Is pressure immobilization recommended for North American snake bites. What are the potential risks and benefits of this technique. How does it compare to other first aid methods for snake envenomation. What do medical experts advise for pre-hospital care of Crotalinae bites. Why is there debate surrounding pressure bandaging guidelines for snake bites in North America.

The Debate Over Pressure Immobilization Bandages for North American Snake Bites

The use of pressure immobilization bandages (PIB) for North American snake bites has become a contentious issue in the medical community. A recent position statement published in the Journal of Medical Toxicology has sparked renewed debate about best practices for pre-hospital care of Crotalinae envenomations. This article explores the controversy surrounding PIB use and examines the scientific evidence informing current recommendations.

Understanding Pressure Immobilization Technique

Pressure immobilization involves applying a firm bandage around the entire length of the bitten limb, combined with immobilization of the affected area. The goal is to slow the spread of venom through the lymphatic system.

How is PIB properly applied?

• Bandage pressure should be between 40-70 mmHg for upper extremities
• 55-70 mmHg pressure is recommended for lower extremities
• The bandage should be comfortably snug, allowing one finger to slip underneath
• The entire bitten limb should be immobilized

Proponents argue that PIB can delay venom absorption and potentially prevent or reduce systemic effects of envenomation. However, its efficacy and safety for North American snake species remain controversial.

The Position Statement on PIB for North American Snake Bites

A joint position statement endorsed by six major toxicology organizations concludes that pressure immobilization bandages cannot be recommended as pre-hospital care for North American Crotalinae bites. This recommendation contradicts recent first aid guidelines published by the American Heart Association (AHA) and American Red Cross (ARC).

Why do toxicology experts advise against PIB for North American snake bites?

1. Most North American venomous snakes produce primarily hemotoxic rather than neurotoxic venom
2. Evidence for PIB efficacy is limited for non-neurotoxic envenomations
3. Potential risks may outweigh benefits for Crotalinae bites
4. Concerns about improper application by laypeople

The position statement authors worry that the AHA/ARC guidelines may be misapplied to North American scenarios, leading to potentially harmful changes in snakebite management.

Examining the Scientific Evidence on PIB Efficacy

The debate surrounding PIB use highlights the challenges of applying scientific evidence to real-world medical practices. While some studies suggest PIB may be beneficial for certain types of snake bites, its effectiveness for North American species is less clear.

What does the research say about PIB for different types of envenomations?

• Studies show PIB can delay venom absorption from some neurotoxic snake bites
• Evidence is limited for non-neurotoxic envenomations like those from pit vipers
• Few clinical trials have assessed PIB for North American snake species
• More research is needed on potential risks and benefits specific to Crotalinae bites

Experts emphasize the need for snake-specific and region-specific evidence before recommending widespread PIB use in North America.

Historical Context: The Evolution of Snakebite First Aid

To understand the current PIB debate, it’s helpful to examine the history of snakebite first aid. Many once-popular treatments have been abandoned as evidence of harm emerged.

Which outdated snakebite treatments have been discredited?

• Tourniquets
• Cryotherapy (application of cold)
• Incision and suction
• Electrotherapy
• Routine fasciotomy

These examples illustrate the importance of rigorous scientific evaluation before adopting new first aid practices. The medical community is understandably cautious about recommending PIB without strong evidence of both safety and efficacy.

Key Considerations for PIB Use in North America

Applying PIB effectively in real-world scenarios involves several important considerations beyond just the technique itself. Medical experts highlight several key questions that must be addressed:

1. Can the snake species be accurately identified?
2. How long will it take to reach definitive medical care?
3. Are laypeople able to distinguish between different snakebite scenarios?
4. What is the likelihood of correct PIB application and maintained immobilization?

These practical concerns underscore the complexity of implementing PIB as a universal first aid recommendation for North American snake bites.

Analyzing the AHA/ARC First Aid Guidelines

The recent American Heart Association and American Red Cross first aid guidelines have sparked controversy by recommending PIB for snake bites. However, a closer examination reveals important nuances in their recommendation.

How strong is the AHA/ARC recommendation for PIB?

