► 3500 SPECIES
► 300 VENOMOUS
► 30000 - 40000 DEATHS ANNUALLY
POISONOUS SNAKES
INDIAN SCENARIO
► 5 DANGEROUSLY POISONOUS SNAKES
KING COBRA
COMMON COBRA
COMMON KRAIT
RUSSELL’S VIPER
SAWSCALED VIPER
MOST COMMON POISONOUS SNAKE IS COMMON KRAIT
► 216 SPECIES
► 52 VENOMOUS
SNAKE VENOM
► Toxic saliva secreted by modified parotid glands of a venomous snake
► Amber coloured when fresh
► Constituents Toxins
Enzymes
Miscellaneous : neurotoxins
cardiotoxins
hemolysin
VENOM CLASSIFICATION
► Neurotoxic elapids(cobra,krait)
► Hemotoxic viperidae
► Myotoxic sea snake
► Krait and russell’s viper is much more toxic than that of cobra
SYMPTOMATOLOGY OF NON VENOMOUS SNAKES
► Universal fear associated induce a state of shock
► Bite site may demonstrate multiple teeth impressions
► Lack of significant local pain or swelling
► Adequate reassurance and symptomatic treatment measures lead to full recovery
SYMP..VENOMOUS SNAKE BITES
► ELAPID BITE
► Local features :
► indistinct fang marks ,
► burning pain,
► swelling and discolouration,
► serosanguinous discharge
Systemic features
► preparalytic stage : emesis,
headache,
LOC.
paralytic stage : ptosis,
ophthalmoplegia
drowsiness,
dysarthria,
dysphagia,
convulsions,
bulbar paralysis,
resp failure .
VIPERID BITE
Local features:
rapid swelling,
discolouration,
blister formation,
bleeding from bite site,
severe pain
Generalised bleeding manifestations.
epistaxis,
hemoptysis,
bleeding gums
hemauria
purpuric spots
Renal failure
HYDROPHID BITE
► Local features: minimal swelling and pain
► Systemic features: myalgia muscle stiffness
myoglobinuria , renal tubular
necrosis
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.
► Baileys method
Management of snake bite
FIRST AID
► DELAY ENRY OF VENOM
► TOURNIQUET
► ABOVE KNEE
► ABOVE ELBOW
CLINICAL ASSESMENT
► VITAL SIGNS—PULSE
--B P
--RESPIRATION –SBC
OBSERVE – BITE MARK
--LOCAL REACTION
--PAINFUL LNE
►
NEUROTOXICITY
► PTOSIS
► OPHTHALMOPLEGIA
► MYASTHENIA LIKE SYMPTOMS
► ASSES SBC
HEMATOTOXICITY
► PURPURA
► ECHYMOSIS
► GINGIVAL SULCUS BLEED
► HEMATURIA
CAPILLARY LEAK SYNDROME
► PUFFINESS
► CHEMOSIS
► PAROTID SWELLING
Lab. Investigations
Haematological-
leucocytosis(>20,000-
severe envenomation)
elevated PCV
thrombocytopenia
evidence of hemolysis
prolonged CT,PT,PTT
elevated FDP
► CT > 20 MINUTES
► SURE SIGN OF ENVONOMATION
► PITVIPER > 2 WEEKS
► ECG: bradycardia
ST /
Twave inversion
QT Prolongation
changes due to hyperkalemia
► Metabolic
hyperkalemia
hypoxemia with resp.Ac
met.Ac or lactic Ac
► Urine
hematuria,proteinuria,Hburia
Mburia
► Renal : ARF -- BU S.Cr S E
► CXR : pulm.edema
intrapulm.Hgs
pleural effusion
► Immunodiagnosis: by ELISA….
