  Of course when a person is
> suffering from hemotoxin from a snake bite, the swelling is induced by
> the chemical happenings, not by physicial trauma such as one would
> have from twisted ankle.  Perhaps that makes a difference.
> 
> Here is the quote from the rec.backcountry FAQ on cold treatment:
> 
>    Ice or Cold Packs
> 
>    Don't use them. Here is what James Wilkerson says in Medicine for
>    Mountaineering (3rd Ed):
> 
>    "Packing an extremity bitten by a poisonous snake in ice or snow
>    probably would not be possible in most wilderness situations
>    because snakes do not inhabit areas where ice and snow are
>    available. However, such therapy for poisonous snake bite has been
>    recommended in the past. The basis of such therapy was the
>    assumption that the active components of snake venom were enzymes,
>    the activity of which would be reduced by cooling. However,
>    subsequent studies have determined that most of the toxins in snake
>    venom are peptides, which are not inactivated by cooling. 
>    Additionally, since snakes are cold blooded animals, their enzymes
>    remain active at temperatures at which a warm blooded human's
>    defenses are immobilized.  Furthermore, some enzymes are driven
>    deeper into warmer tissues by cooling the skin.
> 
>    Few physicians advocate local cold therapy; even fewer would deny
>    that its use outside the hospital as a technique for emergency care
>    has caused the loss of many limbs."
> 
>    Cold causes increased local tissue destruction when applied to
>    North American pit viper bites.  See the following references:
> 
>    Sullivan JB Jr, Wingert WA.  Reptile Bites.  in Auerbach PS, Geehr
>    EC, Ed Management of wilderness and environmental emergencies.  2nd
>    ed.  St.  Louis:  C.V.  Mosby Co., 1989:479-511.
> 
>    Gill KA Jr.  The evaluation of cryotherapy in the treatment of
>    snake envenomation.  So Med J 1968;63:552-6.
> 
>    Durand LS, Rodeheaver GT, Edlich RF.  Poisoning by pit vipers. W Va
>    Med J 1982;78(7):162-7.
> 
> While I'm at it, I might as well throw in the section about
> compression wraps.  Be aware that the FAQ was last updated in 1997 so
> some of this may have changed with advancing knowledge:
> 
>    Compression Wraps
> 
>    Compression wraps, or the Australian wrap was developed to treat
>    the bites of the really potent elapids down under.  Steve Grenard
>    quotes some remarkable information on how effective it can be. 
>    Grenard in fact is pushing its use for all snake bites.  However
>    the technique is still controversial for U.S. snake bites.  At this
>    time we cannot recommend this treatment in the U.S., at least for
>    use by the first aider.  I expect this will change in a few years
>    but that is the situation at present as I see it.  Findlay Russel
>    is opposing its use and has even offered to testify in court in
>    favor of the plaintiff should anybody sue as a result of having a
>    limb damaged by this treatment.  Grenard takes the opposing view. 
>    The prime points of contention are:
> 
>    1.  There is no doubt that this technique is likely to worsen
>    damage to a limb by confining poison to that area.  In extreme
>    cases all or part of the limb might be lost to the local damage
>    caused by hemotoxin.
> 
>    2.  There is also no doubt that compression wraps will reduce the
>    likelihood of systemic and organ damage caused by toxins escaping
>    the region of the bite and reaching heart, kidneys etc.
> 
>    So, which risk do you take?  To whom do you listen?  Unfortunately
>    our legal system is probably not going to recognize the fact that
>    there are risks either way.  If you use this technique at present
>    you can be accused of going beyond your level of training, not a
>    good thing in court.  In addition I think it is still possible for
>    future discoveries to show currently unknown adverse consequences
>    of this treatment on pit viper bites.  Therefore I am forced,
>    somewhat reluctantely, to recommend against its use on pit viper
>    bites in the U.S. at present.
> 
> Do not reproduce without author's express permission.
> To unsubscribe, send the text "unsubscribe
> wilderness-emergency-medicine" as the body of a message (no subject)
> To: Majordomo@list.pitt.edu Submissions To:
> wilderness-emergency-medicine@list.pitt.edu


--Keith Conover, M.D., FACEP
  http://www.pitt.edu/~kconover
  sent with Pegasus high-security email
  download free from www.pmail.com

Do not reproduce without author's express permission.
To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine"
as the body of a message (no subject) To: Majordomo@list.pitt.edu
Submissions To: wilderness-emergency-medicine@list.pitt.edu

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Date: Fri, 19 Apr 2002 19:29:53 -0400
From: "Keith Conover, M.D., FACEP" <kconover+@pitt.edu>
Subject: Re: W-EMED Re: rattle snake bites
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References: "Your message of Thu, 18 Apr 2002 22:11:36 PDT."
 <SnYajXAIc6v8EwQq@wildmedic.org>

Hal's posts on the subject were right on target.

When teaching courses I point out that "Franz Anton Mesmer [1734-
1815] tried electric shock for snakebite, and found it didn't work.  
It still doesn't."

On 19 Apr 2002 at 7:59, Hal Lillywhite wrote:

> 
> [I've tried to post several articles here on this subject but haven't
> seen any of them appear.  I suspect that our IS folks again changed
> our system so I show as posting from a different address and the list
> server no longer recognized me as a legitimate poster.  I've signed up
> again so maybe this will work.]
> 
> In message <SnYajXAIc6v8EwQq@wildmedic.org>, Jel Coward writes:
> >In article <006001c1e66a$df444640$4ab42fc8@supercable.net.ve>, Manuel
> >Sotelo <traumamsd@cantv.net> writes
> >>
> >>How about electric discharges?
> >
> >Last year I had a look around for an evidence base for acute
> >treatment of snake bite.  I could find no evidence for the use of
> >electrical devices.  I did find  a huge amount of ignorance
> >however...
> 
> Par for the course.  I can't think of a subject related to this group
> likely to generate more nonsense than snake bite.
> 
> Here is a quote from the rec.backcountry Snake Bite FAQ:
> 
>    Electrical shock
> 
>    Don't use it. Electrical shock was tried experimentally for a time,
>    and several portable devices were developed. These still turn up in
>    use from time to time at rattlesnake roundups and the like. No
>    research data ever emerged that supported the use of electric
>    shock. (There was, however, an Ignobel Prize awarded to a victim
>    who insisted on this treatment.  This prize is given by the the
>    Annals of Improbable Research and, as the name implies, is not
>    necessarily any great honor.  The ceremony is a spoof, aimed at
>    research which "cannot or should not be repeated.")
> 
> That FAQ runs to over 2,000 lines so I'm not going to post the whole
> thing here (unless I get a lot of requests and Keith personally
> approves).  I could email it to a few people if they request it.  By
> the way, one of the people quoted therein is Keith Connover.  That
> doesn't mean he is responsible for any errors we may have made, he is
> not.  It just means that he helped and provided valuable information. 
> Here is the summary found at the beginning of the FAQ:
> 
> SUMMARY
> 
> Poisonous snakebite is a potentially serious accident.  It can
> lead to severe pain or other problems, and in the rare instance
> even death. In some cases it can cause long term organ damage
> without death.  However in North America it is not nearly as
> dangerous as most believe. Snakes seldom bite humans and even
> when they do so, their bites are seldom fatal.  There is no
> need to allow fear of snakes to ruin your enjoyment of the
> outdoors.  However snake bite is quite serious and can have long
> term complications if not properly treated.  Anybody bitten by a
> venomous snake (or one suspected of being venomous) should seek
> treatment immediately at a hospital.  Modern antivenom can
> eliminate the long term problems and avoid the small possibility
> of death.  Better yet, don't get bitten in the first place.
> 
> Snakes will usually avoid you if you give them a chance.  Try to
> be sure they know you are coming. Don't reach into places they
> might hide. Be careful turning over rock and boards in snake
> country.  Leave snakes alone; there is no simple rule to identify
> which are poisonous.  The same advice applies to dead snakes and
> detached heads - reflex bites are as dangerous as bites from live
> snakes.
> 
> 
> At least half of all bites are caused by foolish behavior:
> handling or taunting venomous snakes, or failing to move away
> from a venomous snake once it has been sighted.  The other half
> are nearly all caused by carelessness or lack of knowledge.  As
> indicated in the data below, a few simple precautions can be
> nearly 100% effective in preventing snake bite.
> 
> If someone is bitten:
> 
> The following treatment protocol is provided by Jeff Isaac and
> Peter Goth in The Outward Bound Wilderness First Aid Handbook,
> Lyons and Burford, 1991.
> 
> "Transport the patient as quickly as possible to antivenom
> (antidote).  Although local discomfort may be severe, systemic
> signs and symptoms may be delayed for two to six hours following
> the bite. Walking your patient out is reasonably safe unless
> severe signs and symptoms occur. It is also significantly faster
> than trying a carry. Splint the affected part if possible.  While it
> is preferable to keep the patient quiet, the benefits of a quicker
> trip to the hospital usually outweigh the disadvantages of physical
> activity.
> 
> 
> Expect swelling. Remove constricting items such as rings, bracelets,
> and clothing from the bitten extremity. A relatively new device called
> the Sawyer extractor can be moderately effective in removing venom if
> applied quickly and properly.  It is worth carrying one of these, not
> because of snake bite (which is rare) but because it is also effective
> on more common problems like bee sting.
> 
> Do not delay. Immediately following the bite of a snake thought to be
> poisonous, evacuation should be started. It can always be slowed down
> or canceled if it becomes obvious that envenomation did not occur, or
> the snake is not poisonous.
> 
> Most medical experts agree that traditional field treatments such as
> tourniquets, pressure dressing, ice packs, and "cut and suck"
> snakebite kits are generally ineffective and dangerous. Poisonous
> snakebite is difficult to treat in the field.  Don't waste valuable
> time trying.
> 
> If it is going to be more than one hour to transport, you should
> consider field treatment.  This should be limited to:
> 
> If it is going to be more than one hour to transport, you should
> consider field treatment.  This should be limited to:
> 
> 1.  A quick cleansing and disinfection of the wound.
> 
> 2.  Application of the extractor if available.
> 
> 3.  Removal of rings, bracelets and other potentially constricting
> items.
> 
> The above should take a total of no more than three minutes.
> Remember the more important treatment is evacuation to definitive
> care.
> 
> (A new field treatment developed in Australia is now being tried in
> the US.  This "Australian wrap" technique is widely accepted in areas
> where elapids are common.  It is controversial here because we have a
> different type of snake.  Some authorities now recommend it while
> others recommend against it.  It may become the recommended treatment
> but at present I cannot recommend it for the average first aid
> situation in the US.)
> 
>       [End of Summary]
> 
> 
> 
> Do not reproduce without author's express permission.
> To unsubscribe, send the text "unsubscribe
> wilderness-emergency-medicine" as the body of a message (no subject)
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--Keith Conover, M.D., FACEP
  http://www.pitt.edu/~kconover
  sent with Pegasus high-security email
  download free from www.pmail.com

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To: Hal Lillywhite <hall@smtp1.mxim.com>, wilderness-emergency-medicine@list.pitt.edu,
 owner-wilderness-emergency-medicine@list.pitt.edu
Subject: Re: W-EMED Re: : rattle snake bites
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Date: Fri, 19 Apr 2002 19:21:30 -0400

There is a way to resolve this, at least in my mind.

If the type of snake venom is known to primarily toxic to local 
tissue, and the systemic toxicity is low, compression techniques are 
more likely to worsen local tissue damage than prevent systemic 
toxicity.

If on the other hand, the main problem is systemic toxicity rather 
than local tissue damage, then the compression techniques make sense.

Luckily, all native poisonous snakes in North America are pretty much 
local-tissue-toxin types, except for a few like the coral snake that 
don't pack much of a systemic wallop anyway.  Which means the 
compression technique doesn't make sense in the backcountry, unless 
you routinely backpack with your pet Russell's Viper.  Only exception 
would be multiple envenomated bites to a limb, especially to someone 
already in bad shape.

But when dealing with exotic snakes in U.S. urban areas, or in other 
areas, especially in Australia -- compression makes sense.

Hope this helps those who haven't been able to make up their own 
decisions yet.  I'd point out that Grenard is more interested in 
exotic bites whereas Findlay Russell works in Tucson where there are 
lots of native pit viper bites.  Does that help you understand their 
positions?

On 19 Apr 2002 at 11:26, Hal Lillywhite wrote:

> In message <F174gZe0J64TBU25JJz00000c09@hotmail.com>, "Jonathan
> Silver" writes: >Hi Chris, >Thanks for the reference. I'll check it
> out. There are more knowledgeable= >=20 >people on this list than I so
> if I=92m wrong here, please someone jump in= > and=20 >correct me. I
> have always been under the impression that we apply cold=20
> >compresses to strains, sprains, etc. to reduce circulation to the
> injury = >in=20 >order to reduce swelling and inflammation. 
> 
> I don't think it is that simple.  Speaking as a current sufferer of
> tendonitis, I believe part of the reason for ice packs is to
> *increase* blood flow while decreasing the flow of other fluids.  I
> believe what happens is that the blood system is driven by that engine
> called the heart and controlled by various body systems.  The body
> reacts to localized cooling by sending extra blood to the affected
> part.  Meanwhile, other fluid actions probably are indeed slowed,
> including the movement of fluid outside the blood vessels.  I'm not an
> expert on this so am subject to correction by someone who knows more. 
> I can assure you that when I ice my tendonitis the area turns red,
> indicating enhanced blood flow there.  Of course when a person is
> suffering from hemotoxin from a snake bite, the swelling is induced by
> the chemical happenings, not by physicial trauma such as one would
> have from twisted ankle.  Perhaps that makes a difference.
> 
> Here is the quote from the rec.backcountry FAQ on cold treatment:
> 
>    Ice or Cold Packs
> 
>    Don't use them. Here is what James Wilkerson says in Medicine for
>    Mountaineering (3rd Ed):
> 
>    "Packing an extremity bitten by a poisonous snake in ice or snow
>    probably would not be possible in most wilderness situations
>    because snakes do not inhabit areas where ice and snow are
>    available. However, such therapy for poisonous snake bite has been
>    recommended in the past. The basis of such therapy was the
>    assumption that the active components of snake venom were enzymes,
>    the activity of which would be reduced by cooling. However,
>    subsequent studies have determined that most of the toxins in snake
>    venom are peptides, which are not inactivated by cooling. 
>    Additionally, since snakes are cold blooded animals, their enzymes
>    remain active at temperatures at which a warm blooded human's
>    defenses are immobilized.  Furthermore, some enzymes are driven
>    deeper into warmer tissues by cooling the skin.
> 
>    Few physicians advocate local cold therapy; even fewer would deny
>    that its use outside the hospital as a technique for emergency care
>    has caused the loss of many limbs."
> 
>    Cold causes increased local tissue destruction when applied to
>    North American pit viper bites.  See the following references:
> 
>    Sullivan JB Jr, Wingert WA.  Reptile Bites.  in Auerbach PS, Geehr
>    EC, Ed Management of wilderness and environmental emergencies.  2nd
>    ed.  St.  Louis:  C.V.  Mosby Co., 1989:479-511.
> 
>    Gill KA Jr.  The evaluation of cryotherapy in the treatment of
>    snake envenomation.  So Med J 1968;63:552-6.
> 
>    Durand LS, Rodeheaver GT, Edlich RF.  Poisoning by pit vipers. W Va
>    Med J 1982;78(7):162-7.
> 
> While I'm at it, I might as well throw in the section about
> compression wraps.  Be aware that the FAQ was last updated in 1997 so
> some of this may have changed with advancing knowledge:
> 
>    Compression Wraps
> 
>    Compression wraps, or the Australian wrap was developed to treat
>    the bites of the really potent elapids down under.  Steve Grenard
>    quotes some remarkable information on how effective it can be. 
>    Grenard in fact is pushing its use for all snake bites.  However
>    the technique is still controversial for U.S. snake bites.  At this
>    time we cannot recommend this treatment in the U.S., at least for
>    use by the first aider.  I expect this will change in a few years
>    but that is the situation at present as I see it.  Findlay Russel
>    is opposing its use and has even offered to testify in court in
>    favor of the plaintiff should anybody sue as a result of having a
>    limb damaged by this treatment.  Grenard takes the opposing view. 
>    The prime points of contention are:
> 
>    1.  There is no doubt that this technique is likely to worsen
>    damage to a limb by confining poison to that area.  In extreme
>    cases all or part of the limb might be lost to the local damage
>    caused by hemotoxin.
> 
>    2.  There is also no doubt that compression wraps will reduce the
>    likelihood of systemic and organ damage caused by toxins escaping
>    the region of the bite and reaching heart, kidneys etc.
> 
>    So, which risk do you take?  To whom do you listen?  Unfortunately
>    our legal system is probably not going to recognize the fact that
>    there are risks either way.  If you use this technique at present
>    you can be accused of going beyond your level of training, not a
>    good thing in court.  In addition I think it is still possible for
>    future discoveries to show currently unknown adverse consequences
>    of this treatment on pit viper bites.  Therefore I am forced,
>    somewhat reluctantely, to recommend against its use on pit viper
>    bites in the U.S. at present.
> 
> Do not reproduce without author's express permission.
> To unsubscribe, send the text "unsubscribe
> wilderness-emergency-medicine" as the body of a message (no subject)
> To: Majordomo@list.pitt.edu Submissions To:
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Date: Fri, 19 Apr 2002 11:11:02 -0800
From: Bobbie Foster <bobbie@fostercalm.com>
Subject: Re: W-EMED Re: : rattle snake bites
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here are my two cents on this topic

