SNAKE BITE

DEPARTMENT OF MEDICINE INTERN DR. SASHMI MANANDHAR

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INTRODUCTION

EMERGENCY
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EPIDEMEOLOGY
IN NEPAL NUMBER 10000 snake bites/year 10-20% poisonous 2/3: Krait 1/3: Cobra 15% mortality Terai: Cobra and Krait Hilly and Himalayan: Pit Vipers 2/3: >15 years Mortality: : >15 years Male > Female April and May (onset of summer) Peak at June, July, Aug, Sept (during and after monsoon) 2/3: Night : hands, rest on foot, head, neck, buttocks, back, chest
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PLACE AGE SEX TIME

SITES

Kavre

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POISONOUS vs. NON POISONOUS (=77 species)

POISONOUS (21) NON POISONOUS (56)

 2 Families:

 3 Families:

Elapidae Cobra Kraits Viperidae Viper Pit vipers

Typhlopidae, Boidae, Colubridae  Common names: Blind Snakes Boas and Pythons Wolf snakes Rat snakes Aquatic snakes
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IDENTIFICATION
POISONOUS Mouth Dorsal and Ventral scales 2 or 1 fang -Run completely across the belly - Ventral scales broader - Broad, flat, triangular - Small, numerous, irregularly arranged scales Elliptical Present

POISONOUS SNAKE
NON POISONOUS No fangs - Does not run completely across the belly - Dorsal and ventral scales similar -Elongated, rounded, beak like or blunt - Large scales (shields)

Head

Pupil Heat sensitizing pits Anal Plate

Rounded Absent

Single row of sub caudal plate

Double row of sub caudal plate

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VENOM APPARATUS

 Similar to hypodermic

needle with a syringe  Fangs:

Modified maxillary teeth At the most ant. of palatine teeth Canalized If lost, replaced by budding units

 Venom Conducting

ducts:

Post. Main venom gland to centre of ant. Accessory gland to fang sheath

 Venom glands:
Modified parotid salivary gland
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VENOM - Composition
Constituents Procoagulant enzymes (Vipers) Haemorrhagins (Zinc metalloprotinases) Cytolytic or necrotic toxins Hemolytic and Myolytic phospholipase A2 Pre synaptic neurotoxins (Kraits) Post synaptic neurotoxins (Cobras) Characters Stimulate clotting cascade However lead to incoagulable state Damage endothelial lining of the vessels Spontaneous systemic hemorrhage Increase permeability Local swelling Damage cell membrane, endothelium, skeletal muscles, nerve cells and RBCs Phospholipase A2 Initially release Acetylcholine transmitter Later interfere with the release Compete with Acetylcholine for receptors in NMJ Lead to paralysis
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BITING MECHANISM
 Raising of the head, Opening of the mouth,

Elevation of fangs, Darting the head forward, Stabbing the victim  Meanwhile
Lower jaw closed upon the bitten parts Effected by post, middle and ant. Temporal muscles Last musc. so folded , compresses 2/3 of the venom gland Venom through the duct into the fang to the victim

 Head immediately withdrawn  Some bite once and withdraw, some bite several

times and hold on to the flesh

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CLINICAL FEATURES
 Dry Bite (when the venom has not been

injected) or Non Poisonous Bite

Fear Heart attack Anxiety Over breathing, Dizziness Extremities Tingling sensation, stiffness or tetany

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CLINICAL FEATURES
 Local features at the bite

site
Swelling (Vipers and Cobras) Fang marks (Vipers) Local pain (Vipers and Cobras) Local bleeding Bruising and Blistering Lymphadenopathy Infection, abcess formation, necrosis
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CLINICAL FEATURES
 Early (When the patient is still responsive)
General
Nausea, vomiting, malaise, abd pain, generalized pain, anxiety, dizziness, drowsiness

Systemic
Hematological (Vipers)
Bleeding and clotting disorders

Neurological (Cobras and Kraits)

Abnormalities of taste and smell Ptosis, external ophthalmoplegia Change in voice Aphonia Dysphagia Facial muscle paralysis

