Treating adder bites

RE: Treating adder bites

Christina Smith — Sun, 09 Jul 2017 23:53:15 GMT

This was a Hebridean island by the way. The farmers were extremely canny. There was an elected trusted paravet who would administer drugs on telephone guidance from the duty vet. Adder bites were very common in dogs. Anti-venom was not available. The usual treatment was penicillin/steroid IV if possible. No fatalities in dogs as far as I am aware. The earlier the treatment the less oedematous swelling. Late treatment made very little difference to the necrosis/skin slough. Almost always axillary/elbow wounds. I was a student at the time and yes we did have telephones. Television arrived in the 60s. There were alot of dairy farms. The cattle were fed mainly on draff a by-product of the whiskey industry. For some reason there was at least one uterine prolapse a day. The common treatment was to sprinkle on a bag of sugar and replace as quickly as possible. Often the cow was down and the uterus badly trampled. They did fine. Always got several days of shot of pen/strep. No doubt the milk went straight into the cartons and the islanders also got their daily dose of antibiotic too. Don't worry it wasn't exported unless some tourist bought the cheese. More interesting anecdote from my father who was born in 1926. Their house cow a jersey, eventually succumbed to TB. The six children all lived into adulthood and were hyperimmune to TB. One died of a brain tumour in his forties. My Dad is 91 next August.

RE: Treating adder bites

Christina Smith — Sat, 10 Jun 2017 17:03:00 GMT

The farmers were pretty clued up and knew the signs. We once had a sheepdog brought in. Asked how he knew that the dog had been bitten. It was seen facing up to two at once. It was a common occurence in the Hebrides

RE: Treating adder bites

Julian Earl — Sat, 10 Jun 2017 10:30:07 GMT

[quote user="Christina Smith"]During the seventies/eighties our practice treated about 10 adder bites in cattle, lower limb or tongue [1] all treated with steroid/penicillin. 1 fatality.[/quote]

How did youdiagnose them as adder bites? I am very impressed if you found the bite marks! The punctures are difficult enoughto see even on a dog or cat under the fur, so did you find them or was it circumstantial evidence?

The bites I've seen have been on limbs or in one dog, a Cocker Spaniel, so quite small and low to the ground, receiving a bite at the ventral neck. A haemorrhagic/bruised reaction and a lot of swelling. Steroids were the only option to reduce the swelling there ASAP. Fluids were always given as well.

RE: Treating adder bites

janine redman — Thu, 08 Jun 2017 23:37:47 GMT

Here in the New Forest we see adder bites through spring and summer. Normally but not always we use anti venom. It does depend on both the severity of the bite and sometimes the financial constraints of the owners. In one notable case we had two dogs , one a GSD , one a Rottweiler both bitten on back legs. The more severely affected got the anti venom, the less affected got nsaids and antibiotics . The dog treated with anti venom recovered rapidly and uneventfully. The other took several days and vet visits to recover.

Personally I think the current anti venom is less effective than the previously available Croatian anti serum.

RE: Treating adder bites

Catriona MacIntyre — Thu, 08 Jun 2017 23:07:57 GMT

I've treated 4 adder bite cases in the last 5 years and not used antivenom in any of them. We did discuss the risks and benefits of antigenic use with a VetsNow ECC specialist and GUVS, and came to the conclusion that unless there are systemic signs, there risk outweighed the benefit.

My usual protocol is NSAIDs, opiate pain relief and broad spectrum antibiotics, to include cover against anaerobic infection. I think our nearest referral centre participates in the VPIS Toxbox scheme, and is about 90 minutes away.

So far, I've probably been very lucky!

RE: Treating adder bites

Christina Smith — Thu, 08 Jun 2017 15:16:32 GMT

During the seventies/eighties our practice treated about 10 adder bites in cattle, lower limb or tongue [1] all treated with steroid/penicillin. 1 fatality.

RE: Treating adder bites

ChrisBVSc — Thu, 08 Jun 2017 14:44:33 GMT

Our existing practice protocol includes giving a low dose of adrenaline subcut alongside the antivenom treatment. Can't remember the exact dose as haven't done it for a while, but I think it was based on VPIS advice from a few years ago. I've treated a good number of dogs with antivenom now (and the adrenaline injection) & haven't had any adverse reactions - they just get much better very quickly!

RE: Treating adder bites

Bob Russell — Thu, 08 Jun 2017 14:00:48 GMT

That is what I was referring to. The antivenom has quite a lot of foreign proteins so pre-treatment with antihistamines is to try to reduce the risk of this! I don't believe there is much or any evidence for this being useful but was the reason I gave corticosteroids many years ago.

Owners ask what they can do. Having something in their pockets tends to give them some extra comfort as some have been put off walking in the Forest because of the perceived risk.

