CASE REPORT

SNAKE BITE : A FORGOTTEN PROBLEM

Muh Rifki Zidny

RSI Siti Aisyah Madiun

2015

INTRODUCTION
Snake bite is a worldwide environmental and
occupational hazard with significant morbidity
and mortality, found to occur more among
farmers, plantation workers and other people
who dwell outdoors especially in rural and poor
communities
Inadequately studied and published data (as
ICD 9 code E905.0, ICD 10 code T63.0 and X20)
two million snake bite envenoming, 100.000
deaths/year in Asia
Epidemics when flood or invaded habitat

Countries with data on snake bite

envenoming

Countries with data on snake bite

mortality

Why snake bite?

One of the most neglected public health
issues in the tropic
Southeast Asia (inc. Indonesia) one of
the highest rate in incidence and mortality
National guidelines??
Poorly informed rural population
Care-givers need better training

Case Report

PATIENT IDENTITY
Mrs. K
Female
70 y.o
Farmer and Breeder
Muslim
From Magetan, East Java

Came to ER RSI
Madiun at May
11th, 2015
because of snake
bite

History taking
bite by snake 1 day before admission. Odem on
the left lower arm since around 1 hour after bitten
by snake in the grass field when the patient was
looking for grass.
The odem bigger and wider since then (until left
upper arm). Tenderness (+), redness (+)
Nausea (+), vomit (+), shortness of breath (-),
fever (-), faint (-), loss of sensation (-), abnormal in
urination (-)
Seek for the traditional treatment in advance
(sucking the blood), but didnt get better condition
History
past illnesses :
Unable to bring
the of
snake
No HT, no DM, no allergy

Physical Examinations
General Condition : Weak BP :
100/50
GCS : E4V5M6
HR : 96
x/m
RR : 20 x/m
T : 36.5 C
Head and Neck : Normal
Chest : symmetric, Chest percussion sonor, no tenderness,
auscultation vesicular. Regular heart sound, no additional
sound.
Abdominal : Flat, abdominal sound normal, percussion
thympani, abdominal tenderness on all area.
Extremities : redness (+), odem (+), tenderness (+) on
left arm and hand, bite mark (-), lateralization (-), Other
extremities normal

Picture of left arm of the patient

Initial Diagnosis

SNAKE
BITE

Initial Assessment in ER

Inf. PZ 20 dpm
Inj. Ceftriaxone 1 gr / 12 h
Inj. Antivenin serum (SABU)
Inj. Ranitidin 2x1 iv
Inj. Ondancetron 2x1 iv
Inj. Antrain 2x1 iv
Immobilization and splitting
Check the blood (DL,PT, APPT, OT/PT/SC, SE, BS)
ECG

Laboratory result
Blood

Leuco
(neutrophil
dominant)

18,9
0

ery

5,25

thrombo

15,9

Hb

207

Blood sugar
2hpp

184

BUN

22,8

Creatinine

1,60

Sodium

129

Potassium

3,2

Chloride

95

Calcium

1,09

ECG
Sinus rhythm
Normal ECG

INITIAL PLANNING
May, 11 2015
Diagnostic
Therapy
IVFD Futrolit 1500 mL/24h
Inj. Cefxon 2x1 gr
Inj. Acran 3x1 amp
Inj. Antrain 3x1 amp
Soft Diet
Wound care
Monitoring
Vital signs, sign of shock, sign of allergic reaction, breathing
failure

Patients progress in ward

May 12th , 2015
Bp : 120/80 mmhg, HR : 80x/m, T
: 36,2, RR : 20x/m
GC : good, E4V5M6
Arm pain (+), nausea (+), vomit
(-), odem (+)
Tx : cefxon 2x1
acran topazol 2x1 amp
Antrain stop
Soft diet, wound care

May 13th , 2015

Bp : 120/90 mmhg, HR : 88x/m,
T : 36,2, RR : 20x/m
GC : good, E4V5M6
Arm pain (+), nausea (-), vomit
(-), odem (+)
Tx : cefxon
wound care
Go home

