Snakebite

Snakebite
Dr.Pratheeba Durairaj,
M.D.,D.A,
http://www.isakanyakumari.com/docs/Snakebite.ppt 09/08/18 12.17

Page 1 of 95
Snake bite: an occupational disease
● Farmers (rice)
● Plantation workers (rubber, coffee)
● Herdsmen
● Hunters
● Snake handlers (snake charmers and in snake
restaurants and traditional Chinese pharmacies)
● Fishermen and fish farmers
● Sea snake catchers (for sea snake skins,
leather)

Page 2 of 95
How common are snake bites?
● Many snake bites and even deaths from
snakebite are not recorded.
● One reason is that many snake bite victims are
treated not in hospitals but by traditional healers.
● India - No reliable national statistics are
available.
● In 1981, a thousand deaths were reported in
Maharashtra State. In the Burdwan district of
West Bengal 29,489 people were bitten in one
year with 1,301 deaths.
● It is estimated that between 35,000 and 50,000
people die of snake bite each year among
India’s population of 980 million.

Page 3 of 95
● In the US: Snakebites frequently go unreported.
The national average is approximately 4 bites
per 100,000 persons.
● Internationally: No accurate international data
exist. Most snakebites and deaths due to
snakebites are not reported.

Page 4 of 95
Classification
● Worldwide, only about 15% of the more than

3000 species of snakes are considered
dangerous to humans.
● The family Viperidae is the largest family of
venomous snakes, and members of this family
can be found in Africa, Europe, Asia, and the
Americas.
● The family Elapidae is the next largest family
of venomous snakes.

Page 5 of 95
Classification
● There are two important groups (families) of
venomous snakes in South East Asia
●
Elapidae have short permanently erect fangs
This family includes the cobras, king cobra,
kraits, coral snakes and the sea snakes.
●
The most important species, from a medical
●
point of view include the following:
Cobras: genus Naja
N naja(spectaled cobra –all over in
India )
N kaouthia (monocled – West Bengal ,MP ,U.P,
Orissa)
N oxiana [Black cobra – northern states -
patternless]
N
philippinensis
N atra
King cobra:
Ophiophagus
hannah
Page 6 of 95
Spectacled Cobra Post synaptic Neurotoxin
Good Response to Neostigmine

Page 7 of 95
Short, permanently erect, fangs of a typical
elapid

Page 8 of 95
KRAITS (genus Bungarus)
B caeruleus common krait [all over India ]
- paired white bands & large hexagonal
scales in top of the snakes
B fasciatus banded krait [black &
yellow band
–W.B,M.P,A.P,BIHAR ,ORRISSA]
B candidus Malayan krait
B multicinctus Chinese krait
Sea snakes (important genera include
Enhydrina, Lapemis and Hydrophis)
Blue spotted sea snake (Hydrophis
cyanocinctus)

Page 9 of 95
Common Krait
Key identification feature are PAIRED white bands.
Often enters human habitation
Pre Synaptic Neurotoxin.
Limited response to
Neostigmine

Page 10 of 95
Viperidae
● Have long fangs which are normally folded
up against the upper jaw but, when the
snake strikes, are erected .
● There are two subgroups, the typical vipers

(Viperinae) and the pit vipers (Crotalinae).
● The Crotalinae have a special sense organ,

the pit organ, to detect their warm-blooded
prey. This is situated between the nostril
and the eye

Page 11 of 95
Russell’s vipers details of fangs

Page 12 of 95
Russell's Viper
Haemotoxic venom BUT can

also present neurotoxic
symptoms
Although nocturnal, encountered

during the day, sleeping under
bushes, trees and leaf particularly
coconut leaf litter
Key identification feature is the

black edged almond or chain
shaped marks on the back

Page 13 of 95
Medically important species in South East Asia
Russell’s vipers -Daboia russelii - [Black edged chain like marking

on body &white triangular marking on the head – throughout India]
Saw-scaled or carpet vipers - Echis carinatus and E sochureki

[most parts of India except Kerala – Arrow shaped mark in head &
hoop like markings in flanks ]
Pit vipers
calloselasma rhodostoma malayan pit viper
Hypnale hypnale hump-nosed viper
Green pit vipers or bamboo vipers (genus trimeresurus)
T albolabris white-lipped green pit viper
T gramineus indian bamboo viper
T mucrosquamatus chinese habu
T purpureomaculatus mangrove pit viper
T stejnegeri chinese bamboo viper

Page 14 of 95
Key Identification
Feature- large plate
PIT VIPER scales on the head.
Encountered under bushes and leaf litter or in

bushes.
Haemotoxic venom.
Causes Renal failure
Late onset envenoming
No effective anti
venom

Page 15 of 95
How to identify venomous snakes
● Some harmless snakes have evolved to
look almost identical to venomous ones.
● Some of the most notorious venomous
snakes can be recognized by their size,
shape, colour, pattern of markings, their
behaviour and the sound they make when
they feel threatened.
● The defensive behaviour of the cobras is
well known they rear up, spread a
hood, hiss and make repeated strikes
towards the aggressor.

Page 16 of 95
CONTD…
● Colouring can vary a lot. Some patterns, like the
large white, dark rimmed spots of the Russell's
viper ,or the alternating black and yellow bands of
●
the banded krait are distinctive.
The blowing hiss of the Russell's viper and the
grating rasp of the saw-scaled viper are warning
●
and identifying sounds.
●
KRAIT bites : nocturnal, indoor, unprovoked &
painless
COBRA & VIPER bites : painful
& accompanied by
neuroparalysis,coagulopathy

Page 17 of 95
The venom apparatus
● Venomous snakes of medical importance have a
pair of enlarged teeth, the fangs, at the front of
their upper jaw.
●
Venom is produced and stored in paired glands
below the eye. It is discharged from hollow fangs
located in the upper jaw. Fangs can grow to 20
●
mm in large rattlesnakes
These fangs contain a venom channel (like a
hypodermic needle) or groove, along which
● venom can be introduced deep into the tissues of
their natural prey.
●
If a human is bitten, venom is usually injected
subcutaneously or intramuscularly.
Spitting cobras can squeeze the venom out of the
tips of their fangs producing a fine spray directed
towards the eyes of an aggressor.

