Bites and

Stings

Epidemiology
3 million bites and 1,50,000 deaths/year from
venomous snake worldwide.
Bites highest in temperate and tropical regions.
3000 species of snakes, out of them only 10-15% of
snakes are venomous
97% of all snake bites are on the extremities

 Common krait(karayat)-Bungarus caeruleus

 Russells viper(kander)-Daboia russelii

Heat-sensing facial pits
(hence the name "pit vipers").

 Echis.carinatus(afai)-Saw scaled viper

Non Poisonous Snakes

Head - Rounded
Fangs - Not present
Pupils - Rounded
Anal Plate - Double row
Bite Mark - Row of small
teeth.
Poisonous Snakes
Head Triangle
Fangs Present
Pupils - Elliptical pupil
Anal Plate - Single row
Bite Mark - Fang Mark

Snake Venom
Snake venom is highly modified saliva

Mechanism of toxicity

Cytotoxic effects on tissues

Hemotoxic
Neurotoxic
Systemic effects.

Toxic dose. The potency of the venom and the

amount of venom injected vary considerably.
20% of all strikes are "dry"

Snake Venom, Necrosis

Proteolytic enzymes have a trypsin-like activity.
Hyaluronidase splits acidic mucopolysaccharides
and promotes the distribution of venom in the
extracellular matrix of connective tissue.
Phospholipases A2- break down membrane
phospholipids -causes cellular membrane damage

Contd..
All these enzymes cause oedema, blister
formation and local tissue necrosis

Snake Venom ,Paralysis

Blocks the stimulus
transmission from
nerve cell to muscle
and cause paralysis
Does not penetrate
the blood-brain barrier

Contd..
Postsynaptic effects are reversible with antivenom
and neostigmine.
Presynaptic nerve terminal, e.g. beta-bungarotoxin
and here neostigmine will not be effective.

Snake venom, Hemorrhages

Activate prothrombin (e.g. ecarin from Echis
carinatus)
Effect on fibrinogen and convert it into fibrin
-thrombin-like activity, such as crotalase (rattlesnake
venom)
Activate factor 5, factor 10 , Protein C
Activate or inhibit platelet aggregation
Haemmorhagins- cause endothelial damage

Clinical syndromic approach

Syndrome 1
Local envenoming
(swelling etc) with
bleeding/clotting
disturbances
VIPERIDAE

Syndrome 2

Ptosis, external opthalmoplegia, facial paralysis etc

and dark brown urine
=Russell's viper, Sri Lanka and South India

Syndrome 3
Local envenoming (swelling etc) with paralysis
=Cobra or king cobra

Syndrome 4
Paralysis with minimal or no local envenoming
Krait, Sea snake

Syndrome 5

Paralysis with dark brown urine and renal failure:

Russle viper

Grade 0

No evidence of envenomation
Suspected snake bite
Fang mark may be present
Pain and 1 inch edema & erythema
No systemic signs- first 12 hours
No lab changes

Grade 1

Minimal envenomation
Fang wound & moderate pain present
1-5 inches of edema or erythema
No systemic involvement in present after 12 hours
No lab changes

Grade 2

Moderate envenomation

Severe pain

Edema spreading towards trunk

Petechiae and ecchymosis limited area

Nausea,vomiting,giddiness

Mild temperature

Grade 3
Severe envenomation
Within 12 hours edema spreads to the extremities
and part of trunk.
Petechiae and ecchymosis may be generalized
Tachycardia
Hypotension
Subnormal temperature

Grade 4
Envenomation very severe
Sudden pain rapidly
Progressive swelling which leads to ecchymosis all
over trunk
Bleb formation and necrosis

Grade 4 contd
Systemic manifestations within 15 min after the bite
Weak pulse,N&V,vertigo
Convulsions, coma

What investigation to do?

CBC
RFT
Coagulation studies
Blood grouping & cross matching
Sr.electrolytes
Urinalysis

20 min whole blood clotting time

A few milliliters of fresh blood are placed in a new,
plain glass receptacle (e.g., test tube) and left
undisturbed for 20 min.