• Classified as Class IIa: “weight of evidence/opinion is in favor of usefulness/efficacy”
• Based on Level C evidence: “expert opinion, case studies, or standards of care”
• Intended to apply to snakebites worldwide, not specifically North America

Critics argue that this recommendation is not supported by strong evidence and may be misinterpreted as applying specifically to North American scenarios. The subtleties of the grading system may be lost on many readers.

Balancing Potential Benefits and Risks of PIB

The decision to recommend PIB for North American snake bites requires careful consideration of both potential benefits and risks. While PIB may help in some cases, it also carries potential downsides that must be weighed.

What are the potential benefits of PIB for snake bites?

• Delaying venom absorption into systemic circulation
• Potentially reducing severity of envenomation
• Buying time to reach medical care

What are the potential risks or drawbacks of PIB use?

• Increased local tissue damage if applied incorrectly
• False sense of security delaying medical care
• Masking symptoms that guide treatment decisions
• Difficulty maintaining proper immobilization

For North American pit viper bites, experts worry that risks may outweigh potential benefits, especially given the challenges of proper application by laypeople.

Current Recommendations for North American Snake Bite First Aid

Given the concerns about PIB use for North American snake bites, what do experts currently recommend for pre-hospital care? The focus is on simple, proven interventions that minimize harm.

What are the key first aid steps for North American snake bites?

1. Move away from the snake to prevent further bites
2. Remove constrictive items like jewelry or tight clothing
3. Gently clean the wound
4. Keep the affected limb lower than the heart
5. Remain calm and seek immediate medical attention

Experts emphasize avoiding potentially harmful interventions like tourniquets, incision, suction, or application of ice. The priority is rapid transport to a hospital for definitive care.

The Importance of Snake-Specific and Region-Specific Recommendations

The PIB debate highlights the need for tailored snakebite management recommendations based on local snake species and healthcare resources. A one-size-fits-all approach to snakebite first aid may not be appropriate given the diversity of venomous snakes worldwide.

Why are snake-specific recommendations important?

• Venom composition varies widely between snake species
• Different envenomations may require different management approaches
• Local healthcare resources and antivenom availability impact treatment options
• Environmental factors affect the practicality of certain interventions

Medical experts stress the importance of developing evidence-based guidelines specific to North American snake species and healthcare contexts.

Challenges in Implementing New Snakebite First Aid Practices

Introducing a new first aid technique like PIB for snakebites presents several practical challenges. Even if proven effective, successful implementation requires careful consideration of real-world factors.

What obstacles might hinder PIB adoption for North American snake bites?

• Difficulty in public education and training
• Variability in proper technique application
• Potential confusion with other bandaging methods
• Resistance to changing established practices
• Limited availability of appropriate bandaging materials

These challenges underscore the need for robust evidence and careful planning before recommending widespread changes to snakebite first aid protocols.

The Role of Professional Medical Societies in Guideline Development

The conflicting recommendations between toxicology organizations and the AHA/ARC highlight the complex process of developing medical guidelines. Professional societies play a crucial role in evaluating evidence and formulating recommendations.

How do medical societies develop snakebite management guidelines?

1. Systematic review of available scientific literature
2. Expert panel discussions and consensus-building
3. Consideration of practical implementation factors
4. Grading of evidence quality and recommendation strength
5. Periodic review and updates as new evidence emerges

The rigorous process aims to produce evidence-based guidelines that balance scientific knowledge with real-world applicability. However, conflicting recommendations can still emerge when evidence is limited or interpretation differs.

Future Directions in Snakebite First Aid Research

The debate surrounding PIB use for North American snake bites underscores the need for further research in this area. Several key questions remain unanswered and require scientific investigation.

What are priority areas for future snakebite first aid research?

• Randomized controlled trials of PIB for North American snake species
• Studies on real-world application and maintenance of PIB by laypeople
• Investigation of potential risks associated with PIB for different envenomations
• Development and testing of alternative first aid techniques
• Evaluation of public education strategies for snakebite prevention and management

Addressing these research gaps will provide a stronger evidence base for future guideline development and help resolve current controversies in snakebite first aid recommendations.

The Importance of Continuous Evaluation and Guideline Updates

The evolving debate over PIB use highlights the dynamic nature of medical recommendations. As new evidence emerges and real-world experiences accumulate, guidelines must be regularly reassessed and updated.

How can the medical community ensure snakebite guidelines remain current?