Page 18 of 95
Veno
m
● Venom is mostly water.
● Enzymatic proteins in venom impart its destructive
properties.
●
Proteases, collagenase, and arginine ester hydrolase
●
have been identified in pit viper venom.
Neurotoxins comprise the majority of coral snake
● venom.
Hyaluronidase allows rapid spread of venom through
●
subcutaneous tissues by disrupting
mucopolysaccharides;
Phospholipase A2 plays a major role in hemolysis
secondary to the esterolytic effect on red cell
membranes and promotes muscle necrosis

Page 19 of 95
Contd…
● Thrombogenic enzymes promote the formation of
a weak fibrin clot, which, in turn, activates
plasmin and results in a consumptive
coagulopathy and its hemorrhagic consequences.
●
Enzyme concentrations vary among species, thereby
●
causing dissimilar envenomations.
Copperhead bites generally are limited to local tissue
● destruction.
Rattlesnakes can leave impressive wounds and cause
● systemic toxicity.
Coral snakes may leave small wounds that later result in
respiratory failure from the typical systemic neuromuscular
blockade

Page 20 of 95
CONTD…
● ELAPID neurotoxins act at peripheral

neuromuscular junction pre /post synaptically –
prevent release of acetylcholine – prevents
impulse transmission
●
VIPER –affect coagulation pathway at several
points – Russels viper –activates V,IX,X,XIII
factors ,platelets , protein C fibrinolysis

Page 21 of 95
Quantity of venom injected at a
bite
● This Venom dosage per bite - is very variable - depends on
the elapsed time since the last bite
the degree of threat the snake feels
the size of the prey.
the species and size of the snake
the mechanical efficiency of the bite whether
one or two fangs penetrated the skin
whether there were repeated strikes
● The nostril pits respond to the heat emission of the prey, which
may enable the snake to vary the amount of venom delivered.

Page 22 of 95
Contd…
● A proportion of bites by venomous snakes do not result
in the injection of sufficient venom to cause clinical
effects.
● About 50% of bites by malayan pit vipers and
russell’s
vipers, 30% of bites by cobras and 5-10% of bites
● by
saw-scaled vipers do not result in any symptoms
or signs of envenoming.
● Snakes do not exhaust their store of venom, even
after
several strikes, and they are no less venomous after
eating their prey.
Although large snakes tend to inject more venom
than
smaller specimens of the same species, the venom
of
smaller, younger vipers may be richer in some dangerous
components, such as those affecting haemostasis.
Page 23 of 95
Pathophysiology
The local effects of venom serve as a reminder of

the potential systemic disruption of organ
system function.
Local bleeding - coagulopathies are not uncommon
with severe envenomations.
Local edema - increases capillary leak and
interstitial fluid in the lungs. Pulmonary mechanics
may be altered
Local cell death - increases lactic acid concentration
secondary to changes in volume status and
requires increased minute ventilation.
The effects of neuromuscular blockade result in
poor diaphragmatic excursion.
Cardiac failure can result from hypotension and
acidosis.
Myonecrosis raises concerns about myoglobinuria
and renal damage.

Page 24 of 95
● Some peopSel ywmhpotaormebstiaenndbysisgnnaksesor
or imagWinehetnhavtenthoemy
suspect
develop quite striking symptoms and signs, even
when no venom has been injected. This results
hhaasv
from
e btebeenenbiitnteej nc,tmeday
announderstandable fear of the consequences
●
of a real venomous bite.
Anxious people may overbreathe so that they
develop pins and needles of the extremities,
stiffness tetany of their hands and feet and
●
dizziness.
Others may develop vasovagal shock after the
● bite or suspected bite - faintness and collapse
with profound slowing of the heart.
Others may become highly agitated and irrational
and may develop a wide range of misleading
symptoms.

Page 25 of 95
Contd…
● Another source of symptoms and signs not
caused by snake venom is first aid and traditional
treatments.
●
Constricting bands or tourniquets may cause
● pain, swelling and congestion.
● Ingested herbal remedies may cause
vomiting.
●
Instillation of irritant plant juices into the eyes
may cause conjunctivitis.
Forcible insufflations of oils into the respiratory
● tract may lead to aspiration pneumonia,
bronchospasm, ruptured ear drums and
pneumothorax.
Incisions, cauterization, immersion in scalding
liquid and heating over a fire can result in
devastating injuries.

Page 26 of 95
When venom has been injected!
Early symptoms and signs
● Following the immediate pain of mechanical penetration of
the skin by the snake’s fangs, there may be increasing local
pain (burning, bursting, throbbing) at the site of the bite
● Local swelling that gradually extends proximally up
the bitten limb
● Tender, painful enlargement of the regional lymph nodes

draining the site of the bite
● Bites by kraits, sea snakes and Philippine cobras may be
virtually painless and may cause negligible local swelling.
● Symptoms and signs vary according to the species of snake

responsible for the bite and the amount of venom injected

Page 27 of 95
Signs/Symptoms Cobra Krait Russell Saw Scaled Other
and Potential Viper Viper Vipers
Treatments
Local Tissue YES NO YES YES YES

Damage/pain
Ptosis/ YES YES YES NO NO

Neurotoxicity
Coagulation NO NO YES YES YES
Renal Problems NO NO YES NO YES
Neostigmine & YES NO? NO? NO NO

Atropine

Page 28 of 95
Local symptoms and signs
• Fang marks
• Local pain
• Local bleeding
• Bruising
• Lymphangitis
• Lymph node enlargement
• Inflammation (swelling, redness, heat)
• Blistering
• Local infection, abscess formation
• Necrosis

Page 29 of 95
Generalised Symptoms and Signs
● General
● Nausea, vomiting, malaise, abdominal pain,
weakness, drowsiness, prostration
● Cardiovascular (Viperidae)
● Visual disturbances, dizziness, faintness, collapse,
shock, hypotension, cardiac arrhythmias,
● pulmonary oedema, conjunctiva oedema

