SESSION 21

DROWNING

Drowning

Drowning is the 3rd leading cause of unintentional injury death worldwide, accounting for 7% of all
injury- related deaths. There are an estimated 236, 000 annual drowning deaths worldwide. (WHO, 2019)

Global estimates may significantly underestimate the actual public health problem related to drowning.
Children, males and individuals with increased access to water are most at risk of drowning. Drowning is
the process of experiencing respiratory impairment from submersion/immersion in liquid; outcomes are
classified as death, morbidity and no morbidity. Submersion injury occurs when a person is submerged in
any liquid. After initial breath holding, the individual attempts to breathe and thus either aspirates water
(previously referred to as “wet drowning”) or has laryngospasm without aspiration (previously referred
to as “dry drowning”).

Nonfatal Drowning

Non fatal drowning is defined as survival at least 24 hours after submersion that caused a respiratory
arrest. The most common consequence is hypothermia. Drowning is the leading cause of unintentional
death in boys 5 through 14 years of age and all children younger than 4 years. An estimated 500,000
drownings occur throughout the world, and for every death, approximately 4 nonfatal drownings occur
(Szpilman, Bierens,Handley et al.2012).Drowning and nonfatal drowning can be prevented by avoiding
rip currents offshore; approximately 85% of shore drownings involve a rip current. Pool drowning can be
prevented by surrounding the pool with fencing and a self – latching /closing gate. It is estimated that
with the enforcement of these safety measures, the incidence of drowning would decrease by 50%
(Szpilman et al., 2012). Factors associated with drowning and nonfatal drowning include alcohol
ingestion, inability to swim, diving injuries, hypothermia, and exhaustion. The majority of drowning
events occur in pools, lakes, and bathtubs. Suicide by drowning rarely occurs in pools and rarely involves
alcohol (Auerbach, 2012). Efforts to save the patients should not be abandoned prematurely. Successful
resuscitation with full neurologic recovery has occurred in nonfatal drowning patients after prolonged
submersion in cold water. This is possible because of a decrease in metabolic demands and/or the diving
reflex. The nonfatal drowning process involves the onset of hypoxia, hypercapnia, bradycardia, and
dysrhythmias. If there is a violent struggles associated with the nonfatal drowning episode, exercise –
induced acidosis and tachypnea can result in aspiration. Hypoxia and acidosis cause eventual apnea and
loss of consciousness. When the victim lose consciousness and makes final effort to breathe, the
terminal gasp occurs. Water then moves passively into the airways prior to death. Scope of the problem

In 2019, an estimated 236 000 people died from drowning, making drowning a major public health
problem worldwide. In 2019, injuries accounted for almost 8% of total global mortality. Drowning is the
3rd leading cause of unintentional injury death, accounting for 7% of all injury-related deaths. Risk
factors *Age: Globally, the highest drowning rates are among children 1–4 years, followed by children 5–
9 years. Drowning is one of the top 5 causes of death for people aged 1–14 years. This relationship is
often associated with a lapse in supervision. *Gender Males are especially at risk of drowning, with twice
the overall mortality rate of females. They are more likely to be hospitalized than females for non-fatal
drowning. Studies suggest that the higher drowning rates among males are due to increased exposure to
water and riskier behaviour such as swimming alone, drinking alcohol before swimming alone and
boating. *Access to water Increased access to water is another risk factor for drowning. Individuals with
occupations such as commercial fishing or fishing for subsistence, using small boats in low-income
countries are more prone to drowning. Children who live near open water sources, such as ditches,
ponds, irrigation channels, or pools are especially at risk. *Flood disasters Drowning accounts for 75% of
deaths in flood disasters. Flood disasters are becoming both more frequent as well as more severe and
this trend is expected to continue as part of climate change. Drowning risks increase with floods
particularly in low- and middle-income countries where people live in flood prone areas and the ability
to warn, evacuate, or protect communities from floods is weak or only just developing. *Travelling on
water. Daily commuting and journeys made by migrants or asylum seekers often take place on
overcrowded, unsafe vessels lacking safety equipment or are operated by personnel untrained in dealing
with transport incidents or navigation. Personnel under the influence of alcohol or drugs are also a risk.
Other risk factors