1. Establish regular review schedules for existing guidelines
2. Maintain active surveillance for new research findings
3. Foster collaboration between different medical specialties and organizations
4. Encourage reporting of clinical experiences and outcomes
5. Promote ongoing dialogue between researchers, clinicians, and public health officials

This approach ensures that snakebite management recommendations evolve in line with the latest scientific evidence and practical considerations.

Balancing Scientific Rigor with Practical Applicability

The PIB controversy exemplifies the challenges of translating scientific evidence into real-world medical practices. While rigorous studies are essential, practical considerations must also inform guideline development.

How can guideline developers balance scientific evidence with practical concerns?

• Consider both efficacy and feasibility of interventions
• Assess potential for misapplication or unintended consequences
• Incorporate input from diverse stakeholders, including first responders and patients
• Provide clear guidance on the strength and limitations of recommendations
• Offer alternatives for different scenarios and resource levels

By carefully weighing both scientific data and real-world factors, medical experts can develop snakebite management guidelines that are both evidence-based and practically applicable.

The Global Context of Snakebite Management

While the current debate focuses on North American scenarios, it’s important to consider snakebite management in a global context. Approaches that may be appropriate in one region might not translate well to others due to differences in snake species, healthcare resources, and environmental factors.

How do snakebite management strategies vary globally?

• PIB is more widely accepted for neurotoxic snake bites in Australia
• Some regions rely heavily on traditional medicine practices
• Antivenom availability and quality vary significantly between countries
• Public health education strategies differ based on local snake species and human behaviors
• Transportation challenges impact pre-hospital care options in remote areas

Understanding these global variations can inform more nuanced and context-specific approaches to snakebite management worldwide.

The Role of Technology in Advancing Snakebite Care

As the medical community continues to grapple with best practices for snakebite management, emerging technologies offer new possibilities for improving care and outcomes.

How might technology enhance snakebite prevention and treatment?

1. Smartphone apps for snake identification and first aid guidance
2. Wearable devices to monitor vital signs and venom spread
3. Telemedicine consultations with toxicology experts
4. Advanced antivenom production and delivery methods
5. Data analytics to predict snakebite hot spots and optimize resource allocation

While these technologies hold promise, their development and implementation must be guided by scientific evidence and practical considerations. The goal is to complement, not replace, sound medical judgment and established best practices in snakebite care.

Commentary: Pressure Bandaging for North American Snake Bite? No!

J Med Toxicol. 2011 Dec; 7(4): 324–326.

Published online 2011 Nov 8. doi: 10.1007/s13181-011-0188-9

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Author information Copyright and License information Disclaimer

This issue of The Journal of Medical Toxicology includes a position statement regarding the use of pressure immobilization for the pre-hospital treatment of North American Crotalinae envenomation. This commentary discusses the background behind the creation of the position statement and explores the issues involved in applying science to real-world public health recommendations and practice.

Keywords: Pressure immobilization, Crotalinae, Envenomation

This issue of The Journal of Medical Toxicology includes a position statement regarding the use of pressure immobilization for the pre-hospital treatment of North American Crotalinae envenomation [1]. It has been jointly endorsed by the American College of Medical Toxicology, the American Academy of Clinical Toxicology, the American Association of Poison Control Centers, the International Society on Toxinology, the European Association of Poison Centres and Clinical Toxicologists, and the Asia Pacific Association of Medical Toxicology, and concludes that pressure bandage with immobilization (PBI) cannot be recommended as pre-hospital care in areas such as North America, where non-neurotoxic snakebite is the norm.

This position statement was formulated because of concern about recently published first aid guidelines of the American Heart Association (AHA) and American Red Cross (ARC) [2]. Those guidelines, designed to be applied by bystanders or the victim, included the following:

“Applying [PBI] with a pressure between 40 and 70 mm Hg in the upper extremity and between 55 and 70 mm Hg in the lower extremity around the entire length of the bitten extremity is an effective and safe way to slow the dissemination of venom by slowing lymph flow (Class IIa, LOE C). For practical purposes pressure is sufficient if the bandage is comfortably tight and snug but allows a finger to be slipped under it. Initially it was theorized that slowing lymphatic flow by external pressure would only benefit victims bitten by snakes producing neurotoxic venom, but the effectiveness of pressure immobilization has also been demonstrated for bites by non-neurotoxic American snakes….”

