This guidance should be read in conjunction with Management flow chart and suspected snake bite clinical pathway (Victoria).
The above clinical pathways are considered to be the guidance source for snake bite within Victoria. Specific advice regarding bites in snake handlers and from exotic snakes should be obtained from a clinical toxicologist (for example, Poisons Information Centre 13 11 26).
At all times when managing snake bite the first aid measures – such as reduce patient movement, apply pressure bandage with immobilisation – should be prioritised and can be implemented in any resource setting, including in the community or any health setting.
Public information for the management of snake bite is available from the Better Health Channel.
This guidance is related to the stock holdings of antivenom.
Snakes endemic to Victoria include the Tiger, Brown, and Red Bellied Black. Bites from endemic snakes are managed with either TIGER or BROWN antivenom.
Snakes that are not endemic to Victoria are usually located along geographical border areas, such as Mildura, or in the care of snake handlers, collectors, or zoos. Bites from non-endemic snakes are managed with POLYVALENT antivenom.
Service levels for minimum antivenom stock holding
All emergency departments should have minimum antivenom stock holdings as defined below.
Urgent care centre (UCC)
Where the UCC is medical practitioner led and maintains stable medical practitioner coverage for the majority of their operating hours, the minimum antivenom stock holdings are recommended.
Where the medical coverage is not stable and does not cover the majority of the service hours then no antivenom stockholding is recommended. Instead, first aid measures and early ambulance transfer to a referral service should be prioritised.
Defining the minimum stock holding
- 2 doses (2 vials) of TIGER snake antivenom
- 2 doses (2 vials) of BROWN snake antivenom
- 2 doses (4 ampoules) of RED BACK spider antivenom.
Service levels and stock holding for POLYVALENT antivenom
- The recommended minimum stock holding of POLYVALENT is 1 dose (1 vial)
It is recommended that the minimum stock holding of POLYVALENT is maintained at:
- the geographically-isolated, border health service at Mildura
- large regional health services (Geelong, Ballarat, Bendigo, Shepparton, and Traralgon)
- metropolitan toxicology services (Austin, Monash, Royal Melbourne).
Specific antivenom for unique/novel/exotic snakes (not covered by the POLYVALENT) should not be a routine stockholding and should be based on local risk. For example the proximity of the Royal Melbourne Hospital to the Melbourne Zoo may create a local risk that requires specific antivenom in addition to the minimum stock holding.
Snake venom detection kits (SVDK)
Snake venom detection kits can be useful, but in inexperienced hands they can have significant rates of snake misidentification, false positives and false negatives.
Given the narrow range of snakes involved and interpretation issues with snake venom detection kits, it is reasonable to exclude snake venom detection kit analysis from clinical pathways. This is, however, a decision for local health services.
- SVDK should be a pathology service provided test
- SVDK test kits should be moved to the pathology service provider and not made available for clinician use within an emergency department.
Red Back spider
The management of Red Back spider envenomation is different to that for snakes. There is no need to apply pressure bandage with immobilisation, instead care is largely supportive. A key feature of Red Back spider envenomation is pain. The provision of adequate analgesia is highlighted as a fundamental aspect of management prior to administration of antivenom.
Transfer and location of care
The preferred location of initial care for patients with snake bite is a critical care area, with 24hr laboratory pathology access, such as an emergency department.
- Patients presenting directly to Ambulance Victoria should be transferred to an emergency department, if necessary bypassing urgent care centres.
- Patients presenting to urgent care centres should have an emergency ambulance transfer arranged at an early stage.
Ensuring that patients who require antivenom are able to receive it in the shortest timeframe requires coordination of resources. The retrieval services (Adult Retrieval Victoria, or PIPER) should be contacted early for advice, coordination of resources, transfer assistance, and potentially shared care in the commencement of antivenom prior to arrival at an emergency department.
Safer Care Victoria convened an expert reference group to provide guidance on the minimum stock holdings for snake and spider antivenom within Victorian health services.
The expert reference group included the following clinical toxicologists and experts in management of snakebite:
Prof. Andis Graudins, Prof. George Braitberg, A/Prof. Bill Nimorakiotakis, Dr Ken Winkel, Prof. Alan Wolff, Kent Garett, Pat Standen, and Alan Eade (chair).
These materials have been endorsed by round table members.
Page last updated: 25 Oct 2018