Page 30 of 95
Snake bite: causes of hypotension and
shock
● Anaphylaxis - Vasodilatation
● Cardiotoxicity
● Hypovolaemia
● Antivenom reaction
● Respiratory failure
● Acute pituitary adrenal insufficiency[In victims of
Russell’s viper bites- haemorrhagic infarction of
the anterior pituitary ]
●
Septicaemia

Page 31 of 95
CONTD…
Bleeding and clotting disorders (Viperidae)
Bleeding from recent wounds (including fang marks
,venepunctures etc) and 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 and mucosae
(petechiae,purpura,ecchymoses)
Intracranial haemorrhage

Page 32 of 95
CONTD…
Renal (Viperidae, sea snakes)
Loin pain, haematuria, haemoglobinuria myoglobinuria,
oliguria/anuria
Symptoms and signs of uraemia
Endocrine (acute pituitary/adrenal insufficiency)
(Russell’s viper)
Acute phase: shock, hypoglycaemia
Chronic phase (months to years after the bite)
loss of secondary sexual hair, amenorrhoea, testicular
atrophy, hypothyroidism etc

Page 33 of 95
CONTD…
Neurological (elapidae, Skeletal muscle
russell’s viper) breakdown (sea snakes,
●
Drowsiness
●
Paraesthesiae russell’s viper)
●
Abnormalities of taste and ● Generalised pain
smell
●
“Heavy” eyelids, ptosis ● Stiffness and
●
External ophthalmoplegia Tenderness of Muscles,
●
Paralysis of facial muscles Trismus
and other muscles
innervated by the cranial ● Myoglobinuria
nerves
●
Aphonia ● Hyperkalaemia
●
Difficulty in swallowing ● Cardiac arrest
secretions
●
Respiratory and ● Acute renal failure
generalised flaccid
paralysis

Page 34 of 95
Complications
● Compartment syndrome is the most frequent

complication of pit viper snakebites.
● Local wound complications may include infection
and skin loss.
● Cardiovascular complications, hematologic
complications, and pulmonary collapse may occur.
● Prolonged neuromuscular blockade may occur
from coral snake envenomations.

Page 35 of 95
Antivenin-associated complications
● Immediate (anaphylaxis, type I)

Result in laryngospasm, vasodilatation, and
leaky capillaries - death
● Delayed (serum sickness, type iii hypersensitivity

reactions)
• Serum sickness occurs 1-2 weeks after
administering antivenin - arthralgias, urticaria,
• and glomerulonephritis
Usually more than 8 vials of antivenin must be
• given to produce this syndrome.
Supportive care consists of antihistamines and
steroids.

Page 36 of 95
Long term complications (sequelae) of
snake bite
● At the site of the bite, loss of tissue may result
from sloughing or surgical debridement of
necrotic areas or amputation
●
Chronic ulceration, infection,
●
Osteomyelitis or arthritis may persist causing
severe physical disability
●
Malignant transformation may occur in skin
ulcers after a number of years

Page 37 of 95
Syndromic Approach
It is realised that the range of activities of a particular
venom is very wide. For example, some elapid venoms,
such as those of Asian cobras, can cause severe local
envenoming , formerly thought to be an effect only of
viper venoms.
In Sri Lanka and South India, Russell’s viper venom
causes paralytic signs (ptosis etc) suggesting elapid
neurotoxicity, and muscle pains and dark brown urine
suggesting sea snake rhabdomyolysis.
There may be considerable overlap of clinical features
caused by venoms of different species
“Syndromic approach” may still be useful, especially
when the snake has not been identified and only
monospecific antivenoms are available

Page 38 of 95
● SYNDROME 1
● Local envenoming (swelling etc) with bleeding/clotting disturbances =
Viperidae (all species)
● SYNDROME 2
● Local envenoming (swelling etc) with bleeding/clotting disturbances,
● shock or renal failure
= Russell’s viper and possibly saw-scaled viper - Echis species - in
some areas)
● with conjunctival oedema (chemosis) and acute pituitary
insufficiency =
● Russell’s viper, Burma
with ptosis, external ophthalmoplegia, 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

Page 39 of 95
● SYNDROME 4
● Paralysis with minimal or no local envenoming
● Bite on land while sleeping, outside the Philippines = krait
● in the Philippines = cobra(Naja philippinensis)
● Bite in the sea = sea snake
● SYNDROME 5
● Paralysis with dark brown urine and renal failure
● Bite on land (with bleeding/clotting disturbance) =
Russell’s viper, SriLanka/South India
● Bite in the sea (no bleeding/clotting disturbances) = sea
snake
● Chronic renal failure occurs after bilateral cortical necrosis
(Russell’s viper bites) and chronic panhypopituitarism or
diabetes insipidus after Russell’s viper bites in Myanmar
and South India

Page 40 of 95
Management of snake bite
● First aid treatment
● Transport to hospital
● Rapid clinical assessment and resuscitation
● Detailed clinical assessment and species diagnosis
● Investigations/laboratory tests
● Antivenom treatment
● Observation of the response to antivenom:decision about the
need for further dose(s) of antivenom
●
Supportive/ancillary
●
treatment Treatment of the
●
bitten part Rehabilitation
●
Treatment of chronic
complications

Page 41 of 95
Aims of first aid
● Attempt to retard systemic absorption of venom

● Preserve life and prevent complications before
the patient can receive medical care(at a
dispensary or hospital)
● Control distressing or dangerous early symptoms
of envenoming
● Arrange the transport of the patient to a place
where they can receive medical care
● ABOVE ALL, DO NO HARM!

Page 42 of 95
FIRST AID –CONTD…
● Unfortunately, most of the traditional, popular, available
and affordable first aid methods have proved to be useless
or even frankly dangerous.
●
Making local incisions or pricks/punctures (“tattooing”) at
● the site of the bite or in the bitten limb
● Attempts to suck the venom out of the wound
● Use of (black) snake stones
● Tying tight bands [tourniquets) around the limb
● Electric shock
Topical application of chemicals ,herbs or ice
packs.

Page 43 of 95
Page 44 of 95
Tight (arterial) tourniquets are not
recommended!
To be effective, these had to be applied around the
upper part of the limb, so tightly that the
peripheral pulse was occluded.
This method was extremely painful and very
dangerous if the tourniquet was left on for too long
(more than about 40 minutes), as the limb might be
damaged by ischaemia- gangrenous limbs
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.