according to Robert Norris at Stanford University 
avoid any method of cooling -- may compound the problem by driving certain venon components deeper into tissue and cause further ischemia.

Robert Norris is speaking at a Wilderness Medical Society conference at the University of California, San Francisco on April 27th -- on snake bites if any one is interested and in the area -- Eric Weiss is also presenting. You can call 415-476-0417 for more details about conference. This conference is for lay people - and ceu's are available for emt's, paramedics and nurses.

-- Stay Safe and Calm,

Bobbie Foster Calm
15135 Lake Lane
Nevada City, CA 95959

530-265-0997 - phone and fax
bobbie@fostercalm.com 
On Friday, April 19, 2002 7:35 AM, Jonathan Silver <jsilveramc@hotmail.com> wrote:
>I can understand why we shouldn't freeze the bite site. We shouldn't do this >for a sprained ankle either yet we apply cold to reduce the swelling. So let >me re-phrase original question:
>
>Will using a cold compress on the bite site cause harm and if not will it >reduce swelling? If it will, isn't this a good thing?
>
>Thanks,
>Jonathan Silver
>
>
>>From: JRD203@aol.com
>>Reply-To: wilderness-emergency-medicine@list.pitt.edu
>>To: wilderness-emergency-medicine@list.pitt.edu
>>Subject: W-EMED Re: : rattle snake bites
>>Date: Wed, 17 Apr 2002 14:29:51 EDT
>>
>>In a message dated 4/17/02 1:30:41 PM Eastern Daylight Time,
>>jsilveramc@hotmail.com writes:
>>
>><< While we're on the subject... Does anyone know why we are advised *not* >>to
>>  ice pit-viper bites?
>>   >>
>>I only found one website
>>(http://www.baptisthospital.com/www/er/index.cfm?fuseaction=snake) which
>>stated that it was because ice does not deactivate the venom, and poses the
>>threat of frostbite. I do recall seeing a photo in a book many years ago of
>>an individual who had been bitten on the foot by a rattlesnake and stuck >>the
>>foot, for several hours, into a bucket of ice. The foot was so badly >>damaged
>>and blackened by the time he removed it that it had to be amputated.
>>
>>Elyse Dickenson
>>Do not reproduce without author's express permission.
>>To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine"
>>as the body of a message (no subject) To: Majordomo@list.pitt.edu
>>Submissions To: wilderness-emergency-medicine@list.pitt.edu
>
>
>_________________________________________________________________
>MSN Photos is the easiest way to share and print your photos: >http://photos.msn.com/support/worldwide.aspx
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-- Stay Safe and Calm,

Bobbie Foster Calm
15135 Lake Lane
Nevada City, CA 95959

530-265-0997 - phone and fax
530-478-1909 - new home -- you can use and leave a message if i don't answer.
bobbie@fostercalm.com


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Date: Fri, 19 Apr 2002 11:26:25 -0700
From: Hal Lillywhite <hall@smtp1.mxim.com>
Subject: Re: W-EMED Re: : rattle snake bites
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In message <F174gZe0J64TBU25JJz00000c09@hotmail.com>, "Jonathan Silver" writes:
>Hi Chris,
>Thanks for the reference. I'll check it out. There are more knowledgeable=
>=20
>people on this list than I so if I=92m wrong here, please someone jump in=
> and=20
>correct me. I have always been under the impression that we apply cold=20
>compresses to strains, sprains, etc. to reduce circulation to the injury =
>in=20
>order to reduce swelling and inflammation. 

I don't think it is that simple.  Speaking as a current sufferer of tendonitis, I believe part of the reason for ice packs is to *increase* blood flow while decreasing the flow of other fluids.  I believe what happens is that the blood system is driven by that engine called the heart and controlled by various body systems.  The body reacts to localized cooling by sending extra blood to the affected part.  Meanwhile, other fluid actions probably are indeed slowed, including the movement of fluid outside the blood vessels.  I'm not an expert on this so am subject to correction by someone who knows more.  I can assure you that when I ice my tendonitis the area turns red, indicating enhanced blood flow there.  Of course when a person is suffering from hemotoxin from a snake bite, the swelling is induced by the chemical happenings, not by physicial trauma such as one would have from twisted ankle.  Perhaps that makes a difference.

Here is the quote from the rec.backcountry FAQ on cold treatment:

   Ice or Cold Packs

   Don't use them. Here is what James Wilkerson says in Medicine for
   Mountaineering (3rd Ed):

   "Packing an extremity bitten by a poisonous snake in ice or snow
   probably would not be possible in most wilderness situations because
   snakes do not inhabit areas where ice and snow are available.
   However, such therapy for poisonous snake bite has been recommended
   in the past. The basis of such therapy was the assumption that the
   active components of snake venom were enzymes, the activity of which
   would be reduced by cooling. However, subsequent studies have
   determined that most of the toxins in snake venom are peptides,
   which are not inactivated by cooling.  Additionally, since snakes
   are cold blooded animals, their enzymes remain active at
   temperatures at which a warm blooded human's defenses are
   immobilized.  Furthermore, some enzymes are driven deeper into
   warmer tissues by cooling the skin.

   Few physicians advocate local cold therapy; even fewer would deny
   that its use outside the hospital as a technique for emergency care
   has caused the loss of many limbs."

   Cold causes increased local tissue destruction when applied to
   North American pit viper bites.  See the following references:

   Sullivan JB Jr, Wingert WA.  Reptile Bites.  in Auerbach PS, Geehr
   EC, Ed Management of wilderness and environmental emergencies.  2nd
   ed.  St.  Louis:  C.V.  Mosby Co., 1989:479-511.

   Gill KA Jr.  The evaluation of cryotherapy in the treatment of snake
   envenomation.  So Med J 1968;63:552-6.

   Durand LS, Rodeheaver GT, Edlich RF.  Poisoning by pit vipers.
   W Va Med J 1982;78(7):162-7.