DISCUSSION

Venomous Snake of
South East Asia
Venom Apparatus
2 ways :
Injecting
Spitting

Classification of Venomous Snake

(medically important in SEARO
Countries)
Three families of venomous snake :
1. Elapidae (Cobras : Naja, and Kraits :
Bungarus)
2. Viperidae
3. Colubridae

Elapidae

Viperidae

Colubridae

Rear fangs of a dangerously venomous Colubrid snake, the rednecked keelback (Rhabdophis subminiatus) (Copyright DA
Warrell)

SNAKE VENOMs
Venom Composition :

Zinc metalloproteinase haemorrhagins

Procoagulant enzyme
Phospholipase A2
Acethylcholinesterase
Hyaluronidase
Proteolytic enzymes & polypetide cytotoxins
(cardiotoxins)
Neurotoxin

Quantity

Epidemiology in SEAR
Male > female, but depends on work force
Peak age : children and young adults
Fatality : young children and elderly

Signs and Symptoms

Has not been injected
Tachypnea, stiffness, palpitation, faint, agitated
(panic attack)

Has been injected

Local
a. Fang marks
f. lymph node enlargement
b. Local pain
g. inflammation
c. Local bleeding h. blistering
d. Bruising
i. local infection
e. Lymphangitis
j. necrosis

 General (systemic)
a. Nausea
g. chemosis
b. Vomiting
h. arrhythmia
c. Abdominal pain i. spontaneous syst.
Bleeding
d. Weakness
j. paresthesia
e. Dizziness
k. paralysis
f. Shock
l. acute renal failure

Patientss condition

A. non venomous snake

B. venomous snake with fangs mark

Management
1. Step of Management

2. First Aid Treatment

most of the traditional, popular, available and
affordable first-aid methods have proved to be
useless or even frankly dangerous.

 As far as the snake is concerned - do not

attempt to kill it if it already dead, bring
it to hospital for identification

 Recommended first-aid methods :

Reassure the victim who may be very anxious
Immobilize the whole of the patients body
Consider pressure-immobilization or pressure
pad
Avoid any interference with the bite wound
Release of tight bands, bandages and
ligatures

3. Transport to hospital
as quickly, but as safely and comfortably, as
possible
Any movement especially movement of the
bitten limb, must be reduced
If possible, patients should be placed in the
recovery position

Pressure immobilisation method. Recommended first aid for

bites by neurotoxic elapid snakes
(by courtesy of the Australian Venom Research Unit, University of Melbourne)

Evacuation of a snake bite victim showing early signs of

paralysis by a village-based motorcycle volunteer. The
victim is supported
between the driver and a pillion passenger
(Copyright Dr Sanjib Sharma)

 Treatment in the Hospital

Primary assessment (ABCDE) need urgent
resucitation when :
Hypotension / shock
Respiratory failure
Sudden deterioration of severe systemic
envenoming
Cardiac arrest
If arrive late renal failure & septicaemia

 Treatment in hospital
4 important questions
Question
In what part of your
body have you been
bitten?
When and under
what circumstances
were you bitten?
Where is the snake
that bit you?

How are you feeling

now?

Patient condition
Left low arm

Note
To see the evidence,
signs of envenoming

She was in the garden

taking some grasses at
10 am and then snake
bite her
She was just running
home after being bitten
so she dont know
about the snake
Pain in the left arm,
nausea, vomiting, pain
in the abdomen

The severity and how

long the patient was
bitten
For identification
purpose

For doctors further

assessment

 Physical examination
Examination (bitten part)
extent of swelling, which is usually also
the extent of tenderness to palpation
(start proximally)
Lymph nodes draining the limb should be
palpated and overlying ecchymoses and
lymphangitic lines
A bitten limb may be tensely
oedematous, cold, immobile and with
impalpable arterial pulses
Early signs of necrosis may include
blistering, demarcated darkening (easily
confused with bruising)
paleness of the skin, loss of sensation

Patient
+

Examination (General)
Blood Pressure, HR, RR
skin and mucous membranes for evidence of
petechiae, purpura, discoid haemorrhages
ecchymoses, chemosis, and epistaxis for
haemorrhages
Abdominal tenderness may suggest
gastrointestinal or retroperitoneal bleeding.
Loin (low back) pain and tenderness
suggests acute renal ischaemia
Intracranial haemorrhage is suggested
by lateralising neurological signs,
asymmetrical pupils, convulsions
Impaired consciousness (in the absence of
respiratory or circulatory failure).

