Bites, Stings and Management

Dr. Ranjan Maheshwari

Professor, Electronics Engg.
Rajasthan Technical University, Kota
2

The Evolution of Venom

Nature provided venom as a means to

Defend against an aggressor.
Hunting tool.
Initiate ex-vivo digestion.
The earliest venomous specie is the
Portuguese Man-of-War amongst
invertebrates about 550 million years ago.

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The Venom

A complex mixture of proteins, obtained from

fauna, that destroy various tissues of the body,
immobilizing or killing the prey.
Venom classified in two major categories:
neurotoxic, or nerve-affecting.
hemotoxic, or blood-affecting.
All venom contain elements of both types, but
one type predominates.

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 Venom and human beings…
Primarily venom is not meant to be used against
the human beings.
But, one may interact venom in close encounter
with
Snake
Spider/Scorpion
Honey bee/yellow wasps
Some marine creatures (Stonefish, stingray, PMOW)

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The Arthropod venom

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 The Insect venom…
Anchor Sting Delivery Sting

In insects, Wasps have two stings in the back.

The longer acts as an anchor
& the shorter goes deep down to deliver venom.
A wasp can sting repeatedly.
The venom causes allergic reactions and often
not lethal.
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Honeybee venom

Unlike the wasp sting apparatus, the

honeybee sting has barbs and once
penetrated, the sting hooks in the victim.
The bee tears its own intestinal organs
while pulling and dies subsequently.
The venom is allergic and may be lethal if
number of bees sting together.
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 The Spider

Spiders & Scorpions belong to sub-class

Arachnida (8 legged, air breathing invertebrates)
The spider venom is hemotoxic and often results
in cellulitis around the bite
The spider has fangs in the front of its mouth to
inject venom into the victim
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 An observation in spider bites
The intense cellulitis is possible only if enzymes are generated
in the victim’s body

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Scorpion venom
The scorpion venom has severe
cardiotoxins, neurotoxins and proteolytic
components.
Proteolysis converts the proteins into amino
acids and peptides.
This venom is lethal and often fatal to
children.

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Vertebrate venom

The only vertebrates possessing venom belong to

the class reptilia and order Squamata.
Two Lizards from Sub-order Sauria.
One of them is beaded lizard (Heloderma
horridum) found in Mexico.
The other is Gila Monster (Heloderma suspectum)
found in Arizona.
No other known lizard is venomous.

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Vertebrate venom…Snakes
The suborder Ophidia refers to snakes.
Snakes lost their legs during the process of
evolution, as they opted to reside in burrows
where limbs are obstacles.
They developed novel techniques to hold
and swallow pray using Mandibular
liberation.
And they developed venom in their
parotid/Duvernoy's gland.
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3

The Snake

A limbless creature, reptile, which came on

this earth 140 million years ago. (about 120
million years before the mammals).
It has only teeth and a strong vertebra to
control the prey.
Venom is another controlling, digestive and
defensive tool.

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Some of the snakes exploit
VENOM
A complex mixture of proteins, obtained from
fauna, that destroys various tissues of the body,
resulting in immobilizing or killing the prey.
Venom classified in two major categories:
neurotoxic, or nerve-affecting.
hemotoxic, or blood-affecting.
All venoms contain elements of both types, but
one type predominates.

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 Venomous Snakes of India
suborder Serpentes

Venom ous Snakes Non-Veno m ou s Sn akes

C ro ta lid a e
Ela p id a e Vip e rid a e Bam boo Pit V iper
Him alayan Pit V iper
Mild ly Ve n o m o u s

Hy d ro p id a e
Co b ra Kra it Vip e rs Sea Snakes
Naja Naja Bungarus caeruleus Echis carinatus Hardly inflicts bites
Vipera Russelli Highly Venom ous

Neuro, Cardio To xic Neurotoxic Myo, Hem otoxic

Intim idating inactive in day Slow acting
More cases less cases More cases

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 There are many harm-less also
Some of them are found in abundance along
with their venomous cousins
Some of them are rare, and getting extinct
due to our ignorance.
They are friendly to us as they help in
agriculture, environment balance and pest
control.
They are either non-venomous or non-biting.
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Rat Snake Ptyas mucosus

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Water snake
Xenochrophis piscator

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Blind snake Typhlina brahmina

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Indian Rock Python Python molurus

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Common Sand Boa Eryx conicus

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Red Sand Boa Erix johnii

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Trinket snake Coelognathus helena

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Glossy Ballied Racer
Platyceps ventromaculatus

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Banded Racer
Argyrogena fasciolata

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Royal snake
Spalerosophis atriceps

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Banded Kukri snake
Oligodon arnesis

