7/21/2023
SNAKE BITE Epidemiology
• > 5 million bites annually by venomous snakes
world wide
• With > 1,25,000 deaths
• Age : 11 – 50 yrs
• Sex : males
• Mc site : lower limbs 40 %
Dr. Humayun Mirza
Associate Professor
Department of Community Medicine
LMDC
Pakistan Scenario Classification of snakes
• Pakistan has second highest number of snake bite • Colubridae • Most non venomous snakes
eg : grass snake
cases in the world after India
• There are 50,000 snake bite cases every year with • Elapidae
• Cobras, krait, mambas, coral
22000 deaths (Health Situation WHO 1990) snake
• Sindh is having more than 50% of all snake bite • Viperidae • American rattlesnake, Asian
cases in Pakistan pitviper, Russels viper, aders
• Hydrophidae
• Sea Snake
Snake venom VENOM CLASSIFICATION
• Toxic saliva secreted by modified parotid glands of a
venomous snake • Neurotoxic elapids(cobra,krait)
• Amber colored when fresh
• Hemotoxic viperidae
• Constituents Toxins
Enzymes • Myotoxic sea snake
Miscellaneous : neurotoxins • Krait and russell’s viper is much more toxic
cardiotoxins
than that of cobra
hemolysin
1
7/21/2023
• Fangs : hollow like • Short and solid
Poisonous or Non-Poisonous hypodermic needles
• Teeth : 2 long fangs • Several small teeth
• Head scales : small large
• Large and opening / pit b/w
• Tail : compressed
eye & nostril (pit viper) • Not much compressed
• Third labial touches eye and
nostril shield (cobra)
• No pit or third labial touches
eye & nostril shield( krait )
VIPERS
2
7/21/2023
SYMPTOMATOLOGY OF NON VENOMOUS
SNAKES SYMP..VENOMOUS SNAKE BITES
• Universal fear associated induce a state of • ELAPID BITE
shock Local features :
• Bite site may demonstrate multiple teeth • unclear fang marks ,
impressions • burning pain,
• Lack of significant local pain or swelling • swelling and discoloration,
• Adequate reassurance and symptomatic • serosanguinous discharge
treatment measures lead to full recovery
SYSTEMIC FEATURES VIPERID BITE
• preparalytic stage : emesis,
headache,
Local features:
rapid swelling,
paralytic stage : ptosis,
ophthalmoplegia
discoloration,
drowsiness, blister formation,
dysarthria,
dysphagia, bleeding from bite
convulsions, site,
bulbar paralysis,
resp failure . severe pain
SYSTEMIC FEATURES-
HYDROPHID BITE
Generalized bleeding manifestations. • Local features: minimal swelling and pain
epistaxis,
• Systemic features: myalgia muscle
hemoptysis,
bleeding gums
stiffness
hematuria • myoglobinuria , renal tubular necrosis
purpuric spots
Renal failure
3
7/21/2023
MANAGEMENT OF SNAKE BITE HOW TO PREVENT SNAKE BITES
Best way to a manage is ? • A WORLD WITHOUT SNAKES
• NEARLY A QUARTER OF US WOULD GO HUNGRY
to prevent a snake bite…..! • THEY ARE IMPORTANT ELEMENTS IN FOOD CHAIN THAT
CONTROL RODENT POPULATION
SYMPTOMATOLOGY OF NON VENOMOUS
FIRST STEP SNAKES
• TO IDENTIFY WHEATHER IT WAS A POISONOUS SNAKE. • Universal fear - a state of shock
• 216 SPECIES- 52 VENOMOUS • Bite site -multiple teeth impressions
• IF THE PAIN NUMBNESS AND OEDEMA IS SPREADING
THEN IT IS A VENOMOUS SNAKE.
• significant local pain or swelling -ABSENT
• SUSPECTED SNAKE BITE • Adequate reassurance and symptomatic treatment
OBSERVATION 24 HOURS
EXAMINATION
• To rule out ptosis
Evidence of early external ophthalmoplegia .