There are other factors that are associated with an increased risk of drowning, such as: *Lower
socioeconomic status, being a member of an ethnic minority, lack of higher education, and rural
populations all tend to be associated, although this association can vary across countries; *Infants left
unsupervised or alone with another child around water; *alcohol use, near or in the water; *medical
conditions, such as epilepsy; *tourists unfamiliar with local water risks and features;

Prevention

There are many actions to prevent drowning. Installing barriers (e.g. covering wells, using doorway
barriers and playpens, fencing swimming pools etc.) to control access to water hazards, or removing
water hazards entirely greatly reduces water hazard exposure and risk. Community-based, supervised
child care for pre-school children can reduce drowning risk and has other proven health benefits.
Teaching school-age children basic swimming, water safety and safe rescue skills is another approach.
But these efforts must be undertaken with an emphasis on safety, and an overall risk management that
includes safety-tested curricula, a safe training area, screening and student selection, and student-
instructor ratios established for safety. Effective policies and legislation are also important for drowning
prevention. Setting and enforcing safe boating, shipping and ferry regulations is an important part of
improving safety on the water and preventing drowning. Building resilience to flooding and managing
flood risks through better disaster preparedness planning, land use planning, and early warning systems
can prevent drowning during flood disasters. Developing a national water safety strategy can raise
awareness of safety around water, build consensus around solutions, provide strategic direction and a
framework to guide multisectoral action and allow for monitoring and evaluation of efforts. Death from
Drowning ( Submersion Injury) is caused by hypoxia secondary to aspiration and swallowing of fluid,
usually water. Swallowed water may cause vomiting and additional aspiration. A majority of drowning
victims aspirate water into the pulmonary tree and develop pulmonary edema. Victims who do not
aspirate fluid develop intense bronchospasm and airway obstruction, the cause of death in “dry
drowning”. Hypotonic fresh water is rapidly absorbed in the circulating system through the alveoli. Fresh
water maybe contaminated with chlorine, mud, and algae causing the breakdown of lung surfactant,
fluid seepage and pulmonary edema. Hypertonic salt water draws protein-rich fluid from the vascular
space into the alveoli, impairing alveolar ventilation and resulting in hypoxia. The body attempts to
compensate for hypoxia by shunting blood to the lungs. This results in increased pulmonary pressures
and deteriorating respiratory status. More and more blood is shunted through the alveoli. However, the
blood is not adequately oxygenated, so the hypoxemia worsens. Anaerobic metabolism occurs, which
leads to lactic acidosis.

CHECK FOR UNDERSTANDING

MULTIPLE CHOICE: (10 points) Read and analyze each sentence/situation carefully and encircle the letter
of the correct answer then write the rationale.

1. A patent was rescued from a school swimming pool, where she was found unconscious, and
transported to a nearby hospital, where her lungs were discovered to be dry. What could cause dry lungs
in this near drowning?

A. Chlorinated pool water is quickly absorbed across the alveolar-capillary membrane.

B. Her young age and the cool pool water prevented serious pulmonary injury.

C. Her glottis spasmed and prevented pool water from entering her lungs.

D. She swallowed the water.

2. In Nonfatal drowning in unclean, swampy water, what are common complications ? SATA (Select all
that apply)

A. Pulmonary fibrosis

B. Pneumonia

C. Acute respiratory distress syndrome (ARDS)

D. Pulmonary hypertension

3. In comparing the pathologic changes to the lungs caused by fresh water versus salt water, which of the
following can be stated?

A. Both cause identical pathologic changes.

B. Salt water causes more damage.

C. Fresh water causes more damage.

D. Cold water of either type causes more damage than warm water of either type.

4. The effects of a near-drowning victim inhaling water into the lungs include:

1) alveolar consolidation. 2) bronchospasm. 3) production of frothy, white secretions. 4) pleural effusion.

A) 2, 3

B) 1, 2, 3

C) 2, 3, 4

D) 1, 2, 3, 4

5. Favorable prognostic factors in clean water near-drowning include:

1) Greater effort to reach the surface.

2) Alcohol in the victim.

3) Colder water.

4) Younger age.