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Common wolf snake
Lycodon aulicus

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Common Cat snake
Boiga trigonata

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Common vine snake
Ahaetulla nasuta

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Common Bronze back Tree snake
Dendrelephis tristis

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Flying tree snake Chrysopelea ornata

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King cobra or Ophiophagus Hannah

It is the largest
venomous snake.
Fatalities have not been
reported in India due to
its bites.
It eats other snakes.
Average length more
than 2 meters

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 Common sea snake or Enhydrina
Schistosa
It is commonly
encountered estuarine
species.
It is one of the most
venomous snakes.
But, it is a non-biting
species.
Average length is 1m.
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Bamboo pit viper
(Trimeresurus Gramineus)
It is a green-colored,
yellow-bellied snake.
Often camouflages in the
leaves
Causes frequent bites to
the forest dwellers.
Venom is very mild
Some recent publications for human beings
mention it as a lineage of
Trimeresurus Stejnegeri.

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A Simple Identification
Check the ventral/belly side of the snake

Possibly Venomous
Non Venomous

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Non-enzymatic Fractions in venom

Neurtoxic polypeptides: low molecular

dialyzable basic polypeptides
Found in elapid and hydrophid venom and
causes respiratory paralysis.
Low molecular weight (around 7000) and
strong basic nature.
Rapid absorption plays important role in
neurotoxicity.

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Bungarotoxin

Extracted from krait,

responsible for pre-synaptic blockade.
Reduces Acetylcholine availability.
and has slow onset of action, even works
after a gap of one hour at any higher dose.

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 Cobra Venom Cardio-toxin
A basic polypeptide, forms dry weight of
venom.
52 to 61 amino acids, molecular weight ~6000.
Causes depolarization of cell membranes.
Affects muscles (skeletal, cardiac and smooth
muscles), neuromuscular junctions and nerves.
Causes respiratory failure, circulatory collapse
and arrest of heart in systole.
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 Cobra Venom Cardio-toxin…

Cardiovascular depression, in the form of

peripheral circulatory failure, is encountered
earlier than neuromuscular blockade.
Cause of early deaths reported after cobra
bites.
Higher the cardio-toxins, earlier is the fatal
circulatory collapse.

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Enzymatic Fraction

Phospholipids: One of various compounds composed of fatty acids,

phosphoric acid and a nitrogenous base.
An important constituent of membranes.
Phospholipase A: Causes hydrolysis of phospho-
glycerides or glycero-phosphatidates.
Damages cell membranes and causes myo-necrosis and
hemolysis.
Synergistically works with Direct Lytic Factor, which
damages RBC Membrane bound phospholipids
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Proteases

responsible for offence against blood

coagulation mechanism.
Damages capillaries and induce bleeding.
Induces transient shock, pain and histamine
release.

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Amino acid esterase

Responsible for anticoagulation

Suppression of fibrination
and bleeding into vital organs.
Prominently observed in Viper venom.

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 Snake Venom Phosphatases
A group of enzymes that act as
catalyst in the hydrolysis of
organic/protein phosphates.
The phosphates are important
in signal transduction by
regulating the proteins they are
attached to.
Indirectly enhance the toxicity
of other venom components.

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Hyaluronidase
Present in most snake venoms.
Depolymerizes hyaluronic acid, cleaves
hexosaminidic linkages of hyaluronic acid.
viscous fluid that occurs especially in the vitreous humor, the
umbilical cord, and synovia and as a cementing substance in
the subcutaneous tissue.
Responsible for swelling and edema at the site of
bite.
However, in some post operative cases it is used to
remove edema and bruising.

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 Nerve Growth Factor
A novel protein,
which stimulates and
controls sensory and
sympathetic nerve
growth.
No role in envenom
pathology.
Its presence in snake
venom is surprising.

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Acetylcholine Esterase
Acetylcholine is a chemical
substance that sends signals
between nerve cells and called a
neurotransmitter.
May be present for inflicting
immediate pain at the site of
injection.
High concentration of
Acetylcholinesterase raises
suspicion of immediate cardio
toxic death.
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Biochemical Variation in Venom

Inter-species or intra-species variations are

very common in venom.
Snakes of similar appearance may be
differentiated by venom constituents (may
or may not contain venom).
European Adder (Vipera berus) or Bothrops
atrox shows vast geographical variation in
venom constituents.

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ECG (Electrocardiogram)

Being one of the most sensitive biosignal,

responds to any physiological or chemo-
physiological alteration.
The cardiotoxins and neurotoxins affects
the the ECG signal directly.
The Hemotoxic substances indirectly affect
the ECG.
Digital ECG can provide better insight.

