SNAKE BITE

&
DOG BITE

Dr. Irfan Habib

ChildLife Foundation
OBJECTIVES

• Identify the snakes (poisonous and non

poisonous), and other poisonous animals

• Identify the clinical presentation

• Steps of management
SNAKES

Krait Russell Viper

 Epidemiology
• Known since 150 million years back
• > 3000 species world wide
• > 85 % are non poisonous
• Only 200 species are poisonous
• South Asia has the highest burden rate of evenomatous
snakes
• Pakistan– an estimated 20,000 snakes
• Half of snakes bites occurs in children
• Snake bites account for approx 125,000 death world wide *

• Chippaux, JP. Snake-bites: appraisal of the global situation. Bull World Health Organ 1998; 76:515.
POISNOUS VS NON POISONOUS
• Large size ? • Usually small size
• Two fang mark • ‘U’ shape fang mark
• Distance b/w the fang • Rounded head and
marks pupil
• Triangular mouth • Usually on limbs
• Elliptical pupil • Dim colored
• Site of bite usually limbs • Smooth skin
• Bright colors • Long and pointed tail
• Scally skins
• Tailored tail, may be
broad
 TYPES OF VENOM
• 1. Neurotoxin venom (cobra, coral)
• 2. Vasculotoxin (viper snakes)
• 3. Myotoxin (sea snakes)

• Venom consists of polypeptides, proteolytic enzymes, toxins,

Phosphodiesterases (CVS), Phospholipase A2 (hemolysis),
cholinesterase (muscle control), Hyaluronidase (tissue
penetration), oxidases and proteases (auto digestion) and
ATPase etc.
 Clinical Features
LOCAL S/S
• Local pain
• Fang marks
• Local bleeding
• Bruising
• Lymphangitis
• Lymph node enlargement
• Inflammation
• Blistering
• Local infection
• Abscess and necrosis
 SYSTEMIC FEATURES
•Drowsiness, paresthesia,
•Cranial nerve •Dizziness •Localized bleeding
involvement. •Faintness •Recent wounds (including
Cardiovascular
•and generalized flaccid •Collapse fang marks, venipuncture's)
paralysis. •Partly-healed wounds.
•Shock •Systemic bleeding
Bleeding and clotting disorders •Bleeding from all orifices
•Hypotension
•Generalized pain •Cardiac •Bleeding into the skin
and tendernessarrhythmias
Neurological
•Stiffness of (petechiae, purpura,
Respiratory muscles, •Pulmonary ecchymosis) and mucosae
•Trismus, (conjunctivae).
edema
Skeletal muscle breakdown
•Myoglobinuria, •Intracranial hemorrhage
•Hyperkalaemia, (meningism from subarachnoid
•Loin (lower back) pain, hemorrhage, lateralizing signs
•Cardiac
Renalarrest,
•Hematuria, haemoglobinuria,
•Acute renal failure. and/or coma)
myoglobinuria,
•Uremia (acidotic breathing, hiccups,
 Early clues for 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, diarrhea, severe headache, “heaviness” of the eyelids,
inappropriate (pathological) drowsiness or early
ptosis/ophthalmoplegia.

• Early spontaneous systemic bleeding.

• Passage of dark brown/black urine.

 LABS

• Blood grouping
• CBC
• Coagulation studies (parameters exceeding critical thresholds (INR
>3.0, aPTT >50 seconds, platelets <50,000/microL, and fibrinogen <75
mg/dL) is associated with a major bleeding risk)
• ABG
• ECG
• BUN, Cr and Lytes with Urine analysis
• 20-minute whole blood clotting test (20WBCT)
 EVENOMATION GRADING
• Grade -0 fang marks but no local or systemic
reaction

• Grade -1 minimal local swelling, no systemic

reaction

• Grade -2 swelling beyond the bite site, systemic

reaction and lab changes

• Grade -3 marked local and systemic reaction with

gross lab changes
FIRST AID
FIELD TREATMENT

• Reducing the spread of venom.