A) 1, 2

B) 3, 4

C) 2, 3, 4

D) 1, 2, 3, 4

6. Risk factors for drowning are the following except:

A. Age

B, Gender

C. Access to water

D. All of the

E. None of the above

7. According to WHO, drowning accounts for _____ of deaths in flood disasters.

A. 50%

B. 75%

C. 85%

D. 100%

8. Other factors that are associated with an increased risk of drowning are the following except:

A. Lower socioeconomic status

B. Infants closely supervised or with a companion around water

C. Alcohol use, near or in the water

D. Medical conditions, such as epilepsy;

E. Tourists unfamiliar with local water risks and features

9. The causes of Submersion injuries are as follows: SATA (Select all that apply)

A. Inability to swim or exhaustion while swimming

B. Entrapment or entangled with object in water

C. Loss of ability to move secondary to trauma, stroke, hypothermia, myocardial infarction

D. Poor judgment due to alcohol or drugs

E. Seizure while in water

10. It draws protein-rich fluid from the vascular space into the alveoli.

A. Hypertonic salt water

B. Hypotonic fresh water

C. A&B

D. None of the above

SESSION 22:

POISONING

POISONING

A poison is any substance that, when ingested, inhaled, absorbed, applied to skin, or produced within
the body in relatively small amounts, injures the body by its chemical action. The branch of medicine
that deals with the detection and treatment of poisons is known as toxicology. Poisoning represents the
harmful effects on the human body of accidental or intentional exposure to toxic amounts of any
substance. Emergency treatment is initiated with the following goals:

*Remove or inactivation of the poison before it is absorbed

*Provision of supportive care in maintaining vital organ function

* Administration of a specific antidote to neutralize a specific poison

*Implementation of treatment that hastens the elimination of the absorbed poison. Acute pesticide
poisoning is one of the most common causes of intentional deaths worldwide

The effect of poisoning may be :Local, Systemic or both

It may occur immediately or several hours or even days after the exposure.

CAUSES OF POISONING

*Chemicals *Household e.g. bleach, kerosene *Industrial e.g. methanol, ethylene glycol, cyanide, arsenic
*Pesticides e.g. organophosphates, organochlorines (e.g. DDT), rat poison

*Therapeutic drug overdose e.g. paracetamol, aspirin, iron tablets, nifedipine, phenobarbitone *Toxic
plants e.g. poisonous mushrooms, toxic herbal preparations *Bites and stings of venomous animals e.g.
snakes, scorpions, bees, spiders, aquatic animals

DANGER SIGNS *No breathing *Wheezy or noisy breathing *Pulse below 50, or above110 beats per
minute, irregular, or very weak *Non-reacting pupils *Loss of consciousness *Continuous seizures
*Temperature > 39°C (mouth or rectum) or 38°C (armpit) *Severe abdominal tenderness *Anuria
*Asterixis (inability to maintain sustained posture with subsequent brief, shock-like, involuntary
movements)

INVESTIGATION

• TLC (Thin Layer Chromatography) • BUN and creatinine • Electrolyte levels • Fasting blood glucose •
Toxicological analysis of identified substance or tissue samples (e.g. gastric aspirate)

Non Pharmacological Treatment •Ensure airways are patent • Remove contaminated clothing, if
necessary •Wash chemical away from the skin with soap and a lot of water •If necessary Perform
nasogastric aspiration if airway is protected

•Carry out gastric lavage or aspiration within the first 1 hour after the event or later if it involves slow
release or highly toxic substances • Detain the patient in the clinic or hospital for close and continuous
observation, re-evaluation, and supportive and symptomatic treatment. •Maintain and continuously
monitor vital signs

Pharmacological Treatment
Initial Management •For hypoglycaemia: Glucose, IV,25-50 ml of 50% over 1-3 minutes •For opioid
overdose: Naloxone, IV, Adult= 0.4-2 mg, repeat every 2-3 minutes (maximum of 10 mg);

Children= 10 micrograms/kg stat, subsequent dose of 100 microgram/kg if no response to initial dose
Then, Naloxone, SC or IM, only if IV route is not feasible.

