Puffadder bite

On Sunday, 7th April 2013, at about 8:00 pm we received a call from a doctor who had a patient which was bitten by a Puffadder earlier that day. We went to see the patient and advised the doctor about his treatment.

On arrival we learnt that the patient was only 1 year and 9 months old. He was playing in a sandpit with his sister when he got bitten by what was identified and confirmed as a small Puffadder (Bitis arietans) . The bite occurred at about 9:50 am in Vaalwater, Limpopo. The parents then started phoning around to find a hospital with antivenom and trained staff. It was decided to drive through to Pretoria which is about a two hour drive.

The patient was transported to a private hospital where he received only three vials of antivenom. It would seem that the hospital did not have sufficient stock of anti-venom. Normally the child would have received between five and eight vials.

By this stage the swelling had reached his elbow and the digits were a dark blue/purple colour. The patient was then transferred to a government hospital that evening where he is being cared for at the moment.

No further anti-venom was given even though supply at the state hospital was generous, due to the lapse in time and the physical presentation of the bite. He only had one puncture wound and seemed to have only received a small dose of venom.

The finger was inflamed, but the tip was still pink, indicating blood circulation to the tip of the finger was not compromised. There was some petechiae between his fingers and on the back on the hand. The hand was swollen and the arm had swollen till just below the elbow in the 10 hours post bite. His blood seemed to be clotting within normal time. Minimal haemorrhaging at the site of the bite was promising.

The parents and doctor were instructed to ensure the patient has lots of fluids to ensure the kidneys are being flushed. Until then this had been a low priority and the child was slightly dehydrated. They were asked to monitor that the patient is passing urine and that it is not discoloured, which would indicate the kidneys may not be functioning properly. Initially we suggested a slight elevation for the hand but the child was not impeded by the swelling and was moving it around freely. Approximately 2 hours later we also requested that they try to get the patient to flex his hand as the movement will increase the chances of a faster recovery. He was given a few basic exercises to do.

The next evening we visited the patient again. The swelling had gone down on his forearm and only the hand was still swollen. The bite site was still very red and inflamed. His fluid intake is good and urine output was brisk. His general condition was very good. Some ecchymoses (red bruising) on his mid forearm is visible but none in the elbow or armpit areas as normally observed. He is mobile and should be discharged soon if he continues to recover this quickly.