SNAKE ENVENOMATION

SNAKESSSSS…
 WHEN A VICTIM ARRIVES
FIRST AID
REASSURANCE

IMMOBILISATION

APPLY TORNIQUET

MINIMAL WOUND HANDLING

SALINE CLEANING, STERILE DRESSING

? INCISION ? SUCTION

? LOCAL ANTIVENOM
ASSESS VITAL SIGNS
START AN IV LINE
MONITOR – CARDIAC RHYTHM, BP, [O2]
SEND BASELINE INVESTIGATIONS
 CONFIRMING THE DIAGNOSIS

IS IT A SNAKE BITE ?

LOOK FOR FANG MARKS

COULD IT BE ANYTHING ELSE ?

BITES OF OTHER INSECTS

SCRATCHES / PENETRATION BY THORNS

CONFIRMING THE DIAGNOSIS

IS IT A POISONOUS SNAKE ?

WATCH FOR LOCAL / SYSTEMIC TOXICITY

WHICH SPECIES IS INVOLVED ?

SNAKE BITE - PROFILE

2500 - 3000 SPECIES WORLDWIDE

500 VENOMOUS SPECIES

52 POISONOUS SPECIES IN INDIA

INCIDENCE > 5 MILLION PER YEAR

DEATH IN TRANSIT, ? TRUE INCIDENCE

 INDIAN SNAKES
ELAPIDAE - COMMON / KING COBRAS,
- KRAIT
 INDIAN SNAKES
VIPERIDAE - RUSSELS, SAW SCALED,
PIT VIPERS
 INDIAN SNAKES
• HYDROPHIDAE - SEA SNAKES
 SNAKE BITE - PREVALENCE
IN INDIA

60 -65% - SAW- SCALED VIPER

20 -25% - RUSSELS VIPER

10 -15% - COBRAS / SEA SNAKES

 POISONOUS
VS
NON-POISONOUS SNAKES
HAZARDOUS BITES ILLEGITIMATE BITES
ACCIDENTAL SNAKE HANDLING
LOWER LIMB BITES
UPPER LIMB BITES
DEVELOPING
COUNTRIES DEVELOPED COUNTRIES
 SNAKE BITE -
PATHOPHYSIOLOGY
CONSTITUENTS OF SNAKE VENOM

ENZYMES
NON - ENZYMATIC COMPOUNDS

NON - TOXIC PROTEINS

 SNAKE VENOM
ENZYMES
PHOSPHALIPASES
HYDROLASES
PHOSPHATASES
PROTEASES, ESTRASES
ACETYLOCHOLINESTERASES
TRANSAMINASES
HYALURONIDASES
ATP ASE, NUCLEOSIDASES
 SNAKE VENOM
NON ENZYMATIC COMPOUNDS

NEUROTOXINS

MYOTOXINS

CARDIOTOXINS

HAEMORRHAGENS
 SNAKE VENOM
NON TOXIC PROTEINS

CARBOHYDRATES

METALS

INFECTIVE ORGANISMS
 VENOM
ACTIONS
DISRUPT CELLULAR FUNCTIONS
BREAK DOWN OF ENDOTHELIUM
INCREASE VASCULAR PERMEABILITY
ACTIVATE COAGULATION SYSTEM
DIRECT CYTOLYTIC ACTION
BREAK TISSUE BARRIERS
PRODUCE ORGAN DAMAGE
 FATAL DOSE

