Chapter 108: Snake Bite

Introduction
• Different geographical region and countries will have different snake
species of medical importance.
• Snakes of medical importance in Malaysia are either equipped with
specialised front fangs or without front fangs. The front-fanged snakes are
either in the family Elapidae (cobras, kraits, coral snakes and sea snakes) or
Crotalinae (Pit vipers). Pythons and some non-front fanged colubroids may
also pose danger to humans.
• All front-fanged and a few rear-fanged snakes are equipped with venom.
• Snake venoms are made of complex and diverse group of proteins, many
with enzymatic activity. Envenoming syndromes are treated with timely
administration of the appropriate antivenom in adequate amount
• It is important to note that a medically important snake found in one
state in Malaysia may not be indigenous in another. Therefore, the
requirement for antivenom may differ from hospitals to hospitals in the
country.
• Early access to experts in the field (Clinical Toxinologist) will assist
healthcare providers in snake species identification and optimal
management, saving lives and limbs.
Note: Assistance/query/consultation for identification and clinical
management of snakebite can be obtained from the National Poison Centre
Malaysia and the Remote Envenomation Consultation Services (RECS)
Malaysia (http://mstoxinology.blogspot.com/p/recs.html).
Clinical features of common snakebite envenoming
• Local envenoming syndrome by cobra (Naja) species include immediate
pain, progressively worsening swelling, blistering and necrosis. Systemic
envenoming manifest as acute neurological and cardiac dysfunction
including ptosis [an early sign], ophthalmoplegia, dysphagia [drooling of
saliva], aphasia, dyspnea, muscle paralysis and arrhythmias.
• Krait (Bungarus) species bites may cause minimal local effects and may
go unnoticed. Systemic envenoming may be delayed and manifest as sud-
den onset of rapidly progressive myalgia and muscle paralysis.
• Sea snake bites cause minimal local effects. Systemic envenoming may
present as generalised myalgia, stiffness, paresis, paralysis and myoglo-
binuria (dark coloured urine). Rhabdomyolysis may lead to acute renal
failure.
• Pit viper bite envenoming may cause progressively worsening pain and
swelling, haemorrhagic blisters, necrosis, hypovolaemic shock from third
space fluid loss and bleeding due to coagulopathy.
POISONS & TOXINS

Note: These clinical features are the manifestations of various toxins in the
venom. Toxic venom components can vary even within the same snake
species. The age, geographical distribution and prey specificity factors may
influence the compositions of venom toxins.

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MANAGEMENT
Prehospital care / First Responder
The objectives are to provide basic life support, to reduce the rate of venom
absorption and to prevent further complications.
Prehospital care interventions include:
• Calm the patient down and move to safety.
• Remove jewellery on the affected limb and loosen tight-fitting clothing.
• Immobilise the affected limb with a splint or sling and reduce movements.
Pressure Bandaging and Immobilization (PBI) is to be applied only by a
trained first-aider. Indications for PBI include 1) the snake is identified as
krait, coral snake or sea snake; 2) if the snake is unidentified, the transport
time to the hospital is prolonged (more than an hour).
• If venom enters the eye (venom ophthalmia), immediately irrigate with
copious amounts of clean water.
• Transfer all patients to the nearest healthcare facility with emergency care.
Note: Document all symptoms and signs that may manifest prior to arrival to
the hospital. Do not interfere with the bitten area by applying tourniquet,
doing incisions, sucking, rubbing, vigorous cleaning, applying herbs/chemi-
cals, massage or electrical shocks. Avoid wasting time to search or kill the
snake. Take several good quality pictures of the snake at a safe distance e.g.
using mobile phone camera. If the snake was killed, bring the it along in a
secure container.
Emergency and Hospital
• Triage to resuscitation zone and Perform rapid clinical assessment
(Primary survey).
• Monitor vital signs and cardiac rhythm, and resuscitate as indicated.
• Obtain detailed history of presenting complaint:
1) time of incident
2) location of incident
3) how exactly did the patient get bitten
4) what happened to the snake
5) part of body bitten
6) what was done after bitten
7) pain score progression (PSP) since incident
8) current complaints
9) allergy history (to horse or papaya) and other co-morbidities
• Perform close serial examination at fixed time intervals (every hour) for
any changes over the bitten area (bite marks and surrounding skin),
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the rate of proximal progression of the oedema (RPP), PSP, palpable ten-
der lymph nodes draining the area, and distal neurovascular status of the
affected limb. Taking serial pictures of the affected area helps.

