Case report on the bite of Macrovipera lebetina obtusa

Here You may discuss on the toxicology of reptiles, envenomation, snake bites, books on this topic, etc. - This "scary" picture (its the admins right arm) should remind you to be very carefull, when handling venomous snakes!

Case report on the bite of Macrovipera lebetina obtusa

Postby Mario Schweiger » Wed Sep 30, 2009 1:51 pm

The original paper was published by me in German language in:
Herpetofauna (Weinstadt), 26: 14 - 16,
and can be viewed here:
http://vipersgarden.at/PDF_files/PDF-4132.pdf

Here the english translation (shortened):

On May, 4th 1982, near the southern Turkish city Iskenderun, I´ve been bitten by a large Macrovipera lebetina obtusa into the right lower arm. The viper was about 150 to 160 cms long and had a diameter of approx. 5 to 6 cms. The punctures of the teeth has been about 5 cms upside the wrist at the inner side of the arm.
Immediatly after the bite I made a torsion on the upper arm. No slices of the punctures have been made, because of the length of the teeth (approx. 25 mm).
Within 20 minutes I returned to the car.
Allready there was a marked swelling up to half of the upper arm and a dark discoloration.
After a half hour drive we arrived at the hospital in Iskenderun. According to the statement of the facts and the consideration of a physician, I received 20 ml of serum injected into the buttocks. Since no improvement occurred - the swelling had reached the shoulder, the entire arm had yellow-green color, and there were blisters on the first - my friends tried to get more antivenin. This needed about two hours. When the nurse who injected me the first serum, saw the new ampoules, she would have us believe that the antivenin is wrong. These were, however, Behringwerke ampoules: Front and Middle East. I could be ruled out finally that it had acted in the first serum scorpion serum. Now I got a new 20 ml of the serum into the buttocks injected. She also told us that we could be given at this hospital no further assistance and referred us to the hospital in Adana, some 150 kilometers away, the trip took place in our own camper. Here again, I got 30 ml of the latter sera, but no further treatments. My condition deteriorated rapidly although by this time I had no secondary poisoning symptoms, like diarrhea and vomiting.
Late in the evening of 5 May, 36 hours after the snake bite, after massive oedema in the right arm, left arm and body, a fasciotomy (cuts to relieve pressure from blood flow and sensory disturbances) of the right forearm have been done since I carried out so far despite all the measures already in mortal danger hovered, my friends called my parents in Austria, which in turn immediately alerted the Austrian Air Ambulance. A more detailed investigation in the aircraft revealed a severely impaired renal function and also greatly reduced clotting ability of blood to escape into the tissue. This led to fall of blood pressure to extremely low values to a circulatory collapse. In an amputation of the right arm could initially be waived. At May, 7th at 4.30 a.m., I arrived in Vienna and was immediately in the 1st Medical University Hospital launched. The findings on admission showed the following picture: massive edema of the entire upper body with both arms. In fasciotomy we saw blackish discolored muscles addition, a Hypalbuminäny (reduction of the protein in the blood), thrombocytopenia observed (decrease of blood platelets) to initiate coagulation, a moderate coagulopathy and renal impairment.
Considered purely subjective, my condition was probably somewhat relieved, as I once again remind on details, what wasn´t possible between arrival at the hospital Adana and the return flight to Vienna. I received immediate therapy in Vienna, anti-serum, albumin, fresh blood, Heparin, dopamine, antibiotic coverage and tetanus prophylaxis. On 7 May, 8.00 p.m. was operated on me. It should be carried out an inzision on the right forearm. When fasciotomy was opened, found that the arm muscles are completely necrotic. It was therefore carried out a high amputation of the right arm.
After the surgery, I came to the ICU and was ventilated, so they found out a necrosis of the lungs. Noticeably improved after the artificial respiration was discontinued the next day. On 2nd day after the surgery, I felt much weaker. Also I feel disturbances in the left arm and both legs. The legs were dead, as well as from the knees, I could not move at all. A neurological examination brought paresthesia in all extremities as well as complete loss of motor function in the legs. Also nerve conduction was slowed generally strong. Again, I received an infusion of 30 ml of serum, since it was assumed that the neurotic disorders due to the constant presence of snake venom. An examination of the spinal cord for possible damage ran negative.
After 8 days of stay in ICU, I was transferred to the normal station, released a further 4 weeks later, in home care. Since I was told that I could expect an improvement in the paralysis in some weeks or months I was very confident. Was bedridden when I spent a week at home every night fevers came up to above 40° Celsius. Therefore, I was taken to the Psychiatric Hospital Salzburg, as it came to a polyneuritis in which each touch of my body brought a lot of pain. The fever caused by high doses of Penicillin could be taken to relieve. Against the inflammation of the nerves I got infusions in the hospital. After 3 weeks in hospital I had to continue treatment at home with tablets. I now had until the end of December in a wheelchair drive.
In the left hand sensory disturbance had subsided to the fingertips. Also I could run with the left foot back languid movements. But now strong flexion contractures in both knees were left on (extension deficit: 100 ° right: 110 °). By at home and in Braunau Hospital conducted physiotherapeutic treatment of paralysis always sounded off, could only still not move the right foot from the knee, although even now in some places in experiments pain and Thermal differences were felt.
Unfortunately, I got in early August due to high doses of fresh blood a serum hepatitis, which again made a 3-week hospital stay needed. Since I was almost only fed by infusions, I lost weight to 40 kg fast.
After being discharged from hospital in Braunau I came to the rehabilitation and physical secondary treatment in the rehabilitation center in Bad Häring / Tirol. The physical therapy brought here massively implemented constant improvement, so I went on trial in mid-January holiday home. The transient event of the dismissal is not yet completely disappeared flexion contracture (extension deficit in the knees left: 30 degrees, right: 20 degrees) have improved significantly over the past 6 weeks so that I start in March 1983, 10 months after the bite, almost could go normal again.
The power in the legs today (March 1983) is approx. 50% of the normal value. In addition sensitivity disturbances in parts arise at both thighs and in both feet, and the motivity of the toes is still reduced.

So, be careful, when handling venomous snakes!

Mario
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Re: Case report on the bite of Macrovipera lebetina obtusa

Postby Francesco Tri » Wed Sep 30, 2009 5:54 pm

What to say ..... must be terrible trouble passing a similar and almost lose their lives for a passion that sometimes helps us live better.
Personally, your story hit me very emotional, and if something is to say: I'm sorry!
Thanks for having told all of us!
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Re: Case report on the bite of Macrovipera lebetina obtusa

Postby Peter Oefinger » Thu Oct 01, 2009 10:22 am

Mario,
I have read your report before and was really shocked. It was a lesson for me that handling viperas is no game!
Thanks for posting.
One question: have been interested in snakes before or only after that accident?
Regards
Peter
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Re: Case report on the bite of Macrovipera lebetina obtusa

Postby Mario Schweiger » Thu Oct 01, 2009 10:38 am

No, I´m interested in herps - and also snakes - since my childhood.
This accident doesn´t realy change something in my life, except that I have to use now a car with automatic transmission.

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