The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.

Letter to the Editor

Editor, - Your article on antivenom (Aust Prescr 2012;35:152-5) updates all physicians working in emergency departments in areas where envenomation cases are likely to be treated.

Most antivenoms have been removed from our rural emergency room. Given your wide readership, it would perhaps have been beneficial for smaller centres, which now have no antivenom, if the article had mentioned the change in policy on treatment, transport and stabilisation of patients in isolated, non-resourced centres.

Martes Alison
General practitioner
Trundle, NSW

Authors' comments

Nick Buckley and Ian Whyte, the authors of the article, comment:

Management of snakebite in remote areas, particularly those without 24-hour laboratory facilities, presents many challenges. Point-of-care tests (for example iSTAT INR and d-dimer) do not substitute for laboratory studies and should not be used under any circumstances. The ‘20 minute whole blood clotting test’ may detect coagulopathy, but requires small clean glass tubes. Even if these are available, in practice the test often will not detect envenomation. Most patients with suspected or confirmed snakebite should therefore be transferred to a larger hospital (with a pressure bandage on the bite and immobilisation) for diagnosis and monitoring.

Most remote hospitals will still be recommended to keep a minimal stock of antivenom. For symptomatic patients, a decision may be made to administer antivenom before or during transfer without laboratory confirmation. Weak evidence suggests early antivenom may reduce the incidence of some complications such as myotoxicity, but at the cost of potential adverse effects from the antivenom (if the patient is not envenomed). This should only be done if the doctor is prepared to treat anaphylaxis.

The NSW Health’s snakebite guidelines recommend stocking of antivenom in Trundle (and the NSW Therapeutic Advisory Group lifesaving drugs register recommends that it is available). It is concerning if it is not, for it follows there is no current quick and reliable means of determining where the nearest hospital is with antivenom stocks.

This is another example of the urgent need for a national policy on stocking antidotes and a regularly audited antidote register with a search tool to locate them in an emergency.