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 • Examine for neurological dysfunction (tailored according to child’s age
group), bleeding tendencies, and muscle tenderness and rigidity.
• Send initial laboratory investigations (full blood count, coagulation profile
and Creatine Kinase) and repeat serially every 6 hours for the first 24 hours
of incident. Consider other tests as necessary (renal function tests, liver
function test, fibrinogen level, D-dimer and urine examination). Review the
trends.
• If laboratory blood test is not available or delayed and the diagnosis is
unidentified snakebite or a pit viper bite, consider performing serial
bedside 20-min Whole Blood Clotting Test (20WBCT).
Put 2mls of venous blood in a clean and dry glass test tube, leave it
standing for 20 min, and then tipped once.
Note: Unclotted blood suggests a pit viper bite with systemic envenomation.
• Review immunisation status: administer IM anti-tetanus injection if
indicated. (Note: Arterial puncture and Intramuscular injections are
contraindicated if the coagulation profile is abnormal)
• Administer analgesia (avoid NSAIDs in pit viper envenoming) and
antivenom as indicated.
• Admit to medical ward for close serial observation of the progress and
response to therapy (vitals, RPP, PSP, LN and blood tests). If there is no
signs and symptoms of envenomation for at least 24hrs or if an expert
verifies the snake to be a non-venomous species and asymptomatic, the
patient may not require hospitalisation.
Antivenom
• Antivenom (AV) is the only proven antidote for envenomation.
• Not all snakebites, even by snakes equipped with venom, results in
envenoming syndrome.
• Antivenoms carries a (low) risk of adverse reactions. Therefore, the
appropriate antivenom should be used only when it is indicated and
administered as early as possible.
• Antivenoms appropriate for use in Malaysia are currently imported from
Thailand and Australia.
The dosage for children is the same as for adults (Table 1)
• Adrenaline, steroid and antihistamine should not be given prophylactically
unless indicated.
• Skin sensitivity test is not necessary as it poorly predicts anaphylactic
reactions, may induce hypersensitivity and will cause unnecessary delay in
antivenom therapy.
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Indications for antivenom
Systemic envenomation
• Coagulopathy.
• Neurological abnormalities.
• Cardiovascular abnormalities.
• Generalised rhabdomyolysis / haemolysis.
• Acute kidney injury.
• Supporting laboratory results.
Local envenomation (with other considerations)
• Progressive significant oedema of the bitten area, especially if involving
the fingers.
• Rapid speed of progression of oedema (trends of RPP) within a few hours.
• Palpable tender lymph node draining the affected limb.
• Rapidly expanding local necrosis.
Note: Helpful laboratory results suggesting envenomation include prolonged
PT/APTT, raised INR (>1.2), reducing fibrinogen level, thrombocytopenia,
leucocytosis, anaemia, hyperkalaemia, hyponatraemia, myoglobinuria and
raised serum enzymes (e.g. Creatine kinase, aminotransferases).
Choice of antivenom
• If snake species is identified and AV is indicated, consider monovalent/
mono-specific antivenom.
• If snake species is unidentified and AV is indicated, consider Neuro
Polyvalent or Hemato Polyvalent antivenom.
Preparation and administration
• Prepare adrenaline, hydrocortisone, antihistamines and resuscitative
equipment prior to antivenom infusion.
• Reconstitute freeze-dried antivenom with the solution supplied or 10ml
WFI (water for injection). Gently swirl (never shake) to dissolve the freeze-
dried powder. Further dilute in 5-10ml/kg of hypotonic crystalloid solution
for children (250-500ml isotonic crystalloid for adults).
• Infuse at a slow rate (1 to 2 ml/min) for 5-10min and if there is no
reaction, increase the rate to 5-10mls/min to complete the infusion in less
than one hour.
• Closely observe patient during and for at least 1 hour after completion of
intravenous infusion. Document pain score prior to, during and after the
antivenom infusion. Document vital signs and clinical progression (RPP,
PSP, LN) every 10-15 min then hourly.
• Repeat antivenom administration until satisfactory response or
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improvement of envenoming signs is observed.

