Snake Bite &

Management
Epidemiology
In SEA, Snake bite is a occupational, environmental &
climatic hazard.

Farmers
Fishermen
Snake handlers
Flood
Swimming
Epidemiology
Estimate 4 mill. Snake bites with
100,000 death per year in Asia (Chippaux 1998)

1999-2003: total 126 of snake bite

reported in HKL (Jamaiah et al)
 Male: female = 3:1
 No fatal cases
 60% the snake could not be identified
 cobra - 25%, followed by viper - 10%,
python - 4% and sea snake - 1%

1958 to 1980: 55000 cases of snakebites recorded in the

hospitals in Malaysia. (N.H.Tan)
 The mortality rate of snakebite in Malaysia is only 0.3 per 100000 population
Epidemiology
Snake Species Total Cases Fatal Cases

Malayan pit viper (Calloselasma 1136 4

rhodostoma)
Sea snake   158 5

Asian common cobra (Naja naja)   112 3

Asian lance-headed viper (Trimeresurus)     25 0

King cobra  (Ophiophagus hannah)       6 0

Krait  (Bungarus)       1 0
Unidentified 3765 6
Snakebites in West Malaysia, Report from monthly statistics of 28 hospitals throughout Malaysia, 1965-1971; Prof. Tan, Nget
Hong
The arsenals
Venomous snakes equipped with fangs
Contain venom channel or groove

Short, permanently erect

elapid fangs (Naja Naja)

Long, hinged front fangs

of a viper (Diabola Siamensis)
Venom
Venom is produced and stored in paired glands below
the eye.
venom
Quantity varies depend on:
Species
Size – but bite of small snake should not be
ignored, treat as same species bite.
Mechanism – one/two fangs, single/multiple
strikes
Size of prey
Snake venoms contain more than 20 different
constituents, mainly proteins, including enzymes
and polypeptide toxins.
Snake do not exhaust their store of venom, no less
venomous after eating their prey)
Venom usually injected into the victim to
immobilize it quickly and begin digestion.
Snake venoms contain more than 20
different constituents, mainly proteins,
including enzymes and polypeptide toxins.
Pathophysiology
 One effect is local bleeding; coagulopathy is not uncommon with severe
envenomation.

 Another effect, local edema, increases capillary leak and interstitial fluid in the
lungs.

 Pulmonary mechanics may be altered significantly.

 The final effect, local cell death, increases lactic acid concentration secondary
to changes in volume status and requires increased minute ventilation.

 The effects of neuromuscular blockade result in poor diaphragmatic excursion.

 Cardiac failure can result from hypotension and acidosis.

 Myonecrosis raises concerns about myoglobinuria and renal damage.

Venom
The local effects of venom serve as a reminder of the
potential for systemic disruption of organ system
function

“Dry bites”:
50% bites by Malayan pit vipers & Russel’s vipers, 30%
of bites by cobras & 5-10% bites by saw scaled vipers
asymptomatic of envenomation.
Enter the Malaysian’s
Slytherin
Majority of snakes occurring in Malaysia are
non-venomous, and constitute no threat to
humans,
A number of species can cause mild to
severe envenoming that may lead to
permanent disability or even death in
humans.
In Malaysia there are ~ 40 species
venomous snakes (18 land snakes, 22 sea
snakes) belonging to 2 families: Elapidae,
Viperidae

There is no simple rule to differentiate a

venomous snake from a non-venomous
snake – some harmless snakes look almost
identical to venomous ones
 Crotalinae
(pit viper)
Viperinae
Viperidae
(viper)