RE: Treating adder bites

Thomas Johnson — Thu, 08 Jun 2017 12:38:30 GMT

[quote user="Bob Russell"]Never seen anaphylaxis but we do suggest people with high risk dogs carry Piriton and give one immediately if possible. I doubt this is clinically significant but does provide comfort to owners! I do not suggest they go home first to collect the Piriton!![/quote]

I think the worry is anaphylaxis from the antivenom rather than the snake bite, as far as I am aware there's no benefit to anti-histamines to treat adder bites.

RE: Treating adder bites

Bob Russell — Thu, 08 Jun 2017 09:04:11 GMT

VPIS recommendations were (hopefully still are!) that the antivenom is given in saline i/v over a period of a few minutes.

I don't put them on fluids as such.

These dogs are usually in pain but not 'shocked'.

Never seen anaphylaxis but we do suggest people with high risk dogs carry Piriton and give one immediately if possible. I doubt this is clinically significant but does provide comfort to owners! I do not suggest they go home first to collect the Piriton!!

RE: Treating adder bites

Jo Dyer — Thu, 08 Jun 2017 08:57:33 GMT

[quote user="ChrisBVSc"]So, what would you give for a serious adder bite, either with antivenom (useful just to know what others are doing), or more importantly what would you give if antivenom wasn't an option?[/quote]

I understand your concerns. At the practice I was with from 2001 to 2012, we used to see around 10 adder bites per year. We always used anti-venom, including one notorious case who got bitten twice! We would give it in iv fluids over a couple of hours, along with steroid or nsaid depending on vet preference, plus antibiotics, and then send them home. We saw them again 24 hours later.

I did a pretty basic clinical audit on the last 20 cases we had seen. It showed the following;

bites were always on the face or foot (50/50)
around half had steroid and half nsaid and it seemed to make no difference to morbidity so I always preferred nsaid (as pointed out above, adder bites are very painful). This was before VPIS came to the conclusion that steroids should not be used.
They were all significantly improved by the follow-up consultation and none had to be seen again for any complications.

Local practices didn't see as many as us (we were next door to a SSSI/nature reserve) but some of them were worried about using anti-venom due to potential anaphylaxis (which we never saw). We heard anecdotal reports of dogs being hospitalised for 5 days or more and sometimes dying despite this.

So..... I would be very worried about not using anti-venom. I suppose the alternative is the usual treatment but with much more protracted iv fluids. How much is the anti-venom now costing? I compare expensive life-saving medication to expensive life-saving surgery; if it is necessary then the owner has to make that decision. Also, compared to a week of hospitalisation and treatment, the price may not be so bad?

Good luck. I hope availability continues and your clients are able to afford the proper treatment, because the alternative has a far less predictable and acceptable outcome in my experience.

RE: Treating adder bites

Bob Russell — Wed, 07 Jun 2017 13:22:15 GMT

Centaur Services. Our wholesaler doesn't stock it or have access to it. Need to go on the VMD website and get an SIC to send to them. Manufactured in Poland.

RE: Treating adder bites

Bibs — Wed, 07 Jun 2017 11:28:52 GMT

Can I ask where people are sourcing their antivenom from?

RE: Treating adder bites

ChrisBVSc — Tue, 06 Jun 2017 18:40:10 GMT

Thanks Thomas that's very interesting. Haven't used steroids myself up to now, sounds like probably best to keep it that way!

RE: Treating adder bites

Julian Earl — Tue, 06 Jun 2017 17:06:35 GMT

This is a very interesting and educational thread! Clearly, I was doing it wrong for years it appears! So perhaps my patients recovered despite my therapy not because of it?

Live and learn, a bit like like the dogs did I suppose!

RE: Treating adder bites

Thomas Johnson — Tue, 06 Jun 2017 16:57:38 GMT

[quote user="ChrisBVSc"]I am also a big fan of antivenom, treated several cases with it over the last few years & they've all recovered fine. Haven't ever attempted purely symptomatic treatment without antivenom though in a severe case, hence my original question, but it does sound like people have had success with this. Which is good to know if I get anyone who doesn't want to pay current prices for antivenom![/quote]

For BVA members the article is here:

http://veterinaryrecord.bmj.com/content/172/1/23.1

The section on steroids says:

Glucocorticoid steroids remain a popular treatment for snake bites in animals despite their known side effects, which can be particularly deleterious in the presence of venom-induced bleeding and blood clotting disorders, and the lack of any evidence for their benefit. They have no place in the management of adder envenoming in humans (Warrell 2005). However, they were used in 51 per cent of the VPIS's cases and the VPIS has received reports that they are preferred to antivenom by some UK veterinarians. In a study of dogs bitten by Daboia (Vipera) palaestinae in Israel, the use of steroids was associated with increased mortality (Segev and others 2004). In 53 dogs bitten by V berus in Sweden, treatment with steroids had no clear positive or negative effects. There was a slight trend towards more swelling in dogs given steroids (but that may have been because veterinarians gave steroids to dogs with more severe swelling) (Lervik and others 2010).

