COMMON TOXIC

BITES
Olowookere O.O
FWACP(FM),DRH(Liverpool)
 SNAKE BITE
 DOG BITE
 SCORPION STING
 HUMAN BITE
How common is this?
SNAKE BITE- OUTLINE
 INTRODUCTION
 SNAKE IDENTIFICATION
 EPIDEMIOLOGY
 PATHOPHYSIOLOGY
 CLINICAL FEATURES
 INVESTIGATIONS
OUTLINE (2)
 FIRST AID
 HOSPITAL CARE
SNAKE BITE
 Worldwide, only about 15% of the more than
3000 species of snakes are considered
dangerous to humans.400 of 3000 snake species
worldwide inject venom.
 Few snakes, with the occasional exception of
king cobras (Ophiophagus hannah) or black
mambas (Dendroaspis polylepis), act
aggressively toward a human without provocation
 The family Viperidae is the largest family
of venomous snakes, and members of this
family can be found in Africa, Europe,
Asia, and the Americas.
 The family Elapidae is the next largest
family of venomous snakes
Toxins
 proteins in the venom can be divided into
4 categories:
 Hemotoxins cause internal bleeding.
 Neurotoxins affect the nervous system.
 Cytotoxins cause local tissue damage.
 Cardiotoxins act directly on the heart.
Viperidae

 subfamily Viperinae: European adders &

Russell’s vipers.
 subfamily Crotalinae: Asian pit vipers,
American rattlesnakes, cottonmouths, and
copperheads, the saw-scaled vipers of Asia
and Africa and Gaboon viper of Africa.
Rattlesnake
 Triangular-shaped head
 Nostril pits(heat-sensing
organs)
 Elliptical pupils
 Subcaudal plates in a
single row
 Enlarged maxillary
fangs
Copperhead Austrelaps superbus

 venom has
neurotoxic,
coagulopathic and
myotoxic actions
 bites rarely fatal.
IDENTIFICATION OF SNAKE
 Elapidae including the cobras, mambas,
coral snakes, kraits and all Australian
venomous snakes.
 Hydrophidae (sea snakes)
 Atractaspididae (the burrowing asps)
 Colubridae eg mongoose snake
PATHOPHYSIOLOGY
 Venom is produced and stored in paired glands
below the eye.
 Fangs can grow to 20 mm in large rattlesnakes.
 Venom dosage per bite depends on:
 the elapsed time since the last bite,
 the degree of threat the snake feels,
 and the size of the prey.
PATHOPHYSIOLOGY(2)
 Proteases, collagenase, and arginine ester
hydrolase have been identified in pit viper
venom.
 Neurotoxins comprise the majority of coral
snake venom.
 Venom is mostly water
PATHOPHYSIOLOGY(3)
Local oedema Neuromuscular blockade

Capillary leak Poor diaphragmatic excursions

Interstitial fluid in the

lungs Hypotension

Altered pulmonary mechanics

Local cell death

PATHOPHYSIOLOGY(4)
Myonecrosis Severe envenomations

Coagulopathies
Myoglobinuria
local bleeding

renal damage.
CLINICAL
 The usual sequence of systemic
symptom development is something like
this:
 (<1hr) Headache (an important
symptom), irritability, photophobia,
nausea, vomiting, diarrhoea, confusion;
coagulation abnormalities; occasionally
sudden hypotension with loss of
consciousness.
CLINICAL
 Paralysis occurs rapidly in small children
with highly venomous snake bites.
 For Hydrophidae, muscle destruction from
myolytic toxins is common and this may
not be associated with muscle tenderness;
it may lead to renal failure.
CLINICAL
 Systemic symptoms include nausea, syncope,
and difficulty swallowing or breathing.
 Determine history of prior exposure to
antivenin or snakebite.
 Determine history of allergies to medicines
because antibiotics may be required.
 Determine history of co-morbid conditions (eg,
cardiac, pulmonary, and renal disease) or
medications (eg, aspirin, anticoagulants)
CLINICAL
Physical
 Vital signs, airway, breathing, circulation
 Fang marks or scratches
 Local tissue destruction
 Soft pitting edema that generally develops
over 6-12 hours but may start within 5
minutes
 Bullae
 Streaking
 Erythema or discoloration
FIRST AID
 A medical emergency.
 DO NOT wash the area of the bite! Retain
traces of venom for use with venom
identification kits!
 DO NOT allow the person to become
over-exerted.
 DO NOT apply a tourniquet.
 DO NOT apply cold compresses to a
snake bite.
FIRST AID
 Adhere to the basic tenets of emergency
life support.
 Reassure the patient to preclude hysteria
during the implementation of ABCs.
 Stop lymphatic spread - bandage firmly,
splint and immobilise!
 Remove any rings or constricting items
because the affected area may swell.
HOSPITAL CARE
 Only 1 in 20 snake bites require the
administration of antivenom.
 Medical management depends on