While I'm at it, I might as well throw in the section about compression wraps.  Be aware that the FAQ was last updated in 1997 so some of this may have changed with advancing knowledge:

   Compression Wraps

   Compression wraps, or the Australian wrap was developed to treat the
   bites of the really potent elapids down under.  Steve Grenard quotes
   some remarkable information on how effective it can be.  Grenard in
   fact is pushing its use for all snake bites.  However the technique
   is still controversial for U.S. snake bites.  At this time we cannot
   recommend this treatment in the U.S., at least for use by the first
   aider.  I expect this will change in a few years but that is the
   situation at present as I see it.  Findlay Russel is opposing its
   use and has even offered to testify in court in favor of the
   plaintiff should anybody sue as a result of having a limb damaged by
   this treatment.  Grenard takes the opposing view.  The prime points
   of contention are:

   1.  There is no doubt that this technique is likely to worsen damage
   to a limb by confining poison to that area.  In extreme cases all or
   part of the limb might be lost to the local damage caused by
   hemotoxin.

   2.  There is also no doubt that compression wraps will reduce the
   likelihood of systemic and organ damage caused by toxins escaping
   the region of the bite and reaching heart, kidneys etc.

   So, which risk do you take?  To whom do you listen?  Unfortunately
   our legal system is probably not going to recognize the fact that
   there are risks either way.  If you use this technique at present
   you can be accused of going beyond your level of training, not a
   good thing in court.  In addition I think it is still possible for
   future discoveries to show currently unknown adverse consequences
   of this treatment on pit viper bites.  Therefore I am forced,
   somewhat reluctantely, to recommend against its use on pit viper
   bites in the U.S. at present.

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Date: Fri, 19 Apr 2002 17:28:08 +0000
From: Jonathan Silver <jsilveramc@hotmail.com>
Subject: RE: W-EMED Re: : rattle snake bites
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Hi Chris,
Thanks for the reference. I'll check it out. There are more knowledgeable 
people on this list than I so if I’m wrong here, please someone jump in and 
correct me. I have always been under the impression that we apply cold 
compresses to strains, sprains, etc. to reduce circulation to the injury in 
order to reduce swelling and inflammation. This is a good thing because 
swelling can painful all by itself. We remove the cold application 
intermittently because the cold application can cause discomfort or, if we 
are using ice packs, cause tissue damage. For the first 24 to 48 hours we 
continue with cold compresses to reduce the swelling and inflammation. After 
that we apply heat to the area to promote circulation and help the healing.

In my readings through various books, they all say, “don’t ice snake bites.” 
I haven’t found any reason why it’s contraindicated, just don’t do it. It 
strikes me as counterintuitive since cooling helps keep swelling down. Can 
someone enlighten me?

Thanks,
Jonathan SIlver


>From: "Pike, Chris" <chris.pike@attws.com>
>Reply-To: wilderness-emergency-medicine@list.pitt.edu
>To: "'wilderness-emergency-medicine@list.pitt.edu'"  
><wilderness-emergency-medicine@list.pitt.edu>
>Subject: RE: W-EMED Re: : rattle snake bites
>Date: Fri, 19 Apr 2002 09:32:22 -0700
>
>I think the reason one would ice an ankle would be to promote circulation 
>by
>contracting (ice is applied) and expanding (ice is removed).  You wouldn't
>want to promote circulation with a snake bite, so you would have to keep 
>the
>ice applied, which would be a risk of frostbite.
>"Medicine for Mountaineering" has a great chapter on snake bite.  
>Basically,
>they say get your rear to the car as quick as possible.  If it is an
>extended trip to the car, immobilize the bite site as much as possible with
>a splint and a light compress (ace bandage or the like), put the person in
>the supine position if possible (bite site same level as head) and go.
>The book also mentions multiple scenarios for a more intense medical
>treatment for snake bite if immediate and quick evacuation is not possible.
>good book.
>
>-----Original Message-----
>From: Jonathan Silver [mailto:jsilveramc@hotmail.com]
>Sent: Friday, April 19, 2002 8:35 AM
>To: wilderness-emergency-medicine@list.pitt.edu
>Subject: Re: W-EMED Re: : rattle snake bites
>
>
>I can understand why we shouldn't freeze the bite site. We shouldn't do 
>this
>
>for a sprained ankle either yet we apply cold to reduce the swelling. So 
>let
>
>me re-phrase original question:
>
>Will using a cold compress on the bite site cause harm and if not will it
>reduce swelling? If it will, isn't this a good thing?
>
>Thanks,
>Jonathan Silver
>
>
> >From: JRD203@aol.com
> >Reply-To: wilderness-emergency-medicine@list.pitt.edu
> >To: wilderness-emergency-medicine@list.pitt.edu
> >Subject: W-EMED Re: : rattle snake bites
> >Date: Wed, 17 Apr 2002 14:29:51 EDT
> >
> >In a message dated 4/17/02 1:30:41 PM Eastern Daylight Time,
> >jsilveramc@hotmail.com writes:
> >
> ><< While we're on the subject... Does anyone know why we are advised 
>*not*
> >to
> >  ice pit-viper bites?
> >   >>
> >I only found one website
> >(http://www.baptisthospital.com/www/er/index.cfm?fuseaction=snake) which
> >stated that it was because ice does not deactivate the venom, and poses 
>the
> >threat of frostbite. I do recall seeing a photo in a book many years ago 
>of
> >an individual who had been bitten on the foot by a rattlesnake and stuck
> >the
> >foot, for several hours, into a bucket of ice. The foot was so badly
> >damaged
> >and blackened by the time he removed it that it had to be amputated.
> >
> >Elyse Dickenson
> >Do not reproduce without author's express permission.
> >To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine"
> >as the body of a message (no subject) To: Majordomo@list.pitt.edu
> >Submissions To: wilderness-emergency-medicine@list.pitt.edu
>
>
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From: "Pike, Chris" <chris.pike@attws.com>
Subject: RE: W-EMED Re: : rattle snake bites
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I think the reason one would ice an ankle would be to promote circulation by
contracting (ice is applied) and expanding (ice is removed).  You wouldn't
want to promote circulation with a snake bite, so you would have to keep the
ice applied, which would be a risk of frostbite.
"Medicine for Mountaineering" has a great chapter on snake bite.  Basically,
they say get your rear to the car as quick as possible.  If it is an
extended trip to the car, immobilize the bite site as much as possible with
a splint and a light compress (ace bandage or the like), put the person in
the supine position if possible (bite site same level as head) and go.
The book also mentions multiple scenarios for a more intense medical
treatment for snake bite if immediate and quick evacuation is not possible.
good book. 

-----Original Message-----
From: Jonathan Silver [mailto:jsilveramc@hotmail.com]
Sent: Friday, April 19, 2002 8:35 AM
To: wilderness-emergency-medicine@list.pitt.edu
Subject: Re: W-EMED Re: : rattle snake bites


I can understand why we shouldn't freeze the bite site. We shouldn't do this

for a sprained ankle either yet we apply cold to reduce the swelling. So let

me re-phrase original question:

Will using a cold compress on the bite site cause harm and if not will it 
reduce swelling? If it will, isn't this a good thing?

Thanks,
Jonathan Silver


>From: JRD203@aol.com
>Reply-To: wilderness-emergency-medicine@list.pitt.edu
>To: wilderness-emergency-medicine@list.pitt.edu
>Subject: W-EMED Re: : rattle snake bites
>Date: Wed, 17 Apr 2002 14:29:51 EDT
>
>In a message dated 4/17/02 1:30:41 PM Eastern Daylight Time,
>jsilveramc@hotmail.com writes:
>
><< While we're on the subject... Does anyone know why we are advised *not* 
>to
>  ice pit-viper bites?
>   >>
>I only found one website
>(http://www.baptisthospital.com/www/er/index.cfm?fuseaction=snake) which
>stated that it was because ice does not deactivate the venom, and poses the
>threat of frostbite. I do recall seeing a photo in a book many years ago of
>an individual who had been bitten on the foot by a rattlesnake and stuck 
>the
>foot, for several hours, into a bucket of ice. The foot was so badly 
>damaged
>and blackened by the time he removed it that it had to be amputated.
>
>Elyse Dickenson
>Do not reproduce without author's express permission.
>To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine"
>as the body of a message (no subject) To: Majordomo@list.pitt.edu
>Submissions To: wilderness-emergency-medicine@list.pitt.edu


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Date: Fri, 19 Apr 2002 10:42:34 -0500
From: Ed <enicholas@tlsinc.com>
Subject: RE: W-EMED Re: rattle snake bites
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I think the best, most succinct comment I have ever heard on snakebite
treatment to use in the field is a set of car keys.......:) What is the
current thinking about applying an Ace bandage (snug, not super tight) for
an extremity bite  during transport if the times are going to be extended,
say over an hour? And has there been any more information about seeing a
neurotoxic component in hemotoxic (rattlers,etc) venom, causing higher
antivenin usage and increased respiratory complications.I have heard some
preliminary information-anyone on the list seen this firsthand ?