Azemiopinae

Poisonous
Colubridae Elapinae
snakes
Laticaudinae

Hydrophiinae
Elapidae

Ephalophiini

Hydrophiini
Family Scientific name Common Malay name
Viperidae
Malayan Pit viper Calloselasma rhodostoma Ular kapak bodoh
Temple pit viper Trimeresurus wagleri Ular kapak tokong
Red-tailed pit viper Trimeresurus popeorum Ular kapak ekor merah
Mountain pit viper Trimeresurus monticola Ular kapak gunung
Sumatran pit viper Trimeresurus sumatranus Ular kapak sumatera
Mangrove pit viper Trimeresurus purpureomaculatus Ular kapak bakau
Flat-nosed pit viper Trimeresurus puniceus Ular kapak hidung pipeh
Elapidae
Common black cobra Naja naja Ular senduk
King cobra Ophiophagus hannah Ular tedung selar
Banded krait Bungarus fasciatus Ular katam belang
Malayan krait Bungarus candidus Ular katam tebu
Red-headed krait Bungarus flaviceps Ular katam kepala merah
Spotted coral snake Callophis gracilis Ular pantai bintik
Blue Malayan coral Maticora bivirgata Ular pantai biru biru
snake
Banded coral snake Maticora intestinalis Ular pantai belang
 LIST OF VENOMOUS SNAKES

Family CROTALIDAE (Pit vipers)

Malayan pit viper (Agkistrodon rhodostoma)

(Ular Kapak Bodoh)

Sumatran pit viper (Trimeresurus sumatranus)

(Ular Kapak Sumatera)

Mangrove pit viper ( Trimeresurus purpureomaculatus)

( Ular Kapak Bakau)
Malayan pit viper (Ular kapak
bodoh)
Sumatran pit viper
(Ular Kapak
Sumatera)
Mangrove pit viper ( Ular Kapak
Bakau)
Trimeresurus wagleri (Ular Kapak
Tokong)
Family ELAPIDAE
Common Black Cobra (Naja naja)
(Ular Senduk)

King Cobra (Opiophagus hannah)

(Ular Tedung Selar)

Banded Krait (Bungarus fasciatus)

(Ular Katam Belang)

Malayan Krait (Bungarus candidus)

(Ular Katam Tebu)

Blue Malayan Coral Snake (Maticora bivirgata)

(Ular Pantai Biru-biru)

Banded Coral Snake (Maticora intestinalis)

(Ular Pantai Belang)
Common Cobras
( Ular
Senduk/Tedung)
 Naja Kauthia (Monocled
Cobra)

Naja Naja

Naja Sumatrana
King Cobra (Ular Tedung Selar)
Banded krait
(Ular katam belang)
Malayan krait (Ular katam tebu)
Blue Malayan coral
snake
(Ular pantai biru-biru)
Banded coral snake (Ular pantai belang)
Family HYDROPHIDAE (Sea Snakes)

Banded Sea Snake (Hydophis cyanocintus)

Hardwick’s Sea Snake (Lapemis hardwickii)

Amphibious Sea Snake (Laticauda colubrina)

(Ular Laut Amfibia)
Banded sea snake Amphibious sea snake
(Ular laut amfibia)
Hardwick’s sea snake
Management of snakebite
First Aid Treatment
Avoid any interference with the
bite wound (e.g. tourniquet,
incisions, sucking, rubbing,
vigorous cleaning, application of
herbs/chemicals, massage or
electrical shocks).
Action
1 Reassure the victim who may be very anxious.
Move away from danger. Reduce physical
movement.
2 Lay patient down in a comfortable position, and
immobilize the bitten area/limb with a splint or
sling. Maintain immobilization throughout the
patient’s stay in the ED.
3 Irrigate eyes with copious amount of water if the
venom enters the eyes.
4 Remove jewelry and loosen tight-fitting clothing
enroute to health centre. Urgent transport.
Pressure Immobilisation
Rapid clinical assessment and reuscitation
1 Manage patient in a controlled environment area
with close monitoring of vital signs and cardiac
rhythm
2 Primary clinical assessment (ABCDE approach) and
resuscitation as indicated
3 Prop up patient to a comfortable position and
administer Oxygen to keep sPO2 >95%
4 Obtain two (2) venous access and maintain with
Normal Saline solution
5 Immobilize the bitten limb
Detailed clinical assessment
History
where, when, neurotoxic/haemotoxic symptoms

Physical examination
General
Bite wound
“Spesific” presentation for diff. venomous
snake
Elapids (neurotoxic)
Local effects

Snake Pain at Local Pain Necrosis Skin

site edema regiona disc.
l LN
Cobra +++ +++ +++ +++ +++
Kraits + - + - -
Coral +++ ++ + - +
snake
Elapids (neurotoxic)

Systemic envenomation – early sign is

vomiting
Neurotoxic – circumoral numbness, ptosis,
resp. muscle paralysis
“Spesific” presentation for diff. venomous
snake

