Snake Bite

Dr.Vemuri Chaitanya

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 %

North India : elapids are common most bites are by cobra, krait South India : vipers

Classification of snakes

Colubridae Elapidae Viperidae

Most non venomous snakes eg : grass snake Cobras, krait, mambas, coral snake American rattlesnake, Asian pitviper, Russels viper, aders Sea Snake

Hydrophidae

Snake venom

It is complex mixture of Component enzymes, low.mol.wt Serine polypeptides, proteases glycoproteins, metal ions. Other proteases Phospholipase A2

Action haemolysis haemolysis Myotoxic Cardiotoxic Neurotoxic Increases vascular permeability

Component Hyaluronidase Neurotoxins Alpha Bungarotoxin Cobrotoxin Beta bungarotoxin Crotoxin

Action/effect Local tissue destruction

Post synaptic inhibition

Pre synaptic inhibition

Poisonous Snakes
Neurotoxic

cobra,krait & coral vipers

Haemotoxic

Myotoxic

sea snake

Common Indian venomous snakes

ELAPIDAE

Common Cobra Naja Naja, Indian Cobra Common Krait Bangarus Caeruleus Saw Scaled Viper Echis Carinatus Russells Viper Vipera Russelli King Cobra Naja Bangarus, Hamadryad Banded Krait Bangarus Fasciatus Sea Snakes

VIPERIDAE

OTHER SNAKES

Poisonous

Non poisonous

Head scales : small Large and opening / pit b/w eye & nostril (pit viper) Third labial touches eye and nostril shield (cobra) No pit or third labial touches eye & nostril shield( krait )

large

Poisonous

Non poisonous

Fangs : hollow like hypodermic needles Teeth : 2 long fangs

Short and solid Several small teeth Not much compressed

Tail : compressed

Non poisonous snake

INDIAN COBRA Neurotoxic Fatal period 8 h

COMMON KRAIT Neurotoxic Fatal period : 18 h

Indian cobra

King cobra

Coral snake

Saw Scaled Viper (Echis Carinata) Venom: Vasculo & Haematotoxic Fatal period : 3 days

Russels Viper ( Vipera russeli ) Venom: Vasculo & Haemato toxic Fatal period : 5 days

Banded Krait ( Bungarus Fasciatus )

Common Krait

Diagnosis look for fang marks

& Identify the snake Features of poisonous snakes

Usually dull coloured (Brown, Black, Grey) Stout body with abruptly compressed and tapering tail Broad belly scales extending entire width of belly Small scales on triangular head Pit between eye and nostril Presence of hood with or without markings Presence of fangs

Clinical features

Flushing, palpitations, sweating, anxiety & fear prominent features in any snake bite victim ( even if snake is non-venomous ) Specific features of venomous snakes depend upon type of snake and consists of local & systemic features of envenomation.

Grades of envenomation
GRADE Non-envenomated (dry) bites FEATURES Presence of fang marks without local / systemic reactions Local swelling & pain without systemic reaction Extensive local effects with min.sys.effects / mild local effects with marked sys.effects , mild lab.abn

Mild envenomation
Moderate envenomation

Grades of envenomation
GRADE Severe envenomation FEATURES Extensive local effects & systemic effects & marked lab.abn

Bites by Elapids

Generally cause minimal local effects Swelling, local pain & local necrosis ( cobra ) Descending paralysis, initially of muscles innervated by cranial nerves commencing with PTOSIS, DIPLOPIA, OPHTHALMOPLEGIA Numbness around lips & mouth, progressing to pooling of secretions, bulbar paralysis & resp.failure Paradoxical resp intercostal muscle paralysis Stomach pain ( Krait ) submucosal hage in stomach Krait bites present in early morning with paralysis can be mistaken for STROKE .

Bites by Viperidae

Severe local effects as early as within 15 min of bite Extensive swelling spreading quickly to involve whole limb. Asso with blistering , necrosis & regional tender lymphadenopathy. Hemostatic abn persistant ooze & bleeding from venepuncture sites, fang marks & later bleeding from gums, epistaxis, petechiae, purpura & ecchymoses Abdominal tenderness gi / retroperitoneal bleed Passage of reddish / dark brown urine / diminishing / nil urine output.