Patient

+ (all
abdominal
area)
-

Examination (Neurotoxic
envenoming)

Patie
nt

Upper lid retract fully looking for

No
ptosis
ptosis
Test eye movement opthalmoplegia
Reaction of the pupils
+
Open mouth and protrude tongue
paralysis/ trismus
Broken neck sign
Paradoxical respiration
Generalized flaccid
-

INVESTIGATION/LAB TEST
1. 20 minutes whole blood test (20WBCT)

20 minute whole blood clotting test in a patient envenomed by a

Papuan taipan who is still beeding from incisions made at the site of
the bite. The blood is incoagulable indicating venom-induced
consumption coagulopathy (Copyright DA Warrell)

2. Blood count neutrophil leukocytosis

3. Blood Film helmet cell
4. Biochemical abnormalities
5. Arterial blood gases and pH resp.failure &
acidaemia
6. Desaturation
7. Urine examination colour, proteinuria, AKI

ANTIVENOM TREATMENT
What is antivenom?
is immunoglobulin [usually pepsin-refined
F(ab)2 fragment of whole IgG]
Monovalent/Polyvalent

Indications?

 (liquid antivenom, 5 ml/ampoule) manufactured

by Biofarma
Dose (1): 2 vials @5ml + NaCl 500 ml (2% of
antivenom), 40-80 drops/mnt
repeat after
6 hour if
needed.
Dose (2): 2 vials, intravenous, slowly (2ml/mnt or
10 mnts)
Children = adult
Monitor for min. 1 hour

 Must never be given by IM, except :

In the peripheral first aid station
On an expedition
IV access impossible

If IM, use upper anterolateral region

of both thighs, @5-10ml

 If continue to bleed briskly repeat after 1-2

hour(s)
If case of deteriorating neurotoxicity or
cardiovascular sign repeat after 1-2 hour(s)

 Antivenin serum

 How long to be effective?

should be given as soon as it is indicated

Reactions?
Anaphylactic
Pyrogenic
Late
How to prevent it? prophylactic drug
& speed and dilution of antivenom
administration

Early anaphylactic reaction to antivenom: urticaria

and pruritus of the trunk and face (Copyright DA
Warrell)

 Treatment of antivenom reaction

Anaphylactic epinephrine 0,5 mg (adult) or
0,01 mg/BW (children). Add antihistamine and
corticosteroid if needed

Pyrogenic correct hydration, antipyretic

Late 5 days course of antihistamine. If fail, continue
with 5 days course of prednisolone
Doses: Chlorphenamine: adults 2 mg six hourly,
children 0.25 mg/kg /day in divided doses.
Prednisolone: adults 5 mg six hourly, children 0.7
mg/kg/day in divided doses

 Treatment of bitten part

Bacterial infection :
interference with the wound (i.e. incision) create risk
of secondary bacterial infection
Compartment syndrome and fasciotomy
Classical sign hard to assess unnecessary
fasciotomy

Main Challenges

Improving
Improving
Improving
Improving

access
clinical management
diagnostic and treatment tools
knowledge

References
Kasturiratne, A et al. 2008. The Global Burden of
Snakebite: A Literature Analysis and Modelling
Based on Regional Estimates of Envenoming and
Deaths. PLoS Med 5(11):e218
Alirol, E et al. 2010. Snake Bite in South Asia: A
Review. PloS Med 4(1):e603
Warrel, D A. 2010. Guidelines for the management
of the snakebite. WHO SEARO
Gold, B S. 2002. Current concept of venomous
snake. N Engl J Med, Vol. 347, No. 5

Thank you