Page 45 of 95
Tight (arterial) tourniquets are not
recommended- WHY?
● Confining this toxin in a smaller area, by use of
compression techniques creates a greater risk of serious
local damage.
● When the tourniquet is removed there is the problem of the

venom rapidly entering the system and causing respiratory
failure in the case of neurotoxic bites
● The Viper’s venom contains pro-coagulant enzymes which

cause the blood to clot. In the small space below the
tourniquet the venom has a greater chance of causing a
clot. When the tourniquet is released the clot will rapidly
enter the body and can cause embolism and death.
● Lastly, there has been a great deal of research showing that
tourniquets DO NOT stop venom from entering the body

Page 46 of 95
Recommended first aid methods
• Reassure the victim who may be very anxious

• Immobilise the bitten limb with a splint or sling
(any movement or muscular contraction increases
absorption of venom into the bloodstream and
lymphatics)
• Consider pressure-immobilisation for some elapid
bites
• Avoid any interference with the bite wound as this
may introduce infection,increase absorption of
the venom and increase local bleeding

Page 47 of 95
Pressure immobilisation method
● An elasticated, stretchy, crepe Bandage,approximately 10

cm wide and at least 4.5 metres long should be used.
●
If that it not available, any long strips of material can be
used.
●
The bandage is bound firmly around the entire bitten limb,
starting distally around the fingers or toes and moving
● proximally, to include a rigid splint.
The bandage is bound as tightly as for a sprained ankle, but
not so tightly that the peripheral pulse (radial, posterior
tibial, dorsalis pedis) is occluded or that a finger cannot
easily be slipped between its layers

Page 48 of 95
Page 49 of 95
Rapid clinical assessment and
resuscitation
● Airway, respiratory movements (Breathing) and arterial pulse
(Circulation) must be checked immediately.
●
The level of consciousness must be assessed.
●
Urgent Resuscitation is needed in
a)Profound hypotension and shock resulting from direct
cardiovascular effects of the venom or secondary effects such
as hypovolaemia or hemorrhagic shock.
b)Terminal respiratory failure from progressive neurotoxic
envenoming that has led to paralysis of the respiratory
muscles.
c)Sudden deterioration or rapid development of severe
systemic envenoming following the release of a tight
tourniquet or compression bandage
d)Cardiac arrest precipitated by hyperkalaemia resulting
from skeletal muscle breakdown (rhabdomyolysis) after sea
snake bite.

Page 50 of 95
History
● Obtain a description of the snake or capture it, if possible, to
determine its color, pattern, or the existence of a rattle.
● Most snakes remain within 20 feet after biting.
●
Assess the timing of events and onset of symptoms. Inquire
about the time the bite occurred and details about the onset of
pain. Early and intense pain implies significant envenomation.
●
Local swelling, pain, and paresthesias may be present.
●
Systemic symptoms include nausea, syncope, and difficulty
● swallowing or breathing.
Determine history of prior exposure to antivenin or snakebite.
history of allergies to medicines
history of co morbid conditions or medications (eg,
aspirin, anticoagulants such as warfarin or GPIIb/IIIa
inhibitors, beta-blockers).

Page 51 of 95
Physical Examination
● Vital signs, airway, breathing, circulation
● Fang marks or scratches (determine coral snake bite
pattern by expressing blood from the suspected wound)
● Local tissue destruction
• Soft pitting edema that generally develops over 6-12
hours but may start within 5 minutes
• Bullae
• Streaking
Erythema or discoloration
• Contusions
• Systemic toxicity
● Hypotension
• Petechiae,
• epistaxis,
• hemoptysis
Paresthesias and dysthesias - Forewarn neuromuscular
blockade and respiratory distress (more common with
coral snakes)

Page 52 of 95
Early clues that a patient has severe
envenoming
Snake identified as a very dangerous one

•
• Rapid early extension of local swelling from the site of the bite
• Tender enlargement of local lymph nodes, indicating spread of
venom in the lymphatic system
• Systemic symptoms: collapse (hypotension, shock)
nausea, vomiting,diarrhoea
severe headache
“heaviness” of the eyelids
inappropriate drowsiness
early
ptosis/ophthalmoplegia
• Early spontaneous systemic bleeding
• Passage of dark brown urine

Page 53 of 95
Lab Studies
● CBC with manual differential and peripheral blood smear

● Prothrombin time and activated partial thromboplastin time,
international normalized ratio (INR).
●
Fibrinogen and split
●
products Type and cross
●
Blood chemistries - electrolytes, BUN, creatinine
●
Urinalysis for myoglobinuria
●
Arterial blood gas determinations for patients with systemic
symptoms

Page 54 of 95
CONTD…
● Imaging Studies:
● Baseline chest radiograph in patients with pulmonary
edema
● Plain radiograph to rule out retained fang
●
Other Tests: Compartmental pressures may need to
be measured.
●
Measurement of compartmental pressures is
indicated when significant swelling is present, pain is
out of proportion to exam, and if paresthesias are
present in the affected limb.

Page 55 of 95
20 minute whole blood clotting test
●
This very useful and n i (f2o0rmWatBv i eCbTed)side test

requires very little skill and only one piece of apparatus -
a new, clean, dry, glass vessel (tube or bottle).
• Place a few ml of freshly sampled venous blood in a small
glass vessel
• Leave undisturbed for 20 minutes at ambient
temperature
• Tip the vessel once
• If the blood is still liquid (unclotted) and runs out, the
patient has hypofibrinogenaemia (“incoagulable blood”) as
a result of venom-induced consumption coagulopathy
• In the South East Asian region, incoagulable blood is
diagnostic of a viper bite and rules out an elapid bite
• Warning! If the vessel used for the test is not made of
ordinary glass, or if it has been used before and
cleaned with detergent, its wall may not stimulate
clotting of the blood sample in the usual way and test
will be invalid
Every 30 minutes for the first 4hours *hourly after
that

Page 56 of 95
● Haemoglobin concentration/haematocrit:
a transient increase indicates haemoconcentration resulting
from a generalised increase in capillary permeability - in
Russell’s viper bite
a decrease reflecting blood loss or intravascular
●
haemolysis
●
- Indian and Sri Lankan Russell’s viper bite
Platelet count: decreased in victims of viper bites.
● White blood cell count: an early neutrophil leucocytosis is
evidence of systemic envenoming from any species.
●
Blood film: fragmented red cells (“helmet cell”, schistocytes)
are seen when there is microangiopathic haemolysis.
Plasma/serum may be pinkish or brownish if there is gross
haemoglobinaemia or myoglobinaemia.

