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{ India estimates in the region of 200,000 snake bites /year with
15-20,000 deaths .

{ Originally made in the last century, are still quoted as no reliable
national statistics are available.

Males are bitten almost twice as often as females
50% of bites by venomous snakes are dry bites with negligible
envenomation
Majority of the bites being on the lower extremities.
Mostly between age group 11-50 yrs.
Only 7 to 15% are under 10 yrs age.
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{ In India, > 3500 species of snakes but only 200 are poisonous.
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{ Saw-scaled viper ·  

 

{ ˜ussellǯs viper ·    
  
{ jommon krait ·    

{ Indian cobra ·  !"#

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{Úind specifically to acetylcholine
receptors, preventing the interaction
between acetylcholine and receptors on
postsynaptic membrane.

{Prevents the opening of the sodium
channel associated with the acetylcholine
receptor and results in neuromuscular
blockade.

{ ASV -rapid reversal of paralysis.

{ Dissociation of the toxin-receptor
complex, which leads to a reversal of
Paralysis 

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1) Inhibiting the release of
acetylcholine from the presynaptic
membrane
2) Presynaptic nerve terminals
exhibited signs of irreversible
physical damage and are devoid of
synaptic vesicles

3) Antivenoms & anticholinesterases
have no effect

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{ Starts within 6-8 min

{ During the initial evaluation, the bite site should be
examined for signs of local envenomation (edema,
petechiae, bullae, oozing from the wound, etc) and
for the regional lymphadenopathy.

{ The bite site and at least two other, more proximal,
locations should be marked and the circumference
of the bitten limb should be measured every 15 min
thereafter, until the swelling is no longer
progressing.

{Gangrene Ȃ Early wet ( ELAPID)
Ȃ SLOWER DRY (Viper) m
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o Ptosis is the earliest foll by external opthalmoplegia.
o Weakness of muscles of palate, jaw , tongue larynx, neck and
muscles of deglutition.
o Generally cranial nerves are involved earlier followed by drowsiness,
coma and respiratory paralysis
o Muscle cramps,hyperacusis
o Paraesthesia, Fasciculations, Perioral Numbness.
o Pupils remain reactive to light till terminal stages where Diaphragm
is affected with resultant respiratory failure.

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ËAsk the patient to look up and observe whether the upper lids
retract fully.
ËTest eye movements for evidence of   

Ë heck the size and reaction of the pupils.
Ërait can cause fixed, dilated non reactive pupils simulating 
  Ȃ however, it can recover fully
ËAsk the patient to open their mouth wide and protrude their
tongue; early restriction often paralysis of pterygoid muscles.
Ë The muscles flexing the neck may be paralysed, giving the  

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pharynx- an early sign
{Ask the patient to take deep breaths in and out.
DzParadoxical respirationdz.
{ Objective measurement of ventilatory capacity by single
breath count is very useful.
{se a peak flow meter, spirometer (FEV1 and FV )
{Ask the patient to blow into the tube of a
sphygmomanometer to record the maximum expiratory
pressure (mmHg).

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haracterized by

Ë Prolonged clotting time,

Ë Úleeding at the site of bite,

Ë echymosis, purpura,epistaxis & bleeding from the
gums, GIT, urinary tract, and cerebral hemorrhages


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Ë Prolonged hypotension
Ë Intravascular hemolysis
Ë DI
Ë HS

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{Recurrent manifestations of poisoning occur due to
ongoing action of venom especially in Viper which has
half life of 26- 96 hrs

{Venom being released from local blebs which acts as a
venom depots not accessible to antivenom.

{Redistribution of venom from tissues into vascular space
as result of ASV.

{So frequent evaluation of patient is essential for 3-4 days

{Delayed manifestation in an initially stabilized patient
can occur even after 3 weeks
 
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{ Úlood grouping and typing
{ joagulation profile ÝPT, PTT, FDP and lotting time.
{ jÚj- may show anemia , leucocytosis, thrombocytopenia.
{ ¯eripheral smear - hemolysis and DI .
{ Ú  , creatinine, electrolytes.
{ jreatine kinase,SGOT,SG¯T
{ rine analysis - hematuria, proteinuria, myoglobinuria.

{ §jG changes are non specific and include bradycardia and
AV block with ST elevation or depression.


{A simple bed side test is adequate for clinical purpose

{seful to monitor the effectiveness of ASV therapy when
more sensitive tests for coagulation are not easily available

{ 2-3 ml of blood is kept in a new clean, dry, test tube
undisturbed for 20 minutes, and then gently tilted. If the
blood is still liquid, it is evidence of coagulopathy.

{In South eastern countries, suggestive of Viper bite and
rules out Elapid bites.