Bites by Viperidae

Lateralising neurological symptoms like asymmetrical pupils intracranial bleed Hypotension resulting from hypovolemia / direct vasodilation Low back pain , indicative of early renal failure Muscle pain rhabdomyolysis Parotid swelling, conj.edema, sub.conj.hage Renal failure russels viper, hump nosed pit viper . Long term comp : hypopituitarism & cardiotoxicity Saw scaled viper doesnt cause renal failure generally

Hydrophid bites

Stiffness, ache, tenderness in muscles Later, rhabdomyolysis, myoglobinuria resulting in acute renal failure .

FEATURE

Cobra Krait
Local pain / tissue damage YES NO YES NO NO NO? YES

Russels Saw viper scaled viper YES YES YES YES YES NO? YES NO YES NO NO YES

Hump nosed viper YES NO YES YES NO NO

Ptosis/Neurologi YES cal signs Hemostatic abn NO Renal Comp Response to Neostigmine NO YES

Response to ASV YES

First Aid- Do it R.I.G.H.T

R Reassure the patient . 70 % snake bites nonvenomous species. Only 50 % of bites by venomous species actually envenomate the pt. I Immobilise in the same way as # limb. Use bandages / cloth to hold splints, not to block blood supply / apply pressure. Do not apply any compression in the form of tight ligatures GH Get to the hospital immediately T- Tell the doctor of any systemic symptoms that manifest on way to the hosp

Traditional Methods to be DISCARDED

Tourniquets traditionally used to stop venom flow. ( increased risk of ischemia , loss of limb, necrosis, massive neurotoxic blockade when tourniquet is released, embolism viper , false sense of security ) Incision & Suction increases risk of severe bleeding as clotting mech is ineffective & infection . No venom is removed by this method Washing the wound it increases the flow of venom into system by stimulating the lymphatic system.

Treatment protocol

Attend to AIRWAY , BREATHING, CIRCULATION Tetanus toxoid Routine antibiotic is not necessary Identify the snake responsible All patients should be kept under observation for a min period of 24 hrs. Determine the exact time of bite Ask the victim as to what he was doing at the time of bite

Pain give PARACETAMOL Not Aspirin & NSAIDS 5o mg TRAMADOL can also be used Care must be taken when removig tight tourniquets tied by victim. Sudden removal can lead to massive surge of venom leading to neurological paralysis, hypotension d/t vasodilation.

investigations

20 minute whole blood clotting test considered most reliable test of coagulation Single breath count

investigations

Complete Blood Count Anemia, Leucocytosis, Thrombocytopenia, HCT Evidence of Hemolysis Fragmented RBCs Prolonged Clotting Time Ampoule method Prolonged APTT Serum Electrolytes Hyperkalemia Raised Urea, Creatinine

investigations

Urine for RBC Viper Bite Hematuria, Proteinuria, Hemoglobinuria, Myoglobinuria ECG Normal, Bradycardia with ST elevation or depression, T inversion, QT prolongation ABG Hypoxemia with Respiratory Acidosis, Metabolic / lactic Acidosis Chest X- ray Normal, Pulmonary Oedema, Intrapulmonary Hemorhages, Pleural Effusion

Monitor vital signs

Observe every patient for minimum 24 hours Pulse, BP, Respiration Urine output Blood urea, Creatinine

Bleeding tendency
Local swelling Vomiting

Diplopia, Ptosis, Muscle Weakness, Breathlessness

Anti Snake Venom

ASV is prepared by hyperimmunising horses against venoms of snake It neutralises the free, unbound venom & to some extent also dissociates the bound toxin ASV is manufactured in India by the Haffkine Central Research Institute, Kasauli & Serum Institute of India, Pune & both are POLYVALENT.