Thanks - Good discussion

Ed Nicholas, EMT
Operations Officer
HEMSI High Angle-Rough Terrain (HART) Team
Search Coordinator
HEMSI Search Dog Unit
Huntsville, Alabama
Day: 256-533-7025
Home:256-859-5550
Pager:256-720-2295
Email:eknsar@hiwaay.net (Home)
Email:enicholas@tlsinc.com (Work)
 


-----Original Message-----
From: Hal Lillywhite [mailto:hall@smtp1.mxim.com]
Sent: Friday, April 19, 2002 10:00 AM
To: wilderness-emergency-medicine@list.pitt.edu
Cc: hall@mxim.com
Subject: Re: W-EMED Re: rattle snake bites 



[I've tried to post several articles here on this subject but haven't seen
any 
of them appear.  I suspect that our IS folks again changed our system so I 
show as posting from a different address and the list server no longer 
recognized me as a legitimate poster.  I've signed up again so maybe this
will 
work.]

In message <SnYajXAIc6v8EwQq@wildmedic.org>, Jel Coward writes:
>In article <006001c1e66a$df444640$4ab42fc8@supercable.net.ve>, Manuel
>Sotelo <traumamsd@cantv.net> writes
>>
>>How about electric discharges?
>
>Last year I had a look around for an evidence base for acute treatment
>of snake bite.  I could find no evidence for the use of electrical
>devices.  I did find  a huge amount of ignorance however...

Par for the course.  I can't think of a subject related to this group likely
to generate more nonsense than snake bite.

Here is a quote from the rec.backcountry Snake Bite FAQ:

   Electrical shock

   Don't use it. Electrical shock was tried experimentally for a time,
   and several portable devices were developed. These still turn up in
   use from time to time at rattlesnake roundups and the like. No
   research data ever emerged that supported the use of electric shock.
   (There was, however, an Ignobel Prize awarded to a victim who
   insisted on this treatment.  This prize is given by the the Annals
   of Improbable Research and, as the name implies, is not necessarily
   any great honor.  The ceremony is a spoof, aimed at research which
   "cannot or should not be repeated.")

That FAQ runs to over 2,000 lines so I'm not going to post the whole thing
here (unless I get a lot of requests and Keith personally approves).  I
could email it to a few people if they request it.  By the way, one of the
people quoted therein is Keith Connover.  That doesn't mean he is
responsible for any errors we may have made, he is not.  It just means that
he helped and provided valuable information.  Here is the summary found at
the beginning of the FAQ:

SUMMARY

Poisonous snakebite is a potentially serious accident.  It can
lead to severe pain or other problems, and in the rare instance
even death. In some cases it can cause long term organ damage
without death.  However in North America it is not nearly as
dangerous as most believe. Snakes seldom bite humans and even
when they do so, their bites are seldom fatal.  There is no
need to allow fear of snakes to ruin your enjoyment of the
outdoors.  However snake bite is quite serious and can have long
term complications if not properly treated.  Anybody bitten by a
venomous snake (or one suspected of being venomous) should seek
treatment immediately at a hospital.  Modern antivenom can
eliminate the long term problems and avoid the small possibility
of death.  Better yet, don't get bitten in the first place.

Snakes will usually avoid you if you give them a chance.  Try to
be sure they know you are coming. Don't reach into places they
might hide. Be careful turning over rock and boards in snake
country.  Leave snakes alone; there is no simple rule to identify
which are poisonous.  The same advice applies to dead snakes and
detached heads - reflex bites are as dangerous as bites from live
snakes.


At least half of all bites are caused by foolish behavior:
handling or taunting venomous snakes, or failing to move away
from a venomous snake once it has been sighted.  The other half
are nearly all caused by carelessness or lack of knowledge.  As
indicated in the data below, a few simple precautions can be
nearly 100% effective in preventing snake bite.

If someone is bitten:

The following treatment protocol is provided by Jeff Isaac and
Peter Goth in The Outward Bound Wilderness First Aid Handbook,
Lyons and Burford, 1991.

"Transport the patient as quickly as possible to antivenom
(antidote).  Although local discomfort may be severe, systemic
signs and symptoms may be delayed for two to six hours following
the bite. Walking your patient out is reasonably safe unless
severe signs and symptoms occur. It is also significantly faster
than trying a carry. Splint the affected part if possible.  While it
is preferable to keep the patient quiet, the benefits of a quicker
trip to the hospital usually outweigh the disadvantages of physical
activity.


Expect swelling. Remove constricting items such as rings, bracelets,
and clothing from the bitten extremity. A relatively new device
called the Sawyer extractor can be moderately effective in removing
venom if applied quickly and properly.  It is worth carrying one of
these, not because of snake bite (which is rare) but because it is
also effective on more common problems like bee sting.

Do not delay. Immediately following the bite of a snake thought to
be poisonous, evacuation should be started. It can always be slowed
down or canceled if it becomes obvious that envenomation did not
occur, or the snake is not poisonous.

Most medical experts agree that traditional field treatments such
as tourniquets, pressure dressing, ice packs, and "cut and suck"
snakebite kits are generally ineffective and dangerous. Poisonous
snakebite is difficult to treat in the field.  Don't waste valuable
time trying.

If it is going to be more than one hour to transport, you should
consider field treatment.  This should be limited to:

If it is going to be more than one hour to transport, you should
consider field treatment.  This should be limited to:

1.  A quick cleansing and disinfection of the wound.

2.  Application of the extractor if available.

3.  Removal of rings, bracelets and other potentially constricting
items.

The above should take a total of no more than three minutes.
Remember the more important treatment is evacuation to definitive
care.

(A new field treatment developed in Australia is now being tried in
the US.  This "Australian wrap" technique is widely accepted in
areas where elapids are common.  It is controversial here because we
have a different type of snake.  Some authorities now recommend it
while others recommend against it.  It may become the recommended
treatment but at present I cannot recommend it for the average first
aid situation in the US.)

      [End of Summary]



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Date: Fri, 19 Apr 2002 15:35:22 +0000
From: Jonathan Silver <jsilveramc@hotmail.com>
Subject: Re: W-EMED Re: : rattle snake bites
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 FILETIME=[D1AFDF00:01C1E7B7]

I can understand why we shouldn't freeze the bite site. We shouldn't do this 
for a sprained ankle either yet we apply cold to reduce the swelling. So let 
me re-phrase original question:

Will using a cold compress on the bite site cause harm and if not will it 
reduce swelling? If it will, isn't this a good thing?