Viper (Haemotoxic)

Local Effects:
Pain, local swelling & bruising within 1-
2hrs and can spread
Necrosis
Tender lymph node
Viper (Haemotoxic)

Haemostatic abnormalities:
Defibrination - coagulopathy
Spontaneous bleeding – gum, bite site
Shock: hypovolaemia
Cardiac arrythmias
ARF
“Spesific” presentation for diff. venomous
snake
Sea snakes (Myotoxic and neurotoxic)

Local effects:
Little pain
no edema

Myopathic myotoxic effects:

Myalgia, weakness
Myoglobinuria
Resp. failure
Sea snakes (Myotoxic and neurotoxic)

Neurotoxic:
ARF and cardiac arrest:
Due to hyperkalaemia and myoglobinuria
Detailed assessment
Early clues that a patient has severe
envenoming:

Snake identified as a very dangerous one.

Rapid early extension of local swelling from
the site of the bite.
Early tender enlargement of local lymph
nodes, indicating spread of venom in the
lymphatic system.
Early systemic symptoms:
collapse (hypotension, shock), nausea,
vomiting, diarrhoea, severe headache,
“heaviness” of the eyelids, inappropriate
(pathological) drowsiness or early
ptosis/ophthalmoplegia.
Early spontaneous systemic bleeding.
Passage of dark brown/black urine.
Detailed assessment
Species diagnosis – identify
the snake if the snake was
brought to hospital
IMAGE GALLERY OF LAND SNAKES OF MEDICAL
SIGNIFICANCE IN MALAYSIA
 Identification of snake bite
Ensure snake is dead

Identify snake by its external appearance

Or
Match snake based on pictures & texts

Look for fang marks (using a pair of forceps)

Note: Fang marks are 2 prick marks of about 1.25 cm apart

Present Absent
(venomous) (non-venomous)

Short anterior fangs Long anterior fangs

Flat oar like tail Large shield scales on head Distinct triangular head

Sea snake Vipers

Cobra, kraits, coral snakes
(hydropiidae) (Crotalidae)
(Elapidae)
Large shield
scale Flat oar tail
 Investigations
&
laboratory tests
20-minute whole blood clotting test
(20WBCT)
1 Place 2mls of freshly sampled venous blood in a small, new
or heat cleaned, dry, glass vessel.
2 Leave undisturbed for 20 minutes at ambient
temperature, then tip the vessel once.

Note: If initial test was normal (fully clotted) repeat test

every 30 minutes for first 3 hours then hourly up to 6hrs
post bite or as necessary. If the blood remain liquid
(unclotted), this is suggestive of
coagulopathy or defibrination syndrome
secondary to systemic envenomation
from a pit viper bite.
Others
FBC
Coagulation profile
Urinalysis, urine myoglobin
BUSE
DIVC screen
CK
ABG – resp. muscle paralysis
Antivenom treatment
Antivenom
Immunoglobulin (usually the enzyme
refined F(ab)2 fragment of IgG)

Purified from the serum or plasma of a

horse or sheep that has been immunised
with the venoms of one or more species of
snake
Antivenom
Monovalent vs Polyvalents

Paraspecific activity - Antibodies raised

against the venom of one species may have
cross-neutralising activity against other
venoms, usually from closely related species

Storage : Keep at 2-6degre celcius

Indication of antivenom (WHO)
Antivenom treatment is recommended if and when a patient with proven
or suspected snake bite develops one or more of the following signs

Systemic envenoming

 Haemostasis abnormalities: spontaneous systemic bleeding,

coagulopathy (20WBCT or other laboratory) or thrombocytopenia
(<100 x 109/litre)

 Neurotoxic signs: ptosis, ophthalmoplegia, paralysis etc

 CVS abnormalities: hypotension, shock, cardiac arrhythmia,

abnormal ECG
Indication of antivenom (WHO)

Systemic envenoming (2)

ARF: oliguria/anuria (clinical), rising blood

creatinine/ urea

Haemoglobin-/myoglobin-uria: dark brown urine,

urine dipsticks, other evidence of intravascular
haemolysis or generalised rhabdomyolysis (muscle
aches and pains, hyperkalaemia)
Indication of antivenom (WHO)
Local envenoming

