ENVENOMATION

SNAKE BITE

Vikas Kesarwani MD
A/Professor
Consultant, Pulmonary & Critical care
medicine,
 Epidemiology
India estimates: 200,000 Snake
bites and 15-20,000 deaths per
year
Males:Female::2:1.

Majority of the bites being on

the lower extremities.
 Epidemiology
India estimates: 200,000 Snake
bites and 15-20,000 deaths per
year
Males:Female::2:1.

Majority of the bites being on

the lower extremities.
50% of bites by venomous
snakes are dry bites. that result
in negligible envenomation.
 Snakes :
Introduction
Anatomy:
 Snakes: Introduction
Cold Blooded:
No efficient thermoregulatory
mechanism.(no sweat glands)
- Venom has digestive enzymes
which starts working even before
the prey is swallowed
- They Do not chew but swallow
their prey completely.
 India: Poisonous
snakes
In India, >200 species of snakes.
Only 52 are poisonous.
Elapidae Cobra, Kraits Neurotoxic

Viperidae Russells Vipers., Hemotoxic

(Vipers) Saw scaled Vipers.,
Pit Vipers.
Hydrophida Sea Snakes Myotoxic
e

Krait and russells viper is much more toxic than that of cobra
 Krait Pit
Vipe
r

Cobra

Rusells
viper
 Snake Venom
Combination of
Enzymes & Non-Enzymatic polypeptides.

-Acidic
-Sp Gravity: 1.030-1.070
-On drying Fine needle like crystals.
-Water Soluble.
-Lethal Dose:
Cobra-0.12gm, Krait0.06gm- Russells V-
0.15gm
 DIAGNOSIS OF SNAKE BITE
FANG MARKS: classically, two puncture
wounds seperated by a
distance varying from 8mm to 4cm,
depending on the species involved.
However a side swipe may produce
only a single puncture,while multiple
bites could result in numerous fang
marks.
 Effects of envenomation
Local effects
Systemic effects:
- Neurotoxic.
- Haemotoxic.
- Cardiotoxic.

Max. with Viper bite, least with Krait bite.

Hence krait bite can sometimse go unnoticed.
unnoticed
 Clinical features:
VENOMOUS SNAKE BITES
ELAPID BITE (Krait,Cobra)
Local features :

indistinct fang marks ,

burning pain,
swelling and discolouration,

serosanguinous discharge
 Systemic features
ELAPID BITE (Krait,Cobra): Neurotoxicity
pre-paralytic stage : emesis,
headache,
LOC.
paralytic stage : ptosis,
ophthalmoplegia
drowsiness,
dysarthria,
dysphagia,
convulsions,
bulbar paralysis,
resp failure .
 COBRA envenomation
Cardiotoxicity

Cardiac Depression
Cardiogenic/Vasogenic
Shock
Systolic cardiac arrest.
 VIPERID BITE (Viper)

Local features:
rapid swelling,
discolouration,
blister formation,
bleeding from bite
site,
severe pain
 VIPERID BITE (Viper)

Systemic features(Haemotoxic)-
Generalised bleeding manifestations.

epistaxis,
hemoptysis,
bleeding gums
hemauria
purpuric spots
Renal failure
 HYDROPHID BITE (sea
snake) Myotoxic

Local features: minimal swelling and

pain
Systemic features:
Myalgia,
Muscle stiffness,
Myoglobinuria , renal tubular necrosis.
Management

Local
Specific
Supportive
 Management: Local
Tourniquet: Between wound & heart, Pressure
adequate to occlude lymphatics only,
Released for few seconds every 10 minutes.
Immobilize affected limb. Elastocrepe
bandage may be applied (except viper bites
with lots of local reaction.)
Clean with Normal Saline.
if bite <1hr old: Short skin incision and
suction
 Management: local
reactions
BULLAE - LEFT INTACT
NECROSIS - DEBRIDEMENT

COMPARTMENT SYNDROME -

FASCIOTOMY
 Specific Management
Anti Snake Venom (ASV)
- Timing
- Dose
- Repeat dose
- Hypersensitivity
Mechanical ventilation
 What is ASV?
Antivenom is immunoglobulin 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.
ASV IN INDIA: Polyvalent

