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Dr.Venugopalan P P
Laed consultant ,Emergency Medicine , Aster DM Health Care
Snake bite : Background in India
● 562 deaths (0.47% of total deaths)
● mostly in rural areas
● More commonly among males than females
● Peaking at ages 15–29.
Snake bite : Background in India
● 45,900 annual snakebite deaths nationally
● Annual age-standardized rate of 4.1/100,000
● Higher rates in rural areas (5.4)
● Highest rate in the state of Andhra Pradesh
(6.2)
Snake bite : Background in India
Annual snakebite Other Indian states
with high incidence of
deaths
snakebites
● Uttar Pradesh (8,700)
● Tamil Nadu
● Andhra Pradesh (5,200)
● West Bengal
● Bihar (4,500)
● Maharashtra
● Kerala.
Snake bite :First aid
● Check history of Evidences of bite
snakebite ● Fang puncture
● Look for obvious marks
evidence of a bite ● Bleeding
● Krait bite no local marks ● Swelling of the
may be seen bitten part
● Digestive hydrolases
● Hyaluronidase
● 5’-nucleotidase
● Kininogenase
● DNAase
● l-amino acid oxidase
● NAD-nucleosidase
● Phosphomono- and
● Phospholipase A2
diesterases
● Peptidases.
Snake venom
Bucherl et al., 1968,1971; Gans and Gans 1978; Lee 1979; Harvey 1991
Snake venom
Phospholipase A2 (lecithinase)
Hyaluronidase
1. Nonvenomous snakes
2. Venomous species are not always
accompanied by the injection of venom (dry
bites)
Dry bite - Concerns
● Dry bites ranges from 10–80% for various venomous
snakes.
● Symptoms due to anxiety and sympathetic over-activity
may be present
● Panic or stress sometimes mimic early envenoming
symptoms, clinicians may have difficulties in determining
whether envenoming occurred or not.
Dry bite :Concerns
● Some people who are bitten by snakes (or suspect or
imagine that they have been bitten)
● Some have doubts regarding bite may develop quite
striking symptoms and signs, even when no venom has
been injected due to understandable fear of the
consequences of a real venomous bite.
○
Bite mark
Neuroparalytic [ Progressive weakness, Elapid
envenomation
Symptoms - 2Ps plus 5 Ds
Dyspnea
Ptosis Dysphonia
Paralysis Dysarthria
Diplopia
Dysphagia
Ptosis and inability to protrude tongue
Neuroparalytic [ Progressive weakness, Elapid
envenomation
Important :
Bilateral dilated, poorly or a non-reacting pupil is not the
sign of brain dead in elapid envenoming
Decision at primary level care centers
● Hypotension
● Hypovolaemia
● Direct
vasodilatation
● Direct
cardiotoxicity
Complications
● Parotid swelling ● Acute respiratory
● Conjunctiva distress
oedema syndrome
● Cub-conjunctival ● Leaking
haemorrhage syndrome
● Renal failure ● Refractory shock.
Long term sequelae
● Pituitary insufficiency with Russell’s viper
(Daboia sp)
● Sheehan’s syndrome
● Amenorrhea in females
Idiopathic systemic capillary leak syndrome
(ISCLS)
● Hypotension-Severe
● Hypoalbuminemia
● Hemoconcentration without albuminuria
● Profound derangement of the vascular endothelium
resulting in leakage of plasma and proteins into the
interstitial compartment
.
Idiopathic systemic capillary leak syndrome
(ISCLS)
● Capillary leak syndrome is a sinister complication of
Daboia russelii bite as it is beset with an excess of
morbidity and mortality.
● Parotid swelling, conjunctival chemosis, myalgia, thirst
and systemic hypotension observed in patients of Daboia
russelii bite indicate capillary leak syndrome.
● More commonly in males as compared to females.
Early lab and Radiological markers of ISCLS
● Hemoconcentration
● Increased HCT
● Leukocytosis
● Pleural effusion[CXR]
Progressive Painful Swelling[PPS]
● Local venom toxicity
● Russel’s viper bite, Saw scaled viper bite and
Cobra bite
● Local necrosis which often has a rancid smell
● Limb is swollen and the skin is taut and shiny
● Blistering with reddish black fluid at and
around the bite site
Progressive Painful Swelling[PPS]
● Skip lesions around main lesion
● Ecchymoses due to venom action destroying
blood vessel wall.
● Significant painful swelling potentially involving
the whole limb and extending onto the trunk
● Compartment syndrome
● Regional tender enlarged lymphadenopathy.
Extensive Loss of skin
Myotoxic envenomation
Sea snakebite
● Muscle aches
● Muscle swelling
● Involuntary contractions of
muscles.
● Passage of dark brown urine.
Myotoxic envenomation
● Compartment syndrome
● Cardiac arrhythmias
● Hyperkalaemia
● Acute kidney injury due to
myoglobinuria
● Subtle neuroparalytic signs
Occult bite
● Krait bite victims often present in the early morning with
paralysis with no local signs with no bite marks.
