Venomous snakebite continues to exact a tremendous toll in human suffering and mortality in India. Contributing to this problem is the fact that all of the current Indian snake antivenom manufacturers include a great deal of misinformation in the package inserts and guidelines that accompany their products. Examples include erroneous recommendations regarding first aid, misleading information regarding the signs and symptoms to be anticipated after Indian snakebite, and misleading and ambiguous recommendations as to initial dosing and repeat dosing of antivenom. In addition, the significant problem of acute adverse reactions to Indian antivenoms is compounded by a lack of appropriate recommendations regarding prevention, diagnosis, and management of such reactions. It is the intent of this article to point out problems with the current Indian antivenom product guidelines and to encourage these manufacturers to produce new literature to accompany their products based on the best available evidence.

Objective.—To evaluate the effect of l-carnitine supplementation on improving endurance exercise in normobaric/normoxic and hypobaric/hypoxic environments.

Methods.—Six-week–endurance-trained male Sprague-Dawley rats (n = 24) were randomly divided into 2 groups: control and experimental; the latter group was supplemented with l-carnitine, administered orally in a dose of 100 mg·kg⁻¹ body weight. The animals were supplemented for 25 days under ambient normobaric/normoxic conditions and thereafter were exposed to 72 hours of hypobaric hypoxia equivalent to 6100 m. The supplementation was continued during the exposure. “Run to exhaustion” was recorded on day 1 (R1) (presupplementation) and on days 7 (R2), 14 (R3), 21 (R4), and 28 (R5, which followed the last 72 hours of hypoxic exposure) of supplementation. Food intake, body weight, and the biochemical measures of plasma glucose, total cholesterol, and high-density lipoprotein (HDL) cholesterol were recorded.

Results.—There was a significant improvement in endurance exercise, as indicated by an increase in run to exhaustion following l-carnitine supplementation under normobaric normoxia (36%–39%) and hypobaric hypoxia (50%). l-carnitine supplementation had no effect on plasma glucose levels either at sea level or after hypoxic exposure. Total cholesterol was decreased in normoxic and HDL cholesterol was increased in normoxic and hypoxic conditions, indicating a beneficial effect of exercise.

Conclusion.—l-carnitine supplementation improved exercise endurance in rats exposed to normobaric normoxic and hypobaric hypoxic conditions. Such supplementation would be beneficial in delaying the onset of fatigue during prolonged exercise in both conditions, indicating its potentially beneficial use at high altitude.

Objective.—Numerous studies support the use of warmed intravenous fluids in hypothermic patients. The most effective method to accomplish this goal in a cold prehospital, wilderness, or combat setting is unknown. We evaluated various methods of warming intravenous fluids for a bolus infusion in a cold remote environment.

Methods.—One liter and 500 mL bags of intravenous fluid at 5°C were heated using various methods in a 5°C cold room. Methods included attachment of 3 types of chemical heat packs and heating the fluid in a pot on a camping stove. For all methods, fluids were run at a wide-open rate through an intravenous line with an 18-gauge catheter attached to the end to simulate a bolus infusion. The temperature of the fluid at the end of the intravenous line was measured. Each method was tested twice. Equipment weight and setup times are reported. Mean infusion temperatures for the various methods are compared.

Results.—Equipment weights ranged from 19 to 665 gm. Setup times ranged from 5 to 11 minutes. The 2 methods which achieved the desired mean infusion temperature of 35 to 42°C without excessive maximum temperatures were 1) 2 Meal Ready to Eat hot packs attached to a 500 mL bag of fluid for 10 minutes prior to infusion, and 2) a camping stove heating the surface of a 500 mL bag of fluid to 75°C prior to infusion. Other methods, including the use of commonly available heat packs and a commercially available IV fluid warmer were ineffective, with mean infusion temperatures ranging from 7 to 12°C.

Conclusions.—Heating of cold intravenous fluids in a cold environment is possible using either Meal Ready to Eat heat packs or a camping stove. Further study is needed to evaluate the ability of either method to consistently produce an appropriate fluid temperature given various ambient and initial fluid temperatures.

Objective.—Outdoor-related activity has been on the rise in recent years, and hiking and backpacking are among those activities with the largest growth in participation. As the number of participants with varying experience increases, it is expected that there will be an increase in injuries related to these activities. Little empirical data exist related to outdoor injury types and rates. Our objectives were to determine incidence and frequency of injuries related to outdoor activity and requiring emergency medical system (EMS) activation at a national park.

Methods.—This retrospective study examines injuries within Yellowstone National Park. Subjects were selected from a database containing all EMS calls within Yellowstone National Park from calendar year 2003 through 2004. Data collected included age, gender, type of injury, location, activity at the time of injury, and EMS response.

Results.—There were 306 injuries reviewed. The mean age of patients was 40.9 years (SD: 23.0), and the group comprised 49.0% males. Emergency medical system transport was not required in 59.2% of injuries, and of those transported, 58.4% of patients required basic life support only. Of all injuries, 77.4% involved soft tissue, including lacerations. Hiking and walking accounted for 38.0% of all injuries, and 56.0% of those injuries involved the lower extremity. Only 8.8% of the injuries involved fractures and/or dislocations.

Conclusions.—In this study of EMS responses at a national park, the majority of injuries sustained were minor in nature. More than one third of injuries occurred while patients were hiking or walking, and most of those injuries involved the lower extremity. These results will help optimize resource planning in the national park setting.