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 Cobra
(Naja Naja)

Photo Courtesy: Capt. Suresh Sharma

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 Cobra (Naja Naja)

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Observations…
ECG
ST level, Larger q waves, T wave inversion
Ischaemia, Mimicked Infarction
Sinus Arrhythmia
Non-ECG
Marked Fang marks, Local pain, Edema
Dilated pupils, Ptosis
Oro-pharyngeal, respiratory paralysis and CNS
complications
Raised SGOT/SGPT
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3

A case of Cobra
bite, a quack
burnt the site,
resulting in more
complication

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4

Krait (Bungarus Caeruleus)

4th lower labial is largest
Photo Courtesy: Capt. Suresh Sharma

3rd and 4th upper labials touch the

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Krait (Bungarus Caeruleus)

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Observations…
ECG
ST level, larger U waves, T wave diminish
Sinus Bradycardia
Non-ECG
Small fang marks, no local symptoms
Stomach ache
Dilated pupils, Ptosis
Oro-pharyngeal, respiratory paralysis and CNS
complications
Reduction in Serum Potassium.
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7

A Krait “Kiss” on the lips

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8

The “Kiss” is Deadly…

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Saw Scaled Viper (Echis Carinatus)
Photo Courtesy: Capt. Suresh Sharma

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Saw Scaled Viper (Echis Carinatus)

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Observations…
ECG
Non-shrinkage in QRS amplitudes (chest leads)
subsequent to renal failure
Sinus Bradycardia
Non-ECG
Marked Fang marks, Local pain, Edema
Raised CT/BT, CK and LDH
Anemia, renal failure and hepatic complications
Confusion and CNS complications

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Russell’s Viper (Vipera
Russelli)

Photo Courtesy: Capt. Suresh Sharma

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Russell’s Viper (Vipera Russelli)

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Observations…
ECG
Non-shrinkage in QRS amplitudes (chest leads)
subsequent to renal failure
Sinus Bradycardia
Non-ECG
Blisters on the limbs
Marked Fang marks, Local pain, Edema
Raised CT/BT, CK and LDH
Anemia, renal failure and hepatic complications
Confusion and CNS complications
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 Mesobuthus Tamulus

A dreadful specie, causes a large number of

deaths every year in the affected zones.
ECG Changes
Rise in Serum potassium, later Sinus arrhythmia.
Non-ECG Changes
Rise in Blood glucose, peripheral hypothermia
Coma, constricted pupils, renal failure
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6

A Krait “Kiss” on the lips

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7

The “Kiss” is Deadly…

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The Victim…Who Wasted Time…

He is having
• Drooping Eyelids,
• Colic Pain
• Respiratory Difficulty
• Choking
• Blurred Vision

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9

Another
Example of
Ptosis or
Drooping
Eyelids…

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0

After a bite or sting

FIRST AID: The necessary premedical

help to save the human life.
Identify the animal, if it is venomous.
If can not identify, sacrifice it for later
identification.

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1

The Don’ts

Do not incise /excise the site of bite.

Do not tourniquet above the limb.
Do not waste time in any superstition.
Do not burn, electrocute or give
herbs/Ghee/lime/Neem/saline.
No recitation of mantras till patient is out of
danger.
https://www.sctimst.ac.in/Post-flood-Management/General-Health-Care/
snake-insects/snake_bit_India.pdf

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2

The Do’s

Tie a firm crepe bandage, covering the bite.

Keep the bitten limb immobile.
Sooth the patient, elevate morale.
Try to suck the venom using Syringe
Technique.

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3

The Syringe Technique

A syringe (2ml to 20 ml, depending upon the

limb) is cut from its discharging end.
The wide opening can suck from a larger
area.
Smooth cutting improves the effectiveness.

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4

The Syringe Technique

Keep the bitten limb immobile
Do not rub, massage or
manipulate the affected area
Apply some sealant (Saliva or
water) gently on the bitten area
Press the opening of the Pump
covering the bitten area with
piston inside
Pull the piston while pressing the
opening onto the contact area
Repeat till fluid oozes out.
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5

The Effectiveness of Syringe Technique

Scientific, Effective, Hygienic, Cheapest,

Handy, Simple and Safe method.
Can develop negative pressure >0.6 atm for
10 seconds to >0.4 for 2 min.
Reduces the in-vivo venom quantity.
Enables time for medical management.
Lesser amount of medication needed.