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CLINICAL FEATURES

 Late (When the patient responds with difficulty)

Hematological
Spontaneous systemic bleeding Skeletal muscle breakdown Acute renal failure

Neurological
Salivation Ptosis Broken neck sign Tachycardia Dyspnea Flaccid paralysis

Endocrine
Acute Phase: Shock , Hypoglycemia Chronic Phase: Weakness, loss of sexual hair, amenorrhea, testicular atrophy, hypothyroidism
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FIRST AID MANAGEMENT

What to do??
 Reassurance  Removal of jewellary, tight fitting

clothes  Pressure immobilization

Crepe bandage 10 cm wide and 4.5 m long Firmly bound around the entire limb, starting from distal part, including a sling Peripheral pulses should be palpable, one finger into the bandage

 Snake to be identified if possible  Immediate transportation to the

hospital Not allowed to walk

What not to do??  Interference with the bite wound  Release of pressure bandage until antivenom therapy started  Tight arterial tourniquets, but if already in place, do not remove, slightly loosen  Traditional methods  Handle the snake with your bare hands as even a severed head can bite!!
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IN THE HEALTH CENTRE

 Rapid clinical assessment and resuscitation
ABC GCS Indications:
Profound hypotension and shock Respiratory failure Acute renal failure and septicemia with necrosis

 History
In which part of the body have you been bitten? When were you bitten? Where is the snake that bit you? Progression of symptoms Colour of urine Fang marks

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IN THE HEALTH CENTRE

 Examinations - General
Vitals Fang marks Swelling Skin changes Lymphadenopathy Abdominal tenderness Loin pain Signs of intracranial hemorrhage

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IN THE HEALTH CENTRE

 Neurotoxicity
External ophthalmoplegia Pupillary reaction Mouth opening and protusion of tongue Cranial nerves Broken neck sign Paradoxical repiration

 Bleeding disorders
Bleeding from orifices

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IN THE HEALTH CENTRE - Investigations

20 WBCT Few ml of fresh venous sample in a test tube Leave undisturbed for 20 min Tip the vessel once Unclotted blood indicates consumption coagulopathy (Hypofibrinoginaemia) - TC: Early neutrophil leukocytosis - Platelets: Decreased in Viper bites Blood film: fragmented red cells ("helmet cell", schistocytes) - microangiopathic haemolysis - Aminotransferases and muscle enzymes (creatine kinase, aldolase) elevated - generalised muscle damage - Mild hepatic dysfunction - Bilirubin elevated - massive extravasation of blood. - Creatinine, urea or blood urea nitrogen levels - renal failure - Early hyperkalaemia - rhabdomyolysis - Bicarbonate low in metabolic acidosis RBCs, Myoglobin

Hematology

Biochemistry

Urine R/E ECG

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SPECIFIC TREATMENT - Antivenin Therapy

 Antivenom
Ig (usually the enzyme refined F(ab0)2 fragment of IgG) Purified from the serum or plasma of a horse or sheep that has been immunised with the venoms of one or more species of snake "Specific" antivenom- antivenom raised against the venom of the snake that has bitten the patient and that it can therefore be expected to contain specific antibody that will neutralise that particular venom Monovalent or monospecific antivenom: neutralises the venom of only one species of snake Polyvalent or polyspecific antivenom: neutralises the venoms of several different species of snakes, usually the most important species, from a medical point of view, in a particular geographical area. Paraspecific activity : Antibodies raised against the venom of one species may have cross-neutralising activity against other venoms, usually from closely related species.
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ANTIVENIN THERAPY - INDICATIONS

 

