SNAKE BITE

ANATOMY:
- No legs.
- Body is covered with scales.
- Body: Head-Trunk-Tail
- Head:
- 2 eyes, poor vision, no eyelids
- 2 nostrils – hissing sound
- Mouth – distensible, no mastication
- No ears
Biting apparatus:
- Upper jaw – 4 rows of teeth
- Lower jaw – 2 rows of teeth
FANGS: Upper jaw of venomous snake.
- Modified teeth
- 2 in upper jaw.
- Connected to venom glands.
- Can be grooved e.g. cobra or krait or
canalized e.g. vipers.
 COBRA X VIPER
• Fangs-
Grooved, short Canalized, long
fine
• Fangs –
Hollow (Canalised) or Grooved in Poisonous snakes
and Absent or Solid in Non-poisonous snakes.
COBRA VIPER
Poison Glands

Salivary Glands

Behind the eyes

One on each side

above the upper
jaw
Tongue – Forked, pick up scent
particles
Snakes are cold blooded -
Hibernation
Snakes regularly moult.
Snakes are oviparous (Cobra) &
viviparous (viper).
Essentially carnivorous
Classification of Snakes:
1. Colubridae – e.g. rat snake
- 75% of total snakes.
- Most are non-venomous.
2. Atractispididae – e.g african vipers
3. Elapidae – e.g. Cobra, Krait
4. Viperidae – e.g. Russel’s viper, saw
scaled viper
5. Hydrophidae – Sea snakes.
Distribution of Snakes:
World: Total no. of species – 3500
Venomous – 350
Can cause death – 200
India: Total no. of species – 330
Venomous – 70 (Land – 40,
Sea – 30)
Commonest – BIG FOUR
BIG FOUR:
1. Common Cobra – Naja Naja
2. Common Krait – Bungarus
Caeruleus
3. Saw Scaled Viper – Echis Carinatus
4. Russel’s Viper – Vipera russelli
English name Scientific Local name
name
Cobra Naja Naja Nag

Common krait Bungarus Manyar

caeruleus

Russel’s viper Viperi Russelli Ghonus

Saw scaled Echis Carinatus Phoorase

viper
WHO clssification of Indian snakes
of medical importance:
CLASS I : Commonly cause death
Cobra, Russell’s Viper, Saw scaled Viper
CLASS II : Uncommon to bite, but can cause
death
Common krait, King cobra
CLASS III : Bites are common, but death rare
Identification of venomous snakes:
1. Broad belly scales
2. Fangs
3. Triangular head – Vipers
4. Hood – Cobra
5. Compressed tail – sea snake
6. Stout body with abruptly ending tail –
Russell’s viper
7. Pit between eyes & nostrils – pit viper
 POISONOUS X NON-POISONOUS
• Teeth –
two long fangs Several small teeth
POISONOUS X NON-POISONOUS
COMMON COBRA:
- Naja Naja
- 5-6 feet.
- Hood formation.
- Markings on back of hood
- Not aggressive
- 3rd supralabial scale largest
Nature of venom - Neurotoxic
COMMON KRAIT:
Bungarus caeruleus
- 3-4 feet
- Steel blue with white bands
- Central line of scales on dorsum is
hexagonal
- Not aggressive, don’t enter human
population
Nature of venom - Neurotoxic
DORSAL SCALES OF KRAIT
SAW SCALED VIPER:
Echis carinatus
- 1.5-2 feet, brown
- Arrow shaped mark on head
- Serrated scales
- When agitated, forms ‘figure of eight’
- Aggressive
Nature of venom – Vasculo- &
haemotoxic
Russell’s Viper:
Vipers russelli
- 5-8 feet, stout body.
- Triangular head, ‘V’ mark on head.
- Very aggressive.
Nature of venom – Vasculo- &
haemotoxic
SEA SNAKES:
- All are venomous
- Flat tail
- Bands on body
- Non aggressive
Nature of venom – myotoxic
SNAKE VENOM
- Most complex of all poisons.
- > 20 components.
- Proteins – enzymes, non-enzymatic
toxins
- Non–proteins – carbohydrates, metals,
lipids, free amino acids etc.
- Cobra & kraits – Neurotoxins
- Vipers – initiate clotting, hyluronidase
Snake Venom
Saliva of the snake
Complex mixture chiefly
proteins many having
enzymatic activities
Coagulant, Fibrinolytic,
Proteolytic and
Neurotoxic properties.
 Proteolytic Enzymes
• Cause digestion of tissue proteins and
peptides and produce marked tissue damage
and destruction.