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 Management of a case…
Identification of species and Estimation of venom
History and observation of symptoms (visual and
biosignals)
Ventilation support if needed
IV Administration of proper ASV
(Mono/polyvalent)
Cautious IM administration of Tetanus Antitoxin
Monitoring and administration ASV as needed
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It is a sad state of affairs…

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The situation in India

1 ASV costs Rs. 450-800.

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Species Identification

It yields definitive information about the

complexities developed in side the body.
It helps in anticipation of further challenges.
So, for efficient medical management, it is
necessary.
It would promote the monovalent ASV, which is
cheaper, exact and more effective.
It helps in developing a regional and global
epidemiological scenario.
(WHO recommends only monovalent ASV)

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Species Identification Methods

ELISA, (An attempt was made at IISc Bangalore)

field kits are stillNon
not Symptomatic
available.
Species identification TableMethods
Symptomatic (developed at IITR)
Decision Tree Classification Method (developed at
IITR)
Artificial Neural Network based Identification
method (developed at IITR) (Patent under consideration)

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Species Identification Table

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Decision Tree Classification

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Artificial Neural Network based
Classification
29 visible symptomatic binary parameters were
chosen from the patients for the feature vector.
3 more conditions (Age, Oxygen saturation and
delay in transportation) were included.
One bias node was added to the feature vector.
Required outputs were six (four for venomous
snake species, one for scorpion and the last for
non-venomous interactions)

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Perceptron model was chosen

Because, the relationships were simple and

direct.
No hidden layers needed.
In other words, the model is a set of six
equations, each with 33 parameters.
The training patterns were chosen from the
patient data. Randomized for species.

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The model

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 Results of 19 typical cases
Case No. Classification results of the perceptron model Medical opinion
BC(1) EC(2) NN(3) RV(4) Scorpion(5) Non Venomous(6) Specie Severity
1 1.1 0.2 -0.2 -0.1 0.0 0.0 BC 1 (Mild)
2 2.0 -0.1 0.0 0.1 0.1 0.0 BC 2 (Moderate)
3 2.9 -0.4 0.7 0.1 -0.3 -0.3 BC 3 (Severe)
4 4.0 -0.1 0.2 0.0 -0.1 0.0 BC 4 (Very severe)
5 0.0 1.7 -0.4 0.3 0.4 0.2 EC 2 (Moderate)
6 0.0 2.7 -0.5 0.3 0.5 0.0 EC 3 (Severe)
7 -0.2 3.5 0.6 0.4 0.0 0.1 EC 4 (Very severe)
8 -0.1 -1.3 1.1 0.1 0.2 0.0 NN 1 (Mild)
9 -0.1 -1.2 2.7 0.3 -0.3 0.3 NN 2 (Moderate)
10 0.0 -1.1 2.9 0.3 0.1 0.0 NN 3 (Severe)
11 0.0 -0.8 3.6 0.2 0.5 0.1 NN 4 (Very severe)
12 -0.1 -2.2 -0.1 1.5 0.5 0.2 RV 1 (Mild)
13 0.0 -0.7 -0.4 2.1 0.4 0.1 RV 2 (Moderate)
14 0.0 -1.0 -0.5 3.3 0.8 -0.2 RV 3 (Severe)
15 0.0 -0.9 -0.3 4.1 0.3 0.1 RV 4 (Very severe)
16 0.0 -0.6 0.0 0.0 1.1 0.1 Scorpion 1 (Mild)
17 0.0 -0.6 -0.1 0.0 2.1 0.1 Scorpion 2 (Moderate)
18 -0.2 -0.5 -0.4 0.0 3.4 0.3 Scorpion 3 (Severe)
19 0.0 -0.2 0.1 0.0 3.8 0.3 Scorpion 4 (Very severe)

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Effect of Venom on Snakes…

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Cobras…
Cobra venom neurotoxins can kill a mouse or a
human within minutes.
They act by binding to a target, a receptor, on the
surface of the muscle cell,
preventing the communication between the nerve
and muscle that results in paralysis and may easily
lead to death.
But, in the cobra DNA sequence, the receptor that
serves as a target for the toxin has a different
structure.

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The neurotoxin can not recognize the receptor in
cobras, It has a sugar molecule (green box) on the
receptor that prevents the binding of neurotoxin.

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The vipers may not be so lucky…

As mentioned in literature,
Vipers enjoy a protection
against their own venom.
Because their blood
contains elements that
inactivates their venom.
But, It was observed that a
viper died by inflicting a
bite on itself…

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Acknowledgements:
Thanks for your patience…
(Late ) Prof. V. K. Mahobia, Kota (Raj.)
Mr. Vishnu Shringi, Snake Rescue Volunteer, Kota
Dr. Peter Macfarlane
Dr. Olaf Dossel
Dr. Chris Thompson
Lt. Gen. (Rtd.) Dr. Rajat Datta
The patients who gave valuable feedback.
Rescued snakes, who taught many lessons…. And finally…