SPECIES VENOM
PER BITE FATAL DOSE

COBRA 60 MG 12 MG
RUSSELS 63 MG 15 MG
KRAIT 20 MG 6 MG
SAW SCALED VIPER 13 MG 8 MG
SNAKE BITE - MANIFESTATIONS

FRIGHT & FLIGHT RESPONSES

FEAR OF DEATH

PALLOR, SWEATING, VOMITING

SHOCK & DEATH

SNAKE BITE MANIFESTATIONS

NO SYMPTOMS / SIGNS

LOCAL EFFECTS

SYSTEMIC EFFECTS
 SNAKEBITE
NO MANIFESTATIONS

NON POISONOUS SNAKES

SUPERFICIAL, DRY BITES

PROTECTION BY CLOTHING, FOOT WEAR

 SNAKE BITE
LOCAL MANIFESTATIONS

ONSET WITHIN MINUTES

SWELLING , ERYTHEMA , BULLAE,
HEAMORRHAGE
TISSUE NECROSIS, GANGRENE
RAPID AND EXTENSIVE SPREAD
REGIONAL LYMPADHENOPATHY

SECONDARY INFECTION
 SNAKE BITE
- SYSTEMIC MANIFESTATIONS

ONSET FROM FEW MINUTES - DAYS

DEPENDS ON VENOM COMPOSITION
NEUROTOXIC - COBRA / KRAIT
HEAMORRHAGIC - VIPERS
MYOTOXIC - SEA SNAKES
 SNAKE BITE
NEUROTOXICITY
PRODUCES NEUROMUSCULAR BLOCKADE
FLACCID NEUROMUSCULAR PARALYSIS
PTOSIS, OPTHALMOPLEGIA
FACIAL INVOLVEMENT - EARLY
REFLEXES SPARED
INTERCOSTALS / DIAPHRAGM / PUPILLARY
COMA - TERMINAL
 SNAKE BITE
CARDIO VASCULAR
MANIFESTATIONS

HYPOTENSION COMMON

DISTURBANCES IN RATE / RHYTHM

PANCARDITIS

ELECTROLYTE DISTURBANCES
 SNAKE BITE
HAEMATOLOGICAL MANIFESTATIONS

ENDOTHELIAL DAMAGE

INTRAVASCULAR COAGULATION

FIBRINOLYTIC SYSTEM ACTIVATION

INTRAVASCULAR HEMOLYSIS

PLATELET DYS FUNCTION

LOCAL / SYSTEMIC BLEEDING

 SNAKE BITE
RENAL DAMAGE
FEW MINUTES TO DAYS

OLIGURIC OR NON OLIGURIC R.F

ATN, GN, INT-NEPH,

CORTICAL NECROSIS, VASCULITIS

 SNAKE BITE
UNUSUAL MANIFESTATIONS

DELAYED TOXICITY

RECURRENT TOXICITY

TOXEMIA WITHOUT BITES

LONG TERM EFFECTS

UNUSUAL MANIFESTATIONS

DELAYED TOXICITY

LOCAL BLEBS AS VENOM DEPOT

INACCESSIBLE TO ANTI - VENOM

UNUSUAL MANIFESTATIONS

RECURRENT TOXICITY

VENOM RELEASE FROM BLEBS

PARTIAL THERAPY
UNUSUAL MANIFESTATIONS
TOXEMIA WITHOUT BITES
SPITTING COBRA
AIMED AT VICTIMS EYE
CONJUNCTIVITIS,
CORNEAL ULCERS
UNUSUAL MANIFESTATIONS

LONGTERM EFFECTS

PERSISTANT EDEMA

SERUM SICKNESS

CORTICAL NECROSIS
 FACTORS AFFECTING OUTCOME
HOST FACTORS

BITES IN CHILDREN
PROXIMAL BITES
EXERTION POST BITE
PROTECTION BY CLOTHING /FOOT WEAR
SECONDARY INFECTION
FACTORS AFFECTING OUTCOME
AGENT FACTORS

NUMBER & DEPTH OF BITES

CONDITION OF FANGS
SPECIES OF SNAKES
DURATION OF BITE
? SIZE OF SNAKES
FACTORS AFFECTING OUTCOME
ENVIRONMENTAL FACTORS

NATURE OF FIRST AID

TIME TAKEN TO TREAT THE VICTIM

CIRCUMSTANCES THAT PROVOKED

THE BITE
 SNAKE BITE
LAB DATA
HEMOGRAM, PERIPHERAL SMEAR
COAGULATION PROFILE-BT,CT,FDP
URINE ANALYSIS
UREA, CREATININE, E.LYTES, SUGAR
CXR, ECG
PERIODIC MONITORING
 SNAKE BITE
SPECIFIC THERAPY
MONO / POLYVALENT ANTIVENOM
INDICATIONS –
SEVERE LOCAL/SYSTEMIC SYMPTOMS
NO STANDARD PROTOCOL