Antidote is defined as therapeutic substance used to counteract the toxic actions of a specific xenobiotic

TYPES OF POISONING

1. Ingestion

2. Inhalation

3. Injection

4. Absorption

1. Swallowed poisons may be corrosive. Corrosive poisons include alkaline and acid agents that can
cause tissue destruction after coming in contact with mucus membranes. Alkaline products: Drain
cleaners, bleach, non phosphate detergents, oven cleaners, and button batteries

Acid products: Toilet bowl cleaners, pool cleaners, metal cleaners, rust removers, and battery acid.
Petroleum distillates/hydrocarbons,Kerosene,Turpentine ,Drug overdose and Food poisoning

Management: *Check and maintain ABC. *Take ECG. *Assess neurologic status *Give water and milk to
drink for dilution of strong acid and alkaline poison. Gastric emptying procedure: *Syrup of Ipecac to
induce vomiting in the alert patient (never use with corrosive poison). *Gastric lavage for the obtunded
patient, gastric aspirate is saved and sent to the laboratory for testing (toxicologic screens) *Activated
charcoal administration (1g/Kg). *Cathartic, when appropriate Sorbitol (1-2 g/kg) Sodium sulfate
Magnesium citrate. *If there is specific antidote available then administer it as early as possible. *If
antidote is not available then remove the ingested material by administration of charcoal, diuresis,
dialysis or hemoperfusion. *Hemoperfusion involves detoxification of the blood by processing it through
an extra corporeal circuit and an adsorbent cartridge containing charcoal and resin, after which clean
blood is returned to the patient. Food Poisoning is a sudden illness that occurs after ingestion of
contaminated food or drink. Botulism is a serious form of food poisoning that requires continual
surveillance. The key to treatment is determining the source and type of food poisoning. If possible, the
suspected food should be brought to the medical facility and a history obtained from the patient or
family. Food, gastric content, vomitus, serum and feces are collected for examination. The patient’s
respiration, blood pressure, level of consciousness, CVP (if indicated), and muscular activity are
monitored closely. Measures are instituted to support the respiratory system. Death from respiratory
paralysis can occur with botulism, fish poisoning and some other food poisoning.

2. Carbon monoxide poisoning may occur as a result of industrial or household incidents or attempted
suicide. Carbon monoxide bound Hb called Carboxyhemoglobin, does not transport O2. Carbon
monoxide exerts its toxic effect by binding to circulating Hb and thereby reducing the O2 carrying
capacity of the blood. Hb absorbs Carbon monoxide 200 times more rapidly than O2. Signs of Carbon
Monoxide Poisoning: •Headache •Muscular weakness •Palpitation •Dizziness •Confusion progress
towards coma •Skin color blue •False reading of pulseoximetry

MANAGEMENT:

GOAL- To reverse cerebral and myocardial hypoxia

INTERVENTIONS: *Carry the patient to fresh air immediately, open all doors and windows *Loosen all
tight clothing *Initiate CPR if required; administer 100% O2. *Prevent chilling; wrap the patient in
blanket. *Keep the patient as quiet as possible. *Do not give alcohol in any form or permit the patient to
smoke. 3. Skin contamination injuries from exposure to chemicals are challenging because of the large
number of possible offending agents with diverse actions and metabolic effects. The severity of a
chemical burn is determined by the mechanism of action, the penetrating strength and concentration,
and the amount and duration of exposure of the skin to the chemical. GOAL- prevent skin from exposure.
*Wash the exposed skin thoroughly with water. *NOTE- water should not be applied to burns from lye or
white phosphorous because of the potential for an explosion or for deepening of the burn. *All evidence
of these chemicals should be brushed off the patient before any flushing occurs. *Start with standard
burn treatment according to size and location of wound (antimicrobial treatment, debridement, tetanus
prophylaxis, antidote administration as prescribed) *Plastic surgery may be required for further
management of wound. 3. Organophosphate (OP) compounds are a diverse group of chemicals used in
both domestic and industrial settings.