Even though the AHA/ARC recommendation is weak (Class II: “conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.” Class IIa: “weight of evidence/opinion is in favor of usefulness/efficacy”; level of evidence C: “recommendation based on expert opinion, case studies, or standards of care.”) [3] and meant to apply to snakebites worldwide, we are concerned that the recommendations will be applied to North American Crotalinae envenomations. We are also concerned that this guideline was graded above the level of current evidence and that the subtleties of the recommendation grading system are very likely to be underappreciated by most.

The pre-hospital use of PBI in North American snakebite would be a major change in how such cases are managed. The history of snakebite first aid and emergency care is full of concepts that, despite initial theoretical appeal and/or anecdotal evidence, ultimately proved to be harmful. Once-common practices, such as tourniquets, cryotherapy, incision, suction, electrotherapy, and fasciotomy, have been eliminated as their effectiveness was refuted, and more importantly, evidence of harm emerged [4–9]. With this perspective, the introduction of a new practice must be based on the scientific demonstration of efficacy and safety.

The application of science to real-world scenarios can be complex. The aim of PBI is to sequester venom in the limb, delaying its arrival into the central circulation and thereby delaying or even preventing the onset of the potential systemic consequences of envenomation [10]. Apart from directly measuring the clinical efficacy of PBI for various endpoints, together with risks of harm of properly applied PBI, it is important to consider context-specific considerations. Key questions are: (1) the certainty regarding the kind of snake involved, (2) the expected time to arrival at a place where definitive therapy can be provided, (3) whether lay individuals are able to distinguish between scenarios with different management considerations, and (4) the likelihood that PBI will be applied correctly or incorrectly and that immobilization can be realistically maintained.

In addition to these concerns, the larger questions include when, how, and on what basis should a new recommendation in the management of snakebite be put forward? Moreover, when universal benefit may not result, should first aid training be guided by utilitarian endpoints in which many patients might benefit by an intervention that harms some, or even worse, harms many patients and benefits few?

When evaluating the application of PBI to Crotalinae envenomations, the science is incomplete. Randomized, prospective, controlled, studies of PBI in human Crotalinae envenomations have not been performed. Our current state of knowledge comes primarily from animal models and a few studies in neurotoxic snakebite, where local tissue injury is not the major concern. This is an entirely different clinical problem to that posed by Crotalinae envenomations, where local tissue injury predominates. Furthermore, extrapolating from animal models to humans can be problematic, especially when animal studies have used fatality from systemic effects—rather than tissue injury—as a primary end-point. The data on tissue injury in animal studies is limited, but a porcine study demonstrated that tissue pressures in a range that would, in other contexts, result in the consideration of fasciotomy, and which might result in ischemic injury, can occur from PBI [11]. Recent studies in humans have demonstrated that both trained and lay individuals applied PBI that resulted in either ineffective or tissue pressures in the same range [12–14]. Finally, the porcine study of Crotalinae envenomation used in support of the AHA/ARC guidelines [2] actually drew the opposite conclusion, stating: “On the basis of our findings, we cannot recommend pressure immobilization widely for viper envenomation…” [11].

Thus the existing science points away from adoption of PBI in Crotalinae envenomation rather than towards it. Given that 98% of North American venomous snakebites are by Crotalinae, that fewer than 0.2% of those victims die, and that virtually all have soft-tissue injury, the key question is whether deploying pressure immobilization as a first aid strategy in this context will lead to a large number of people with increased and/or permanent limb injury while saving virtually no lives [15, 16]. Clearly, more work needs to be done. But our interpretation of the current state of knowledge is that the potential for harm of PBI in the vast majority of Crotalinae envenomations outweighs the potential benefits.

In the context of limited evidence, it is understandable that learned and well-intentioned individuals may disagree. This makes the consensus of toxicologists and envenomation specialists worldwide in opposition to the use of PBI in the prehospital setting all the more striking. The six organizations that endorse the position statement represent the mainstream medical opinion among experts on four continents. There is currently strong consensus that this technique should not be promulgated or taught in areas where non-neurotoxic snakebite predominates. Thus, in North American Crotalinae snakebite, the evidence for PBI would be more properly graded as Class III: “conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful [3].”

