Snake Bite

Dr Ugi Sugiri Sp EM
Emergency Dept.
Fatmawati General Hospital
 Epidemiology
 > 5 million bites annually by venomous snakes
world wide
 With > 1,250,000 deaths
 Age : 11 – 50 yrs
 Sex : males
 Site : lower limbs 40 %
 Classification of snakes
 Colubridae  Most non venomous
snakes eg : grass snake
 Elapidae  Cobras, krait, mambas,
coral snake
 Viperidae  American rattlesnake,
Asian pitviper, Russels
viper, aders

 Hydrophidae  Sea Snake

 King cobra

INDIAN COBRA
Neurotoxic
Fatal period – 8 h
Common Krait
Neurotoxic
Fatal period : 18 h

Banded Krait
( Bungarus Fasciatus )
Coral snake
Saw Scaled Viper Russels Viper
(Echis Carinata) ( Vipera russeli )
Venom: Vasculo & Venom: Vasculo & Haemato
Haematotoxic toxic
Fatal period : 3 days Fatal period : 5 days
 Poisonous Non poisonous
 Fangs : hollow like  Short and solid
hypodermic needles
 Teeth : 2 long fangs  Several small teeth

 Tail : compressed  Not much compressed

 Head scales : small &  Large

triangular
Non poisonous snake
Diagnosis – look for fang marks
 Snake venom
Component Action
Serine proteases haemolysis

Other proteases haemolysis

Phospholipase Myotoxic
A2 Cardiotoxic
Neurotoxic
Increases vascular
permeability
Component Action/effect

Hyaluronidase Local tissue destruction

Neurotoxins

Alpha Bungarotoxin Post synaptic inhibition

Cobrotoxin

Beta bungarotoxin Pre synaptic inhibition

Crotoxin
 Poisonous Snakes
 Neurotoxic – cobra, krait & coral

 Haemotoxic – vipers

 Myotoxic – sea snake

 Clinical effects
Possible serious syndromes from envenomation:
 Neurotoxicity

 Systemic toxicity including hypotension and

shock
 Coagulopathy

 Rhabdomyolysis

 Renal failure

 Local tissue necrosis including cobra spit

 Neurotoxicity

 Neurotoxins block
transmission at the
NM junction
 Flaccid/Respiratory
paralysis
 Anticholinesterase
drugs
 Unphysiologic
drowsiness
 Hypotension/shock

 Vasodilation
 Direct action of
venom on
myocardium
 Bleeding/hypovolemia
 Vipers: profound
hypotension within
minutes (ACE
inhibitors)
 Coagulopathy

 Procoagulants and
anticoagulants
 Intravascular coagulation,
consumption
coagulopahty
 Thrombocytopenia
 Bleeding from old and
recent wounds, gingiva,
epistaxis, hematemesis,
melena
 Renal failure/rhabdomyolysis

 ATN: hypotension/hypovolemia,
DIC, direct toxic effect on
tubules, hemoglobinuria,
myoglobinuria

 Generalized rhabdo: Release of

myoglobin, muscle enzymes, uric
acid, K (presynaptic neurotoxins)
 Local necrosis

 Increased
vascular
permeability
 Swelling and
brusing
 Myotoxins and
cytotoxins
 Ischemia/
thrombosis
 Venom
ophthalmia
Snake Bite Protocol
 Assesment

 Time of bite
 Activity at the time of bite
 First aid action taken since the bite
 Clinical examination
 20 mn whole Blood Clotting Test
 Local signs
 fang marks
 local pain
 local bleeding
 bruising
 lymphangitis
 lymph node enlargement
 inflammation (swelling, redness, heat)
 blistering
 local infection, abscess formation
 necrosis
 General symtoms (1)