Thanks,
Jonathan Silver


>From: JRD203@aol.com
>Reply-To: wilderness-emergency-medicine@list.pitt.edu
>To: wilderness-emergency-medicine@list.pitt.edu
>Subject: W-EMED Re: : rattle snake bites
>Date: Wed, 17 Apr 2002 14:29:51 EDT
>
>In a message dated 4/17/02 1:30:41 PM Eastern Daylight Time,
>jsilveramc@hotmail.com writes:
>
><< While we're on the subject... Does anyone know why we are advised *not* 
>to
>  ice pit-viper bites?
>   >>
>I only found one website
>(http://www.baptisthospital.com/www/er/index.cfm?fuseaction=snake) which
>stated that it was because ice does not deactivate the venom, and poses the
>threat of frostbite. I do recall seeing a photo in a book many years ago of
>an individual who had been bitten on the foot by a rattlesnake and stuck 
>the
>foot, for several hours, into a bucket of ice. The foot was so badly 
>damaged
>and blackened by the time he removed it that it had to be amputated.
>
>Elyse Dickenson
>Do not reproduce without author's express permission.
>To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine"
>as the body of a message (no subject) To: Majordomo@list.pitt.edu
>Submissions To: wilderness-emergency-medicine@list.pitt.edu


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Date: Fri, 19 Apr 2002 07:59:58 -0700
From: Hal Lillywhite <hall@smtp1.mxim.com>
Subject: Re: W-EMED Re: rattle snake bites
In-reply-to: "Your message of Thu, 18 Apr 2002 22:11:36 PDT."
 <SnYajXAIc6v8EwQq@wildmedic.org>
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[I've tried to post several articles here on this subject but haven't seen any 
of them appear.  I suspect that our IS folks again changed our system so I 
show as posting from a different address and the list server no longer 
recognized me as a legitimate poster.  I've signed up again so maybe this will 
work.]

In message <SnYajXAIc6v8EwQq@wildmedic.org>, Jel Coward writes:
>In article <006001c1e66a$df444640$4ab42fc8@supercable.net.ve>, Manuel
>Sotelo <traumamsd@cantv.net> writes
>>
>>How about electric discharges?
>
>Last year I had a look around for an evidence base for acute treatment
>of snake bite.  I could find no evidence for the use of electrical
>devices.  I did find  a huge amount of ignorance however...

Par for the course.  I can't think of a subject related to this group likely to generate more nonsense than snake bite.

Here is a quote from the rec.backcountry Snake Bite FAQ:

   Electrical shock

   Don't use it. Electrical shock was tried experimentally for a time,
   and several portable devices were developed. These still turn up in
   use from time to time at rattlesnake roundups and the like. No
   research data ever emerged that supported the use of electric shock.
   (There was, however, an Ignobel Prize awarded to a victim who
   insisted on this treatment.  This prize is given by the the Annals
   of Improbable Research and, as the name implies, is not necessarily
   any great honor.  The ceremony is a spoof, aimed at research which
   "cannot or should not be repeated.")

That FAQ runs to over 2,000 lines so I'm not going to post the whole thing here (unless I get a lot of requests and Keith personally approves).  I could email it to a few people if they request it.  By the way, one of the people quoted therein is Keith Connover.  That doesn't mean he is responsible for any errors we may have made, he is not.  It just means that he helped and provided valuable information.  Here is the summary found at the beginning of the FAQ:

SUMMARY

Poisonous snakebite is a potentially serious accident.  It can
lead to severe pain or other problems, and in the rare instance
even death. In some cases it can cause long term organ damage
without death.  However in North America it is not nearly as
dangerous as most believe. Snakes seldom bite humans and even
when they do so, their bites are seldom fatal.  There is no
need to allow fear of snakes to ruin your enjoyment of the
outdoors.  However snake bite is quite serious and can have long
term complications if not properly treated.  Anybody bitten by a
venomous snake (or one suspected of being venomous) should seek
treatment immediately at a hospital.  Modern antivenom can
eliminate the long term problems and avoid the small possibility
of death.  Better yet, don't get bitten in the first place.

Snakes will usually avoid you if you give them a chance.  Try to
be sure they know you are coming. Don't reach into places they
might hide. Be careful turning over rock and boards in snake
country.  Leave snakes alone; there is no simple rule to identify
which are poisonous.  The same advice applies to dead snakes and
detached heads - reflex bites are as dangerous as bites from live
snakes.


At least half of all bites are caused by foolish behavior:
handling or taunting venomous snakes, or failing to move away
from a venomous snake once it has been sighted.  The other half
are nearly all caused by carelessness or lack of knowledge.  As
indicated in the data below, a few simple precautions can be
nearly 100% effective in preventing snake bite.

If someone is bitten:

The following treatment protocol is provided by Jeff Isaac and
Peter Goth in The Outward Bound Wilderness First Aid Handbook,
Lyons and Burford, 1991.

"Transport the patient as quickly as possible to antivenom
(antidote).  Although local discomfort may be severe, systemic
signs and symptoms may be delayed for two to six hours following
the bite. Walking your patient out is reasonably safe unless
severe signs and symptoms occur. It is also significantly faster
than trying a carry. Splint the affected part if possible.  While it
is preferable to keep the patient quiet, the benefits of a quicker
trip to the hospital usually outweigh the disadvantages of physical
activity.


Expect swelling. Remove constricting items such as rings, bracelets,
and clothing from the bitten extremity. A relatively new device
called the Sawyer extractor can be moderately effective in removing
venom if applied quickly and properly.  It is worth carrying one of
these, not because of snake bite (which is rare) but because it is
also effective on more common problems like bee sting.

Do not delay. Immediately following the bite of a snake thought to
be poisonous, evacuation should be started. It can always be slowed
down or canceled if it becomes obvious that envenomation did not
occur, or the snake is not poisonous.

Most medical experts agree that traditional field treatments such
as tourniquets, pressure dressing, ice packs, and "cut and suck"
snakebite kits are generally ineffective and dangerous. Poisonous
snakebite is difficult to treat in the field.  Don't waste valuable
time trying.

If it is going to be more than one hour to transport, you should
consider field treatment.  This should be limited to:

If it is going to be more than one hour to transport, you should
consider field treatment.  This should be limited to:

1.  A quick cleansing and disinfection of the wound.

2.  Application of the extractor if available.

3.  Removal of rings, bracelets and other potentially constricting
items.

The above should take a total of no more than three minutes.
Remember the more important treatment is evacuation to definitive
care.

(A new field treatment developed in Australia is now being tried in
the US.  This "Australian wrap" technique is widely accepted in
areas where elapids are common.  It is controversial here because we
have a different type of snake.  Some authorities now recommend it
while others recommend against it.  It may become the recommended
treatment but at present I cannot recommend it for the average first
aid situation in the US.)

      [End of Summary]



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Date: Thu, 18 Apr 2002 22:11:36 -0700
From: Jel Coward <jel@wildmedic.org>
Subject: Re: W-EMED Re: rattle snake bites
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 <006001c1e66a$df444640$4ab42fc8@supercable.net.ve>

In article <006001c1e66a$df444640$4ab42fc8@supercable.net.ve>, Manuel
Sotelo <traumamsd@cantv.net> writes
>
>How about electric discharges?

Last year I had a look around for an evidence base for acute treatment
of snake bite.  I could find no evidence for the use of electrical
devices.  I did find  a huge amount of ignorance however - including a
response from a site that IIRC was a rattlesnake farm/centre where it
was clear that they did not have a clue about what might or might not
work (they seemed to like the electrical thing)

Cheers
-- 
Jel Coward

http://www.wildmedic.org
http://www.wemsi.org

jel@wildmedic.org

'There's no such thing as bad weather - just bad  clothing"
                                                Anon Norwegian
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Date: Wed, 17 Apr 2002 19:38:35 -0400
From: Manuel Sotelo <traumamsd@cantv.net>
Subject: W-EMED Re: rattle snake bites
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<< While we're on the subject... Does anyone know why we are advised *not*
to
 ice pit-viper bites?
  >>
How about electric discharges?
Regards

Manuel Sotelo

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Date: Wed, 17 Apr 2002 14:29:51 -0400 (EDT)
From: JRD203@aol.com
Subject: W-EMED Re: : rattle snake bites
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In a message dated 4/17/02 1:30:41 PM Eastern Daylight Time, 
jsilveramc@hotmail.com writes:

<< While we're on the subject... Does anyone know why we are advised *not* to 
 ice pit-viper bites?
  >>
I only found one website 
(http://www.baptisthospital.com/www/er/index.cfm?fuseaction=snake) which 
stated that it was because ice does not deactivate the venom, and poses the 
threat of frostbite. I do recall seeing a photo in a book many years ago of 
an individual who had been bitten on the foot by a rattlesnake and stuck the 
foot, for several hours, into a bucket of ice. The foot was so badly damaged 
and blackened by the time he removed it that it had to be amputated.