WATCH FOR HYPERSENSTIVITY

 SNAKE BITE
ANTIVENOM
SENSITIVITY TESTING
0.02 ML OF 1:10 SOLUTION I.D
ERYTHEMIA&WHEAL >10mm IN 30M
 SNAKE BITE
ANTIVENOM
DESENSITATION

0.01 ml of 1:100 SOLUTION SC

INCREASE VOLUME EVERY 15 M TILL 1ml

1 ML SC EVERY 2 HOURS
SNAKEBITE - SEVERITY

MILD
MODERATE
SEVERE
 MILD ENVENOMATION
CELLULITIS < 2CM/HR
PT, APTT - NORMAL
FDP < 5 , BT, CT - NORMAL
CARDIOTOXICITY - NIL
NEUROTOXICITY - NIL
HYPOTENSION - NIL
MYOTOXICITY - NIL
MODERATE ENVENOMATION
CELLULITIS 2-5 CM/HR
PLATELET > 20,000
FDP > 5 , BT, CT - NORMAL
CARDIOTOXICITY–LV DYSFUNCTION(MILD-MOD)
NEUROTOXICITY - MILD PTOSIS
WEAKNESS OF LIMBS
NO RESPIRATORY FAILURE
HYPOTENSION - SYSTOLIC > 90
 SEVERE ENVENOMATION
CELLULITIS > 5CM/HR
PLATELET COUNT < 20,000
FDP > 200, BT, CT - PROLONGED
CARDIOTOXICITY - SEVERE LV DYSFUNCTION
NEUROTOXICITY - SEVERE PTOSIS,
RESPIRATORY INSUFFICIENCY
HYPOTENSION - SYSTOLIC < 90
MYOTOXICITY - RHABDOMYOLYSIS,MYOGLOBINURIA
 SNAKE BITE
ANTIVENOM DOSAGE

MILD ENVENOMATION - 15 VIALS PER DAY

MODERATE ,, - 30 VIALS PER DAY

SEVERE ,, - 60 VIALS PER DAY

 SUPPORTIVE THERAPY
DIC - BLOOD & BLOOD PRODUCTS
SHOCK - VOLUME SUPPLEMENTS /INOTROPHS
ARF - CONSERVATIVE / DIALYSIS
CNS - NEOSTIGMINE + ATROPINE
CVS - ANTI ARRYTHMICS / INOTROPHS
ANTIBIOTICS - TETANUS PROPHYLAXIS
 ABC
REASSURE
IV ACCESS 18G
REMOVE TOURNIQUET
IMMEDIATE MEASURES BP
ECG
CORRECT SHOCK
WOUND TOILET AND DRESSING
INJ TT
TYPE OF SNAKE IMMOBILISE LIMB
TIME OF BITE INJ PETHIDINE 20MG I.V
SITE OF BITE INJ DICLOFENAC 1 AMP IM
NUMBER OF FANG MARKS RECORD
TYPE OF FIRST AID GIVEN

• PETECHIAE
• PURPURA
PAIN
INDURATION
PROTOCOL FOR MANAGEMENT
ON EXAMINATION
•
•
LOCAL BLEED
ENT BLEED
CREPITUS
CELLULITIS
OF SNAKE ENVENOMATION •
•
TACHYCARDIA
HYPOTENSION
• PROLONGED CLOTTING TIME
• HEMOCONCENTRATION

•BT,CT,PT,APTT,FDP,
•PLATLET COUNT,HB,TC,DC,
•S.CREATITNE,S.ELECTROLYTES
•ABG,ECG,CPK(WHEN REQUIRED)
• WEAKNESS,PTOSIS,OPTHALMOPLEGIA
INVESTIGATIONS • PALATAL,PHARYNGEAL PARALYSIS
• RESP MUSCLE PARALYSIS-HYPOXIA,ACIDOSIS
• CONVULSIONS,COMA

• CARDIOTOXICITY,ARRHYTHMIAS
• RENAL FAILURE-OLIGURIA,UREMIA,VOMITING
• COMPARTMENT SYND,GANGRENE,NECROSIS
TREATMENT

•ANTISNAKE VENOM
•OTHER MEASURES
 CONCLUSION

SNAKE BITE - UNIVERSAL PROBLEM

EARLY INTERVENTION - LIFE SAVING

NEED FOR UNIVERSAL PROTOCOL

THANK YOU