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 Antivenom reactions
Early hypersensitivity reactions are mostly rate dependent anaphylactoid
reaction. Symptoms range from itching, urticaria, nausea, vomiting,
palpitation, bronchospasm, laryngeal oedema to hypertensive shock.
In the event of antivenom reaction:
• Stop antivenom infusion.
• Give adrenaline IM 0.01 mg/kg of 1:1,000 (1 mg/mL) solution, into upper
lateral thigh and repeat 5 to 10 minutes if not improved (max of 0.5 mg total
dose). If IM injection is contraindicated, give slow IV boluses of 0.01 mg/kg
of 1:10,000 (0.1mg/mL) solution every 2 min (max of 0.3 mg total dose).
If not improving start IV infusion at 0.05-1 mcg/kg/min titrated to response.
• Give boluses of IV 0.9% saline at 20 mL/kg as required.
• Give slow IV antihistamine and steroid (e.g. chlorpheniramine maleate
0.2mg/kg), hydrocortisone 4mg/kg/dose).
• Give nebulised adrenaline in the presence of stridor or partial obstruction.
• Give nebulised salbutamol in the presence of bronchospasm or wheeze
• Once the patient is hemodynamically stabilised and the signs and
symptoms subsided, the antivenom infusion should be restarted at a
slower rate with very close vigilance for further reactions.
Pyrogenic reactions usually develop 1-2 hours after treatment and is
believed due to pyrogenic contamination during the manufacturing process.
Symptoms include fever, rigors, vomiting, tachycardia and hypotension.
In the event of such reaction, provide treatment as above and treat fever
with paracetamol and tepid sponging.
Late reactions (serum sickness) may occur between 1 to 12 days (mean 1
week) with symptoms of fever, arthralgia, lymphadenopathy, etc.
Treatment of serum sickness:
• Give chlorpheniramine maleate 0.25mg/kg/day in divided doses for 5 days.
• If fails to respond in 24hrs, give oral prednisolone (0.7mg/kg/day) for 5 days.
Anticholinesterases
• Should be considered in severe neurotoxic envenoming when antivenom
is inadequate or unavailable.
• Give test dose of either IV Edrophonium chloride (Tensilon) 0.25mg/kg
(max 10mg) or IV Neostigmine 0.05-0.07mg/kg (max 0.5-2.5mg), with IV
Atropine sulphate 50μg/kg (max 0.6mg).
• If patient convincingly responds, maintain with IV Neostigmine
methylsulphate (50-100μg/kg) and Atropine, 4 hourly by continuous
infusion.
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Supportive treatment
• Provide respiratory support/assisted ventilation in those with clinical
signs of respiratory compromise/paresis.
• Give analgesia to relief pain (avoid aspirin/NSAIDs). In severe pain,
IV tramadol may be given. Pain relief will normally be seen following
optimal antivenom therapy.
• Give broad-spectrum antibiotics if the wound appears contaminated
with devitalised tissues or necrosis has developed.
• Correction of coagulation abnormalities with fresh frozen plasma and
platelets is strictly per case-by-case basis.
• Renal failure requires measurement of daily urine output, serum creatinine,
urea and electrolytes. If urine output fails to increase after rehydration and
diuretics (e.g. frusemide), start renal dose of dopamine (2.5μg/kg/minute
IV infusion) and place on strict fluid balance. Dialysis may be required in
severe cases of envenoming with renal complications.
• Clean and dress wound. Debridement of necrotic tissues should be
carefully carried out as needed and should not be mistaken with the
debridement for necrotising fasciitis.
• Observe for the unlikely event of compartment syndrome (pain, swelling,
cold distal limbs and muscle paresis). Orthopaedic opinion regarding
surgical intervention must be supported with significantly raised
(>40mmHg) intracompartmental measurements using Stryker or
Wick catheters.
• Give optimal amount of appropriate antivenom prior to any urgent
surgical intervention.