COBRA
KRAIT
RUSSELS VIPER
SAW SCALED VIPER
Potency; 1 ml ASV neutralizes:
0.6mg Cobra, 0.45mg Krait, 0.6mg Rusells V,
0.45mg Saw scaled Viper.
-Lethal Dose:
Cobra-0.12gm, Krait0.06gm- Russells V-0.15gm
Trying to capture, kill, or transport
a snake for identification
purposes seems of little value
and possibly dangerous
 ASV Indication:
Systemic manifestaiton
NEUROTOXICITY
HAEMOTOXICITY
NEPHROTOXICITY
CARDIOTOXICITY
RHABDOMYOLYSIS
REPEATED VOMITING
Others:
-Local swelling involving more than half of the
bitten limb.
-Rapid extension of swelling.
-Development of an enlarged tender lymph node
draining the bitten limb
 Timing of ASV
Best effects are observed within four
hours of bite .
Effective in symptomatic patients
even 48 hours after bite.
Efficacious even 6-7 days after the
bite from vipers.
Dose

5 vials(50ml)

5-10 vials
(50-100ml)

10-20 vials
(100-200ml)
 Repeat dose
Criteria for repeating the initial dose of
antivenom
Persistence or recurrence of blood

incoagulability after 1-2 hr

Deteriorating neurotoxic or cardiovascular

signs after 1-2 hr

Continuing absorption- due to improved blood

supply following correction of shock,

hypovolaemia etc A redistribution of venom
from the tissues into the vascular space.
 Antivenom
reactions
20% of patients, usually develop a reaction
20% of patients, usually develop a reaction
Types:
1. Early anaphylactic reactions- within 10-
180 min
2. Pyrogenic (endotoxin) reactions- develop
1-2 hours
3. Late (serum sickness type) reactions-
develop 1-12 (mean 7) days.

Fatal reactions have probably been under-

reported, as death after snake bite is usually
attributed to the venom.
 Antivenom reactions:
What to do ?
At the earliest sign of a reaction:
Antivenom administration must be temporarily

suspended
Adrenaline-0.1% solution, 1 in 1,000, 1 mg/ml is the

effective treatment for early anaphylactic reactions.

IV hydrocortisone (adults 100 mg, children 2 mg/kg

body weight). The corticosteroid is unlikely to act

for several hours, but may prevent recurrent
anaphylaxis
Anti H2 antihistamines-Ranitidine adults 50 mg,

children 1 mg/kg.
In case of circulatory collapse- start fluids, inotropes

along with IV adrenaline

 Skin testing for ASV

Skin/conjunctival hypersensitivity
testing does not reliably predict
early or late antivenom reactions
and is not recommended.
 ASV and children

? Dose of antivenom
Snakes inject the same dose of

venom into children and adults.

Children must therefore be given

exactly the same dose of antivenom

as adults.
 Mechanical ventilation
If patient has respiratory distress or
bulbar paralysis- intubate and ventilate.
If delayed can cause aspiration or
hypoxia and cardiac arrest.
Even if the facility for MV is not available
Ambuing can save the day.
This helps even during transport.
 SUPPORTIVE CARE

ANTIBIOTICS
METHYL PREDNISOLONE
FFP,FRESH BLOOD
PREVENTION AND Rx OF HYPOTENSION
 Summary

Snake bites may be by a non-venomous snake

or a dry bite. Not all snake bites require ASV.
ASV is the main stay in the treatment of snake
bites.
ASV must be initiated if indicated at the earliest
Respiratory failure can be because of different
reasons-Neurotoxicity, shock, sepsis, ARF
MV may be main stay of treatment or just
supportive depending on the cause of failure.
HAEMOTOXIC ENVONOMATION

MILD CT < 30 MINS

CLOT SIZE = 50% blood col
initial dose = 5 vials
MODERATE CT > 30 MINS
CLOTS ONLY SPECKLES
intial dose = 10 vials
SEVERE INCOAGULABLE
initial dose = 15 vials