Contd
The tube is then tipped once to 45 to determine
whether a clot has formed. If not, coagulopathy is
diagnosed

Hess's test
Blow up a blood pressure cuff to 80 mm Hg and
leave it on for 5 minutes.
If a crop of purpuric spots appears below the cuff, the
test is positive.

First Aid

First Aid

Donts

No Tornique
No Suction apparatus to be used(Sawyers)
Do not run
No role of Ice application

ASV

When to use ASV?

How much to use?
What if a reaction occurs?
When to stop ASV?

When to use ASV

Hemostatic abnormalities(lab and clinical)
Progressive local findings
Neurotoxicity
Systemic signs and symptoms
Generalised rhabdomyolysis

Polyvalent antivenin
Manufactured by hyper immunizing horses against
venoms of four standard snakes
Cobra (naja naja)
Krait (B.caerulus)
Russels viper(V.russelli)
Saw scaled viper(Echis carinatus)

Contd..
Lyophilised form: stored in a cool dark place & may
last for 5 years
Liquid form: has to be stored at 4c with much
shorter life span
Each 1ml of reconstituted serum neutralise
0.6 mg of naja naja
0.45 mg of Bungarus caerulus
0.6 mg of V.russelli
0.45 mg of Echis carinatus

Guide for initial dose of antivenin

Grade

Amount of
Antivenin

Route

None

None

None

None

5 vials

IV 1:10 dilutions

5-10 vials

IV 1:10 dilutions

10-20 vials

IV 1:10 dilutions

Dose in Paediatric
Same as adult as the amount of venom does not
change-hence the dose of antivenom should be the
same
Only the dilution changes

Skin testing- Done if patient is

stable and time available
0.02ml of 1:100 solution of serum is injected sc
A positive reaction occurs within 5 to 30 mins.
Appearance of wheal & surrounding erythema

What to do in case of anaphylactic reaction to ASV

Adrenaline 0.5 to 1ml IM
If hypotension,severe bronchospasm or laryngeal
edema give 0.5 ml of adrenaline diluted in 20 ml of
isotonic saline over 20 mins iv.

contd..
A histamine anti H1 blocker-chlorpheniramine maleate-10
mg IV
Pyrogenic reactions-antipyretics
Late reactions-respond to CPM-2 mg, 6 hrly or oral
prednisolone-5 mg 6 hrly

What if the patient needs ASV

following reaction
Dose should be further diluted in isotonic saline and
restarted as soon as possible.
Concomitant IV infusion of epinephrine may be
required to hold allergic sequelae at bay while further
antivenom is administered

When to stop using ASV

Bleeding subsides
Lab values returns to baseline
Signs of neurotoxicity reverses
Local effects halts progression

Supportive treatment
Anticholineesterase have variable but useful role
Trial
Atropine sulphate 0.6 mg
Edrophonium chloride 10 mg IV (or) Neostigmine:
1.52.0 mg IM (children, 0.0250.08 mg/kg)

Contd..
If objective improvement is evident at 5 min
continue neostigmine at a dose of 0.5 mg (children,
0.01 mg/kg) every 30 min as needed with
atropine by continuous infusion of 0.6 mg over 8 h
-children, 0.02 mg/kg over 8 h

Contd
Hypotension

Administration of crystalloid (2040 mL/kg)

Trial of 5% albumin (10 20mL/kg)

CVP guided fluids

Inotropic support and invasive monitoring

Contd..
Oliguria & renal failure- fluids,diuretics, dopamine
no response-fluid restriction- Dialysis
Local infection- TT,antibiotics
Haemostatic disturbances-FFP,fresh whole
blood,cryoprecipitates

Cobra spit opthalmia

Topical antimicrobial
0.1% adrenaline relieves pain
No need for ASV

Compartment syndrome
If signs of compartment syndrome are present and
compartment pressure > 30 mm Hg:
Elevate limb
Administer Mannitol 1-2 g/kg IV over 30 min
Simultaneously administer additional antivenom, 4-6
vials IV over 60 min
If elevated compartment pressure persists another 60
min, consider fasciotomy