-the degree of systemic envenomation

-the type of venom.
 Give Tetanus prophylaxis
FIRST AID (2)
 DO NOT cut into a snake bite with a knife
or razor.
 DO NOT try to suction the venom by
mouth.
 DO NOT raise the site of the bite above
the level of the person's heart.
 DO NOT remove bandage in the field.
 DO NOT give antivenom in the field.
CLINICAL
 Regional lymphadenopathy may be
marked. Contributes to abdominal pain in
children.
 Systemic toxicity
 Hypotension
 Petechiae, epistaxis, hemoptysis
 Paresthesias and dysthesias -
neuromuscular blockade and respiratory
distress (more common with coral snakes)
CLINICAL
 (1-3 hrs) Cranial nerve paralysis (ptosis,
diplopia, dysphagia etc), abdominal pain,
haemoglobinuria, hypertension,
tachycardia, haemorrhage.
 (>3hrs) Limb and respiratory muscle
paralysis leading to respiratory failure,
peripheral circulatory failure with pallor
and cyanosis, myoglobinuria, eventually
death.
LAB STUDIES
 FBC
 PT and PTTK,
 Group and cross match blood
 Blood chemistries, including electrolytes,
BUN, creatinine
 Urinalysis for myoglobinuria
 Arterial blood gas determinations for
patients with systemic symptoms
PRE-TREATMENT

 Subcutaneous adrenaline (0.25mg for

adults, 0.01mg/kg for children),
 iv steroids (hydrocortisone 2mg/kg) is still
recommended, although severe reactions
are rare.
 In general the risk from the snake toxins
is much greater than the risk of
administering the antivenom.
SURGICAL CARE
 Fasciotomy is indicated for those patients
with elevated compartment pressures
>30-40 mm Hg.
 Physical hallmark of compartment
hypertension (pain with passive range of
motion) for the clinical assessment.
 Skin grafting.
DOG BITE
 Almost one half of all dog bites involve an
animal owned by the victim's family or
neighbours.
 A large percentage of dog bite victims are
children.
 Although some breeds of dogs have been
identified as being more aggressive than other
breeds, any dog may attack when threatened.
 Approx. 4 million Americans are bitten by
dogs, and about 44 percent of whom are
younger than 14 years.
Human behaviour as a factor

Many human behaviour (especially by people unfamiliar with dogs) may

factor into bite situations.
The majority of dogs won't respond to all or even any of these behaviours
with aggression, however, some will. These behaviours include:
 Attempting to take food or water away from a dog, or moving towards a
dog's food or water or between a dog and its food or water, even
inadvertently.

 Attacking a dog or its companions (which could be other dogs, humans,

or acting in a manner that the dog perceives as an attack )

 Startling a resting or sleeping dog.

 Approaching or touching a sick or injured dog.

Initial Wound Management
 After confirming that the victim is medically
stable
 Physicians should begin a primary
assessment by taking a history.
 Several medical conditions place a patient
at high risk of wound and rabies virus
infection from a dog bite
Information that can help determine
the patient's risk of infection
includes:
 the time of the injury, whether the animal
was provoked, and
 the general health, immunization status and
current location of the animal.
 The patient's tetanus immunization status,
current medications and allergies must be
noted.
During the physical examination:

