SNAKE BITE

Epidemiology
India estimates: 200,000 Snake
bites and 15-20,000 deaths per
year
Males:Female::2:1.
Majority of the bites being on the
lower extremities.
Epidemiology
India estimates: 200,000 Snake
bites and 15-20,000 deaths per
year
Males:Female::2:1.
Majority of the bites being on the
lower extremities.
Snakes : Introduction
Anatomy:
India: Poisonous snakes
Elapidae Cobra, Kraits Neurotoxic
Viperidae
(Vipers)
Russells Vipers.,
Saw scaled Vipers.,
Pit Vipers.
Hemotoxic
Hydrophidae Sea Snakes Myotoxic
In India, >200 species of snakes.
Only 52 are poisonous.
Krait and russells viper is much more toxic than that of cobra
Krait
Cobra
Pit
Viper
Rusells
viper
Snake Venom
Combination of
Enzymes & Non-Enzymatic polypeptides.

-Acidic
-Sp Gravity: 1.030-1.070
-On drying Fine needle like crystals.
-Water Soluble.
-Lethal Dose:
Cobra-0.12gm, Krait0.06gm- Russells V-0.15gm
DIAGNOSIS OF SNAKE BITE
FANG MARKS: classically, two puncture
wounds seperated by a distance varying
from 8mm to 4cm, depending on the
species involved.
However a side swipe may produce only a
single puncture,while multiple bites could
result in numerous fang marks.
Effects
Local effects
Systemic effects:
- Neurotoxic.
- Haemotoxic.
- Cardiotoxic.

Max. with Viper bite, least with Krait bite.
Hence krait bite can sometimse go unnoticed.
Clinical features:
VENOMOUS SNAKE BITES
ELAPID BITE (Krait,Cobra)
Local features :
indistinct fang marks ,
burning pain,
swelling and discolouration,
serosanguinous discharge

Systemic features

ELAPID BITE (Krait,Cobra): Neurotoxicity
pre-paralytic stage : emesis,
headache,
LOC.
paralytic stage : ptosis,
ophthalmoplegia
drowsiness,
dysarthria,
dysphagia,
convulsions,
bulbar paralysis,
resp failure .
Cardiac Depression
Cardiogenic/Vasogenic Shock
Systolic cardiac arrest.

cobra
Cardiotoxicity

viper bite
Local features:
rapid swelling,
discolouration,
blister formation,
bleeding from bite site,
severe pain

Systemic features(Haemotoxic)-
Generalised bleeding manifestations.
epistaxis,
hemoptysis,
bleeding gums
hemauria
purpuric spots
Renal failure

Sea Snake
Myotoxic

Local features: minimal swelling and
pain
Systemic features:
Myalgia,
Muscle stiffness,
Myoglobinuria , renal tubular necrosis.
Management
Local
Specific
Supportive
Management: Local
Tourniquet: Between wound & heart, Pressure
adequate to occlude lymphatics only, Released
for few seconds every 10 minutes.
Immobilize affected limb. Elastocrepe bandage
may be applied (except viper bites with lots of
local reaction.)
Clean with Normal Saline.
if bite <1hr old: Short skin incision and suction
Management: local reactions
BULLAE - LEFT INTACT
NECROSIS - DEBRIDEMENT
COMPARTMENT SYNDROME -
FASCIOTOMY
Specific Management
Anti Snake Venom (ASV)
- Timing
- Dose
- Repeat dose
- Hypersensitivity
Mechanical ventilation
What is ASV?
Antivenom is immunoglobulin purified from the serum or
plasma of a horse or sheep that has been immunised with
the venoms of one or more species of snake.
ASV IN INDIA: Polyvalent
COBRA
KRAIT
RUSSELS VIPER
SAW SCALED VIPER
Potency; 1 ml ASV neutralizes:
0.6mg Cobra, 0.45mg Krait,
0.6mg Rusells V, 0.45mg Saw scaled Viper.
-Lethal Dose:
Cobra-0.12gm, Krait0.06gm- Russells V-0.15gm
ASV Indication:
Systemic manifestaiton
NEUROTOXICITY
HAEMOTOXICITY
NEPHROTOXICITY
CARDIOTOXICITY
RHABDOMYOLYSIS
REPEATED VOMITING
Others:
-Local swelling involving more than half of the bitten
limb.
-Rapid extension of swelling.
-Development of an enlarged tender lymph node
draining the bitten limb
Timing of ASV
Best effects are observed within four
hours of bite .
Effective in symptomatic patients even 48
hours after bite.
Efficacious even 6-7 days after the bite
from vipers.
Dose
5 vials(50ml)
5-10 vials
(50-100ml)
10-20 vials
(100-200ml)
Repeat dose
Criteria for repeating the initial dose of
antivenom
Persistence or recurrence of blood incoagulability
after 1-2 hr
Deteriorating neurotoxic or cardiovascular signs
after 1-2 hr
Continuing absorption- due to improved blood
supply following correction of shock, hypovolaemia
etc A redistribution of venom from the tissues
into the vascular space.
Antivenom reactions
20% of patients, usually develop a reaction
Types:
1. Early anaphylactic reactions- within 10-180
min
2. Pyrogenic (endotoxin) reactions- develop 1-
2 hours
3. Late (serum sickness type) reactions-
develop 1-12 (mean 7) days.

Fatal reactions have probably been under-
reported, as death after snake bite is usually
attributed to the venom.
Antivenom reactions
At the earliest sign of a reaction:
Antivenom administration must be temporarily
suspended
Adrenaline-0.1% solution, 1 in 1,000, 1 mg/ml is the
effective treatment for early anaphylactic reactions.
IV hydrocortisone (adults 100 mg, children 2 mg/kg
body weight). The corticosteroid is unlikely to act for
several hours, but may prevent recurrent anaphylaxis
Anti H2 antihistamines-Ranitidine adults 50 mg,
children 1 mg/kg.
In case of circulatory collapse- start fluids, inotropes
along with IV adrenaline
Skin testing for ASV
Skin/conjunctival hypersensitivity
testing does not reliably predict early
or late antivenom reactions and is not
recommended.
ASV and children

Snakes inject the same dose of venom
into children and adults.
Children must therefore be given exactly
the same dose of antivenom as adults.
Mechanical ventilation
If patient has respiratory distress or bulbar
paralysis- intubate and ventilate.
If delayed can cause aspiration or hypoxia
and cardiac arrest.
Even if the facility for MV is not available
Ambuing can save the day.
This helps even during transport.
SUPPORTIVE CARE
ANTIBIOTICS
METHYL PREDNISOLONE
FFP,FRESH BLOOD
PREVENTION AND Rx OF HYPOTENSION


Summary
Snake bites may be by a non-venomous snake
or a dry bite. Not all snake bites require ASV.
ASV is the main stay in the treatment of snake
bites.
ASV must be initiated if indicated at the earliest
Respiratory failure can be because of different
reasons-Neurotoxicity, shock, sepsis, ARF
MV may be main stay of treatment or just
supportive depending on the cause of failure.