Local swelling involving more than half of the bitten

limb (in the absence of a tourniquet) Swelling after bites
on the digits (toes and especially fingers)

Rapid extension of swelling (for example beyond the

wrist or ankle within a few hours of bites on the hands or
feet)

Development of an enlarged tender lymph node draining

the bitten limb
Antivenom treatment

Choice of antivenom:

If species known: monovalent

If unknown: Polyvalents

Local administration of antivenom is not

effective and not recommended.
Antivenom treatment

Malaysian CPG
Antivenom treatment

Antivenom is the only specific antidote to snake venom. A most important

decision in the management of a snake-bite victim is whether or not to
administer antivenom.
What we had…

Monovalent: N. Naja

Polyvalent: N. Naja, Common Krait (Bungarus

caerulus), Russel’s viper (Daboia russelli), Saw scaled
viper (Echis carinatus)
Antivenom:
Dosage & route administration
Amount given is usually empirical

Recommendations from manufacturers are usually

conservative as they are mainly based on animal
studies

Snakes inject the same dose of venom into children

and adults. Children must therefore be given exactly
the same dose of antivenom as adults
 Antivenom:
Dosage & route administration
Two methods of administration are recommended:

1) Intravenous “push” injection:

reconstituted freeze-dried antivenom or neat liquid
antivenom is given by slow intravenous injection (</=
2ml/minute).
This method has the advantage that the
doctor/nurse/dispenser giving the antivenom must
remain with the patient during the time when some
early reactions may develop.
Antivenom:
Dosage & route administration
2) Intravenous infusion:
reconstituted freeze-dried or neat liquid antivenom is
diluted in approximately 5-10 ml per kg body weight of
isotonic saline / 5% dextrose fluid and is infused at a
constant rate over a period of about one hour.
starting slow over 10-15 min then increased to a higher
rate if no reaction.
Closely observe patient during and for at least one
hour AFTER completion of intravenous infusion.
Serially chart vitals signs and clinical progression
 Antivenom:
Dosage & route administration
Infusion may be discontinued when satisfactory
improvement occurs, even if recommended dose has
not been completed

Do not perform sensitivity test as it poorly predicts

anaphylactic reactions

Prepare adrenaline, hydrocortisone, antihistamine &

resuscitative equipment & be ready if allergic reactions
occur
 Antivenom:
Dosage & route administration
Pretreatment with adrenaline SC remains
controversial
Small controlled studies in adults showed it
effective in reducing risk of reactions

There is no strong evidence to support use of

hydrocortisone/antihistamine as premedications
Consider their use in patients with atopy
ANTIVENOM REACTIONS
 A proportion of patients, usually more than 20%, develop a reaction
either early (within a few hours) or late (5 days or more) after being
given antivenom.

 Early anaphylactic reactions:

 usually within 10-180 minutes of starting antivenom,
• Itch, urticaria, dry cough, fever, GIT sympt. and tachycardia.
• Some may dev. anaphylaxis shock

 It is due to complement 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
 ANTIVENOM REACTIONS
Early anaphylactic reactions (2):

Stop antivenom infusion: give adrenaline IM

(0.01ml/kg of 1 in 1000)

Antihistamines eg. Chlorpheniramine 0.2mg/kg,

hydrocortisone 4mg/kg dose & IV fluid (if
hypotensive)

If mild reactions restart infusion at a slower rate

 ANTIVENOM REACTIONS
Pyrogenic (endotoxin) reactions :

• usually develop 1-2 hours after treatment.

• Symptoms : chills (rigors), fever, vasodilatation and

hypotension. Febrile convulsions may be precipitated in
children.

These reactions are caused by pyrogen contamination during

the manufacturing process. They are commonly reported.

Symptomatic tx: treat fever with paracetamol & tepid

sponging, hydration
 ANTIVENOM REACTIONS
Late (serum sickness type) reactions :

Develop 1-12 (mean 7) days after treatment.

Clinical features:
• Fever, nausea, vomiting, diarrhoea, recurrent urticaria,
arthralgia, myalgia, lymphadenopathy, periarticular
swellings, mononeuritis multiplex, proteinuria with
immune complex nephritis and rarely encephalopathy.