• Expediting transfer to an appropriate
medical center.
PRINCIPLES OF MANAGEMENT
• PRE HOSPITAL MANAGEMENT (FIRST AID)

• Remove the victim from snake territory

• Place the patient at rest

• Reassure the patient

• Remove anxiety and fear

• Clean the wound

Ct.
• Immobilized the effected limb below heart level

• With hold alcohol or sedative drugs

• Transport the patient to near by hospital

DON’T
• Incision • Most traditional first
aid methods should
• Oral suction be discouraged:
• Mechanical suction they do more harm
• Cryotherapy than good !
• Surgery
• Electric shock
• Ash, red chili in
wound
• Use ice.
• Cut and suck.
• Alcohol.
• Banding
*Ann Emerg Med. 2004; 43: 187-8.
** Ann Emerg Med. 2004;43:181-6
HOSPITAL MANAGEMENT
• Re evaluation of bite

• Clinical assessment

• Lab analysis

• Specific management
Ct.
ABC

O2 (as needed)

Close monitoring (vitals, cardiac rhythms,

saturation, detail hx.)

Local examination (swelling, it’s extent, limb

circumference every 15 minutes)

Large bore iv cannula

Ct.
Fluid resuscitation (Normal Saline) or
dopamine infusion

Blood product as needed

Antibiotic ?

Tetanus immunization

Wound care
 ANTIVENOM SCHEDULE (POLYVALENT)
• Mild envenomation (systemic manifestation > 3 hours
after bite) neurotoxic/ hemotoxic 8 – 10 vials

• Severe envenomation (systemic manifestation in < 3 hours

after bite ) neurotoxic / hemotoxic 10 – 15 vials

• SLOW ADMINISTRATION IN 1 HOUR INFUSION AND PATIENT

SHOULD BE MONITORED FOR 2 HOURS
• Patients who require major surgery can go up to 25 vials of
ASV

Test dose: usually not recommended

Prophylaxis :
Adrenaline (0.3 mg SC)
Steroid
Antihistamine
 Freeze-dried (lyophilized) antivenoms
are reconstituted, usually with 10 ml of
sterile water for injection per ampoule.

Intravenous infusion: Reconstituted freeze-dried or neat

liquid antivenom is diluted in approximately 5-10 ml
of isotonic fluid per kg body weight (i.e. 250-500 ml of
isotonic saline or 5% dextrose in the case of an adult
patient) and is infused at a constant rate over a
period of about one hour.
CRITERIA FOR MORE ANTIVENOM
• Persistence or recurrence of blood
incoagulability after 6 hours .

• Deteriorating neurotoxic or cardiovascular

signs after 1-2 hours.
 WHO
• With proven or suspected snake-bite develops one or more
of the following signs:

• Systemic envenoming
• Haemostatic abnormalities: Spontaneous systemic
bleeding, coagulopathy (20WBCT or other laboratory tests
such as prothrombin time) or thrombocytopenia
(< 100 000/cu mm).

• Neurotoxic signs: Ptosis, external ophthalmoplegia, paralysis

etc.

• Cardiovascular abnormalities: hypotension, shock, cardiac

arrhythmia, abnormal ECG.
 Ct.
• Acute kidney injury (renal failure): oliguria/anuria
(clinical), rising blood creatinine/ urea.

• Hemoglobin-/myoglobinuria:) dark brown urine, urine

dipsticks,

• Other evidence of intravascular hemolysis or generalized

rhabdomyolysis (muscle aches and pains,
hyperkalemia).

• Supporting laboratory evidence of systemic

envenoming.
 LOCAL ENVENOMING
• Local envenoming
• Local swelling involving more than half of the bitten
limb (in the absence of a tourniquet) within 48 hours of
the bite. 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 bite on the hands or
feet).