The following should be recorded:

 the measurement and classification of the
wound (laceration, puncture, crushing or
avulsion)
 The range of motion of the affected and
adjacent areas should be documented.
 Nerve, vascular and motor function, including
pertinent negative findings.
General Treatment
 Timely and copious irrigation with normal saline or Ringer's
lactate solution may reduce the rate of infection markedly.
 Injection of the tissue with irrigant solution should be avoided,
because this can spread the infection.
 Necrotic or devitalized tissues should be removed, but care
must be taken not to debride so much tissue as to cause
problems with wound closure and appearance.
 All wound must never be sutured.
 Baseline radiographs may be obtained, especially with
puncture wounds near a joint or bone.
 Tetanus Toxoid Immunization
 Antibiotic Treatment
Only 15 to 20 percent of dog bite wounds become
infected.
 Crush injuries, puncture wounds and hand wounds
are more likely to become infected than scratches
or tears.
 Most infected dog bite wounds yield polymicrobial
organisms.
 Staphylococcus aureus - the most common aerobic
organisms, occurring in 20 to 30 percent of infected
dog bite wounds.
Assessing the Risk of Rabies
 The patient's risk of infection with rabies virus must
be addressed immediately.
 Because of the serious risk to the public of a rabid
animal on the loose, it is important to document the
conditions surrounding the attack.
 Patients with a bite from a non provoked dog should
be considered at higher risk for rabies infection than
patients with a bite from a provoked dog.
 If the dog owner is reliable and can confirm that the
animal's vaccination against rabies virus is current,
 the dog may be observed at the owner's home.
 Observation by a veterinarian is appropriate when
the vaccination status of the animal is unknown.
 If the animal cannot be quarantined for 10 days,
the dog bite victim should receive rabies
immunization.
Vaccination Status Treatment Regime
Not previously RIG Administer 20 IU per kg body
weight. If anatomically feasible, the full
vaccinated dose should be infiltrated around the
wounds and any remaining volume
should be administered IM at an
anatomic site distant from vaccine
administration.
Vaccine HDCV, RVA, or PCEC 1 mL, IM
(deltoid area), once daily on days 0, 3,
7, 14 and 28

Previously RIG should not be administered.

vaccinated

Vaccine HDCV, RVA, or PCEC 1.0 mL, IM (deltoid

area), once daily on days 0 and 3

RIG = rabies immune globulin HDCV - human diploid cell vaccine; RVA -
rabies vaccine adsorbed;
PCEC- purified chick embryo cell vaccine.
SCORPION STING
Introduction
 Scorpion stings are a major public health problem in
many underdeveloped tropical countries
 Scorpions are eight-legged carnivorous arthropods,
 members of the order Scorpiones within the class Arachnida.
 There are about 2000 species of scorpions, found widely
distributed south of about 49° N, except New Zealand and
Antarctica.
 The northernmost part of the world where scorpions live in the
wild is Sheerness on the Isle of Sheppey in the UK, where a
small colony of Euscorpius flavicaudis has been resident since
the 1860s.
Life and habits

 Scorpions have quite variable lifespans and the actual

lifespan of most species is not known.
 The age range appears to be approximately 4-25 years (25
years being the maximum reported life span in the species
Hadrurus arizonensis).
 Lifespan of Hadogenes species in the wild is estimated at
25-30 years.
 Scorpions prefer to live in areas where the temperatures
range from 20°C to 37°C (68°F to 99°F), but may survive
from freezing temperatures to the desert heat.
 Scorpion stings cause a wide range of
conditions,
 from severe local skin reactions to
neurologic,
 respiratory, and
 cardiovascular collapse.
Pathophysiology

 Scorpions use their pincers to grasp their prey;

 then, they arch their tail over their body to drive their
stinger into the prey to inject their venom, sometimes
more than once.
 The scorpion can voluntarily regulate how much venom
to inject with each sting.
 The striated muscles in the stinger allow regulation of the
amount of venom ejected, which is usually 0.1-0.6 mg.
 If the entire supply of venom is used, several days must
elapse before the supply is replenished.
Venom
 All scorpion species possess venom.
 The venom is composed of varying concentrations of neurotoxin,
cardiotoxin, nephrotoxin, hemolytic toxin, phosphodiesterases,
phospholipases, hyaluronidases, glycosaminoglycans, histamine,
serotonin, tryptophan, and cytokine releasers

 Scorpion venom is described as neurotoxic in nature. The most potent

toxin is the neurotoxin
 One exception to this generalization is Hemiscorpius lepturus which
possesses cytotoxic venom.
 The neurotoxins consist of a variety of small proteins as well as sodium
and potassium cations, which serve to interfere with neurotransmission
in the victim.
 Scorpions use their venom to kill or paralyze their prey so that it can be
eaten; in general it is fast-acting, allowing for effective prey capture.
History