Page 57 of 95
Biochemical abnormalities
● Elevated Aminotransferases and muscle enzymes (creatine

kinase, aldolase etc) in severe local damage or generalized
muscle damage (Srilankan and South Indian Russell's viper
●
bites, sea snakebites).
Slight increases in other serum enzymes - Mild hepatic
● dysfunction
● Elevated Bilirubin - in massive extravasation of blood.
Creatinine, urea or blood urea nitrogen levels - raised in the
●
renal failure of russell’s viper and saw-scaled viper bites and
sea snake bites.
● Early hyperkalaemia - in extensive rhabdomyolysis in sea
snake bites.
Bicarbonate will be low in renalfailure

Page 58 of 95
● Arterial blood gases and pH may show
evidence of respiratory failure
(neurotoxic envenoming) and acidaemia
● Desaturation: patients with respiratory
failure or shock using a finger oximeter.
●
Urine examination: the urine should be tested
by dipsticks for blood/haemoglobin/myoglobin.
Haemoglobin and myoglobin can be separated by
immunoassays but there is no easy or reliable
test. Microscopy will confirm whether there are
● erythrocytes in the urine.
Red cell casts indicate glomerular bleeding.
Massive proteinuria is an early sign of the
generalised increase in capillary permeability

Page 59 of 95
GRADES- MILD, MODERATE, OR SEVERE
Mild envenomation - local pain, edema, no signs of systemic

toxicity and normal lab values.
Moderate envenomation - severe local pain
edema larger than 12 inches surrounding the wound
systemic toxicity including nausea, vomiting
alterations in lab values (fallen hematocrit or platelet
values).
Severe envenomation
generalized petechiae, ecchymosis
blood-tinged sputum
hypotension, hypoperfusion
renal dysfunction
changes in prothrombin time and activated partial
thromboplastin time, and other abnormal tests defining
consumptive coagulopathy.
Grading envenomations is a dynamic process. Over
several hours, an initially mild syndrome may progress to a
moderate or even severe reaction.

Page 60 of 95
Medical Care
● Treatment is based on the severity of envenomation; it is
divided into field care and hospital management.
● Field care
• Reassure the patient to preclude hysteria during the
• implementation of ABCs.
Monitor vital signs and establish at least 1 large bore
• intravenous and crystalloid infusion.
• Administer oxygen therapy.
Restrict activity and immobilize the affected area
• (commonly an extremity); keep walking to a minimum.
Negative-pressure suctioning devices offer some benefit if
• used within several minutes of envenomation. Do not make
• an incision in the field.
Immediately transfer to definitive care.
Do not give antivenin in the field.

Page 61 of 95
CONTD…
● Hospital care
• Physicians who have little experience treating
snakebites frequently see patients.
• Regional centers often have more experience
in the care of snakebite victims. Surgical
evaluation for envenomation is paramount.
• Definitive treatment includes reviewing the
ABCs and evaluating the patient for signs of
shock (eg, tachypnea, tachycardia, dry
pale skin, mental status changes,
hypotension).

Page 62 of 95
Surgical Care
● Surgical assessment follows the injury site and
assess for the development of compartment
syndrome.
•
Fasciotomy is not indicated in every bite, only
for those patients with objective evidence of
• elevated compartment pressures.
Liberal use of the Stryker pressure monitor is
warranted. Tissue injury after compartment
● syndrome is not reversible but is preventable
Make serial evaluations for further grading and to
rule out compartment syndrome. Depending on
clinical scenarios, measure compartment
pressures every 30-120 minutes. Fasciotomy is
indicated for pressures greater than 30-40 mm
Hg.

Page 63 of 95
Compartmental syndromes and
fasciotomy
Clinical features
● Disproportionately severe pain
● Weakness of intracompartmental muscles
● Pain on passive stretching of intracompartmental
muscles
●
Hypoaesthesia of areas of skin supplied by
●
nerves running through the compartment
Obvious tenseness of the compartment on
palpation

Page 64 of 95
CONTD…
● The most reliable test is to measure
intracompartmental pressure directly through a
cannula introduced into the compartment and
connected to a pressure transducer or
● manometer
Intracompartmental pressures exceeding 40
mmHg (less in children) may carry a risk of
●
ischaemic necrosis
Early treatment with antivenom remains the
● best way of preventing irreversible muscle
damage
Criteria for fasciotomy in snake-bitten limbs
Haemostatic abnormalities have been
corrected
Clinical evidence of an intracompartmental
syndrome
Intracompartmental pressure >40 mmHg (in
adults)

Page 65 of 95
Pharmacotherapy
● The goals of pharmacotherapy are to
neutralize the toxin, to reduce morbidity
and to prevent complications
● Antibiotics
● Immunizations -- Snakes do not harbor
Clostridium tetani in their mouths, but
bites may carry other bacteria, especially
gram-negative species.
● Tetanus prophylaxis recommended if
patient not immunized.
● Antivenin

Page 66 of 95
What is antivenom?
● Antivenom is immunoglobulin (usually the
enzyme refined F(ab)2 fragment of IgG] 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.
●
“Specific” antivenom, implies that the antivenom
has been raised against the venom of the snake
that has bitten the patient and that it can
therefore be expected to contain specific antibody
● that will neutralise that particular venom.
Monovalent or monospecific antivenom
neutralises the venom of only one species of
●
snake.
Polyvalent or polyspecific antivenom neutralises
the venoms of several different species of snakes.

