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PAPERS: Roger Smalligan, Judy Cole, Narcissa Brito, Gavin D Laing, Bruce L Mertz, Steven Manock, Jeffrey Maudlin, Brad Quist, Gary Holland, Stephen Nelson, David G Lalloo, Gonzalo Rivadeneira, Maria Elena Barragan, Daniel Dolley, Michael Eddleston, David A Warrell, and R David G Theakston Crotaline snake bite in the Ecuadorian Amazon: randomised double blind comparative trial of three South American polyspecific antivenoms BMJ 2004; 329: 1129 [Abstract] [Full text]

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Publications policy of the BMJ

Craig J. Currie   (12 November 2004)

Might it be more effective to suck the wound?

Richard G Fiddian-Green   (12 November 2004)

Publications policy of the BMJ 12 November 2004
Craig J. Currie, Director and Senior Research Fellow Cardiff Research Consortium Send response to journal: Re: Publications policy of the BMJ	Sir, I have submitted and had rejected what I consider to be many good study reports from the BMJ, all of which were subsequently published elsewhere. Others, I’m sure, will have had the same experience. On may occasions you editorially justify rejection of the basis of; something like, "....of not enough interest to a general audience...". How can you justify publishing a study entitled "Crotaline snake bite in the Ecuadorian Amazon: randomised double blind comparative trial of three South American polyspecific antivenoms"? [1] I can’t wait for the day when all scientific publication is independent and open access! Yours faithfully, Dr. Craig Currie 1. BMJ 2004;329:1129 Competing interests: None declared
Might it be more effective to suck the wound? 12 November 2004
Richard G Fiddian-Green, FRCS, FACS c/o Herhold, Maitland and Co, 44 Dover Street, London W1 Send response to journal: Re: Might it be more effective to suck the wound?	The question not addressed in this study is whether antiserum improves outcome relative to a placebo in a field trial. I would have suspected any antiserum to have an adverse effect upon outcome. It is not without good reason that antiserum is rarely used anymore in the routine management of tetanus (1). In must be the very rare victim of a snake bite, if indeed it is from a poisonous snake, that receives the correct antiserum in the correct dose at the correct time for the correct length of time with proper support outcome and is has any reasonable chance of being improved by an antiserum. I speak from years of exposure to the proximate possibilty of a snake bite in South Africa. There are may poisonous snakes in South Africa as all trout fishermen such as I know all too well. The commonest, the puff adder, may cause severe hypotension/shock as well as hemolytic, coagulopathic, hemorrhagic, and local reactions. Death may ensue rapidly but more commonly occurs in 12-24 hours. The berg adder is much less common. Its venom is mildly neurotoxic. The ringhals, or spitting cobra, is one of the commonest poisonous snakes. Its venom can cause haemolysis if it entrs the tissues. Bait fishermen in the hotter climes may encounter the boomslang whose venom is haemotoxic, causing a coagulopathy whic may not develop until the second or third day after the bite. They might also encounter a green mamba whose venom contains dendrotoxin which may cause convulsions by enhancing acetylcholine release at neuromuscular junctions and blocking voltage-gated potassium channels. The black mamba's venom contains neurotoxins and cardiotoxins. It was the mamba stories that scared us most as children for they were reputed to chase people and be capable of keeping up with a galloping horse. As a boy I always carried a snake bite kit when out fishing. As an adult I insisted that a kit be kept on the farm. These kits often included a tourniquet, a knife to cut into a bite and make it bleed, potassium pemanganate to place into the wound to neutralise the venom and a vial of polyvalent antiserum to neutralise the toxin but no treatment for anaphyactic reactions. I never had occasion to use a kit and know of only one fisherman, a boy at my boarding prep [pre-prep]school, who was bitten on his big toe by a puff adder. He had one friend suck his toe to remove the venom whilst the other ran for help. He did not develop any local or systemic complications. What is more he was a live snake collector who caught the snake, put it in a laundary bag he carried for this purpose, and took it back for identifiction. Most of the experience with antisera has been obtained in rural hospitals by GPs with very unsophisticated means and limited if any experience with managing the critically ill. I suspect in this day and age the best way of treating snake bite that occurs in the field is to prevent and treat local infections and get the victim to a sophisticated hospital capable of providing conventional support of organ dysfunctions, including haematological dysfunctions, as soon as possible. I venture to suggest that giving a antiserum, certanly in th field, should be avoided at all costs because the side effects are likely to be far more dangerous than the bites. The reality is that many bites are from unidentified and most likely nonpoisonous snakes and it is the rare bite from a poisonous snake in which penetration has been enough to introduce a significant dose of venom. Might the authors have any credible evidence-base to dispute this recommendation? 1. : Attygalle D, Rodrigo N. New trends in the management of tetanus. Expert Rev Anti Infect Ther. 2004 Feb;2(1):73-84. Competing interests: None declared