 For patients presenting with scorpion

stings, ascertaining the following is
essential:
 Time of envenomation
 Nature of the incident
 Description of the scorpion
 Local and systemic symptoms
 The toxicity, variation, and duration of the symptoms depends on the following
factors:
 Scorpion species
 Scorpion age, size, and nutritional status
 Healthiness of the scorpion's stinging apparatus (telson)
 Number of stings and quantity of venom injected
 Depth of the sting penetration
 Composition of the venom
 Site of envenomation: Closer proximity of the sting to the head and torso results in
quicker venom absorption into the central circulation and a quicker onset of
symptoms.
 Age of the victim
 Health of the victim
 Weight of the victim relative to amount of venom
 Presence of comorbidities
Lab Studies

 Obtain a FBC for leukocytosis and hemolysis in patients with

stings from the Hemiscorpius species.
 Electrolyte evaluation is warranted in patients with venom-
induced salivation, vomiting, and diarrhoea.
 Coagulation parameters should be measured for venom-
induced defibrination because, at high concentrations, the venom
is an anticoagulant.
 Glucose levels should be measured to evaluate for
hyperglycemia from liver and pancreas dysfunction.
 Creatine kinase and urinalysis help evaluate for venom-induced
excessive motor rhabdomyolysis.
Modern treatment
 Cold compression
 Local analgesics
 Barbiturates- used to counteract scorpion-induced
hyperactivity
 Antivenom
Most must think that 'yes, this is the one'. The hard
fact is that it's use is limited, unpredictable and not
very effective.
 In snake antivenom, there is a relative success but
scorpion is another story altogether.
 A scorpion's toxin is a very bad antigen. The
antibodies produced against it, unlike in snakes,
usually is so specific that even different sub species
or geographic race needs different anti-venom.
 This means that antivenom produce in one country
is not effective in another country by the same
species.
 Also it is species specific such that each species
requires a different antivenom.
Modern treatment contd
 Hospitalisation
This depends on the condition of the
victim. Symptomatic relief also helps to
boost the victim's survival chance.
 Immobilisation
 Apply antiseptic
What the victim can do.
 Stay calm.
Going into anxiety only makes things worse.
 Signal for help
Since you most likely can't think straight, inform others and let others do the thinking
and walking.
 Move to the nearest shade to rest when help is on the way
Simple as that. Make yourself comfortable despite the pain........
 Clean the wound.
Keep it clean to prevent infection. However, I must note that stings usually don't have
much traumatic damage to tissue. Nevertheless, keep yourself occupied with minor
non-energy sapping task.
 Think positive
Do not start writing your will there and then. ``It may well be a self fulfiling prophecy``.
The danger is real for negative thinking is known to weaken the body defence. If
nothing else, try to identify the scorpion which stings you to prevent straying into
some dark alleys of thoughts. If that causes distress, forget it.
 Don't touch the scorpion yourself, be it dead or alive.
Supposedly squashed and dead scorpions may be able to give another nasty sting. .
Human bites
First aid
 Human bites can be as dangerous as or even
more dangerous than animal bites because of
the types of bacteria and viruses contained in
the human mouth.
 If someone cuts his or her knuckles on another
person's teeth, as might happen in a fight, this is
also considered a human bite.
If you sustain a human bite that
breaks the skin

 Stop the bleeding by applying pressure.

 Wash the wound thoroughly with soap and water.
 Apply an antibiotic cream to prevent infection.
 Apply a clean bandage. If the bite is bleeding, apply
pressure directly on the wound using a sterile bandage
or clean cloth until the bleeding stops.
 Seek emergency medical care.
Symptoms 

Bites may produce symptoms ranging from

mild to severe:
 Skin breaks with or without bleeding
 Puncture wounds
 Major cuts
 Crushing injuries
Human Bites
Forearm First Finger
When to Contact a Medical
Professional
   
 All human bites that break the skin should be promptly evaluated by
a doctor. Bites may be especially serious when:

 There is swelling, redness, pus draining from the wound, or pain.

 The bite occurred near the eyes or involved the face, hands, wrists,
or feet.

 The person who was bitten has a weakened immune system (for
example, from HIV or receiving chemotherapy for cancer). The
person is at a higher risk for the wound to become infected.
Prevention 
  
 Teach young children not to bite others.
 NEVER put your hand near or in the
mouth of someone who is having a seizure
.
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