PATHOPHYSIOLOGY:

The primary mechanism of action of organophosphate pesticides is inhibition of acetylcholinesterase

(AChE). AChE is an enzyme that degrades the neurotransmitter acetylcholine (ACh) into choline and
acetic acid. ACh is found in the central and peripheral nervous system, neuromuscular junctions, and red
blood cells (RBCs). Organophosphates inactivate AChE by phosphorelation. Once AChE has been
inactivated, ACh accumulates throughout the nervous system, resulting in overstimulation of muscarinic
and nicotinic receptors. Clinical effects are manifested via activation of the autonomic and central
nervous systems and at nicotinic receptors on skeletal muscle. Organophosphates can be absorbed
cutaneously, ingested, inhaled, or injected. Although most patients rapidly become symptomatic, the
onset and severity of symptoms depend on the specific compound, amount, route of exposure, and rate
of metabolic degradation.

SIGNS & SYMPTOMS

Can be divided into 3 broad categories, including:

(1) muscarinic effects, (2) nicotinic effects, and (3) CNS effects.

A. Signs of MUSCARINIC EFFECTS of Organophosphates: •SLUDGE (Salivation•Lacrimation •Urination•

Diarrhea •GI upset• Emesis) •DUMBELS (Diaphoresis and diarrhea •Urination• Miosis• Bradycardia,
bronchospasm •Emesis •Excess Lacrimation •Salivation)

B. NICOTINIC Signs & Symptoms •Muscle fasciculations •Cramping, weakness •Diaphragmatic failure
Autonomic nicotinic effects include: Hypertension, Tachycardia, Mydriasis, & pallor.

C. CNS Effects: •Anxiety •Emotional lability •Restlessness •Confusion •Ataxia •Tremors •Seizures •Coma

Treatment Medical Care: *Airway control and adequate oxygenation are paramount in organophosphate
(OP) poisonings. *Intubation may be necessary in cases of respiratory distress due to laryngospasm,
bronchospasm, bronchorrhea, or seizures. *Immediate aggressive use of atropine may eliminate the
need for intubation. *Succinylcholine should be avoided because it is degraded by acetylcholinesterase
(AChE) and may result in prolonged paralysis.

Medication:

The mainstays of medical therapy in organophosphate (OP) poisoning include ATROPINE, pralidoxime ,
and diazepam.

Initial management must focus on adequate use of atropine. Optimizing oxygenation prior to the use of
atropine is recommended to minimize the potential for dysrhythmias.

Anticholinergic agents

These agents act as competitive antagonists at the muscarinic cholinergic receptors in both the central
and the peripheral nervous system. These agents do not affect nicotinic effects. Adult: 1-2 mg IV bolus,
repeat q1-5min prn for desire effects (drying of pulmonary secretions and adequate oxygenation)

Strongly consider doubling each subsequent dose for rapid control of patients in severe respiratory
distress

Pediatric: 0.05 mg/kg IV, repeat q1-5min prn for control of airway secretions Strongly consider doubling
each subsequent dose to rapidly stabilize patients with severe respiratory distress.

CHECK FOR UNDERSTANDING (Poisoning)

MULTIPLE CHOICE: (10 points) Read and analyze each sentence/situation carefully and encircle the letter
of the correct answer then write the rationale.

1. It represents the harmful effects on the human body of accidental or intentional exposure to toxic
amounts of any substance.

A. Poison

B. Poisoning
C. Inhaled Substance

D. Toxins

2. Emergency treatment of poisoning is initiated with the following goals except:

A. Activation of the poison before it is absorbed

B. Provision of supportive care in maintaining vital organ function

C. Administration of a specific antidote to neutralize a specific poison

D. Implementation of treatment that hastens the elimination of the absorbed poison.

3. Acute pesticide poisoning is one of the most common causes of intentional deaths worldwide

A. Toxic Plants poisoning

B. Acetaminophen poisoning

C. Acute pesticide poisoning

D. All of the above

4. Poisoning can be via:

A. Ingestion

B. Inhalation

C. Injection

D. Absorption

E. All of the above

5. Hemoperfusion involves detoxification of the blood by processing it through an extra corporeal circuit
and an adsorbent cartridge containing charcoal and resin, after which clean blood is returned to the
patient.

