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Bites from the adder, Vipera berus, are well known for causing local and general toxicity. We report a case of a 63-year-old female who was bitten in one of her lower extremities. She was seen twice in the emergency department with symptoms and signs consistent with severe envenomation. Despite treatment with antihistamines and corticosteroids the oedema persisted. A lymphoscintigraphy was performed showing dermal backflow in the right leg, confirming the diagnosis of lymphoedema. Based on the present case report and review of the literature antivenom therapy should be considered more actively.

The clinical course after adder bites (Vipera berus) is unpredictable. Antivenom can reduce morbidity markedly. Preventive use of low-molecular-weight heparin is not routinely recommended. We present a case report, where indication for antivenom was not found, and the patient developed pulmonary embolus. Thrombotic complications are known, but to our knowledge pulmonary embolus has not previously been described in the literature.

Correct treatment of adder bites can reduce morbidity. We aim at creating an evidence-based guideline on pre- and in-hospital treatment of bites by the European adder (Vipera berus). Pre-hospital treatment consists of reassurance, immobilisation, elevation and paracetamol for pain. Icepacks, oral suction and tourniquets should be avoided. In-hospital treatment includes tetanus prophylaxis, paracetamol or opioids, antiemetics and the monovalent ovine immunoglobulin Fab fragment ViperaTAb. We strongly advise emergency departments to carry up-to-date guidelines regarding bites from the European adder.

Bites from the adder, Vipera Berus, can have serious clinical consequences due to systemic effects. Meanwhile, the local swelling calls for attention as well. Two cases of seven- and eleven-year-old boys are reported. The first patient was bitten in the 5th toe, the second in the thumb. Both developed fasciotomy-requiring compartment syndrome of the lower and upper limb, respectively. Recognition of this most seldom complication of an adder bite is vital to save the limb. We recommend that the classical signs and symptoms of compartment syndrome serve as indication for surgery. However, compartment pressure measurement can be helpful in the assessment of children.

Introduction: The adder is the only poisonous snake in Denmark. Approximately five children and adults are each year hospitalized in Ringkoebing due to adder bites. The aim of this study was to illuminate who they are, under which circumstances they are bitten, their symptoms and treatment. What are the recommendations of treatment in the literature?, Material and Methods: Historical review including patients who were discharged with the diagnosis DT 630 adder bite from Ringkoebing Hospital from January 1st 1995 through June 17th 2000., Results: A total of 31 patients between two and 78 years of age were admitted to the hospital. 55% were 13 years old or less. Thirty of the patients were tourists in the area. The patients stayed in hospital for 20 hours on average. Common symptoms were edema, pain, nausea and signs of shock. 35% were moderately poisoned, the remaining were less affected. Symptomatic treatment was sufficient., Discussion: The average time in hospital was shorter than in other reviews. Like in other reviews a frequent use of antibiotics and antihistamines, which do not correlate with recommendations in the literature, was found. All patients need observation for a minimum of six hours. Patients without symptoms can then be discharged with relevant anti-tetanus. Patients with symptoms should be observed for at least 24 hours. Treatment is symptomatic. Sheep-fab-fragment antivenom, ViperaTAb, which is less allergenic than other antivenoms on the market, should be employed in case of severe symptoms.

A case of arterial hypertension following an adder bite (Vipera Berus) in a six year-old boy is presented. Initially he had gross local symptoms and mild systemic symptoms, but was not treated with viper venom antiserum. Ten days after the initial admittance he developed symptoms of high blood pressure. Microscopic haematuria was found, and renal function was mildly impaired. It was concluded that the adder bite had caused the temporary rise in arterial blood pressure and renal dysfunction. Treatment with viper venom antiserum is recommended if local symptoms progress to involve the trunk or if systemic symptoms evolve.

Two cases of bites by the common viper were reviewed. Emphasis was focused on proper medical monitoring in an intensive care unit for a minimum of one day. Observations should include ECG, Hb, leucocytes, electrolytes in both blood and urine, CPK, and coagulation factors. Surgical intervention, heparin and cryotherapy are not recommended. Proper treatment with immobilisation of the bitten extremity, tetanus antitoxin and volume therapy is recommended. In severe cases Zagreb Antitoxin should be used. Patients with cardio-pulmonary problems require special attention.