1 ml of ASV neutralises

Cobra 0.6 mg Common krait 0.45mg Russels viper 0.6 mg Saw scaled viper 0.45 mg

Indications

As per W.H.O Guidelines ONLY if a pt devoleps one / more of the following signs/symptoms ASV should be administered : SYSTEMIC ENVENOMING Evidence of coagulopathy: detected by 20WBCT or visible spontaneous systemic bleeding Evidence of neurotoxicity : ptosis, ext.ophthalmoplegia CVS abn : hypotension, shock, arrhythmias ARF Hemoglobinuria / myoglobinuria Persistant severe vomiting / abd.pain

LOCAL ENVENOMING : Local swelling > of involved limb Rapid extension of swelling Enlarged tender lymph nodes draining the bitten limb.

ASV administration

NO ASV TEST DOSE MUST BE ADMINISTERED . Recommended initial dosages are 100 ml( 10 vials) of polyvalent ASV for adults & children based on published research that russells viper injects on an avg of 63 mg of venom. Our initial dose must be calculated to neutralize the avg dose of venom injected.

Range of venom inj = 5mg 147 mg Sugg ASV dose = 100 -250 ml Initial dose of 100 ml must be diluted in 100 ml of NS & given over 1 hour. Pt should be carefully monitored for 2 hrs. Local adm of ASV, near the bite site ineffective, painful, raises intracompartmental pressure. SHOULD NOT BE DONE.

Victim who arrives late ?

Often after several days , usually with ARF Are there any signs of current venom activity ? Perform 20WBCT & determine if any coagulopathy is +, if + adm ASV. If - , treat ARF dialysis Neurotoxic envenoming look for ptosis, resp failure , + adm 1 dose of ASV , resp support

ASV reactions
Pt should be monitored closely First sign of any one of the following : 1. Utricaria 6. Vomiting 11.Bronchospasm 2. Itching 7. Diarrhoea 12.Angioedema 3. Fever 8. Abd.cramps 4. Chills 9. Tachycardia 5. Nausea 10. Hypotension Discontinue ASV & give 0.5 mg of 1 :1000 adrenaline IM

ASV reactions

Long term protection : 100 mg Hydrocortisone IV 10 mg H1 Antihistaminic IV After 10 -15 min , pt not improved /worsened : give 2 nd dose of 0.5 mg of 1:1000 adrenaline IM Once pt has recovered , restart ASV slowly for 10-15 min , close observation & later normally.

Repeat doses of ASV

HEMATOTOXIC POISONING : 20 WBCT abn initial dose given over 1 hr. Repeat 20WBCT after 6 hrs Abn another dose to be given. Repeat same dose again. 20WBCT & Repeat doses of ASV to be continued on 6 hrly manner untill coagulation is restored.

Repeat doses of ASV

NEUROTOXIC POISONING : Assess the pt 1-2 hrs after the initial dose If symptoms persist / worsen , 2 nd dose which is same as 1st dose is to be given & then ASV can be discontinued.

Role of Neostigmine in Neurotoxic poisoning

Anticholinestrase & prolongs life of Ach - which can reverse resp.failure & neurotoxic symptoms ( post synaptic ) Neostigmine test : 1.5 -2.0 mg IM preceeded by 0.6 mg atropine IV Observe for 1 hr If victim responds , continue 0.5 mg Neostigmine IM hrly with 0.6 mg Atropine IV over 8 hrs If no improvement in symptoms after 1 hr , stop Neostigmine

Supportive Therapy
RESPIRATORY FAILURE : ABG Intubate & Ventilate Neostigmine & Atropine HYPOTENSION : Plasma expanders Dopamine 2.5 5 micrograms/Kg/min

Supportive Therapy
PERSISTANT / SEVERE BLEEDING : Majority timely use of ASV will stop sys.bleed ASV + Blood Transfusion RENAL FAILURE Hemodialysis / peritoneal dialysis COMPARTMENT SYNDROME : Fasciotomy SURGICAL DEBRIDEMENT OF WOUND

Thank You