highly sensitive but specificity inadequate to diff b/w diff species of snakes
SPECIFIC MANAGEMENT ASV
► HORSE SERUM
► ASV IN INDIA
COBRA
KRAIT
RUSSEL’S VIPER
SAW SCALED VIPER
1 mi ASV --- 0.6m6 cobra R viper
--- 0.45mg krait S viper
Indication ---- systemic manifestaiton
► NEUROTOXICITY
► REPEATED VOMITING
► HAEMOTOXICITY
► NEPHROTOXICITY
► CARDIOTOXICITY
► RHABDOMYOLYSIS
► PROLONGED CT ALONE
PIT VIPER -- NO
SNAKE NOT IDENTIFIED
NEUROTOXIC ENVONOMATION
► INITIAL DOSE 10 - 15 VIALS
► REASSESS
► IMPROVEMENT 30 -- 60 MIN
► REPEAT 5 VIALS AFTER 60 -- 90 MINS
► SUPPORTIVE – NEOSTIGMINE AFTER ATROPINE
HAEMOTOXIC ENVONOMATION
► MILD CT < 30 MINS
CLOT SIZE = 50% blood col
initial dose = 5 vials
► MODERATE CT > 30 MINS
► CLOTS ONLY SPECKLES
► intial dose = 10 vials
► SEVERE INCOAGULABLE
► initial dose = 15 vials
► REPEAT CT AFTER 6 – 9 HOURS
► IF CT PRONGED REPEAT 5- 10 VIALS
► LOW DOSE INFUSION – FOLLOWING
DAYS
SUPPORTIVE CARE
ANTIBIOTICS
METHYL PREDNISOLONE
FFP,FRESH BLOOD
PREVENTION AND Rx OF HYPOTENSION
PRVENTION OF SHOCK
PREVENTION OF ARF
► PROPER FLUID ADMINISTRATION
► CORRECT MYOCARDIAL DYSFUNCTION
► MONITOR OUTPUT BU S.Cr SE
► AVOID NEPHROTOXIC DRUGS
► PROTEIN RESTRICTION
Management of local reactions
► BULLAE - LEFT INTACT
► NECROSIS - DEBRIDEMENT
► COMPARTMENT SYNDROME – FASCIOTOMY
► MOST COMFORTABLE POSITION
REACTIONS TO ANTIVENOM
► ANAPHYLACTOID 10 – 90 MINS
► PYROGENIC 2 HOURS
► SERUM SICKNESS 5 – 21 DAYS
► Rx local anaesthetic ice pack
dr.muhammed faisal
calicut medical college
► 30000 - 40000 DEATHS ANNUALLY
POISONOUS SNAKES
INDIAN SCENARIO
► 5 DANGEROUSLY POISONOUS SNAKES
KING COBRA
COMMON COBRA
COMMON KRAIT
RUSSELL’S VIPER
SAWSCALED VIPER
MOST COMMON POISONOUS SNAKE IS COMMON KRAIT
► 216 SPECIES
► 52 VENOMOUS
SNAKE VENOM
► Toxic saliva secreted by modified parotid glands of a venomous snake
► Amber coloured when fresh
► Constituents Toxins
Enzymes
Miscellaneous : neurotoxins
cardiotoxins
hemolysin
VENOM CLASSIFICATION
► Neurotoxic elapids(cobra,krait)
► Hemotoxic viperidae
► Myotoxic sea snake
► Krait and russell’s viper is much more toxic than that of cobra
SYMPTOMATOLOGY OF NON VENOMOUS SNAKES
► Universal fear associated induce a state of shock
► Bite site may demonstrate multiple teeth impressions
► Lack of significant local pain or swelling
► Adequate reassurance and symptomatic treatment measures lead to full recovery
SYMP..VENOMOUS SNAKE BITES
► ELAPID BITE
► Local features :
► indistinct fang marks ,
► burning pain,
► swelling and discolouration,
► serosanguinous discharge
Systemic features
► preparalytic stage : emesis,
headache,
LOC.
paralytic stage : ptosis,
ophthalmoplegia
drowsiness,
dysarthria,
dysphagia,
convulsions,
bulbar paralysis,
resp failure .
VIPERID BITE
Local features:
rapid swelling,
discolouration,
blister formation,
bleeding from bite site,
severe pain
Generalised bleeding manifestations.
epistaxis,
hemoptysis,
bleeding gums
hemauria
purpuric spots
Renal failure
HYDROPHID BITE
► Local features: minimal swelling and pain
► Systemic features: myalgia muscle stiffness
myoglobinuria , renal tubular
necrosis
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.