Page 67 of 95
CONTD…
● For example, Haffkine, Kasauli, Serum Institute

of India and Bengal “polyvalent anti-snake venom
serum” is raised in horses using the venoms of
the four most important venomous snakes in
India (Indian cobra, Naja naja; Indian krait,
Bungarus caeruleus; Russell’s viper,Daboia
● russelii; saw-scaled viper, Echis carinatus).
Antibodies raised against the venom of one
species may have cross-neutralising activity
against other venoms, usually from closely
related species. This is known as paraspecific
activity.

Page 68 of 95
CONTD…
● Antivenom treatment carries a risk of
severe adverse reactions and in most
countries it is costly and may be in limited
supply. It should therefore be used only in
patients in whom the benefits of antivenom
treatment are considered to exceed the
●
risks.
●
How long after the bite can antivenom be
expected to be effective?
Antivenom treatment should be given as soon as
it is indicated. It may reverse systemic
●
envenoming even when this has persisted for
several days or, in the case of haemostatic
abnormalities, for two or more weeks.
However, when there are signs of local
envenoming, without systemic envenoming,
antivenom will be effective only if it can be given
within the first few hours after the bite.

Page 69 of 95
Indications for Antivenom
Antivenom treatment is recommended if and when
a patient with proven or suspected snake
develops one or more of the following signs
●
Systemic envenoming
Haemostatic abnormalities:
spontaneous systemic bleeding (clinical)
coagulopathy (20WBCT or other laboratory)
●
thrombocytopenia (<100 x 109/litre)
(laboratory)
● Neurotoxic signs: ptosis, external ophthalmoplegia,
paralysis etc (clinical)
● Cardiovascular abnormalities: hypotension, shock, cardiac
arrhythmia (clinical),abnormal ECG
Acute renal failure: oliguria/anuria, rising blood creatinine/
urea, (Haemoglobin-/myoglobin-uria:) dark brown urine,
other evidence of intravascular haemolysis or generalised
rhabdomyolysis (muscle aches and pains, hyperkalaemia)

Page 70 of 95
CONTD…
Local envenoming
➢ Local swelling involving more than half
of the bitten limb (in the absence of a
tourniquet)
➢ Swelling after bites on the digits (toes and
especially fingers)
➢ Rapid extension of swelling (for example
beyond the wrist or ankle within a few
hours of bites on the hands or feet)
➢ Development of an enlarged tender
lymph node draining the bitten limb

Page 71 of 95
Contraindications to antivenom
● There is no absolute contraindication to
antivenom treatment
●
Patients who have reacted to horse (equine) or
sheep (ovine) serum in the past (for example
after treatment with equine Anti-tetanus serum,
equine anti-rabies serum or equine or ovine
● antivenom)
Those with a strong history of atopic diseases
(especially severe asthma) should be given
antivenom only if they have signs of systemic
envenoming.

Page 72 of 95
Prophylaxis in high risk patients
● High risk patients may be pre-treated

empirically with
Subcutaneous epinephrine
Intravenous antihistamines (both anti-H1, such
as promethazine , anti- H2, such as cimetidine or
ranitidine)
Corticosteroid.
● In asthmatic patients, prophylactic use of an
inhaled adrenergic ß2 agonist such as salbutamol
may prevent bronchospasm

Page 73 of 95
Selection of antivenom
● Antivenom should be given only if its stated
range of specificity includes the species known or
thought to have been responsible for the bite.
●
Liquid antivenoms that have become opaque
should not be used as precipitation of protein
indicates loss of activity and an increased risk
●
of reactions.
If the biting species is known, the ideal
treatment is with a monospecific/monovalent
antivenom, as this involves administration of a
lower dose of antivenom protein than with a
●
polyspecific/ polyvalent antivenoms.
Polyspecific/polyvalent antivenoms are preferred
in many countries because of the difficulty in
identifying species responsible for bites.

Page 74 of 95
Administration of antivenom
● Freeze-dried (lyophilised) antivenoms are
reconstituted, usually with 10 ml of sterile water.
The freeze-dried protein may be difficult to
●
dissolve
Skin and conjunctival “hypersensitivity” tests
may reveal IgE mediated Type I hypersensitivity
to horse or sheep proteins but do not Predict
the large majority of early (anaphylactic) or late
(serum sickness type) antivenom reactions. Since
● they may delay treatment and can in themselves
be sensitizing, these tests should not be used.
●
Epinephrine should always be drawn up in
readiness before antivenom is administered.
Antivenom should be given by the intravenous
route whenever possible.

Page 75 of 95
Intravenous injection
● Intravenous “push” injection: reconstituted freeze-
dried antivenom or neat liquid antivenom is given by
slow intravenous injection (not more than 2
ml/minute). This method has the advantage that the
doctor/nurse/dispenser giving the antivenom must
remain with the patient during the time when some
early reactions may develop. It is also economical,
●
saving the use of intravenous fluids, giving sets,
cannulae etc.
Intravenous infusion: reconstituted freeze-dried or
neat liquid antivenom is diluted in approximately 5-
10 ml of isotonic fluid per kg body weight (ie 250-
500 ml of isotonic
saline or 5% dextrose in the case of an adult
patient) and is infused at a constant rate over a
period of about one hour

Page 76 of 95
OTHER ROUTES
Local administration of antivenom at the site of
the bite is not recommended
Extremely painful
Increase intracompartmental pressure
Not effective.
Intramuscular injection of antivenom
Antivenoms are large molecules are absorbed
slowly via lymphatics.
Bioavailability is poor, especially after intragluteal
injection and blood levels of antivenom never reach
those achieved rapidly by intravenous
administration.
Pain of injection of large volumes of
antivenom Risk of haematoma formation in
patients with
haemostatic abnormalities.