• Viperidae- more amount

• Elapidae- less amount

• Hydrophidae- very little amount

Toxicity:
Most toxic venom – Sea snake.
Most toxic venom among land
snakes – Krait
Large yield per bite – Cobra &
Russell’s viper.
SNAKEBITE:
- India – 2 lakh bites per year &
15000 deaths.
- Maharashtra – highest incidence
- Most common snake responsible is
saw scaled viper.
- Dry bites-
CLINICAL FEATURES:
Non venomous snake bites-
- Psychological shock
Venomous snakebite:
Without envenomation –
1. Dry bite
2. Protective gear
3. Leakage of venom
4. Superficial bite
With envenomation-
Elapid Bites:
Local: Minimum signs.
- Swelling, blisters can be.
- Spitting cobras – eyes
Systemic:
a) Preparalytic stage:
- Vomiting, hypersalivation
- Ptosis, blurred vision, headache,
vertigo, hyperacusis
b) Paralytic stage:Muscles pass into
paralysis, ultimately death due to
respiratory failure.
Viper Bite:
Local: swelling, blisters, necrosis,
bleeding, intracompartmental
syndrom
Systemic: Incoagulable blood due to
defibrination.
Widespread hemorrhages.
Hydrophid bite:
Local: Very minimal
Systemic: stiffness & tenderness of
muscles.
Rhabdomyolysis.
Myoglobinuria
Trismus – early feature
 Signs and Symptoms
• Fright leading to shock
• Bite mark
 Local Symptoms
• Cobra-

Within 6 to 8 minutes

Tender, inflamed,
oozing of
blood stained fluid

Minimal swelling
 Krait

• Symptoms as in Cobra bite.

• No swelling or burning pain at the site of bite
• Feeling of drowsiness or intoxication is more
intense.
• Albumin appears in
urine.
 Viper-

Local symptoms
Severe pain within
minutes
• Swelling and blood-
stained discharge from
the site of bite seen
within 15 minutes.
• Marked swelling with
redness but without
tenderness.
 Viper
Systemic symptoms-
• Pain, giddiness, dilatation of pupils.
• Main feature is shock.
• Bleeding and clotting time prolonged.
• Hemorrhagic syndrome (bleeding all over)
• Death is due to shock and hemorrhage.
• Renal failure
Diagnosis of Snake bite:
1. Fang marks
2. Identification of snake
3. Lab investigations:
- Immunodiagnosis
- 20 minute test.
20 min Blood clotting test
Treatment:
A] First Aid:
1. Reassurance
2. Immobilization
3. No beverages
4. No torniquet
5. No Incision & suction
6. No cryotherapy
7. No electric shock
8. Drugs - avoid
Antivenom therapy:
 INDICATIONS
• Haemostatic abnormalities
• Hypotension & shock , abnormal ECG
• Neurotoxicity and generalised rhabdomyolysis
• Tender enlargement of local lymph node
• Rapidly progressive & sever local finding
• Manifestation of systemic toxicity
Reid’s criteria:
1. Prolonged hypotension
2. Persistent shock
3. Progressive swelling
4. Pregnant women & children
5. ECG changes – Bradycardia, T inversion,
QT prolongation
6. Leucocytosis - > 20000/cu mm
7. ↑ Sr. CPK
8. Acidosis
Timing :
- As early as possible.
- It’s never late
Availability:
Haffkin institute, Mumbai
Serum Institute, Pune
Central Research Institute, Kasauli