In response to criticisms from members of the clinical toxicology community, the AHA and the ARC have acknowledged that their guideline regarding snakebite does not define the snake groups, geographic locations, and individual circumstances in which PBI might be applicable and also that the data regarding PBI in Crotalinae envenomation are limited and insufficient to deem PBI safe and effective. They are planning to clarify the guideline. For future guidelines, content experts from the position-statement-sponsoring organizations will be invited to assist in the writing (Rose Marie Robertson, personal communication 2011). We applaud the AHA and ARC for their evidence-based approach and their ongoing process of review and clarification.

We agree with the conclusions of the position statement: “The use of pressure immobilization for the pre-hospital treatment of North American Crotalinae envenomation is not recommended [1].”

In the absence of definitive data on much of the pre-hospital management of Crotalinae snakebite, the following recommendations are based on the best available evidence, as well as expert consensus [17, 18]:

1. Get a safe distance away from the snake.

2. Remove jewelry and loosen tight-fitting clothing.

3. Loosely splint or otherwise immobilize the extremity in a functional position.

4. As a default action, maintain the bitten extremity in a neutral position with regard to the heart. Other potential actions should be guided by an experienced clinician.

5. Get to a hospital, preferably transported by an EMS provider. In general, supine positioning will prepare providers in managing possible effects such as hypotension and/or vomiting.

6. Avoid useless and/or potentially harmful interventions, such as tourniquets, incision, suction, cryotherapy, or electric shock.

Steven A. Seifert, Email: ude.mnu.dulas@trefiess.

Julian White, Email: [email protected].

Bart J. Currie, Email: ua.ude.seiznem@trab.

1. American College of Medical Toxicology, American Academy of Clinical Toxicology, American Association of Poison Control Centers, European Association of Poison Control Centres, International Society of Toxinology, Asian Pacific Association of Medical Toxicology (2011) Pressure immobilization after North American Crotalinae snake envenomation. J Med Toxicol. doi:10.1007/s13181-011-0174-2 [PMC free article] [PubMed]

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Pressure Immobilisation First Aid : School of Biomedical Sciences

Bites to the lower limb

1. Move the victim away from the snake. Calm and reassure them. Jewelry such as toe rings and ankle bracelets should be removed before the bandage is applied.

Regardless of where on the limb the bite has occurred, commence bandaging from just above the toes (leave these uncovered so that blood flow to the nail beds can be monitored).

Crepe bandages are ideal, but any flexible material may be used. Clothing, towels etc may be torn into strips.  Panty hose have been successfully used.

Do not take off clothing, as the movement of doing so will promote the movement of venom into the blood stream. Keep the bitten limb, and the patient, still.

Bandage upwards from the lower portion of the bitten limb. Even though a little venom may be squeezed upwards, the bandage will be more comfortable, and therefore can be left in place for longer if required.

2. The bandage should be as tight as you would apply to a sprained ankle.

3. Extend the bandage as high as possible up the limb.

4. Apply a splint to the leg. Any rigid object may be used as a splint.  e.g. spade, piece of wood or tree branch, rolled up newspapers etc.

5. Bind it firmly to as much of the leg as possible.

Keep the patient still. Lie the patient down to prevent walking or moving around.

Bites to the hand or forearm

Bandage as much of the arm as possible, starting at the fingers.

Use a splint to the elbow.

Keep the patient still. Lie the patient down to prevent walking or moving around.

Note: We do not recommend that the arm be bent at the elbow and placed in a sling as this can create a tourniquet effect at the elbow.

Bites to the trunk

If possible apply firm pressure over the bitten area. Do no restrict chest movement. Keep the patient still.

Bites to the head or neck

No first aid for bitten area. Keep the patient still.

Summary

1. Research stresses the importance of keeping the patient still. This includes all the limbs. Bring transport to the patient if possible.
2. DO NOT cut or incise the bitten area.
3. DO NOT apply an arterial tourniquet. (Arterial tourniquets, which cut off the circulation to the limb, are potentially dangerous, and are no longer recommended for any type of bite or sting in Australia.)
4. DO NOT wash the bitten area or suck the bite. The type of snake involved may be identified by the detection of venom on the skin. No attempt should be made to catch or kill the snake.
5. Note: Even if the bitten or stung person is ill when first seen, the application of pressure-immobilisation first aid may prevent further absorption of venom from the bite or sting site during transport to hospital.
6. If the bandages and splint have been applied correctly, they will be comfortable and may be left on for several hours. They should not be taken off until the patient has reached medical care.
7. The treating doctor will decide when to remove the bandages. If a significant amount of venom has been injected, it may move into the blood stream very quickly when the bandages are removed. They should be left in position until appropriate antivenom and resuscitation equipment have been assembled.
8. Bandages may be quickly reapplied if clinical deterioration occurs, and left on until antivenom therapy has been effective.
9. Hospital Staff 
   Please note that first aid measures are usually removed soon after the patient is admitted. Do not leave on for hours.

