VENOMOUS SNAKES OF IRAQ / SNAKEBITE FIELD MANAGEMENT CONSIDERATIONS

THE TRUE VIPERS

Levantine or Blunt-Nosed Viper (Vipera lebetina)- Range: along
Tigris-Euphrates drainage in northern Iraq. Venom: hemorrhagic.
Blunt-Nosed Viper (Vipera lebetina obtusa.) Range: Iraq. Venom: hemorrhagic.
Kurdistan Viper (Vipera raddei kurdistanica.) Range: extreme northern Iraq.
Desert Horned or Sand Viper (Cerastes cerastes gasperetti) Range: southwestern
Iraq, widespread in Iraq east of the Euphrates. Venom: hemorrhagic.
Saw-Scaled Viper (Echis carinatus sochureki) Range: southern Iraq and
elsewhere on the Arabian peninusla. Lower Tigris-Euphrates drainage. Venom:
markedly hemorrhagic.
Persian Sand Viper (Pseudocerastes persicus persicus) Range: northern Iraq.
Venom: hemrorhagic.
Field's Sand Viper (Pseudocerastes persicus fieldi.) Range: southwestern Iraq.
Venom: hemorrhagic.

Viperid antivenoms: Antivenoms for the Levantine and Desert Horned Vipers are
available from foreign sources and should be secured and given whenever
possible. Treatment of severe envenomations causing marked hemorrhagic problems
is difficult. Blood clotting abnormalities should be managed by a hematologist
as administration of whole blood products to such cases may exacerbate
hemorrhagic symptoms and DIC. Specific or polyvalent viperid antivenoms are the
best and only specific treatment for envenomation by these snakes. Since
systemic as well as local hemorrhage may be present, bites by these snakes
should be field managed by application of wide-area, low pressure bandaging of
affected extremity in order to prevent systemic spread of the venom. Indubitably
the worst of these snakes is the Saw Scaled Viper which carries an extremely
high mortality rate as a result of difficult to control systemic hemorrhage
and/or DIC.

Note: Sand Vipers are referred to locally as "um grun" or "garna."

ELAPID OR NEUROTOXIC SNAKES

Desert Black Snake (Walterinnesia aegyptica)

The only land-based or terrestrial elapid in Iraq is a widespread species

known as the Desert Black Snake. Its fangs are large and fixed in position
and it is widespread on the ground in Iraq including outside of desert
habitats such as the Mosul Region which is steppe-grassland. It has been
discovered in Jarmos into the foothills of the Zagros mountains. In Iraq
according to some researchers it is often confused with a harmless species
known as "abrid" or "urbid." It can be found in buildings, playing fields,
cultivated fields as well as open desert. The venom of this species is
highly neurotoxic, related to that of cobras and coral snakes, and acts
pre-synaptically. Any bite suspected from this species should be immediately
field-treated by wrapping the bitten extremity with a wide-area, low
pressure ACE or crepe bandage wrap. The best and only specific treatment is
antivenom which may be available from foreign producers. In the absence of
antivenom, at the first sign of neurological symptoms, the victim should be
sedated, electively intubated and placed on mechanical ventilation and
supported for as long as respiratory paralysis exists. On return of
spontaneous effort the victim should be carefully observed and slowly and
carefully weaned. Immediately wrapping the affected extremity may buy enough
time for evacuation to a medical facility equipped to support this patient
but if respiratory distress occurs, field intubation and manual (BAG/TUBE OR
BAG/MASK) ventilation may be necessary. In animal experiments subjects
expired while still be injected intravenously and within 40 to 70 minutes
when injected subcutaneously. Most snakebites are subcutaneous.

COBRAS IN IRAQ ?

There are rumors which may be a hoax that the Kurdish people have imported and
released cobras as a defense against Iraqui incursions in the north. We have no way of knowing if
this is true. Cobras are both neurotoxic and tissue necrotizing but any suspected cobra bite should
be treated by application of the
ACE elastic bandage.