A. True

B. False

6. A serious form of food poisoning that requires continual surveillance. A. Contaminated food

B. Expired Food

C. Bacterium

D. Botulism

7. Signs of Carbon Monoxide Poisoning are the following: SATA (Select all that apply)

A. Headache

B. Muscular weakness

C. Palpitation

D. Dizziness

E. Redness of the skin

8. An enzyme that degrades the neurotransmitter acetylcholine (ACh) into choline and acetic acid.

A. RBC

B. CNS

C. AChE

D. ACh

9. In Organophosphorus poisoning, SLUDGE is a sign categorized under:

A. Muscarinic effects, B. Nicotinic effects

C. CNS effects

D. All of the above

10. This medication should be avoided in the treatment of Organophosphorus poisoning.

A. Sugammadex

B. Quelicin

C. Succinylcholine

D. Anectin

SESSION 23

ANIMAL BITES

Animal and Human Bites

Bites are a common reason for visits to the ED. Dog bites constitute 80 % to 90% of these bites and are
responsible for majority of deaths from bites by a nonvenomous animal (Cline et al., 2012 ). Cat bites
have a high risk of infection because of the presence of Pasteurella in their saliva. All animal bites must
be reported to public health authorities, which must provide follow-up screening of the offending animal
for rabies. If the animal cannot be located and rabies vaccination verified, rabies prophylaxis for the
person who has been bitten must be instituted ( ENA, 2013 ). Human bites usually associated with rapes,
sexual assaults, or other forms of battery. The human mouth contains more bacteria than that of most
other animals, so a high risk of bite-related infection exists. Depending on the circumstances surrounding
the event, the victim may delay seeking treatment. The ED nurse should inspect any bitten tissue for pus,
erythema, or necrosis. A health care provider should take photographs, which can be used as evidence in
criminal and legal proceedings. Guidelines for collecting forensic evidence for photographing with and
without a measuring device should be followed. Cleansing with soap and water is then necessary,
followed by the administration of antibiotics and tetanus toxoid as prescribed (Cline et al., 2012).

Snake Bites

Venomous (poisonous) snake caused more than 2,800 bites in the United States in 2008 (Moriarty, Dryer,
Repolgie, et al., 2012 ). Across the globe more than 50,000 snakebites occur each year; approximately
7,000 of these are venomous (Ahmed, Ahmed, Nadeem et al., 2008 ). Children between 1 and 9 years
old of age are the most likely victims. The greatest number of bites occurs during the daylight hours and
early evening of the summer months. The most frequent poisonous snakebites in the United States
occurs from the pit vipers (Crotalidae). The most common site is the upper extremity ( ENA, 2013). Of
these bites, only 20% to 25% result in envenomation (injection of a poisonous material by sting, spine,
bite, or other means). Typically, even a venomous snake will produce a dry bite (little to no venom) most
of the time. Venomous snakebites are medical emergencies. Nineteen different species of venomous
snakes are found in various regions within the United States. Nurses should be familiar with the types of
snakes common to the geographic region in which they practice. However, the exotic pet industry sells
atypical snakes as “pets”. Because of this, venomous snakes such as cobras and asps may be found
outside of their typical place of residence ( Lubrich & Krenzelok, 2009).

Clinical Manifestations

Snake venom consists primarily of proteins and has a broad range of physiologic effects. It may affect
multiple organ systems, especially the neurologic, cardiovascular, and respiratory systems. Classic clinical
signs of envenomation are edema, ecchymosis, and hemorrhagic bullae, leading to necrosis at the site of
envenomation. Symptoms include lymph node tenderness, nausea, vomiting, numbness, and a metallic
taste in the mouth. Without decisive treatment, these clinical manifestations may progress to include
fasciculations, hypotension, paresthesias, seizures, and coma (Moriarty et al., 2012 ). There are two
major groups of venomous snakes:

1. Elapids (cobra family): There are about 300 venomous species of Elapidae, including kraits, mambas,
coral snakes and sea snakes. They have short fangs in the front of the upper jaw and strike downward,
followed by chewing. Their venom is mainly neurotoxic but it can also harm body tissue or blood cells. If
a cobra bites you, you can die from paralysis of the heart and lungs very quickly after the bite.

2. Vipers: There are more than 200 species of Viperidae, which includes pit vipers (like rattlesnakes,
copperheads, water moccasins, or cottonmouths) and Old-World vipers (adders). They have long, hollow,
venomous fangs attached to movable bones in their upper jaw. They fold their fangs back into their
mouth when they’re not in use.