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Imposition of a plaster bandage from 2,000 rubles in Rostov-on-Don

A medical bandage can be an effective treatment tool in the hands of an experienced qualified doctor. The duration of the recovery period after a surgical operation or injury directly depends on the correct application of the bandage. Specialists of the Rostov medical center “Best-Clinic” are fluent in the techniques of applying dressings of all types and apply their experience in helping our patients.

Why dressings are applied

Dressings are necessary to achieve the following goals:

• protection of the wound surface from external factors and infection
• pressurizing internal organs to stop internal bleeding
• retention of drugs on the surface of the wound
• immobilization of the site of dislocation or fracture

The purposes pursued when applying dressings can be very different, so there are many varieties of medical dressings that differ from each other in the application technique and dressing materials used. Also, dressing is carried out not only for injuries of the limbs, but also after surgical procedures, for example, during operations on the face.

Types of dressings

Different types of dressings are used in modern medicine:

• Pressure

A medical pressure bandage is commonly called a tourniquet and is applied when venous or capillary bleeding occurs. It is also effective when used to stop bleeding from large arteries. It is important to know that a pressure bandage should not be left on the body for a long period of time (in the cold season, the tourniquet must be removed after two hours from the moment of application, and in the warm season – after one hour).

• Occlusal (preventing air and moisture exposure to the wound)

This type of bandage has a powerful therapeutic effect, as it accelerates the formation of epithelium on the surface of the wound, protects the wound from external factors and improves the granulation process. Occlusive dressings are applied during the treatment of dermatological diseases, and are also often used in military field surgery.

• Medicinal (ensuring the supply of medicinal substances to the wound)

When such dressings are applied, the material used is impregnated with the drug. Thus, a long-term access of the drug to the wound surface is achieved. Naturally, the drug bandage can be on the body for a strictly defined time, after which it is necessary to perform a dressing.

• Retainers

Retaining bandages are widely used in sports medicine. Medical dressings of this variety are applied to athletes to ensure the fixation of the joints in case of instability resulting from sports injuries. Retaining dressings are made of modern elastic materials, making their use as comfortable as possible for patients.

• Compression

Bandages of this variety are very effective in the treatment of diseases of the veins of the legs. After applying the bandage, the patient should experience the feeling of a tight-fitting boot, while the toes should not go numb. Compression bandages are applied using special elastic bandages.

• Immobilization (immobilization)

Immobilization dressings are also called transport dressings because they are applied to patients to ensure immobility at the time of transport of the patient. They are applied for joint injuries, fractures, suppurative processes of the limbs and soft tissue injuries, characterized by a large area.

• Aseptic

The main function of an aseptic medical dressing is to prevent infection from entering the wound surface. To apply a dressing of this type, a sterile gauze napkin is used, used in several layers, and cotton wool. Also, an aseptic dressing helps to dry the wound.

• Corrective (providing correction of deformities)

These dressings are applied with an elastic or mesh-tubular bandage, wadding and cotton fabric. Corrective dressings allow you to eliminate congenital or acquired body deformities.

Dressings can be applied using different types of materials. They are thus divided into three categories:

• Splints (hard bandages)

When applying a splint, it is necessary to lay the areas of bony protrusions with a soft material so that abrasions and bedsores do not form under the dressing.

• Soft
• Hardening (starch and gypsum)

Plaster casts are most often used in the treatment of fractures and are an effective means of immobilization. They are very durable and allow the patient to perform an X-ray examination without removing the dressing.

The comfort of the patient and the therapeutic effect of dressings directly depends on the quality of the consumables used in the application.

What is an application kit

This term refers to a collection of medical consumables needed to make various types of dressings that are applied for first aid purposes.