Patients who suffer early reactions and are treated

with antihistamines and corticosteroid are less likely
to develop late reactions.
 ANTIVENOM REACTIONS

Late (serum sickness type) reactions :

Treat with chlorpheniramine 0.2mg/kg/day

in divided doses x 5 days

If severe, give oral prednisolone

(0.7-1mg/kg/day) x 5-7 days
Observation of the response to antivenom
If an adequate dose of appropriate antivenom has been
administered, the following responses may be seen.

• General: the patient feels better. Nausea,

headache and generalised aches and pains may
disappear very quickly. This may be partly
attributable to a placebo effect.

• Spontaneous systemic bleeding: usually stops

within 15- 30 minutes.
Response to antivenom
Blood coagulability (as measured by
20WBCT): usually restored in 3-9 hours.
Bleeding from new and partly healed wounds
usually stops much sooner than this.

 CVS: BP may increase within the first 30-60

minutes and arrhythmias such as sinus
bradycardia may resolve.
Observation of the response to antivenom
• Neurotoxic:
envenoming of the post-synaptic type (cobra
bites) may begin to improve as early as 30 minutes
after antivenom, but usually take several hours.
Envenoming with presynaptic toxins (kraits and
sea snakes) is unlikely to respond in this way.

• Active haemolysis and rhabdomyolysis may cease

within a few hours and the urine returns to its normal
colour.
Criteria for repeating antivenom
Persistence or recurrence of blood incoagulability
after 6 hr or brisk bleeding after 1-2 hr

In patients who continue to bleed briskly (the dose of

antivenom should be repeated within 1-2 hours)

Deteriorating neurotoxic or cardiovascular signs after

1-2 hr

Give same dose as initial dose

Other measures
ATT
Analgesia
Cleaned wound
Broad spectrum antibiotic
Admit to ward for at least 24 hours (unless snake is
definitely non-venomous)
Ventilatory support
Hydration and urine output monitoring
Monitor for compartment synd.
Other measures
Neurotoxic envenomation
Antivenom treatment alone cannot be relied upon to
save the life of a patient with bulbar and respiratory
paralysis.

A trial of Anticholinesterase drugs have a variable, but

potentially very useful effect in patients with
neurotoxic envenoming, especially those bitten by
cobras.
Venom
opthalmia
Pitfalls in management
(a) Giving antivenom “prophylactically” to all
snake bite victims

Not all snake bite by venomous snakes will result in

envenoming

On average, 30% bites by cobra, 50% by Malayan pit

vipers & 75% by sea snakes DO NOT result in
envenoming
Pitfalls in management
Antivenom is expensive & carries risk of causing
severe anaphylactic reactions (as derived from horse /
sheep serum)

Hence it should be used only in patients in whom the

benefits of antivenom are considered to exceed risks
Pitfalls in management
(b) Delaying in giving antivenom in district hospitals
until victims are transferred to referral hospitals

Antivenom should be given as soon as it is indicated to

prevent morbidity & mortality

District hospitals should stock important antivenoms &

provide care & safe monitoring for antivenom infusion
Pitfalls in management
(c) Giving polyvalent antivenom for envenoming by
all types of snakes

Polyvalent antivenom does not cover ALL types of

snakes

E.g. Sii polyvalent (India) is effective in cobra & some

kraits envenomation but is not effective against
Malayan pit viper

Refer to manufacturer drug insert for details

Pitfalls in management
(d) Giving smaller doses of antivenom for children

Dose should be same as for adults

Amount given depends on the amount of venom

injection rather than size of victim
Pitfalls in management
(e) Giving pretreatment with hydrocortisone /
antihistamine for snake bite victim

Snakebites do not cause allergic / anaphylactic

reactions

These drugs may be considered in those who are given

ANTIVENOM
 REFERENCES
•The Clinical Management of Snake Bites in the South East Asian Region -
WHO, 27 April 2006

• WHO Guidelines for the Clinical Management of Snake bites

• Clinical Protocol Management of Snake Bite – MOH, June 2008

•SNAKEBITE MANAGEMENT GUIDE FOR HEALTHCARE PROVIDERS IN

MALAYSIA
Prepared by Dr Ahmad Khaldun Ismail – December 2011. Updated: June 2013 ©
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