For the veterinarian managing a dog bitten by an adder, we would suggest that the most urgent decision is whether or not antivenom is indicated. Steroids are not an alternative to a specific therapy and may worsen the outcome.

RE: Treating adder bites

ChrisBVSc — Tue, 06 Jun 2017 16:13:04 GMT

[quote user="Thomas Johnson"]

[quote user="ChrisBVSc"]If you wanted to use antivenom but couldn't because costs were a constraint (which is my main concern now the price has gone up), what do you think would be better - nsaid, or steroid (suggested in the Cambell & Chapman poisons book) alongside other analgesics.[/quote]

VPIS published data showing that mortality was higher if dogs were given steroids to treat adder bites.

[/quote]

Was this with steroid given WITH antivenom, or just steroid treatment alone? (I only ask because a colleague thought she might have heard differently).

I am also a big fan of antivenom, treated several cases with it over the last few years & they've all recovered fine. Haven't ever attempted purely symptomatic treatment without antivenom though in a severe case, hence my original question, but it does sound like people have had success with this. Which is good to know if I get anyone who doesn't want to pay current prices for antivenom!

RE: Treating adder bites

Bob Russell — Tue, 06 Jun 2017 09:57:37 GMT

If you give anti-venom there is rarely that degree of reaction. It may be that the adders around here are only introducing 'warning' doses of venom but severe local reactions seem very rare.

The only dog I have lost was as a result of a strike on the foot, relatively mild at the time, that went on to develop liver failure. Idiosyncratic reaction perhaps?

RE: Treating adder bites

Julian Earl — Mon, 05 Jun 2017 21:39:39 GMT

All of them but they usually have severe hemorrhagic swelling in the vicinity of the bite.

RE: Treating adder bites

Virginia Campbell — Mon, 05 Jun 2017 20:38:08 GMT

Did they all get steroids or just the really sick or swollen ones??

RE: Treating adder bites

Julian Earl — Mon, 05 Jun 2017 17:58:38 GMT

[quote user="Thomas Johnson"]

VPIS published data showing that mortality was higher if dogs were given steroids to treat adder bites.

[/quote]Interesting but not my experience! Published data versus anecdote perhaps? Salutary.

RE: Treating adder bites

Thomas Johnson — Mon, 05 Jun 2017 09:10:10 GMT

VPIS published data showing that mortality was higher if dogs were given steroids to treat adder bites.

RE: Treating adder bites

Bob Russell — Sat, 03 Jun 2017 10:56:10 GMT

With antivenom most of the swelling goes down rapidly. I give it slowly i/v via a catheter and use the very tiny saline drip bags.

When antivenom was £100-200 it was probably almost as economical as more intensive hospitalisation etc. Not so clear cut as it has become even more expensive.

i do make owners aware of the risks associated with antivenom use but have not had a problem so far.

RE: Treating adder bites

Julian Earl — Fri, 02 Jun 2017 18:44:00 GMT

We see a lot of them over the years here in Lincolnshire, nearly always in dogs visiting the same local woodland. I have never used the anti-venom and usually would treat symptomatically: This involves fluiids due to the extreme swelling observed plus the toxic effects of course. Antibiosis on principle and, I am afraid steroids for the massive oedema. I believe that my success rate was good with few deaths occurring that I can recall in well over ten years. Analgesia as seems appropriate as well.

RE: Treating adder bites

Bob Russell — Fri, 02 Jun 2017 16:28:22 GMT

I tend to stick with opiates but have used NSAI's uneventfully. I suspect those that have liver problems are 'programmed' to have them.

We had issues with the Croatian antivenom arriving short dated then it became unavailable totally for a bit. New stuff via Centaur seems to have a reasonable expiry on it.

Not sure how many practices have an odd bottle at the back of the fridge but should someone be unlucky and get more cases in a day than antivenom then (with appropriate explanation and consent) there is little reason not to use it!

"The fact that European snake antivenom retained its potency for a considerable time after its expiry date may be of significance elsewhere in the world where people more commonly suffer snake bites. If the cold chain has been maintained, it could be the case that a time-expired antivenom may still be efficacious, if no other supplies are available.”

Two weeks letter in the same publication (June 21, 2014, vol 174, p 639) Nicola Bates and Nick Edwards, representatives of the Veterinary Poisons Information Service (VPIS, www.vpisuk.co.uk) wrote:

“An antivenom for dogs is currently in development [the one being developed in Wales] but until this becomes available, we would agree with Mr Sim that the use of out of data antivenom is probably acceptable, at the discretion of the veterinary surgeon, provided the antivenom has been stored appropriately.” (Liverpool School of Tropical medicine).

Obviously the VMD would not agree!