SEA-SNAKES-NEUROTOXIC AND ELAPID-LIKE

Hook-Nosed Sea Snake (Enhydrina schistosi)

Arabian Gulf Sea Snake (Hydrophis gracilis)
Others of the genus Hydrophis are found in Arabian Gulf Waters

Sea snake bites are rare and are endured primarily by fisherman when
handling netted fish and bathers. Serious envenomations by sea snake bite is, however, extremely
dangerous and potentially fatal. Sea Snake antivenom is
manufactured in Australia for species in their waters. Other Australian
elapid antivenoms may also be useful in sea snake bite. Field management is
to immediately wrap the affected extremity with a wide-area, low pressure
bandage (e.g. ACE or crepe-wrap). In the absence of antivenom, victims
demonstrating any neurologic symptoms should be sedated. electively
intubated and placed on mechanical ventilation until spontaneous respiratory
effort returns which may take several days to a week or more at which time
the victim should be carefully weaned from ventilatory support. See

Local antivenoms and other expertise may be available from the Antivenom and
Vaccine Production Center at the King Fahad National Guard Hospital, Riyadh,
Saudi Arabia and from the Razi Institute in Iran.

References
Khalef, Kamel. Reptiles of Iraq. Published by Ministry of Education of
Iraq and Al-Rabitta Press, Baghdad. May, 1959.
Leviton et al: Handbook to Middle East Amphibians and Reptiles. SSAR, St.
Louis. 1992.
Welch, KRG. Snakes of the World. Part I-Venomous Snakes. KCM Books,
Somerset, U.K. 1994.
For more snakebite related websites, please visit the index page located at:
 Medical Pages Index

For comments and more information please e-mail: [email protected] or

[email protected]. Telephone: 718.226.2034 (M-F 9-3); 718.227.6234(after hours).

Some additional caveats and points to consider:

1. There are harmless as well as venomous snakes in the region. Consider any snakebite venomous
until medically evaluated as otherwise.
2. The best thing you can do is not get bitten. Protective clothing, footware
and gloves should be used at all times when there is risk of snakebite.
3. Venom is excreted in the urine. IV solutions, good hydration and voiding of urine will help to
eliminate venom. Do not drink any water in the field
but wait for solutions to be given intravenously, in the field or in the
hospital.
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THE SNAKEBITE EMERGENCY WEBPAGE SNAKEBITE EMERGENCY FIRST-AID INFORMATION

WHAT TO DO IF BITTEN BY A VENOMOUS SNAKE

Allow bite to bleed freely for 15-30 secs.

Cleanse and rapidly disinfect area with Betadine, assuming not allergic
to iodine, fish or shellfish.

If bite on hand, finger, foot or toe, wrap leg/arm rapidly with 3" to 6" Ace
or crepe bandage past the knee or elbow joint immobilizing it. Leave area of
fang marks open. But first, if possible, apply hard direct pressure over bite using a 4 x 4 gauze pad
folded in half twice to 1 x 1. Tape in place with adhesive tape. Soak gauze pad in Betadine(tm)
solution if available and victim is not allergic to iodines, fish or shellfish.

Strap gauze pad tightly in place with adhesive tape

Overwrap dressing above and below bite area with ACE or crepe bandage, but not
too tight. No tighter than you would use for a sprain. Make sure pulses are present. Wrap ACE
(elastic) bandage as tight as one would for a sprain. Not too tight. Check for pulses above and below
elastic wrap; if absent it is too tight.
Unpin and loosen. If pulses are strong (normal) it may be too loose.

Immobilize bitten extremity, use splinting if available.

If possible, try and keep bitten extremity at heart level or in a

gravity-neutral position. Raising it above heart level can cause venom to
travel into the body. Holding it down, below heart level can increase
swelling.

Evacuate to nearest hospital or medical facility as soon as possible

Try and identify, kill and bring (ONLY if safe to do so) offending snake.
This is the least important thing you should do. Visual
identification/description usually suffices, especially in the U.S. and
in regions where the local fauna is known. Local symptoms will alert doctors
to whether the bite is venomous or not.

Bites to face, torso or buttocks are more of a problem.

ACE/crepe bandaging can not be applied to such bites. A
pressure dressing made of a gauze pad may help.