Page 77 of 95
CONTD…
Situations in which intramuscular administration might be
considered
1) At a peripheral first aid station, before a patient with
obvious envenoming is put in an ambulance for a journey
to hospital that may last several hours
2) On an expedition exploring a remote area very far from
medical care
3) When intravenous access has proved impossible.
Although the risk of antivenom reactions is less with
intramuscular than intravenous administration, epinephrine
(adrenaline) must be readily available.
● The dose of antivenom should be divided between a
number of sites in the upper anterolateral region of both
thighs.
● A maximum of 5-10 ml should be given at each site by
deep intramuscular injection followed by massage to
aid absorption.
● Finding enough muscle mass to contain such large
volumes of antivenom is particularly difficult in children

Page 78 of 95
Dose of antivenom
● The recommended dose is often the amount of

antivenom required to neutralise the average
venom yield when captive snakes are milked of
●
their venom.
In practice, the choice of an initial dose of
● antivenom is usually empirical.
Since the neutralising power of antivenoms varies
from batch to batch, the results of a particular
clinical trial may soon become obsolete if the
● manufacturers change the strength of the
antivenom.
●
Snakes inject the same dose of venom into
children and adults.
Children must therefore be given exactly the
same dose of antivenom as adults.

Page 79 of 95
How much ?
● Intial dose to neutralise likely average dose
venom of the snake
●
Russell viper – 63 mg +/-7mg
●
Indian ASV 1 vial neutralises 7mg of venom – so
10 vials ![starting dose ]
●
COBRA -100-150 ml +neostigmine +ventilatory
●
support
VIPER -150 ml –retest 6 hrs-no clot –ASV 50-
● 100ml- retest /observe
If in renal failure - dialysis

Page 80 of 95
ADVERSE REACTIONS OF ASV
● NO test dose – [poor predictors & may sensitise
the patient to ASV]
●
A proportion of patients, usually more than 20%,
develop a reaction either early (within a few
hours) or late (5 days or more) after being given
● antivenom.
Early anaphylactic reactions: usually within 10-
180 minutes of starting antivenom, the patient
begins to itch (often over the scalp) and develops
urticaria, dry cough, fever, nausea,
●
vomiting, abdominal colic, diarrhoea and
tachycardia.
A minority of these patients may develop severe
life-threatening anaphylaxis: hypotension,
bronchospasm and angio-oedema.

Page 81 of 95
CONTD…
● Pyrogenic (endotoxin) reactions usually develop 1-2 hours
after treatment. Symptoms include shaking chills (rigors),
fever, vasodilatation and a fall in blood pressure. Febrile
convulsions may be precipitated in children. These
reactions are caused by pyrogen contamination during the
manufacturing process. They are commonly reported.
● Late (serum sickness type) reactions develop 1-12 (mean

7) days after treatment. Clinical features include fever,
nausea, vomiting, diarrhoea, itching, recurrent urticaria,
arthralgia, myalgia, lymphadenopathy, periarticular
swellings, mononeuritis multiplex, proteinuria with
immune complex nephritis and rarely encephalopathy.
● Patients who suffer early reactions and are treated with

antihistamines and corticosteroid are less likely to develop
late reactions.

Page 82 of 95
Treatment of early Anaphylactic and
Pyrogenic Antivenom reactions
At the earliest sign of a reaction:
● Antivenom administration must be temporarily
suspended
● Epinephrine (adrenaline) (0.1% solution, 1 in 1,000,
1 mg/ml) is the effective treatment for early
anaphylactic and pyrogenic antivenom reactions
● Epinephrine (adrenaline) is given intramuscularly (into the
deltoid muscle or the upper lateral thigh) in an initial dose
of 0.5 mg for adults, 0.01 mg/kg body weight for
●
children.
Severe,life-threatening anaphylaxis can evolve very rapidly
and so epinephrine (adrenaline) should be given at the very
first sign of a reaction, even when only a few spots of
urticaria have appeared or at the start of itching,
●
tachycardia or restlessness.
The dose can be repeated every 5-10 minutes if the
patient’s condition is deteriorating

Page 83 of 95
● Anti H1 antihistamine such as chlorpheniramine maleate
(adults 10 mg, children 0.2 mg/kg by intravenous injection
over a few minutes)
● Intravenous hydrocortisone (adults 100 mg, children 2
mg/kg bodyweight) - prevent recurrent anaphylaxis.
● Anti H2 antihistamines such as cimetidine or ranitidine
have a role in the treatment of severe anaphylaxis.
● Both drugs are given, diluted in 20 ml isotonic saline, by
slow intravenous injection (over 2 minutes). Doses:
cimetidine - adults 200 mg, children 4 mg/kg;ranitidine -
adults 50 mg, children 1 mg/kg.
● Late (serum sickness) reactions usually respond to a 5-day
course of oral antihistamine. Patients who fail to respond
in 24-48 hours should be given a 5-day course of
prednisolone.
● Doses: Chlorpheniramine: adults 2 mg six hourly, children
0.25 mg/kg /day in divided doses
●
Prednisolone: adults 5 mg six hourly, children 0.7
mg/kg/day in divided doses for 5-7days

Page 84 of 95
Recurrence of systemic envenoming
● In patients envenomed by vipers, after an initial

response to antivenom (cessation of bleeding,
restoration of blood coagulability), signs of
systemic envenoming may recur within 24-48
hours.
●
This is attributable to:
Continuing absorption of venom from the
“depot” at the site of the bite, perhaps assisted
by improved blood supply following correction of
shock, hypovolaemia etc.
A redistribution of venom from the tissues
into the vascular space, as the result of
antivenom treatment.

Page 85 of 95
Conservative treatment when no
antivenom is available
● Neurotoxic envenoming with respiratory paralysis: assisted
ventilation. Anticholinesterases should always be tried
● Haemostatic abnormalities - strict bed rest to avoid even minor
trauma
transfusion of clotting factors and platelets;
fresh frozen plasma and cryoprecipitate with platelet
concentrates
fresh whole blood.
Intramuscular injections should be avoided.
● Shock, myocardial damage:
Hypovolaemia corrected with colloid/crystalloid,
Ancillary pressor drugs (dopamine or adrenaline)
● Renal failure: conservative treatment or dialysis
● Dark brown urine (myoglobinuria or haemoglobinuria) correct
hypovolaemia and acidosis and consider a single infusion of
● mannitol
● Severe local envenoming
Surgical intervention may be needed but the risks of surgery in a
patient with consumption coagulopathy, thrombocytopenia and
enhanced fibrinolysis must be balanced against the life
● threatening complications of local envenoming.
Prophylactic broad spectrum antimicrobial treatment is justified