Bee Sting
Honey bee belong
Family- Hymenoptera
Sub Family-Apidae
Only the females have adapted a stinger from the
ovipositor on the posterior aspect of the abdomen

Venom
Histamine.
Melittina membrane active polypeptide that can
cause degranulation of basophils and mast cells,
constitutes more than 50 percent of the dry weight of
bee venom
Venom commonly causes pain, slight erythema,
edema, and pruritus at the sting site

Presentations
Local reaction
Toxic manifestation and anaphylaxis
Delayed reaction Serum sickness

Treatment
Immediate removal is the important principle and
the method of removal is irrelevant.
Sting site should be washed thoroughly with soap
and water to minimize the possibility of infection.

Contd..
Intermittent ice packs at the site- diminish swelling
and delay the absorption of venom while limiting
edema.
Oral antihistamines and analgesics may limit
discomfort and pruritus.
Nonsteroidal anti-inflammatory drugs (NSAIDs) can
be effective in relieving pain

Severe systemic reaction

Epinephrine 0.3 to 0.5 mg (0.3 to 0.5 mL of 1:1000
concentration) in adults and 0.01 mg/kg in children
(never more than 0.3 mg).
Injected IM and the injection site massaged to hasten
absorption
If hypotension,severe bronchospasm or laryngeal
edema give 0.5 ml of adrenaline diluted in 20 ml of
isotonic saline over 20 mins
Observation for 24 hours in ICU

Contd
Parenteral antihistamines (diphenhydramine 25 to 50
mg IV, IM, or PO) and H2-receptor antagonists
(ranitidine 50 mg IV)
Steroids (methylprednisolone 125 mg) -to limit
ongoing urticaria and edema and may potentiate the
effects of other measures.
Bronchospasm is treated with -agonist nebulization.

Contd..
Hypotension
-massive crystalloid infusion, and central venous
pressure monitoring may be helpful in these patients.
-Persistent hypotension require dopamine.
-If dopamine is ineffective, an intravenous infusion of
epinephrine can be used

Preventive Care
Every patient who has had a systemic reaction
-insect sting kit containing premeasured
epinephrine and be carefully instructed in its use.
Patient must inject the epinephrine at the first sign of
a systemic reaction.
Medic alert tag

Scorpion sting- C. exilicauda

Scorpions have a world-wide distribution.
Highly toxic species are found in the Middle East,
India, North Africa, South America, Mexico, and the
Caribbean island of Trinidad.

Mechanism of action
Venom can open neuronal sodium channels and
cause prolonged and excessive depolarization

Symptoms and sign

Somatic and autonomic nerves may be affected
Initial pain and paresthesia at the stung extremity
that becomes generalised
Cranial nerve- abnormal roving eye movements,
blurred vision, pharyngeal muscle incoordination and
drooling and respiratory compromise

Contd
Excessive motor activity
Nausea, vomiting, tachycardia, and severe agitation
can also be present.
Cardiac dysfunction, pulmonary edema, pancreatitis,
bleeding disorders, skin necrosis, and occasionally
death can occur

Treatment

Pain Management
Ice pack
Immobilization of limb
Local anaesthetics are better than opiates

Tetanus prophylaxis, wound care and antibiotics

Benzodizepines for motor activity.

Contd..
Stabilize Airway Breathing and Circulation
Hyperdynamic circulation
Always combination of alpha blocker with beta
blocker to prevent unopposed alpha action causing
tachycardia
Nitrates for Hypertension/MI

Contd..
Hypodynamic Circulation:
CVP guided fluids
Decrease preload with furosemide (not hypovolumic)
Reduction of afterload improves outcome-Prazosin,
nitroprusside, hydralizine, ACE inhibitor
Dobutamine is the best inotrope, avoid Dopamine
Noradrenaline can be used

Newer modality
Insulin has shown to improve cardiopulmonary status
in case of scorpion envenomation

THANK YOU