Antivenom is the only and best treatment for snakebite and you must get as
much as is necessary as soon as possible. Antivenom administration should not
be delayed. Up to 20 vials may be needed to neutralize the effects of rattlesnake and other crotalid
venoms in North America. Precise figures for
venoms of snakes in the Middle East are not available but Israeli experts may
have experience and should be consulted. Children always need more
as envenomation is apt to be much more serious in a small person
compared to a larger one.

PLEASE READ THE FOLLOWING DISCUSSION:

This website suggests the use of containment or sequestration of injected venom

at or near the bite site using broad (3"-6" wide) compression bandaging such as
crepe or ACE(tm)-type elastic bandage. This is the standard worldwide accepted
first-aid treatment for bites by elapid snakes such as cobras, mambas, coral snakes and many
Australian species. This method has delayed on the onset of serious snakebite symptoms as long
as 24 hours in Australia where victims of deadly bites were that far from medical assistance. The
method remains controversial in the U.S. although a number of top snakebite experts have recently
recommended its use in crotalid bites in printed references appearing in peer-reviewed journals. A
recent study conducted at the Naval Medical Center (San Diego) and Loma Linda University Medical
center in experimentally envenomated pigs indicates that the ACE wrap works to contain the venom
and buy time to get to the hospital. A complementary study at Stanford, however, indicates that
people are often unable to apply the wrap with sufficient pressure to work effectively. We
recommend wrapping it tightly but maintaining a palpable pulse in the absence of precise means of
measuring the under-wrap pressure (which should be 60 to 70 mm Hg or slightly less ... slightly
below average diastolic blood pressure).

The use of containment/sequestration for certain types of North American pit

viper (rattlesnake, moccasin and copperhead) bite is felt by some to increase
the risk of disfiguring local tissue injury, which, while not necessarily life-
threatening by itself may necessitate skin grafts and extensive repair and
treatment once the acute, life -threatening phase of the event has passed.Some
experts feel the spread of venom to vital organs can be life-threatening and
that you have no way of knowing how life-threatening a snakebite is in the first
moments of the event. Therefore, users of this method must recognize that there
is a trade-off: containment as a life-saving measure at the risk of local tissue
damage which while not necessarily life-threatening, could be disfiguring,
painful and/or which could require prolonged and extensive follow-up treatment.
We therefore urge readers who decide to use this method on ANY type of snakebite
to do so as a life or death decision and to make this decision in
pre-recognition of the above information. In addition some U.S. crotalid bites,
particularly from large species, results in widespread damage to limbs even when
bites were to digits and hands or feet. Thus the wide-area, low-pressure wraps
can prevent the spread of venom and more widespread damage. Again some experts
feel that this increases the intensity of more localized damage. So while
snakebite mortality without these dressings may be low, we have been appraised
of too many unnecessary and tragic deaths and widespread disfigurement without
its use and in general advocate its use if it is properly applied. Disfiguring
local injury can be limited to a much smaller area compared to crotalid
(pit-viper: rattlers, copperheads, cottonmouths) snakebite where this type of
containment has not been used. Compression bandages are standard in Australia
but these are mostly elapid bites although some have some SERIOUS local tissue
or muscle effects as well. The venom of the King Brown Snake, a widely
distributed species (Pseudechis australis) has as its main target: skeletal
muscle tissue. Bites by Cobras which also have local effects also have direct
acting cardiotoxins so containment can be life-saving in bites by these snakes.
We strenuously oppose the out of hand dismissal of containment, used in
Australia for nearly 20 years successfully, by a few experts in the United
States. Denial of the value of this method by these U.S. experts has resulted in
the death of professional and hobbyist handlers of cobra and other elapid snakes
who erroneously were led to believe that the method should not be used because
of their admonitions that local tissue destruction is its only effect and should
NOT be used under any circumstances. A number of advocates of the method have
been bullied and threatened by a few others who are opposed to this treatment
because they say there is no proof it is of value in rattlesnake bite but they
can point to no studies which disprove its worth whereas there have been animal
studies done using Diamondback rattler venom on pigs and monkeys demonstrating
that it serves to prevent spread of venom and suppress widespread swelling.

Steve Grenard
Staten Island University Hospital South
375 Seguine Avenue
Staten Island NY 10309
[email protected]
[email protected] (always cc to second e-mail address)
718-226-2034 (M-F 9-3)
718-227-6234 (eves and weekends)