One or more of the following signs Systemic envenoming Haemostatic abnormalities: spontaneous systemic bleeding , coagulopathy (20WBCT or other laboratory) or thrombocytopenia (<100 x 109/litre) Neurotoxic signs: ptosis, external ophthalmoplegia, paralysis etc Cardiovascular abnormalities: hypotension, shock, cardiac arrhythmia, abnormal ECG Acute renal failure: oliguria/anuria, rising blood creatinine/ urea (Haemoglobin-/myoglobin-uria:) dark brown urine, urine dipsticks, other evidence of intravascular haemolysis or generalised rhabdomyolysis (muscle aches and pains, hyperkalaemia) Supporting laboratory evidence of systemic envenoming

Local envenoming Local swelling involving more than half of the bitten limb (in the absence of a tourniquet) Swelling after bites on the digits (toes and especially fingers) Rapid extension of swelling (for example beyond the wrist or ankle within a few hours of bites on the hands or feet) Development of an enlarged tender lymph node draining the bitten limb

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ANTIVENIN THERAPY - CONTRAINDICATIONS

 No absolute contraindications  Sensitive to horse or equine serum  Strong history of atopic diseases

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Antivenin therapy
 Freeze dried antivenon
Reconstituted with 10 ml of sterile water for injection/vial

Route and doses

 2 vials in 20 ml distilled water IV over 10 min at not > 2ml/min  4 vials in 500 ml of 5%dextrose infusion over 4hours interval for 8-12 hours  Patient monitored every hr  If symp deteriorate, 2 vials IV stat  Tapering: 2 vials in D5 4hrly over 8-12 hrs, then 2 vials in D5 6 hourly till the symp diasappear
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 3 routes:
IV push: Not > 2ml/min IV infusion
4 vials in 5 10 ml of isotonic solution/kg over 4 hrly Tapering: 2 vials 4 hrly, 2 vials 6 hrly Max: 20-24 vials/day

Local infiltration: 5-10 ml

Snakes inject same dose of venom in children and adult, so same dose of antivenom needs to be administerd

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Antivenin therapy - Monitoring

Symptoms General Spontaneous systemic bleeding Blood coagulopathy Blood pressure increase Neurologic signs Rhabdomyolysis Feels better 15-20 mins 3-9 hours 30-60 mins Within 30 min (post synaptic type) Within few hours Timing

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Antivenin Therapy - Reactions

Reactions Early anaphylactic reactions Features - Within 10 180 min - Utricaria, dry cough, fever, nausea, vomiting, abd colic, diarrhoea, tachycardia - May lead to hypotension, bronchospasm, angioedema -Within 1-2 hrs -Pyrogen contamination during manufacture -Chills and rigors, fever, hypotension, febrile convulsion -1-2 days (mean 7 days) -Fever, nausea, vomiting, diarrhoea, itching, arthralgia, lymphadenopathy, pariarticular swelling, proteinuria, nephritis, encephalopathy
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Pyrogenic/endotoxin reactions

Late (serum sickness) type of reaction

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Antivenin therapy - Reaction

 Prevention
IM Promethazine IM Adrenaline
0.1% solution 0.25 mg in adults 0.01 mg/kg in children Immediately before start of therapy

 Treatment
Temp. stop the therapy: 15-30 min Epinephrine
0.1% solution, 1 in 1000, 1mg/dl (0.5 mg in adults, 0.01 mg/kg in children) IM in delthoid or up. Lat thigh Dose repeated every 30 min, Not exceeding 5

Salbutamol inhalation: asthmatic patients

Additional RX
Chlorpheneramine, Hydrocortisone, Cimetidine, Ranitidine

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SUPPORTIVE RX
 Neurotoxic envenomation: Assisted ventillation,

Anticholinestarase drug

 Hemostatic abnormalities: Bed rest to avoid trauma, Blood

transfusion

 Hypotension and Shock:Colloid, crystalloid, Dopamine,

Adrenaline

 Oliguria and renal failure:, Fluid challenge, Frusemide challenge,

Mannitol challenge

 Bacterial infections: Prophylactic course of Pn, gentamycin, TT  Necrosis: Debridement, split sking graft, amputation
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REFERENCES
 Snakebite management guideline DoHS  WHO Management of Snake bites in SEA  www.emedicine.com  www.wikipedia.com

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THANK YOU

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