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Úanipulation of bitten area
Incision and excision over the bite .
Tourniquet
Suction
jhemical application
Stimulants and Alcoholic beverages
jauterization
jryotherapy
§lectric shock

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Admit for observation Ȃ 24 hrs
Reassure the patient
Take care of AÚ
Monitor vitals, urine for hematuria and
clotting time

Monitor HR, RR , chest expansion and
sensorium periodically

lose observation for early neurotoxic effects
such as ptosis , opthalmoplegia, speech and
swallowing difficulty periodically
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{Avoid IÚ injections

{Vascular access should be obtained in the unbitten limb
for treatment of shock.

{eep pressure immobilization/ constriction bands in
place till anti venom is administered

{Anticonvulsant for seizures

{Ventilator support may be needed for respiratory failure
or unstable airway.

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{Sedation and analgesic for pain.
(Paracetamol,
Pethidine).

{Neostigmine is given in Indian cobra and krait
bite with neurological manifestations.

Dose

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Mechanical ventilation is instituted to buy time till the organs recover

{ Aspiration can complicate MV
{ Respiratory paralysis due to Shock, ARF, Sepsis, etc..

Treatment is directed towards the cause

ASV
Úroad Spectrum Antibiotics - hloramphenicol + Metronidazole
Úlood and blood products Ȃ Fresh whole blood ideal
Volume expanders
Source control - Surgical debridement, Fasciotomies
Inotropes Ȃ Persistent shock
Dialysis
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{ Snakes inject the same dose of venom into children and adults but
children fare worser due to greater amt of toxins injected per unit
body mass.

{ hildren must be given exactly the same dose of antivenom as
adults.

{ No absolute contraindication

{ se ASV cautiously in those with High-risk for reactions
Prev. history of allergic reaction to antitetanus/antirabies serum
Strong history of atopic diseases and severe asthma

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{Mix one vial of anti venom with 10 ml of injection water
or saline or dextrose - between palms of the hand till
dissolved ie.. it appears clear.

{Donǯt shake vigorously

{If foam appears , turbid or milky , it indicates denatured
protein and there is a great risk of anaphylaxis if this is
used.

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{Epinephrine ALWAYS kept ready at hand before.

{Intravenous Dzpushdz injection
ƒ 2ml/min
in places with less facility

{Intravenous infusion È reconstituted ,diluted in 5-10 ml/kg
isotonic saline or glucose]

{Avoid IM and local administration at bite site
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{ 20%, of patients, usually more than develop a reaction

{ omplement activation by IgG aggregates or residual Fc
fragments or direct stimulation of mast cells or basophils by
antivenom protein are more likely mechanisms for these
reactions.
{ Types
1. Early anaphylactic reactions- within 10-180 min
2. Pyrogenic (endotoxin) reactions- develop 1-2 hours
3. Late (serum sickness type) - develop 1-12 days (mean 7)

Fatal reactions have probably been under-reported as
death after snake bite is usually attributed to the venom.
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0.01ml/kg of 1Ý1000 IM/IV Adrenaline ( Max dose
0.5ML)
Hydrocortisone-6-10mg/kg/dose IV
Volume replacement for shock
PM 0.2mg/kg /dose IV

{If patient found sensitive to equine ASV, desensitization
may be necessary by administering graded dose of
antivenin at a regular interval .

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Inject intradermal over forearm with 0.02ml of antivenin
diluted 1Ý10 with other forearm as control

Observe the patient for local or general symptoms of
hypersensitivity.

Appearance of erythema or wheal > 10mm within 30 min
is positive test

Needs desensitisation with 0.01 ml of 1Ý100 solution
increasing concentration at 15 min interval till 1 ml given
subcutaneously given over 2 hrs.
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Antivenom administration must
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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
There is increasing evidence for anti H2 antihistamines-Ranitidine
Ȃ adults 50 mg, children 1 mg/kg.

{ Pyrogenic reactions require- antipyretics.
{ In case of circulatory collapse- start fluids, inotropes along with IV
adrenaline
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{Long term effects

Hypopituitarism, bilateral thalamic hematoma
sually swelling resolves within 2-3 weeks ; Sometimes may persist
upto 3 months or permanent.
Necrosis,Gangrene and resultant cosmetic defects
Rarely clotting defects and neurotoxicity persist.

{ Overall mortality Ȃ 10% but 50-70% children may eventually succumb
despite ASV administration .


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{ASV is the main stay in the treatment of snake bites
{ASV must be initiated if indicated at the earliest
{Not all snake bites require ASV

{Respiratory paralysis 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.


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{Pregnant patient is treated the same manner as the
nonpregnant patient. Spontaneous abortion, bleeding,
fetal death & malformations are common.
{Lactating mothers can continue lactating
{Fetal demise is difficult to predict because of associated
symptoms, such as coagulopathy or hypotension, and
complications of treatment including anaphylaxis.
{Generally speaking, the severity of the mother's clinical
course seems to be the best indicator of the fetal survival.