Category 1 Continuing Medical Education credit for WMS member physicians is available for this article. Go to  http://wms.org/cme/cme.asp?whatarticle;eq1831 to access the test questions.

The prevention and management of venomous snakebite in the world's mountains present unique challenges. This paper presents a series of practical, clinically sound recommendations for management of venomous snakebite in a mountain environment. The authors performed an extensive review of current literature using search engines and manual searches. They then fused the abundant knowledge of snakebite with the realities of remote first aid and mountain rescue to develop recommendations. A summary is provided of the world's most troublesome mountain snakes and the mechanisms of toxicity from their bites. Preventive measures are described. Expected symptoms and signs are reviewed in lay and medical terms. A review of currently recommended first-aid measures and advanced medical management for physicians, paramedics, and other clinicians is included. Venomous snakebites in mountainous environments present unique challenges for management. This paper offers practical recommendations for managing such cases and summarizes the approach to first aid and advanced management in 2 algorithms.

Imported human paragonimiasis has been reported in the United States. However, autochthonous cases are rare. We describe a case of probable Paragonimus kellicotti infection associated with ingestion of crayfish and review all autochthonous cases in this country.

Fatalities following rattlesnake bite are rare in the United States, usually occur some hours following the bite, and are generally secondary to direct venom effects. We report a patient with acute syncope and subsequent massive aspiration resulting in airway obstruction and rapid death following a probable Northern Pacific rattlesnake (Crotalus oreganus oreganus) bite.

Objective.—There have been few studies evaluating snakebite mortality in Venezuela and South America. In this study we evaluate trends in fatal snakebites occurring in Venezuela between 1995 and 2002.

Methods.—Epidemiological data for this study were retrieved from the records of the Ministry of Health of Venezuela. Using these data, we analyzed the impact of snakebites in Venezuela during the study period.

Results.—During the study period, there were 266 reports of death due to snakebite; 79.7% were males, and 20.3% were females (P < .01). Annual mean deaths numbered 33 per year. Of total deaths, 24.1% occurred in victims 55–70 years old. Deaths in young children (<5 years old) accounted for 7.1% of the total. Mortality rate by age showed an age-dependent rate, with higher rates in older ages (P = .038).

Conclusion.—Snake envenomations are an important cause of injury and deaths in Venezuela as in many American countries. Surveillance of envenomations is essential for establishing guidelines, planning therapeutic supplies, and training medical staff on snakebite treatment, as well as assessing risk zones for travelers.

Category 1 Continuing Medical Education credit for WMS member physicians is available for this article. Go to  http://wms.org/cme/cme.asp?whatarticle;eq1832 to access the test questions.

Rabies, a fatal encephalitis of viral origin, is still a major health problem in the developing world. It begins, after exposure, with centripetal spread of the virus through peripheral nerves to the central nervous system. The virus proliferates there and spreads to the tissues via peripheral nerves. The diagnosis is not difficult when a nonimmunized patient presents with hydrophobia after a bite by a known rabid animal. Failure to identify an exposure and administer postexposure prophylaxis, however, can lead to a fatal outcome. We report 3 fatal cases of rabies in which the risk of developing rabies had not been seriously considered. Two had apparent dog bites, but 1 had a minor abrasion. Because rabies is uniformly fatal, possible exposure should be seriously considered in patients with mammalian bites or scratches.

Objective.—Mass participation in competitive open water swimming is becoming increasingly popular. The purpose of this study was to determine whether infrared emission detection (IRED) tympanic temperature measurement taken in participants approximately 1 minute following a long-distance open water swimming event is a suitable screening tool for hypothermia.

Methods.—We studied 15 males and 7 females who completed the 20-km Rottnest Channel Swim off the coast of Perth, Western Australia. Following the swim, each athlete was clinically assessed for hypothermia through the observation of gait, cognitive processing, and demeanor. Approximately 1 minute following the swim, participants underwent temperature measurement using one of two IVAC Core Check 2090 IRED tympanic thermometers set to core equivalent mode. Further tympanic readings and an oral temperature reading were taken at 5 minutes post swim in subjects triaged to the medical tent after the initial clinical screen.

Results.—At 1 minute post event, the average tympanic temperature measurement was 28.9°C (95% CI, 28.3–29.7), while at 5 minutes postevent it was 31.6°C (95% CI, 31.1–32.2). The average oral temperature at 5 minutes post event was 34.3°C (95% CI, 33.7–34.7). The difference between the screening tympanic and oral temperatures was statistically significant (P = 0.000)

Conclusions.—Infrared emission detection tympanic thermometry is unsuitable as a screening tool for hypothermia following a prolonged open water swim because it substantially overestimates the incidence and severity of hypothermia in participants.

Category 1 Continuing Medical Education credit for WMS member physicians is available for this article. Go to  http://wms.org/cme/cme.asp?whatarticle;eq1833 to access the test questions.

Families are traveling with their children in increasing frequency. Travel to Asia offers children many opportunities to learn about new cultures and history. It also offers the potential for exposure to numerous infectious agents not commonly encountered in the United States. Families must begin to prepare for travel to Asia weeks before departure. Children should be up to date on routine vaccinations. Appropriate education should be given on arthropod avoidance and malaria prophylaxis. Additional education and possible prophylaxis should be completed for other infectious agents frequently encountered in Asia. With appropriate pretrip immunizations and prophylaxis, children can travel to Asia with minimal risk of acquiring infection. This article provides general advice to assist providers with pretravel preparation and education of families traveling with children to Asia.