► Baileys method
Management of snake bite
FIRST AID
► DELAY ENRY OF VENOM
► TOURNIQUET
► ABOVE KNEE
► ABOVE ELBOW
CLINICAL ASSESMENT
► VITAL SIGNS—PULSE
--B P
--RESPIRATION –SBC
OBSERVE – BITE MARK
--LOCAL REACTION
--PAINFUL LNE
►
NEUROTOXICITY
► PTOSIS
► OPHTHALMOPLEGIA
► MYASTHENIA LIKE SYMPTOMS
► ASSES SBC
HEMATOTOXICITY
► PURPURA
► ECHYMOSIS
► GINGIVAL SULCUS BLEED
► HEMATURIA
CAPILLARY LEAK SYNDROME
► PUFFINESS
► CHEMOSIS
► PAROTID SWELLING
Lab. Investigations
Haematological-
leucocytosis(>20,000-
severe envenomation)
elevated PCV
thrombocytopenia
evidence of hemolysis
prolonged CT,PT,PTT
elevated FDP
► CT > 20 MINUTES
► SURE SIGN OF ENVONOMATION
► PITVIPER > 2 WEEKS
► ECG: bradycardia
ST /
Twave inversion
QT Prolongation
changes due to hyperkalemia
► Metabolic
hyperkalemia
hypoxemia with resp.Ac
met.Ac or lactic Ac
► Urine
hematuria,proteinuria,Hburia
Mburia
► Renal : ARF -- BU S.Cr S E
► CXR : pulm.edema
intrapulm.Hgs
pleural effusion
► Immunodiagnosis: by ELISA….
highly sensitive but specificity inadequate to diff b/w diff species of snakes
SPECIFIC MANAGEMENT ASV
► HORSE SERUM
► ASV IN INDIA
COBRA
KRAIT
RUSSEL’S VIPER
SAW SCALED VIPER
1 mi ASV --- 0.6m6 cobra R viper
--- 0.45mg krait S viper
Indication ---- systemic manifestaiton
► NEUROTOXICITY
► REPEATED VOMITING
► HAEMOTOXICITY
► NEPHROTOXICITY
► CARDIOTOXICITY
► RHABDOMYOLYSIS
► PROLONGED CT ALONE
PIT VIPER -- NO
SNAKE NOT IDENTIFIED
NEUROTOXIC ENVONOMATION
► INITIAL DOSE 10 - 15 VIALS
► REASSESS
► IMPROVEMENT 30 -- 60 MIN
► REPEAT 5 VIALS AFTER 60 -- 90 MINS
► SUPPORTIVE – NEOSTIGMINE AFTER ATROPINE
HAEMOTOXIC ENVONOMATION
► MILD CT < 30 MINS
CLOT SIZE = 50% blood col
initial dose = 5 vials
► MODERATE CT > 30 MINS
► CLOTS ONLY SPECKLES
► intial dose = 10 vials
► SEVERE INCOAGULABLE
► initial dose = 15 vials
► REPEAT CT AFTER 6 – 9 HOURS
► IF CT PRONGED REPEAT 5- 10 VIALS
► LOW DOSE INFUSION – FOLLOWING
DAYS
SUPPORTIVE CARE
ANTIBIOTICS
METHYL PREDNISOLONE
FFP,FRESH BLOOD
PREVENTION AND Rx OF HYPOTENSION
PRVENTION OF SHOCK
PREVENTION OF ARF
► PROPER FLUID ADMINISTRATION
► CORRECT MYOCARDIAL DYSFUNCTION
► MONITOR OUTPUT BU S.Cr SE
► AVOID NEPHROTOXIC DRUGS
► PROTEIN RESTRICTION
Management of local reactions
► BULLAE - LEFT INTACT
► NECROSIS - DEBRIDEMENT
► COMPARTMENT SYNDROME – FASCIOTOMY
► MOST COMFORTABLE POSITION
REACTIONS TO ANTIVENOM
► ANAPHYLACTOID 10 – 90 MINS
► PYROGENIC 2 HOURS
► SERUM SICKNESS 5 – 21 DAYS
► Rx local anaesthetic ice pack
dr.muhammed faisal
calicut medical college