 General: Nausea, vomiting, malaise, abdominal pain,

weakness, drowsiness, prostration

 Cardiovascular (Viperidae): Visual disturbances,

dizziness, faintness, collapse, shock, hypotension,
cardiac arrhythmias, pulmonary oedema,
 General symtoms (2)
 Bleeding and clotting disorders (Viperidae)
 bleeding from recent wounds (including fang marks,
venepunctures etc) and from old partly-healed
wounds
 spontaneous systemic bleeding - from gums,
epistaxis, bleeding into the tears, haemoptysis,
haematemesis, rectal bleeding or melaena,
haematuria, vaginal bleeding, bleeding into the skin
(petechiae, purpura, ecchymoses) and mucosae (eg
conjunctivae), intracranial haemorrhage..
 General symtoms (3)
 Neurological (Elapidae, Russell’s viper):
Drowsiness, paraesthesiae, abnormalities of taste and
smell, “heavy” eyelids, ptosis, external ophthalmoplegia,
paralysis of facial muscles and other muscles innervated
by the cranial nerves, aphonia, difficulty in swallowing
secretions, respiratory and generalised flaccid paralysis

 Skeletal muscle breakdown (sea snakes, Russell’s

viper): Generalised pain, stiffness and tenderness of
muscles, trismus, myoglobinuria (Fig 34),
hyperkalaemia, cardiac arrest, acute renal failure
 General symtoms (4)
 Renal (Viperidae, sea snakes): Loin (lower back)
pain, haematuria, haemoglobinuria, myoglobinuria,
oliguria/anuria, symptoms and signs of uraemia
(acidotic breathing, hiccups, nausea, pleuritic chest
pain....)
 Endocrine (acute pituitary/adrenal insufficiency)
(Russell’s viper)
 Acute phase: shock, hypoglycaemia
 Chronic phase (months to years after the bite):
weakness, loss of secondary sexual hair,
amenorrhoea, testicular atrophy, hypothyroidism etc
(Fig 35)
 General symtoms (5)
Hydrophid bites

• Stiffness, ache, tenderness in muscles

• Later, rhabdomyolysis, myoglobinuria –

resulting in acute renal failure .
 Management
 ABCs
 Pressure immobilization
 Clinical assessment / 20WBCT
Pressure immobilisation is recommended for bites by neurotoxic elapid
snakes, including sea snakes but should not be used for viper bites because of
the danger of increasing the local effects of the necrotic venom.
 20WBCT
 Few ml of fresh venous blood placed in a NEW,
CLEAN, DRY, GLASS test tube
 Left undisturbed for 20mn
 Gently tilted to 45° and examined
 If it has remained liquid: consumption
coagulopathy  ASV required
 Clotted: ASV not necessary (at this stage)
 Criteria for giving ASV
 Clinical features
 Grades of envenomation
 Criteria
 Incoagulable blood (20WBCT)
 Visible neurological signs (ptosis, ophtalmoplegia, descending
paralysis)
 Clear evidence of current systemic bleeding
 ASV to be given only if one or more of this signs are
present
 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 FEATURES
Non-envenomated (dry) Loc efect 2,5-15 cm, no syst
bites efect
Mild envenomation Loc efect 15-40 cm, syst
efect
Moderate envenomation Loc efect 40-50 cm, syst
sign
 Grades of envenomation
GRADE FEATURES
Severe envenomation Loc efect > 50 cm, severe
syst sign

ACEP
Pedoman Terapi SABU Menurut DepKes RI (2001)

Beratnya Ukuran edema/ Gejala SABU

Envenomasi eritema kulit Sistemik (vial)
(cm)
0 = Tidak ada <2 - 0

1 = Minimal 2-15 - 5

2 = Sedang 15-30 + 10

3 = Berat >30 ++ 15

4 = Berat skl <30 +++ 15

FEATURE Russels Saw Hump
Cobra Krait viper scaled nosed
viper viper
Local pain / YES NO YES YES YES
tissue damage
Ptosis/Neurologi YES YES YES NO NO
cal signs
Hemostatic abn NO NO YES YES YES
Renal Comp NO NO YES NO YES
Response to YES NO? NO? NO NO
Neostigmine
Response to ASV YES YES YES YES NO
 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 killer
 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
 Prolonged Clotting Time – 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.
 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 > ½ 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.
 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