Snake Bite

• Snake bite is acute life threatening time limiting medical emergency in tropical countries
• a prompt and effective Tx is required to save a life of pt.
• Effect of sake bite is d/t envenomation of toxins 
• Neurotoxins
• Cardiotoxins
• Nephrotoxins
• Mycotoxins

• Effect of envenomation ~ Type of snake & amount of venom injected

Type of snake
• Cobras, Kraits - Nuerotoxic
• Sea Snakes - Myotoxic
• Viper - Vasculotoxic
In Myanmar
• Viper bite – commonest (90%)
• Cobra and other (10%)
Non poisonous snakes
• Head – Rounded
• Fangs – Not present
• Pupils – Rounded
• Anal plate – Double row
• Bite mark – Row of small teeths

Poisonous snakes
• Head – triangle
• Fangs – Present
• Pupils – Elliptical pupil
• Anal plate – Single row
• Bite Mark – Fnag Mark
viper
cobra
Krait
Sea snake
Venom composition
• More than 90% of snake venom (dry weight) is protein
• digestive hydrolases,
• hyaluronidase
• phospholipase A2 and peptidases
• Zinc metalloproteinase haemorrhagins
• Procoagulant enzymes
• Acetylcholinesterase
• Postsynaptic (α) neurotoxins such as α-bungarotoxin and cobrotoxin
Bites by small snakes should not be ignored or dismissed.
They should be taken just as seriously as bites by large snakes of the same species
Quantity of venom injected at a bite, “dry
bites”

This is very variable, depending on the species and size of the snake,
The mechanical efficiency of the bite, whether one or two fangs penetrated the skin and
whether there were repeated strikes.
Clinical features
• Risk factors – farmers , fishermen , Rainy season ,
dark time
• Local Features
• Fang marks
• Increasing pain at the bite site
• Tender,painful swelling of regional lymph nodes
• Commonest symptom of early systemic envenoming is Vomiting
Systemic Features (Viper) - Vasculotoxic

• General Condition- Anxious ,later drowsiness ,fainting

• Vomiting ,epigastric pain
• Bleeding
- External-From openings
- Internal- Brain(pitutary),Adrenal,Liver,Heart
• Renal involvement - renal angle tenderness,oliguria(Acute renal failure)
• DIC ,Shock
Systemic Features (Cobra) - Neurotoxic
• Early neurotoxic symptoms such as blurred vision, a feeling of heaviness of eyelids &
drowsiness.
• Then followed by
-ptosis
-dysphagia
-sweating
-central cyanosis
-tingling & numbness of lower limbs
or all 4 limbs
-respiratory failure
Examination
Local
• Swelling spreading proximally
• Tender regional lymph nodes
• Fang mark
• Persistence local bleeding ,bruising ,blistering,necrosis,abscess
Systemic
• Haemorrhage – Skin, mucosa, internal organs
Signs of developing neurotoxicity
• Bilateral ptosis
• Partial or complete opthalmoplegia
• Cranial nerve weakness
• General muscle weakness
• Respiratory weakness/ distress
• Do not assume that snake bitten patients are unconscious or even irreversible “brain
dead” just because their eyes are closed, they are unresponsive to painful stimuli,
are areflexic, or have fixed dilated pupils.
• They may just be paralysed!
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.
• Early tender enlargement of local lymph nodes, indicating spread of venom
• in the lymphatic system.
• Early systemic symptoms: collapse (hypotension, shock), nausea, vomiting,
• diarrhoea, severe headache, “heaviness” of the eyelids, inappropriate
• (pathological) drowsiness or early ptosis/ophthalmoplegia.
• Early spontaneous systemic bleeding.
• Passage of dark brown/black urine.
Management of snake bite
First aid treatment
o Reassurance
o Clean the bite site
o Apply a cloth pad over bite site and apply a firm bandage to produce moderate
pressure
o Keep the bitten limb still with a splint
o Keep the patient still and carry them to the hospital
o If the snake has been killed, bring it

AVOID
Incision,rubbing,massage,burning,tattooing,tight tourniquet, applying herbs
Aims of first-aid
• attempt to retard systemic absorption of venom.
• preserve life and prevent complications before the patient can receive medical care
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, AIM TO DO NO HARM!
• MOST TRADITIONAL FIRST AID METHODS SHOULD BE DISCOURAGED :
• THEY DO MORE HARM THAN GOOD !
• Tight (arterial) tourniquets are not recommended!
• Traditional 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 gets occluded.
• This method can be 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.
• Tourniquets have caused many gangrenous limbs
Urgent resuscitation is required in
• Profound hypotension and shock
• Terminal respiratory failure
• Respiratory distress
• Sudden deterioration
• Cardiac arrest
Emergency care
• Check airway , breathing , circulation
• Protect airway and ventilate if required
• Volume resuscitation , consider inotropes if shocked
• Control hemorrhage and provide clotting factors (FFP ,Cryoprecipitate etc) AFTER
adequate dose of AV has been given
Bedside tests
• 20 minute whole blood clotting test
(2 hourly in 1st 12 hours and 4 hourly in 2nd 12 hours)
• PEFR
• Urine Albumin
 20-minute whole blood clotting test
(20WBCT)
• Place 2 mls of freshly sampled venous blood in a small, new or heat cleaned, dry,
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 Asia region, incoagulable blood is diagnostic of a viper bite and
rules out an elapid bite*.
• Arterial puncture is contraindicated in patients with haemostatic abnormalities
(Viperidae and some Australasian Elapidae)
Investigations
• Prothrombin time based on INR( abnormal- PT > 4.5 sec , INR > 1.2 )
• APTT
• FDP
• CP ( auto )
• Urea , electrolytes , creatinine
• ABG
• Urine RE