Management

Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive
items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile
dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and
circulation are the priorities of care. Ice, incision and suction, or a tourniquet is not applied. Tetanus and
analgesia should be administered as necessary. Initial evaluation in the ED is performed quickly and
includes information about the following: Whether the snake was venomous or nonvenomous;
discourage bringing the snake for identification – even a dead snake’s venom is poisonous). Do not
handle any snake brought to ED. If the snake is transported to the ED, caution should be taken because
the snake is frequently in a stunned, not dead, state. Where and when the bite occurred and the
circumstances of the bite. Sequence of the events, signs and symptoms (fang puncture, pain, edema,
and erythema of the bite and nearby tissues). Severity of poisonous effects. Call the local poison control
phone number to gain access to information about an exotic snakebites presentation and management,
as necessary. The poison control center may also be able to assist with retrieving antivenin for these
particular species (Lubrich & Krenzelok, 2009). Vital signs Circumference of the bitten extremity or
area at several points. The circumference of the extremity that was bitten is compared with the
circumference of the opposite extremity. Laboratory data (complete blood count, urinalysis, and
coagulation studies). The course and prognosis of snakebite injuries depend on the kind and amount of
venom injected; where on the body the bite occurred; and the general health, age, and size of the
patient. There is no one specific protocol for treatment of snakebites. Generally, ice, tourniquets,
heparin and corticosteroids are not used during the acute stage. Corticosteroids are contraindicated in
the first 6 to 8 hours after the bite because they may depress antibody production and hinder the action
of antivenin (antitoxin manufactured from the snake venom and used to treat snakebites ). Parenteral
fluids may be used to treat hypotension. If vasopressors are used to treat hypotension, their use should
be short term. Surgical exploration of the bite is rarely indicated. Typically, the patient is observed closely
for at least 6 hours. The patient is never left unattended. Some useful tips to avoid getting bitten:
*Always be careful where you put your hands and feet. Don’t reach into unknown spaces and holes, or
underneath objects without first being sure a snake isn’t hiding underneath.

*Don’t lie down or sit down in areas where there might be snakes.

*Wear high-top leather boots when walking through or working in areas with dense vegetation. *Do not
attempt to capture, handle or keep venomous snakes.

*If you’re going camping, take extra care around swamps and other places where snakes typically live. *If
you come across a snake, slowly back away from it and avoid touching it.

MULTIPLE CHOICE: (10 points) Read and analyze each sentence/situation carefully and encircle the letter
of the correct answer then write the rationale.

1. What might the bite look like when a venomous snake bites?

A. Pale in color

B. A bruise

C. Small red bumps

D. Small marks or wounds

2. Venomous snakes are safe to handle when...

A. They are babies

B. They are asleep

C. They are dead

D. None of the above

3. If a snake bites you, or someone you are with, what things are important to observe and remember?
SATA (Select all that apply).

A. How many times the snake bit

B. How the bite felt (painful or painless)

C. What the snake looked like

D. All of the above

4. If someone is bitten by a snake and you can't get help right away, what first aid can you give?

A. Keep the bite below the level of the heart

B. Clean the area with soap and water

C. Cover the area with a clean dressing

D. All of the above

5. What else can you do if you are with someone who is bitten by a snake?

A. Give the person an alcoholic drink

B. Try to suck the venom out of the wound

C. Put ice on the bite

D. None of the above

6. Which of these areas are places where snakes are often found?

A. High grass

B. Piles of leaves

C. In rocks or piles of wood

D. All of the above

7. First aid for snakebite should include which of the following?

A. Limit activity and try to immobilize the part of the body that was bitten

B. Call 911 or emergency services

C. Try to remain calm

D. All of the above

8. What can you do to lower your risk for being bitten by a snake?

A. Catch any snakes you see on a hike and move them off the trail

B. Wear thick leather boots when hiking through tall grass

C. Kill any snakes you see on a hike

D. None of the above

9. Classic clinical signs of envenomation are:

A. Edema

B. Ecchymosis

C. Hemorrhagic bullae

D. All of the above

E. none of the above

10. Corticosteroids are given in the first 6 to 8 hours after the bite because they stimulate antibody

production and hinder the action of antivenin.

A. true

B. False