• size and reaction of the pupils.
• Early paralysis
4
7/21/2023
LOCAL EXAMINATION EVIDENCE OF SYSTEMIC ENVENOMATION
• Oedema petechiae bullae oozing from the wound should be • CT> 10 MINUTES
noted • Bleeding manifestations
• Extent of swelling • Oliguria /haematuria
• Circumference of the bitten limb should be noted every 15 • Hypotension
minutes- spreading
• Ptosis
• Circumoral paraesthesia
• Aphonia/Dysarthria
CLASSIFICATION INVESTIGATIONS
• GRADE 0 – NO ENVENOMATION • Blood grouping
• Hb, elevated PCV
• GRADE 1- MINIMAL ENVENOMATION
• TC-leucocytosis
(local pain and swelling) • Platelet count- thrombocytopenia
• GRADE 2-MODERATE ENVENOMATION • Peripheral smear – Haemolysis
• BT,CT(20 min)
(Pain ,swelling, ecchymosis spreading
• prolonged PT ,aPTT
+mild systemic/ lab manifestations) • Urea Serum Electrolytes- hyperkalemia
• GRADE 3-SEVERE ENVENOMATION • Urine Routine-haematuria
• Metabolic /resp acidosis
(Marked local response+severe systemic
findings+significant lab findings)
MONITORING TREATMENT
• Level of consiousness • Local wound care
• Pulse, BP, Resp rate,Capillary refill time
• Clotting time 1/2hr -1hourly • Inj TT
• Urine output • Observation -24 hrs
• Muscle weakness
5
7/21/2023
GRADE 2 AND 3
• Moderate and Severe Envenomation • NEVER APPLY A TOURNIQUET ABOVE THE SITE
Inj TT • IF THE PATIENT COMES WITH A TOURNIQUET
Antibiotics(Ampicillin / always CHECK FOR VASCULARITY
3 rd genertion cephalosporins+ • Do not suck out venom
metronidazole) • Do not incise the bite wound nor apply any chemicals
local anti oedema measures
ANTI SNAKE VENOM (ASV) ASV- ANTI SNAKE VENOM
• Antivenom is 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
immunized with the venoms of one or more species of
snake.
• Monovalent or monospecific antivenom
• Polyvalent
INDICATIONS OF ASV DOSAGE
• Neurotoxicity • 10 vials polyvalent asv (irrespective of body weight and age)
• Bleeding/coagulopathy • 2nd dose - overt bleeding is present
• Myoglobinuria/haemoglobinuria
10 vials
• Cardiac toxicity
OR
• Local swelling involving more than half of the bitten limb
• Rapid extension of swelling Do 20 minute clotting time and give
• Development of an enlarged tender Lymph node draining the bitten 2 vials Q6H till the coagulation
limb
parameters are normal
• ARF
6
7/21/2023
HOW TO GIVE ASV ? ASV REACTION
• No test dose is required • Urticaria ,itching ,fever , shaking chills ,nausea ,vomiting
,diarrhoea abdominal cramps ,tachycardia hypotension ,
bronchospasm and angioedema
• One vial is added with 100 ml of normal saline. After 10 -15
• ASV is discontinued
minutes 9 vials can be added in the same fluid over one hour
• 0.01mg/kg of Adrenaline is given
(1:1000)as IM should be given
TIMING OF ASV RESPONSE TO ASV
• Best effect – used within 4 hours • Normalization of BP
• Can be administered upto 48 hours • Bleeding stops within 15 – 30 mts
• Efficacy is seen upto 6- 7 days • Normalization of coagulation parameters within
6 hours
• Neurological sign will be resolving within 30-48
hours
NEUROPARALYTIC SYMPTOMS COMPLICATIONS
• Neostigmine -0.05mg to 0.1mg/kg every 4 hours • Shock
• Renal failure
• Myocardial failure
• Atropine 0.02mg/kg (5minutes prior to neostigmine) • Shock lung
• Bleeding
7
7/21/2023
THANK YOU