 ELISA
Indication for antivenom
• Rapid extension of local swelling
• Tender lymphadenopathy
• Developing paralysis ( bilateral ptosis, slurred speech ,difficulty in opening mouth
,protruding tongue ,increased salivation and drooling ,generalized weakness )
• Respiratory paralysis
• Non-clotting blood
• Spontaneous systemic bleeding
• Shock
• Oliguria/ Anuria
• Heavy proteinuria (3+ )
• Antivenom is the only specific antidote to snake venom.
• A most important decision in the management of a snake-bite victim is whether or
not to administer antivenom
• Antivenom should be given only to patients in whom its benefits are considered
likely to exceed its risks. Since antivenom is relatively costly and often in limited
supply, it should not be used indiscriminately.
• The risk of reactions should always be taken into consideration
 Snake unidentified

Neurotoxic envenoming signs

yes No

20WBCT
ASV (cobra) 40mg

Non-clot Clot
Algorithm for management of
unidentified snake bite ASV(viper)160 mg -look for neurotoxic signs ½ hourly

- 20 WBCT 2 hourly for 24 hrs

S/S of neurotoxic envenomation

Non-clot

Yes
No
No Yes

ASV (cobra) 40 mg
Observe for 24 hrs ASV(viper) 160 mg
Algorithm for ASV dosage in confirmed Rusell’s viper
bite ( YGH guideline)
• ASV should be given as soon as possible if it is indicated
• Reverse systemic envenoming even when this has persisted for several days or in
hematological abnormalities , up to 7 days
• Green snake bite => non-clot 20WBCT + severe local swelling + urine albumin
negative
Indication for repeating more anti-venom ( both Viper and Cobra)

• Incoagulable blood after 6 hrs

• Persistent bleeding ( repeat ASV in 1-2 hrs )
• Deteriorating CVS signs ( hypotension,shock,arrythmia )
• Persistent neurotoxic symptom and signs in 1-2 hrs after ASV
If above indications present - 40 mg ASV for cobra
-80 mg ASV for viper

Maximum dose for viper ,240 mg MPF ASV

•
Response to antivenom
• General: The patient feels better. Nausea ,headache and generalized aches and pains
may disappear very quickly.
• Spontaneous systemic bleeding (e.g from the gums): This usually stop within 15-
30minutes.
• Blood coagulability(20WBCT): This is usually restored in 3-9 hours.
• In shocked patients: Blood pressure may increase within the first 30-60 minutes and
arrhythmia such as sinus bradycardia may reslove.
 Treatment of neurotoxic envenoming

• IV atropine 0.6 mg for adult , 50 microgram/kg for children

• Anticholinesterase (Tensilon/Endrophonium chloride)10 mg for adults 0.25/kg for
children
• Observe effects for improvement of s/s for 10-20 mins
• If respond ,maintain on neostigmine 0.5-2.5 mg every 1-3 hrs up to 10 mg/24 hrs
maximum with atropine to block muscarinic side effects
• Keep ambubag ready
• Consider assisted ventilation ,ICU
• Neurotoxic envenoming of the post-synaptic type(Cobra bites)
may begin to improve as early as 30minutes after antivenom ,
but usually take several hours.
• Active haemolysis and rhabdomyolysis may cease within a few
hours and the urine returns to its normal colour.
Management of anaphylaxis
• Fluid replacement using crystalloids
• IV adrenaline 1:1000; 1mg/ml ( 0.5 mg )
• IV chlorpheniramine 10mg
• IV hydrocortisone 100 mg
Treatment of nephrotoxic envenoming
• Monitor BP, PR, Fluid status ,urine output ,bleeding manifestations
• Monitor urine albumin, urea and creatinine
Treatment of complications
• Treatment of Shock( volume and fluid replacement)
• Treatment of DIC( FFP,CRP )
• Treatment of ARF ( renal replacement therapy)
• Treatment of paralysis ( Neostigmine ,Atropine, ventilator )
• Physiotherapy and Wound management
Other treatments
• Anti Tetanus Toxin injection
• IV antibiotics
• Health education
THANK YOU