SNAKE BITES
Types, Diagnosis & PM
Findings
By
Dr. Srikanth.S
1st year PG,
Dept of Legal Medicine,
OMC, Hyderabad.
INTRODUCTION
Snake bite is an acute life threatening; time limiting medical
emergency.
A preventable public health hazard.
Often faced by rural population with heavy rainfall and
humid climate.
WHO estimates number of bites to be 83,000 per annum
with 11,000 deaths in India.
No reliable National Statistics are available.
There are more than 2000 species of snakes in the world and
about 300 species in India; out of which 52 are venomous.
Commonest type of snake bite is from Russell’s viper
followed by Hump nosed viper, Cobra, Krait and Cat snake.
The commonest site paddy fields followed by home and
road.
The commonest location of the body below the knees >
hand.
The venomous snakes found in India belong to three families
• Elapidae : Neurotoxic
• Viperidae : Hemotoxic
• Hydrophidae (Sea snakes) : Myotoxic
Elapidae have short permanently erect fangs. Includes :
• Indian Cobra
• King Cobra
• Kraits
Viperidae have long fangs folded up against the upper jaw but are erected when
the snake strikes.
Two sub-groups
• Typical vipers (Viperinae) &
• Pit vipers (Crotalinae)
• The Crotalinae have a special sense
organ, the pit organ, to detect their
warm-blooded prey. Situated b/w
the nostril and the eye.
CLINICAL PRESENTATION OF
SNAKEBITE VICTIM DEPENDS
UPON
• Species of snake.
• Amount of venom injected.
• Season of the bite (Summer > Winter).
• Whether snake is fed or unfed.
• Dry or complete bite.
• Venom injected in vessel.
Asymptomatic : (i.e. non-venomous snakes S/S related)
• Fright (M/C symptom)
• Bite marks
• Slight pain
• Oozing of blood
• Oedema
• Itching
• Tingling
• Lodging of a tooth
• Wound heals normally
Dry bite :
• When a snake bites, but venom fails to get injected…
• Approx 20% of all snake bites are dry bites, except in sea snake bites – incidence
is 80%.
• About 50% of bites by Pit vipers and Russel’s vipers, 30% of bites by cobras and 5-
10% of bites by saw-scaled vipers are dry bites.
Causes :
Layers of clothing or shoes – over the bitten part.
When a snake bites but does not inject venom.
Superficial bite
Side swipes
OCCULT SNAKE BITE
Wherein patients are unaware of the bite and fang marks are absent.
• Krait bite victims often present early in the morning with paralysis with no local
signs.
Patient was healthy at night
severe epigastric/umbilical pain with vomiting persisting for 3-4 hours
typical neuroparalytic symptoms within next 4-6 hours
• No history of snake bite.
NEURO – PARALYTIC : Elapid envenomation
Typical symptoms within 30 min – 6 hours ---- cobra bite,
6-24 hours or as late as 36 hours----- krait bite.
In chronological order of appearance of symptoms :
Heavy eyelid, Ptosis f/b
Diplopia,
Dysarthria,
Dysphonia,
Dysphagia and
Finally, Paralysis of intercoastal and skeletal muscle occur in descending manner.
Remember as 5 Ds and 2 Ps
To identify the impending respiratory failure bed side through PFT in adult via :
Peak flow meter, if available
Single breath count > 30 normal
Breath holding time > 45 sec in inspiration normal
Ability to complete one sentence in one breath.
• Cry in a child whether husky or loud can help
In identifying impending respiratory failure.
• Bilateral dilated, poorly or a non-reacting pupil
is not the sign of brain dead in elapid venoming.
“Broken neck” sign. Observed in a 14-year old boy bitten by
a Russel’s viper in India.
Seen in envenoming by Cobras, Kraits and in some cases by
Russel’s viper frequently leads to progressive descending paralysis.
Caused by paralysis of the neck flexor muscles. In this case,
neuroparalysis persisted for five days despite antivenom treatment,
VASCULOTOXIC : Viperidae
Local symptoms and signs
• Local pain & swelling
• Local bleeding
• Bruising
• Tender LN enlargement
• Blistering
• Local infection & abscess formation
• Necrosis.
Characteristics of Russel’s vipers bite
• Oedema with blood oozing from site of bite
• Wet gangrene
• Extensive oedema up to the groin
• Gum bleed
• Bilateral conjunctival oedema (chemosis)
after a bite by a Russel’s viper .
Early stage of full thickness necrosis
5 days after Russel viper bite.
• Thoroughly examine the gingival sulci, using a torch and tongue depressor, as
these may show the earliest evidence of spontaneous systemic bleeding.
• Abdominal tenderness gastrointestinal or retroperitoneal bleeding.
• Loin pain and tenderness acute renal ischemia (Russel’s viper bites).
• Lateralizing neurological signs, asymmetrical pupils, convulsions or impaired
consciousness Intracranial haemorrhage.
• MYOTOXIC : Sea snakebite
• Generalized muscle ache, muscle swelling, involuntary contraction of muscle.
• Passage of dark brown urine.
• Compartment syndrome, cardiac arrhythmias due to hyperkalemia.
• Kidney injury due to myoglobinuria.
• Subtle neuroparalytic signs.
DIAGNOSIS :
• Snake identification
• Snake venom components.
• Radioimmunoassay (RIA)
Most sensitive and specific test
Snake venom components like cholinesterase and thromboplastin can be detected.
• Enzyme immunoassay (EIA) - More widely used.
• Immunological detection – by ELISA.
• Urine – Venom is detectable, even when the patient is treated with antivenin.
• Animal testing – Swab from fang marks or an extract from skin- injected in to a
small animal (e.g. a frog) and see for toxicity.
• The various autopsy samples like Vitreous humour, CSF, blood from right
ventricles, pieces of liver and kidney including the bitten skin bits of victims
were collected from dead bodies and subjected them for both ELISA and
Histopathological examinations.
POST MORTEM APPEARANCE :
Common to all poisonous snakes :
1. Fang marks – 1, 2 or several depending upon the type of bite. If fang marks not seen use
Bailey’s technique.
2. Washing from the site of the bite and tissue underneath – shows venom components.
3. Internal organs – Congested.
Elapids
Local changes are minimal ; internal organs are congested.
Vipers
Local changes – extensive local cellulitis, discolouration and swelling.
Haemorrhages – prominent. Occur from punctures, mucus membranes, into bowel, lungs and
almost all other tissues
Purpuric spots on pericardium.
Sea snakes
Signs of rhabdomyolysis
MEDICO LEGAL IMPORTANCE
Poisoning is mostly accidental.
Occasionally, murder by throwing a poisonous snake on to someone; UTHARA
MURDER CASE.
Very rarely used for suicide;
QUEEN CLEOPATRA committed suicide.
Cattle poisoning.
Biowarfare
Method of execution. Famous people who were killed in this way were 9th century
Viking leader Ragnar Lodbrok and Gunnar the king of Burgundy.
Snake venom as a drug of addiction.
REFERENCES :
1. V.V. PILLAY, FORENSIC MEDICINE AND TOXICOLOGY.
2. DR. ANIL AGARWAL TEXT BOOK OF FORENSIC MEDICINE AND TOXICOLOGY.
3. K.S NARAYANA REDDY TEXT BOOK OF FORENSIC MEDICINE & TOXICOLOGY.
4. NATIONAL LIBRARY OF MEDICINE.
5. H.S. BAWAKASA, SNAKE BITE POISONING.