- Lyophilized form
- Reconstitute with normal saline
Route:
- Always I.V.
- Must not be injected around bite.
- Can be given I.M. , if patient is
not yet hospitalized.
Hypersensitivity test:
Not necessary, if patient is
hospitalized.
Dose:
- No fixed dose.
- No upper limit.
- No change in dose as per sex or age.
- Haemotoxic – 10 vials ---- wait for 6 hours
---- lab. Investigations --- Repeat dose.
- Neurotoxic – 7 vials --- 1 hour --- ptosis ---
repeat.
Contraindications:
No absolute contraindication.
Other treatment:
1. Coagulation abnormalities – Clotting
factors, platelets
2. Shock – vasopressors,
colloids/crystalloids
3. Renal failure - Dialysis
Neurotoxicity by elapids:
1. Atropine – 0.6mg adults
2. Edrophonium chloride – 10mg
3. Estimate duration of lid
retraction
4. Anticholinesterase therapy:
Neostigmine
It is in the form of a lyophilised
powder of horse serum
produced by immunisation of
horses with venom of four
snakes-
Common cobra
Common krait
Russell’s viper
Saw-scaled viper
 Hospital Treatment
• Stabilize airway, breathing, and circulation.

• Institute monitoring (cardiac and pulse

oximetry).

• Establish two large-bore IV lines with normal

saline infusion (administer a bolus of 20–
40mL/kg of body weight if the patient is
hypotensive; if hypotension persists, consider
albumin).
• Take rapid history and perform rapid physical
examination (including vital signs).

• Measure/record circumferences of the bitten

extremity every 15 min until swelling has
stabilized.
• Send laboratory studies (CBC, metabolic panel,
PT/INR/PTT, fibrinogen level, FDP, blood type and
screening, urinalysis).

• If normal, repeat CBC, PT/INR/PTT, fibrinogen

level, and FDP every hour until it is clear that no
systemic envenomation has occurred.

• If abnormal, repeat 6 h after antivenom

administration .
Determine severity of envenomation.

• None ("dry bite"): fang marks only

• Mild: local findings only (e.g., pain, local

ecchymosis, nonprogressive swelling)

• Moderate: swelling that is clearly progressing,

systemic signs or symptoms, and/or laboratory
abnormalities
• Severe: respiratory distress,neurologic dysfunction
and/or cardiovascular instability/shock
 Locate and administer antivenom as indicated:

Starting dose Based on severity of envenomation

• None or mild: none
• Moderate: 4–6 vials
• Severe: 6 vials
Mix reconstituted vials in 250 mL of normal saline.
• No pretesting for potential allergy; no
premedication
• Give IV over 1 h(with physician in close attendance)
 If acute reaction to antivenom
• Stop infusion.
• Treat with standard doses of epinephrine (IM
or IV; the latter route only in the setting of
severe hypotension), antihistamines (IV), and
glucocorticoids (IV).
• When reaction is controlled, restart
antivenom as soon as possible (may further
dilute in a larger volume of normal saline).
• Scorpion:
•Scientific Name: Mesobethus Tumulus
• Position in classification: Animal Irritant.
• Identification:
Cephalothorax (fused head & chest), an
abdomen, & six segmented tail which
terminates in a bulbous enlargement called
telson.
- Length – 3”.
Red Scorpion
• Venom:
Complex, varies with species.
- Phospholipase- A – causes GI &
pulmonary hemorrhages & DIC.
• Mode of Action:

Affect sodium channels → Prolongation of

action potential & spontaneous
depolarization of nerves of both adrenergic
& parasympathetic nervous systems →
Adrenergic & cholinergic symptoms.

Hyperkalemia, hyperglycemia, increased

secretion of renin & aldosterone.
• Clinical Features:
Local – Local pain, swelling, redness &
regional lymhadenopathy.
Systemic – S/o autonomic stimulation,
pulmonary oedema.
• Fatal Dose:
Uncertain
• Fatal Period:
2-3 hours.
• Treatment:
A) First Aid:
1. Immobilisation
2. Torniquet
3. Negative- pressure suction.
B) Hospital:
1. Hemodynamic monitoring
2. Ventillation
3. Prazocin Hydrochloride -500µgm every 4-6
hrs.
4. Antivenom
• PM appearance:
Widespread haemorrhages.
• Medico legal Aspects:
Accidental.