● Snakebite victim gets up in the morning with severe
epigastric/umbilical pain with vomiting persisting for 3
– 4 hours and followed by typical neuroparalytic
symptoms within next 4- 6 hours.
● There is no history of snakebite.
Occult bite
● Unexplained respiratory distress in children in the
presence of ptosis or sudden onset of acute flaccid
paralysis in a child (locked-in syndrome) is highly
suspicious symptoms in endemic areas particularly of
Krait bite envenomation
● Patients may present with throat, chest or joint pain.
Early morning symptoms of acute pain
abdomen with or without neuroparalysis can
be mistaken for
● Acute appendicitis
● Acute abdomen
● Stroke
● GB syndrome
● Myasthenia gravis
● Hysteria
Krait bite vs GBS
Circulation
Airway
Breathing
Deal with any life threatening
symptoms on presentation.
Vasculotoxic patients
M- Medications
E -Events
Pregnant women
Monitor
1. Uterine contractions
2. Foetal heart rate.
Lactating women
● Encouraged to continue
breastfeeding.
Red flags in Snake bite
Red flags in Snake bites
1.Rapid early extension of local swelling from the site of
the bite.(Cobra bite on finger, necrosis may start in few
minutes)
Difficult???
Poisonous snakes
● All poisonous snakes are generally brightly
coloured
● Venomous snakes have a very distinctive
head,looks like hand or triangular and side
portion is wide.
● Cobra group of snakes are Highly Venomous
● Venomous snakes has heat sensitive pit
http://www.walkthroughindia.com/know-the-difference/difference-poisonous-non-poisono
us-snakes/
Poisonous snakes
● All sea snakes are Highly Poisonous
● Poisonous snakes Family- Elapidae,Colubridae
and Viperidae
● Highly Venomous snakes in India– King
Cobra,Indian Cobra,Russell’s Viper,Saw
Scaled Viper,Malabar pit viper and Krait.
http://www.walkthroughindia.com/know-the-difference/difference-poisonous-non-poisono
us-snakes/
Non Poisonous snakes
● Non Poisonous Snakes are not brightly
coloured
● Non Poisonous Snake head is usually narrow
and elongated
● Usually Non-venomous snake do not have
Fangs but few snakes do have Fangs
http://www.biologydiscussion.com/zoology/reptiles/difference-between-poisonous-snake
s-and-non-poisonous-snakes-reptiles/41078
Non Poisonous snakes
● Pythons are Non Venomous but
equipped with rows of teeth
● Common non Poisonous Snakes in
India– Rat snake,Banded kukri,Bronze
back tree snake,Sand boa and Indian
Python
http://www.biologydiscussion.com/zoology/reptiles/difference-between-poisonous-snake
s-and-non-poisonous-snakes-reptiles/41078
Poisonous vs Non Poisonous
Poisonous vs Non Poisonous
Poisonous vs Non Poisonous
Poisonous vs Non Poisonous
Identification of Snake??
● Many cases the biting snake is not seen, and very often
its description by the victim is often misleading
● Identification of the type of snake should not hold the
treatment.
● At times the bite mark might not be visible (e.g., in the
case of Krait)
● Clinical manifestations of the patient may not correlate
with the species of snake brought as evidence
Identification of Snake??
● Examine carefully the snake, if brought, and identified if
possible.
● Discourage bringing the killed snake into the emergency
department.
● Identification of the species even if killed should be
carried out carefully, since crotalids can envenomate
even when dead.
How to identify snakes
Snake is not available for identification
Symptoms
Caused by contamination of
● Chills the ASV with pyrogens during
● Rigors the manufacturing process
● Fever
● Hypotension
“Any new sign or
symptom after
starting the ASV in
drip should be
suspected as a
reaction to ASV”
Late (serum sickness–type) reactions
● Develop 1–12 (mean 7) days after treatment
● Clinical features
NO EPINEPHRINE Premed:
No Reaction
Inject Entire Solution E
intravenously
● Debridements of
necrotic tissues
● Fasciotomy in
Compartment
syndrome
How to monitor Compartment pressure?
● Insert a 16 no. needle in the
suspected compartment at a
depth of 1 cm
● Connect to a simple tubing
irrigated with normal saline
Measure rise in the saline
column in the tubing
How to monitor Compartment pressure?
● Rise more than 40 cm of
saline corresponds to 30 mm
Hg of lymphatic/ capillary
pressure
● Suggestive of excessive
compartment pressure
● Necessitates fasciotomy
procedure.
Nut shell
Suspected snake bite
● Neuroparalytic
symptoms with no
Overt bite local signs
History of bite Nonvenomous (70%) Occult bite ● Severe abdominal
Krait pain, vomiting
/ Venomous (30%) No history of bite
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