The Flying Death Adder

Note: The purpose of this site if to provide free open access medical education (FOAMed) in the context of rural and remote health. Though all stories have been inspired by real cases, all identifying details such as names, ages, locations and background descriptions have been thoroughly changed to ensure the absolute privacy of the patients, families and communities we serve.

The Situation:

The school day had ended, and dusk was approaching on one of the pristine islands in the Torres Strait.  A 10-year-old girl and her friends were slowly making their way home when they came across a death adder on the road. The group armed themselves with sticks and approached the snake. Making a game of it, the snake was flicked into the air with a stick and landed on the road again. On the second throw, the snake was inadvertently hurtled directly at the girl by her twin brother. Its fangs collided with her index finger of her open hand leaving one tooth lodged in the pulp.

Immediately the girl pulled out the tooth, sucked the fang wounds and sprinted to her house. Neither child mentioned events of the afternoon to their family. They proceeded to have dinner and get ready for bed. As her mother was settling her into her room for sleep the girl finally burst into tears and sheepishly divulged what had occurred.

Minutes later the family presented to the small medical clinic. As it was afterhours and phones on the island were not working due to a fault, the nurse on-call was alerted to the situation by the loud knocking on the clinic door downstairs. She quickly assessed the patient, applied a pressure immobilisation bandage and used a satellite phone to alert the on-call doctor on Thursday Island.

I had just finished my dinner, when I received the call and made the immediate decision to medically retrieve the child to Thursday Island. The health centre on the island where she lived was staffed by one nurse and one indigenous health worker and the only investigations available were point-of-care blood tests, urine dipstick and a glass jar to check clotting time. She was asymptomatic with normal snakebite observations but required transfer to a hospital setting to have appropriate tests prior to release of her pressure immobilisation bandage and ongoing monitoring.

I tasked the retrieval via the coordination service based 2,200km away and the rescue helicopter was dispatched from an island nearby. As I was awaiting my patient’s arrival, I printed the snakebite protocol and pre-emptively began writing pathology forms to monitor her progress for the next 12 hours. I asked for urine sample, ECG and placement of two IVCs prior to transfer. The bite site was also swabbed, and the sample placed into a sterile jar, so a venom-detection kit could be run if there were any future signs of envenomation.

The patient was well on arrival to Thursday Island and travelling with her was a large white Styrofoam box with ‘2x Death Adder Inside!!’. While awaiting the arrival of the helicopter and filled with remorse, her brother snuck out from the clinic to track down and capture the snake. Alarmingly, only one snake was present.

The pathology lab is closed afterhours, so a staff member was called in to run the first set of bloods. Examination and initial investigations were normal. The decision was made to remove the pressure immobilisation bandage as per protocol. She was observed in resus and she remained well. Before transfer to the ward for hourly snakebite observation her repeat examination and blood tests were normal. I finished my notes, made a plan for the evening and headed home for a few hours of sleep.

Two hours later, within minutes of me falling asleep, I was alerted by phone that her eyelids were droopy and that she felt weak in her arms. I requested that her PIB be replaced, to move her to a high acuity area and for the VKD to be run from the swab of the bite site. After arriving at the hospital, I confirmed ptosis was present, but the remainder of the examination was normal. Power in limbs was 5/5 in and bedside peak flow was unchanged. The VDK was strongly and quickly positive for death adder.

Through discussion with the on-call toxicology at Cairns Hospital it was decided to give one vial of death adder antivenom. Preparations were made for resuscitation in case of anaphylaxis. Administration of antivenom went smoothly, PIB was removed and there was no progression of weakness. Apart from ongoing ptosis, the patient remained well and I went home to bed several hours later.

Her overnight course was uneventful and by late that afternoon her ptosis had mostly resolved. By the next day she was ready for discharge. She was up to date with her tetanus immunisation. I discussed signs and symptoms of serum sickness with her family and prescribed a small dose of prednisolone to try to avoid this. She flew home after a two-night inpatient stay. The siblings had been thoroughly told off by their understandably-annoyed mother and I doubt they will be throwing snakes again.

Discussion

In the dry season it is not unusual to manage one or two cases of snakebite each week through Thursday Island. Use of robust protocols has streamlined the medical management and made clinical decision making reasonably simple. We receive outstanding advice from the friendly Cairns Hospital toxicologist as needed. Often the greatest challenge of the situation is logistics. Almost all patients require transfer via rescue helicopter to Thursday Island Hospital as this is the sole place formal pathology is available in the region. As there is only one rescue helicopter available, there can be inevitable delays due to weather, higher acuity patients needing urgent transfer or maintenance of the helicopter. Most clinics have the ability to perform point-of-care blood tests, urine dipstick, ECG and whole blood clotting time by where patient’s blood is placed next in glass jar and if blood dose not clot within 20 minutes coagulopathy is likely present. Sometimes these crude tests are the best that is available and can give some useful clinical information.

Sometimes clear envenomation occurs and antivenom is required prior to transfer. I have personally prescribed snake antivenom multiple times via telehealth with specialist advice. The venomous snakes in our regions are the taipan, Papuan black snake, death adder and eastern brown snake. Profiles of each snake can be reviewed below:

https://www.nps.org.au/australian-prescriber/articles/snake-bite-a-current-approach-to-management

A venom detection kit can be invaluable in the case of snakebite, but I find that in practice it is often performed incorrectly. It is necessary to watch the kit closely as the first well to change colour will identify the snake, however often this is left on a bench while staff are running. A good explanation of how to use a VDK is here:

Death adders are ambush predators and envenomation occurs in about 60% of bites. Further information on how to approach a death adder bite is summarised below:

Death Adder