• Development of an enlarged tender lymph node

draining the bitten limb
 ADVERSE REACTIONS

• Mostly anti venom induced

• Early (Type I HS)

• Pyrogen induced reaction

• Late reaction (serum sickness, Type IV HS)

PREVENTION
Know your local snakes
Know the sort of places
• Education ! where they like to live and
hide After rains
Know atDuring
what flooding
times of
• Be specially vigilant
year, at Atwhat times harvest
of
time
day/night they are active.
• Wear proper shoes orAt boots
nightand long
trousers

• Use a light when walking at night.

RABIES DEFINITION

A zoonotic viral disease that clinically manifests as...

1> Encephalitis also called FURIOUS RABIES (80% cases)

OR

2> Myelitis also called DUMB RABIES (20%), due to inflammation of spinal cord presenting as
acute flaccid paralysis.

Because there is no treatment (cure) for Rabies.

Its 99.999% FATAL

MORE PRACTICAL DEFINITION

A NEGLECTED disease that is 99.999% VACCINE PREVENTABLE. Yet still kills more

people than Dengue Fever and Bird-flu combined.

PREVALENCE
• The rabies virus survives in widespread,
varied, rural fauna reservoirs
• Pakistan, 150,000 dog bites, 2000-5000 died per year
• In Asia estimated deaths 55,000/year
How it spreads virus in the body
INCUBATION PERIOD

DEATH AFTER ONSET OF

SPECIES INCUBATION PERIOD
SYMPTOMS
1-3 months (can be few days to 25
Humans 1-2 weeks
yrs)
3-8 weeks (can be few days to 6
Dogs <7 days
mon)
2-6 weeks (can be few days to 6
Cats <7 days
mon)
2-9 weeks (can be few days to 15 <7 days (can be 1-2
Horses
mon) weeks)
Rodents ? Quicker

• An animal cannot transmit Rabies during incubation period.

• Smaller the animal, quicker the disease course
RABIES PROPHYLAXIS

Fortunately, we have PROPHYLAXIS!

Because there is no treatment (cure) for Rabies yet!

Its ALMOST 100% FATAL

Post Exposure Prophylaxis (PEP)

HOW TO APPROACH ANIMAL BITE

 Step # 1: First aid
• Scrub and flush wound thoroughly with soap and flowing
water from a tap for at least 10 minutes.
• Clean with antiseptic (Povidone or alcohol)
• Washing wound should be done at home ASAP
• DO NOT stitch the wound
• Cover lightly with gauze
First: Primary wound care

Photos: Dr David Anderson

 Step # 2: INTERVIEW/Q&A

• When?
• Where on the body? How many bites?
• Biting animal ?dog or other
• Provoked/unprovoked
• Animal’s behavior
• Can the animal be observed?
• Previous vaccination?
• Drug Hx
• Immune Hx
When a Dog Bite victim arrived

- Who should get vaccine only

- Who should get both vaccines and Rabies immunoglobulin

- And the cases in which there is no need of vaccine or

Immunoglobulin

- How to administer immunoglobulin and vaccines

Step 3: What are the indications
for PEP?
Category of exposure Type of exposure Recommended post-
exposure prophylaxis

Touching or feeding N one…if reliable case

animals lick on intact history is available.
I skin. Contact with
secretion or excretion
of a rabid animal or
human.
Nibbling of uncovered Administer vaccine
skin minor scratches or immediately.
II abrasion without
bleeding.

Single or multiple Administer rabies

transdermal bites or vaccine immediately
III scratches, lick on and rabies
broken skin immunoglobulin.
contamination of
A victim of wound category -3, required
Another Dog Bite victim
both vaccine and immunoglobulin
Step # 4: RIG (Rabies Immune Globulin)

Indication: CAT-III wound by rabid or assumed rabid animal.