Page 86 of 95
● Anticholinesterase (eg “Tensilon”/edrophonium)
test
● Baseline observations
● Give atropine intravenously
● Give anticholinesterase drug
● Observe effect
● If positive, institute regular atropine and (long
acting) anticholinesterase

Page 87 of 95
Criteria for giving more antivenom
● Persistence or recurrence of blood
incoagulability after 6 hr of bleeding after
1-2 hr
●
Deteriorating neurotoxic or cardiovascular
● signs after 1-2 hr
If the blood remains incoagulable (as
measured by 20WBCT) six hours after the initial
●
dose of antivenom, the same dose should be
repeated.
In patients who continue to bleed briskly,
●
the dose of antivenom should be repeated within
1-2 hours.
In case of deteriorating neurotoxicity or
cardiovascular signs, the initial dose of
antivenom should be repeated after 1-2 hours,
and full supportive treatment must be
considered.

Page 88 of 95
How can snake bites be avoided?
● Education ! Know your local snakes,
know the sort of places where they like to
live and hide, know at what times of year,
at what times of day/night or in what
kinds of weather they are most likely to be
● active.
Be vigilant after rains, during flooding, at
● harvest time and at night.
Wear proper shoes or boots and long
trousers, especially when walking in
● the dark or in undergrowth.
Use a light (torch) when walking at
night.

Page 89 of 95
CONTD…
● Avoid snakes as far as possible,
including snakes performing for snake
charmers. Never handle, threaten or
attack a snake and never intentionally
trap or corner a snake in an enclosed
space.
● Avoid sleeping on the ground.
● Keep young children away from areas
● known to be snake-infested.
Avoid or take great care handling
dead snakes, or snakes that appear to
● be dead.
Avoid having rubble, rubbish, termite
mounds or domestic animals close to
human dwellings, as all of these attract
snakes.

Page 90 of 95
CONTD…
● Frequently check houses for snakes and, avoid
types of house construction that will provide snakes
with hiding places (eg thatched roof with open
eaves, mud and straw walls with large cracks and
cavities, large unsealed spaces beneath floorboards).
● To prevent sea snake bites, fishermen should avoid
touching sea snakes caught in nets and on lines. The
head and tail are not easily distinguishable. There is a
risk of bites to bathers and those washing clothes in
muddy water of estuaries, river mouths and some
coastlines

Page 91 of 95
CASE REPORT Year : 2007 | Volume : 11 | Issue : 3 |
Page : 161-164 Neurotoxic snake bite with respiratory
Department of Anesthesiology, Institutefailure
of Medical Sciences, Banaras Hindu University,
Varanasi - 221 005, India
● Thirteen patients with severe neuroparalytic snake envenomation

admitted in intensive care unit with respiratory failure over a
four months period. Initially ptosis and ophthalmoplegia,
followed by bulbar palsy and respiratory muscle weakness was
the common sequele.
● All of them received cardio-respiratory support with mechanical
ventilation, anti-snake venom (median dose of 20 vials) and
anticholinesterase therapy.
● Except one suffering from hypoxic brain injury due to delayed
presentation, rest survived with complete neurological
● recovery.
So good outcome in such cases is related with early cardio
● respiratory support and anti venom therapy
Polyvalent anti-snake venom (ASV) started as loading dose (50 ml
● over two hours) and maintenance infusion (50 ml six hourly).
We have also used anticholinesterase (i.e. neostigmine started at
a rate of 25 mcg/kg/hour) and anticholinergic (glycopyrolate)
combination as infusion to reverse the neuromuscular blockade till
ptosis improved in every case

Page 92 of 95
Low dose of snake antivenom is as effective as high dose in
patients with severe neurotoxic snake envenoming
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
In the study, 55 snake bite victims requiring ventilatory support for
severe neurotoxic envenoming received either 150 ml of polyvalent
snake antivenom (SAV) (low dose SAV group, n = 28) or 100 ml of
SAV at presentation followed by 100 ml every 6 hours until recovery
of neurological manifestations (high dose group, n = 27).
The median dose of SAV in the high dose group was 600 ml (range
300 to 1600).
The duration of mechanical ventilation in the low dose group
(median
47.5 hours; range 14 to 248) was similar to that in the high
dose group (median 44 hours; range 6 to 400).
The mean (SD) duration of intensive care unit stay was similar in
the two groups.
There were three deaths in the high dose group; two patients in the
low dose group had neurological sequelae. All other patients improved,
had no residual neurological deficit, and were discharged.
We conclude that there is no difference between a protocol using
lower doses of SAV and one with higher doses in the management of
patients with severe neurotoxic snake envenoming

Page 93 of 95
● REFERENCES
● WHO/SEARO GUIDELINES FOR THE CLINICAL
MANAGEMENT OF SNAKE BITE IN THE
SOUTH
EAST ASIAN REGION by David A Warrell-
Supplement to The Southeast Asian Journal
of Tropical Medicine & Public Health

Page 94 of 95
Page 95 of 95

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Snakebite

http://www.isakanyakumari.com/docs/Snakebite.ppt 09/08/18 12.17

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● Worldwide, only about 15% of the more than

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● There are two subgroups, the typical vipers

● The Crotalinae have a special sense organ,

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Haemotoxic venom BUT can

Although nocturnal, encountered

Key identification feature is the

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Russell’s vipers -Daboia russelii - [Black edged chain like marking

Saw-scaled or carpet vipers - Echis carinatus and E sochureki

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Encountered under bushes and leaf litter or in

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● ELAPID neurotoxins act at peripheral

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The local effects of venom serve as a reminder of

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● Tender, painful enlargement of the regional lymph nodes

● Symptoms and signs vary according to the species of snake

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Local Tissue YES NO YES YES YES

Ptosis/ YES YES YES NO NO

Coagulation NO NO YES YES YES

Renal Problems NO NO YES NO YES

Neostigmine & YES NO? NO? NO NO

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● Compartment syndrome is the most frequent

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● Immediate (anaphylaxis, type I)

● Delayed (serum sickness, type iii hypersensitivity

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● Attempt to retard systemic absorption of venom

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