Elyse Dickenson
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Date: Wed, 17 Apr 2002 17:23:12 +0000
From: Jonathan Silver <jsilveramc@hotmail.com>
Subject: W-EMED Re: rattle snake bites (was:  forwarded bounced message: ...)
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 FILETIME=[8DAF2C40:01C1E634]

While we're on the subject... Does anyone know why we are advised *not* to 
ice pit-viper bites?

Thanks,
Jonathan Silver


>From: wjgrimes <wjgrimes@u.arizona.edu>
>Reply-To: wilderness-emergency-medicine@list.pitt.edu
>To: wilderness-emergency-medicine@list.pitt.edu
>CC: dknapp@calpoly.edu
>Subject: Re: W-EMED forwarded bounced message: nonmember submission about 
>Sawyer Extractor
>Date: Wed, 17 Apr 2002 10:19:47 -0600
>
>>Just a little more information on rattle-snakes. Living in Arizona,
>>we have encounters with them with pretty high frequency. I get
>>rattled at least three times a month. The best example of the lack
>>of danger may be that in about 25 years of mountain rescue work in
>>the Tucson area, there was one rescue caused by a rattle snake. A
>>man was climbing down a cliff and stopped by a ledge where he
>>suddenly noticed a rattle snake next to him. He panicked and jumped
>>about 25 feet to the ground and broke his leg. The snake never
>>touched him.
>
>
>Most of our encounters are like the individual who wrote in. You walk
>along, hopefully alert and watching, and you either see the snake, or
>the snake starts rattling. They are trying to tell you that they are
>there and they don't want to get hurt. It is extremely rare for
>someone to get bitten.
>
>Our poison control people sometimes say that rattle snakes are very
>bright. They are conscious of race, age, whether someone is right or
>left handed, and they like alcohol. The evidence for this is that
>nearly half the bite victims are white males between the ages of
>18-30 who are bitten on the right hand unless they are left handed.
>And the majority have been drinking.
>
>On the rare occasions when someone is bitten, the advice is to get to
>a medical center as fast as possible. The Sawyer kits or cut and suck
>does remove some poison, but this should never delay getting to a
>medical center. The problem with cutting is that there is a chance
>you may do more harm.
>
>In our morning paper, a six year old girl sat on a rock in a local
>canyon yesterday, and was bitten on the foot by a large diamondback
>(>5 ft). She was rushed to our trauma section, and is doing fine. One
>of my colleagues was bitten last year when he cleaned out an
>irrigation box near his house (he reached in without looking). The
>physician told him that there were two bad things that were happening
>to him. First, he got bitten, and second, they were going to treat
>him for it. Between the two, the treatment was far worse. He got the
>Wyeth formula, full of horse proteins and causing him to suffer a
>week of hives and misery after the bite swelling was long gone. Now,
>this is all changing, but that has created another problem. A group
>at our University headed by Findley Russell, developed a new vaccine
>called Crofab. I believe that the technology involves immunizing
>goats, and purifying the immunoglobulin fraction from the goat. The
>partially pure antibody is cut, leaving the part that binds to venom
>proteins, but removing the part that causes inflammation. This
>promises to be a big improvement. However, right now the old Wyeth
>formulation is not being produced very fast, probably due to the loss
>of the market to the new method, and as was published recently on
>this newslist, the freeze-dry method for producing Crofab had a
>set-back and is in short supply. The word here is don't plan on being
>bitten until after June.
>
>
>Finally, I once read a nice book on Grizzly bears by Doug Peacock. He
>said that walking in wilderness requires the bears. They make you
>listen, see, smell, and generally raise your alertness to the "right"
>level. We feel that our rattle-snakes do the same.
>
>
>
>
>
>--
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>Just a little more information on rattle-snakes. Living in Arizona, 
>we have encounters with them with pretty high frequency. I get 
>rattled at least three times a month. The best example of the lack 
>of danger may be that in about 25 years of mountain rescue work in 
>the Tucson area, there was one rescue caused by a rattle snake. A 
>man was climbing down a cliff and stopped by a ledge where he 
>suddenly noticed a rattle snake next to him. He panicked and jumped 
>about 25 feet to the ground and broke his leg. The snake never 
>touched him.


Most of our encounters are like the individual who wrote in. You walk 
along, hopefully alert and watching, and you either see the snake, or 
the snake starts rattling. They are trying to tell you that they are 
there and they don't want to get hurt. It is extremely rare for 
someone to get bitten.

Our poison control people sometimes say that rattle snakes are very 
bright. They are conscious of race, age, whether someone is right or 
left handed, and they like alcohol. The evidence for this is that 
nearly half the bite victims are white males between the ages of 
18-30 who are bitten on the right hand unless they are left handed. 
And the majority have been drinking.

On the rare occasions when someone is bitten, the advice is to get to 
a medical center as fast as possible. The Sawyer kits or cut and suck 
does remove some poison, but this should never delay getting to a 
medical center. The problem with cutting is that there is a chance 
you may do more harm.

In our morning paper, a six year old girl sat on a rock in a local 
canyon yesterday, and was bitten on the foot by a large diamondback 
(>5 ft). She was rushed to our trauma section, and is doing fine. One 
of my colleagues was bitten last year when he cleaned out an 
irrigation box near his house (he reached in without looking). The 
physician told him that there were two bad things that were happening 
to him. First, he got bitten, and second, they were going to treat 
him for it. Between the two, the treatment was far worse. He got the 
Wyeth formula, full of horse proteins and causing him to suffer a 
week of hives and misery after the bite swelling was long gone. Now, 
this is all changing, but that has created another problem. A group 
at our University headed by Findley Russell, developed a new vaccine 
called Crofab. I believe that the technology involves immunizing 
goats, and purifying the immunoglobulin fraction from the goat. The 
partially pure antibody is cut, leaving the part that binds to venom 
proteins, but removing the part that causes inflammation. This 
promises to be a big improvement. However, right now the old Wyeth 
formulation is not being produced very fast, probably due to the loss 
of the market to the new method, and as was published recently on 
this newslist, the freeze-dry method for producing Crofab had a 
set-back and is in short supply. The word here is don't plan on being 
bitten until after June.


Finally, I once read a nice book on Grizzly bears by Doug Peacock. He 
said that walking in wilderness requires the bears. They make you 
listen, see, smell, and generally raise your alertness to the "right" 
level. We feel that our rattle-snakes do the same.





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Date: Tue, 16 Apr 2002 16:57:16 -0700
From: "John Richards, MD" <jrrichards@ucdavis.edu>
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Dear Fellow Emergency Physician,

We are conducting a short web-based survey on Droperidol (Inapsine) use in
the ED since the FDA warning of 12/2001. It takes less than 5 minutes to
complete.

We would truly appreciate your participation, and no personal or internet
information (i.e. cookies, IP addresses) will be collected. If you have
already received this email and have taken the survey we thank you.

Sincerely,

John Richards, MD
Assistant Professor
Division of Emergency Medicine
U.C. Davis Medical Center
Sacramento, CA 95817
(916) 734-1537

Click the following link to take the survey:

http://emergency.ucdmc.ucdavis.edu/sweiss/nedocs/


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 Sawyer Extractor
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David

If this device provides you piece of mind than by all means carry it. The
majority of fear bites from rattlesnakes are non venomous bites and those
that are rarely cause death (simple terms vipers-hem-toxin) body mass and
amount of venom are of importance in the laboratory . In the field respect
and appropriate behavior are the most important factors, as you described
the snake warned you and your son and you gave him room to make his escape,
no harm, no foul. Knowing your in snake country and adjusting your behavior
to the threat is all the battle. The only right choice is the one that
provides you with the amount of security you need to continue to trek in
that enviorment.


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Subject: Re: W-EMED forwarded bounced message: nonmember submission about
 Sawyer Extractor
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David

I hike in rattlesnake country with my children in delayed evacuation
situations.  I carry a Sawyer extractor.  I don't believe it's a miracle
cure, but it's light, simple, won't delay an evacuation and likely will do no
harm (there has been some evidence of adverse effects from concentrating the
venom locally, but I'll take that risk).  If one of my children is bitten by
a rattlesnake I will want to know I did everything possible.

