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Toxicology - Pressure immobilisation

Indications

First aid for suspected bites by:

Snakes (all Australian species, including sea snakes)

Funnel web spider (not required for redback spiders)

Mouse spider

Blue ringed octopus

Cone shell

Contraindications (absolute in bold)

Immediate resuscitation required

Alternatives

Local pressure and immobilisation

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

or

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Occlusion to circulation (if applied too tightly)

Compartment syndrome (due to coagulopathy with bleeding)

Procedural hygiene

Standard precautions

PPE: non-sterile gloves

Area

Usually applied prehospital (place immediately if required)

Visible acute bay until initial assessment complete

Staff

Procedural clinician

Equipment

Elasticised bandages (10-15cm wide)

Crepe bandages if elasticised bandages are unavailable

Clothing as a substitute outside hospital (if bandages not available)

Splint or sling for affected limb if further transport required

Positioning

Supine

Immobilise the whole patient after application of bandage

Medication

Nil

Sequence (limb)

Do not wash the wound, a swab may be required later for the venom detection

Begin bandage at the distal end of affected limb, applying over existing clothing if possible

Leaving tips of toes or fingers exposed for ongoing neurovascular checks

Apply proximally with 50% overlap of bandage

The bandage should tight, and difficult to slide a finger underneath, while allowing circulation

Apply to the whole limb (toes to groin or fingers to axilla)

Splint the leg or apply a sling to the arm, restricting limb movement

Mark on the bandage the underlying bite location (for later window and venom testing)

Keep the patient and the limb completely at rest on a bed or stretcher

Sequence (non-limb)

Do not wash the wound, a swab may be required later for the venom detection

Apply local pressure where possible and immobilise the patient supine on a bed or stretcher

Avoid bandages to the face, neck or penis

Post-procedure care

Transport as soon as possible to a hospital with:

Doctors able to manage snakebite

Laboratory capable of operating at all hours

Adequate antivenom stocking for definitive treatment

Monitor patient and anticipate:

Vascular compromise of bandaged limb

Cardiac arrest

Hypotension

Respiratory failure secondary to paralysis

Seizures

Uncontrolled haemorrhage (venom-induced consumptive coagulopathy)

Remove bandage only after:

Patient fully assessed and found to show no objective evidence of envenoming, or

Antivenom administration has been completed

Tips

Avoid techniques such as tourniquets, ice, cutting, sucking of the bite site or electric shocks

Pressure bandage immobilisation may be left on for many hours while subsequent management steps are completed

Discussion

Available evidence suggests that a bandage (preferably elasticated) applied at 55mmHg to a human limb will limit drainage of lymph containing venom without compromising vascular flow. Clinically, a pressure of 55mmHg is hard to define at the bedside, we suggest the bandage should be tight and difficult to slide a finger underneath without causing avoid pain or paraesthesia.

The key part of first-aid technique for these bites is immobilisation of the patient, preventing muscle and skin movement increasing lymphatic flow. This is more important than the application of the pressure bandage and should not be overlooked.

All Australian snakebites can be managed with pressure immobilisation, outside Australia pressure bandaging is not recommend following venomous bites associated with local tissue necrosis. In these cases, localisation of toxin may worsen tissue damage.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Australian Resuscitation Council Guidelines (2015): Guideline 9.4.8 Envenomation

Murray L, Little M, Pascu O, Hoggett KA. Toxicology handbook. 3rd ed. Sydney: Elsevier Australia; 2015.

eTG complete. Melbourne: Therapeutic Guidelines; 2012 Jul (updated 2018 Jul). Toxicology: general approach. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=toxicology-general-approach

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

In: UpToDate. Waltham (MA): UpToDate. (2019): Snakebites worldwide: Management (online updated Jan 2019)

Canale E, Isbister GK, Currie BJ. Investigating pressure bandaging for snakebite in a simulated setting: bandage type, training and the effect of transport. Emerg Med Australas. 2009;21(3):184-190. doi:10.1111/j.1742-6723.2009.01180.x

Parker-Cote J, Meggs WJ. First Aid and Pre-Hospital Management of Venomous Snakebites. Trop Med Infect Dis. 2018;3(2):45. Published 2018 Apr 24. doi:10.3390/tropicalmed3020045

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