Gives immediate protection for up to 14 days until antibodies
produced after vaccination
 RABIES IMMUNIZATION
100
Antibody titer

10
RIG PROTECTION

0.5

day 0 day 7 day 14 day 90 day 360

Vaccine administration
RIG administration
Rabies Immune Globulin (RIG)

• Human (HRIG) dose: 20 IU/kg

• Equine (ERIG) dose: 40 IU/kg
(Highly purified ERIG F(ab)2' products are safe)
• Important: do not give more than calculated amount as it reduces
immunogenicity of vaccine
• Give only once, into wound to neutralize virus
• Do not give RIG if vaccine alone has been given > 1 week back as it
interferes with natural antibody response
• Passive ab lasts up to 3 weeks
 Infiltration of RIG into the Wound

Photos: Dr David Anderson

Step # 5: VACCINATE

• LYSSAVAC: IM ONLY (Deltoid in older children, Thigh in younger)

• RABIPUR: IM as well as ID
Cell culture Vaccines available
VACCINE BRAND ROUTE VOLUME

Purified Duck Lyssavac ® IM ONLY 1.0 ml

Embryo Vaccine
Purified Vero Cell Verorab® IM/ID 0.5 ml
Vaccine
Purified Chick Rabipur® IM/ID 1.0 ml
Embryo Cell

Purified Vero Cell Indirab® IM 0.5 ml

Vaccine ???ID
REGIMENS
ESSEN 1-1-1-1-1 0, 3, 7, 14, 28 5 Days

ZAGREB 2-1-1 0, 7, 21 3 Days

TRC 2-2-2-0-2 0, 3, 7, or 28 4 Days

WHO Recommended Schedules
Pre-exposure
Prophylaxis

3-dose series intramuscular or intradermal regimen

day 0 3
day 0 7 21 or 28

Re-exposure: No Rabies
immunoglobulin
FAQ’s
• How long does it take for dogs and cats to develop
rabies, and how long does a rabid animal survive?

Incubation period- few days to several months, the duration

of illness – until death – varies from 1 to 7 days.
 FAQ’s

Q: Is rabies always fatal?

Almost 100% fatal, with no specific treatment available
anywhere in the world

Only seven recorded cases of human rabies survivors in the

world, who received intensive nursing care.
Almost all of them received preventive/ pre-exposure rabies
vaccination that might have modified the course of illness.
FAQ
• Q: Can the rabies vaccine and immuno-globulin be given
to a pregnant woman or a lactating mother?

• Yes. All rabies vaccines are inactivated, safe and potent

and can be given to pregnant women or lactating
mothers.
• The rabies virus is not known to cross the placental barrier
in women and healthy babies have been born via
caesarean section.
 FAQ
Q: What
are the important points to be considered while administering
modern rabies vaccines?
Given in the deltoid region (i.e. upper arm, near the shoulder)
in small children, into the anterolateral area of the thigh.

● The IM or ID dose is same for all age groups.

● All the rabies vaccines can be used for IM regimen, but only PVRV and PCECV are approved for
ID.

● Antibody response to ID regimen has been unsatisfactory in some groups receiving chloroquine
for anti-malarial.
 FAQ
• Q: What precautions should be taken while administering RIG?
- All emergency drugs and facilities for managing any adverse reactions must be
available.

- Should be kept outside for a few minutes before administration to the patient.

- Administered before administering the anti-rabies vaccination.

- Never be administered later than 7 days after start of vaccination.

- Not be administered in the same syringe as the vaccine, or at the same site.

- Care must be taken to avoid injecting into blood vessels and nerves.
Diluted with sterile normal saline to double or three times the volume.
 FAQ
Q: Is there any possibility of failure after PEP?

Occasional human rabies cases reported despite PEP,

due to various factors…….
Individual health status.
Delayed vaccination,
Not-use of rabies immunoglobulin in category III.
Incomplete course of vaccination.
Immunocompromised status
FAQ
• Q: if a previously immunized person is bitten by a
rabid dog again, what is the re- exposure
vaccination schedule
Only two doses are given on days 0 and 3.

Persons previously immunized against rabies have two distinct

comparative advantages.

Not necessary to administer RIG, even in a category III

exposure.
Pre-vaccination leads to added protection by inducing
memory cells.