POISONS & TOXINS

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Guide to dosages of appropriate antivenom for Malaysia

Species the AV is raised from Manufacturer: Antivenom First Dose ml/vial
Monocle cobra, Naja kaouthia QSMI Thai Red Cross: Cobra Antivenin 100mls/10 vials
King Cobra, Ophiophagus hannah QSMI Thai Red Cross: King Cobra Antivenin Subsequent dose 1-2 hr
Malayan krait, Bungarus candidus QSMI Thai Red Cross: Malayan Krait Antivenin 50mls/5 vials
Banded krait, Bungarus fasciatus QSMI Thai Red Cross: Banded Krait Antivenin Subsequent dose 1-2 hr
Malayan pit viper, Calloselasma Rhodostoma QSMI Thai Red Cross: Malayan Pit Viper 30mls/3 vials
Green pit viper, Cryptelytrops Albolabris QSMI Thai Red Cross: Green Pit Viper Antivenin Subsequent dose 6 hr
Malayan pit viper, Calloselasma rhodostoma, QSMI Thai Red Cross: Hemato Polyvalent Snake An- 30mls/3 vials
Green pit viper, Cryptelytrops Albolabris, tivenom Subsequent dose 6 hr
Thai Russell’s Viper, Daboia siamensis

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Monocled Cobra, Naja kaouthia, QSMI Thai Red Cross: Neuro Polyvalent Snake An- 50-100mls/ 5-10 vials
King Cobra Ophiophagus hannah, tivenom Subsequent dose 1-2 hr
Banded Krait Bungarus fasciatus,
Malayan Krait, Bungarus candidus.
Beaked sea snake, Seqirus, Australia: Sea snake Polyvalent Antivenom 10-30mls/1-3 vials
Hydrophis (Enhydrina) schistosus. Subsequent dose 1-2 hr
Note:
• Subsequent doses are indicated according to the clinical signs and symptoms.
• The doses are based on animal studies and manufacturer’s recommendations.
• Monocle cobra, Naja kaouthia antivenom has good cross neutrality with the Equatorial spitting cobra, Naja sumatrana venom.
• Green pit viper antivenom has good cross neutralization with venom from other green pit vipers belonging to the Trimeresurus
complex group.
• Beaked sea snake, Hydrophis schistosus antivenom has good cross neutralization with many other sea snake venom.
Measuring Rate of Proximal Progression (RPP) of the oedema
1. A more informative parameter for reviewing progressive painful swelling
2. First: Determine the border of the micropore to be used to mark the
proximal margin of the oedema, e.g. distal border to distal border of the
micropore markers (Figure 1).
3. Second: Palpate for the most proximal margin of the swelling and apply a
small strip of micropore tape to the most proximal margin of the oedema.
4. Label the current time and date on the micropoer tape.
5. Determine a fixed interval to review the progression, e.g. every 1-2 hours.
6. Measure the distance between two micropore tape borders over the
fixed time interval (Figure 2).
7. The RRP for that interval will be documented in cm/hr.

Figure 1 (above).

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Figure 2 (above).

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Serial Clinical Progress Observation Chart at fixed regular time intervals

Date Time GCS PR BP RR SpO2 PSP RPP LN
d/m am/pm 3-15 bpm mmHg bpm % 0-10 cm/hr Yes/No

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PSP= pain score progression, RPP = rate of proximal progression, LN = enlarged tender lymph node
 Serial Blood Results (evey 4-6 hours for first 24 hours or after Antivenom administratrion)
Date Time 20WBCT WBC Hb Platelets PT APTT INR CK

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