Tod
Lander, Wyoming

Keith Conover, M.D., FACEP wrote:

> > All, apologies in advance if this is an inappropriate forum for this
> > question.....
> >
> > My son (who is 5 years old, 40 lbs) and I were hiking in the Pinnacles
> > National Monument in Central California, when we happened upon a
> > medium sized rattlesnake.  He was about 4 feet away when alerted us to
> > his presence by rattling at us. He then slithered into the grass, and
> > we calmly gave him as much clearance as was possible.
> >
> > It occurred to me that if for whatever reason my son had been bitten,
> > we were 3 miles from our car and about 45 minutes by car to the
> > nearest hospital.  Therefore, it seemed at least possible that he
> > could have died if bitten.
> >
> > I have since purchased a sawyer extractor kit, and put it in my pack -
> > in the hopes that this will not only provide peace of mind, but some
> > actual benefit should either he or I get bitten by a snake (or other
> > creature).
> >
> > So my questions are: is this a reasonable precaution or is the sawyer
> > kit just another 8oz to carry? What is the current protocol for
> > treating a snakebite in the wilderness? And, are there any other
> > precautions that we should be taking - Gaiters are not a viable option
> > - as it can reach 110 degrees - although we typically wouldn't hike
> > over 95 degrees...
> >
> > tia
> >
> > dbk
> >
> >
> > A sense of humor keen enough to show a man his own absurdities as well
> > as those of other people will keep a man from the commission of all
> > sins, or nearly all, save those that are worth committing. Samuel
> > Butler
> >
> > David Knapp
> > Network Analyst, CSA
> > Cal Poly State University, SLO
> > dknapp@calpoly.edu
> >
> > ---
> > Outgoing mail is certified Virus Free.
> > Checked by AVG anti-virus system (http://www.grisoft.com).
> > Version: 6.0.344 / Virus Database: 191 - Release Date: 4/2/2002
> >
> >
>
> --Keith Conover, M.D., FACEP
>   http://www.pitt.edu/~kconover
>   sent with Pegasus high-security email
>   download free from www.pmail.com
>
> Do not reproduce without author's express permission.
> To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine"
> as the body of a message (no subject) To: Majordomo@list.pitt.edu
> Submissions To: wilderness-emergency-medicine@list.pitt.edu



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From: "Keith Conover, M.D., FACEP" <kconover+@pitt.edu>
Subject: W-EMED forwarded bounced message: nonmember submission about Sawyer
 Extractor
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> All, apologies in advance if this is an inappropriate forum for this
> question.....
> 
> My son (who is 5 years old, 40 lbs) and I were hiking in the Pinnacles
> National Monument in Central California, when we happened upon a
> medium sized rattlesnake.  He was about 4 feet away when alerted us to
> his presence by rattling at us. He then slithered into the grass, and
> we calmly gave him as much clearance as was possible.  
> 
> It occurred to me that if for whatever reason my son had been bitten,
> we were 3 miles from our car and about 45 minutes by car to the
> nearest hospital.  Therefore, it seemed at least possible that he
> could have died if bitten.
> 
> I have since purchased a sawyer extractor kit, and put it in my pack -
> in the hopes that this will not only provide peace of mind, but some
> actual benefit should either he or I get bitten by a snake (or other
> creature).
> 
> So my questions are: is this a reasonable precaution or is the sawyer
> kit just another 8oz to carry? What is the current protocol for
> treating a snakebite in the wilderness? And, are there any other
> precautions that we should be taking - Gaiters are not a viable option
> - as it can reach 110 degrees - although we typically wouldn't hike
> over 95 degrees...
> 
> tia
> 
> dbk
> 
> 
> A sense of humor keen enough to show a man his own absurdities as well
> as those of other people will keep a man from the commission of all
> sins, or nearly all, save those that are worth committing. Samuel
> Butler
> 
> David Knapp
> Network Analyst, CSA
> Cal Poly State University, SLO
> dknapp@calpoly.edu
> 
> ---
> Outgoing mail is certified Virus Free.
> Checked by AVG anti-virus system (http://www.grisoft.com).
> Version: 6.0.344 / Virus Database: 191 - Release Date: 4/2/2002
> 
> 

--Keith Conover, M.D., FACEP
  http://www.pitt.edu/~kconover
  sent with Pegasus high-security email
  download free from www.pmail.com

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From: alread@alread.cix.co.uk (Alistair Read)
Subject: Re: W-EMED Blizzard Pack
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Hi all,
We have got a few Blizzard Packs are our rescue base. These are vacuum 
packed tubes that are reasonably light to pack. We have not used them 
operationally but just standing in them certainly brings about a feeing of 
warmth. They are constructed from two layers of a reflective space blanket 
with a v-shaped baffle joining the two layers together. It is slightly 
elasticated and can be made to form to the body well. The V shaped baffle 
appears to trap air.

We have been given them to trial mainly with a view to giving to the 
associates of the casualty but a few team members have taken them for use 
with school groups.

Alistair Read

OVMRO - http://www.ogwen-rescue.org.uk
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Date: Tue, 09 Apr 2002 18:45:08 +0000
From: Jonathan Silver <jsilveramc@hotmail.com>
Subject: W-EMED Blizzard Pack
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Hi all,

I just received some information on an emergency bivy bag call the Blizzard 
Pack. I'm wondering if anyone on the list has any experience with it. It 
looks like a beefed up, triple layer, mylar space blanket. Their web site 
is: www.blizzardpack.com

Any info would be appreciated.

Thanks,
Jonathan Silver
NY-No.J Appalachian Mountain Club

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From: "Keith Conover, M.D., FACEP" <kconover+@pitt.edu>
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Hello all - 
some time ago there was a question about devices for pre-hospital 
hypothermia rewarming. I knew I had seen a device tested by the 
Canadian Military. I finally managed to track down the reference - 
the research was done at the U of Manitoba under Dr Gordon 
Giesbrecht:   

Giesbrecht GG, P Pachu and X Xu (1998). Design and evaluation of a 
portable rigid forced-air warming cover for pre-hospital transport of 
cold patients. Aviat Space Environ Med. 69:1200-1203.  

I haven't found a web based reference yet. 

Scott Loree, EMT-A.  
Scott.Loree@ualberta.net
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From: Manuel Sotelo <traumamsd@cantv.net>
Subject: Re: W-EMED Hot & Cold Acclimtization
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References: <F170BRSU6UUqzhKitHe0001fa7f@hotmail.com>


Mike
Try the Gatorade Sports Science Institute http://www.gssiweb.com/
Regards
Manuel Sotelo

Hi there,
Anyone know any articles, web pages, resources, etc for information on
acclimitization to colder environments as well hot/dry environments. I know
there has been some specific research on this I just can't remember what it
is.
Thanks
Mike Webster



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A good place to start is Paul Auerbach's Wilderness Medicine (2001, 4th
edition, Mosby, 1910 pp). The references are comprehensive and fairly up to
date. 

Penny S. Reynolds, PhD			Phone: (804) 287 6892
Assistant Professor of Biology			email: preynold@richmond.edu
Department of Biology			FAX (804) 289 8233
E-312 Gottwald Science Center		http://www.richmond.edu/~preynold/
University of Richmond
Richmond VA 23173 
USA

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Date: Thu, 04 Apr 2002 15:28:26 -0500
From: Mike Webster <rescue_@hotmail.com>
Subject: W-EMED Hot & Cold Acclimtization
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<html><div style='background-color:'><DIV>
<P>Hi there,</P>
<P>Anyone know any articles, web pages, resources, etc for information on acclimitization to colder environments as well hot/dry environments. I know there has been some specific research on this I just can't remember what it is.</P>
<P>Thanks</P>
<P>Mike Webster</P></DIV></div><br clear=all><hr>MSN Photos is the easiest way to share and print your photos: <a href='http://g.msn.com/1HM501601/12'>Click Here</a><br></html>
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