Dr Mohammad Naeem Assistant Professor Department of Community Medicine Khyber Medical College, Peshawar

Epidemiology
3 million bites and 1,50,000 deaths/year from venomous snake worldwide. Bites highest in temperate and tropical regions. 3000 species of snakes, out of them only 10-15% of snakes are venomous 97% of all snake bites are on the extremities

Common Snakes - INDIA

Cobras(nagraj) Najanaja,N.oxiana, N.kabuthia Neurotoxicity usually predominates.

 Common krait(karayat)-Bungarus caeruleus

 Russells viper(kander)-Daboia russelii Heat-sensing facial pits (hence the name "pit vipers").

 Echis.carinatus(afai)-Saw scaled viper

Non Poisonous Snakes

Head - Rounded Fangs - Not present Pupils - Rounded Anal Plate - Double row Bite Mark - Row of small teeth. Poisonous Snakes Head Triangle Fangs Present Pupils - Elliptical pupil Anal Plate - Single row Bite Mark - Fang Mark

Snake Venom
Snake venom is highly modified saliva

Mechanism of toxicity
Cytotoxic effects on tissues Hemotoxic Neurotoxic Systemic effects.

Toxic dose. The potency of the venom and the amount of venom injected vary considerably. 20% of all strikes are "dry"

Snake Venom, Necrosis

Proteolytic enzymes have a trypsin-like activity. Hyaluronidase splits acidic mucopolysaccharides and promotes the distribution of venom in the extracellular matrix of connective tissue. Phospholipases A2- break down membrane phospholipids -causes cellular membrane damage

Contd..
All these enzymes cause oedema, blister formation and local tissue necrosis

Snake Venom ,Paralysis

Blocks the stimulus transmission from nerve cell to muscle and cause paralysis
Does not penetrate the blood-brain barrier

Contd..
Postsynaptic effects are reversible with antivenom and neostigmine. Presynaptic nerve terminal, e.g. beta-bungarotoxin and here neostigmine will not be effective.

Snake venom, Hemorrhages

Activate prothrombin (e.g. ecarin from Echis carinatus) Effect on fibrinogen and convert it into fibrin -thrombin-like activity, such as crotalase (rattlesnake venom) Activate factor 5, factor 10 , Protein C Activate or inhibit platelet aggregation Haemmorhagins- cause endothelial damage

Clinical syndromic approach Syndrome 1

Local envenoming (swelling etc) with bleeding/clotting disturbances VIPERIDAE

Syndrome 2 Ptosis, external opthalmoplegia, 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

Syndrome 4
Paralysis with minimal or no local envenoming Krait, Sea snake

Syndrome 5 Paralysis with dark brown urine and renal failure: Russle viper

Grade 0
No evidence of envenomation Suspected snake bite Fang mark may be present Pain and 1 inch edema & erythema No systemic signs- first 12 hours No lab changes

Grade 1
Minimal envenomation Fang wound & moderate pain present 1-5 inches of edema or erythema No systemic involvement in present after 12 hours No lab changes

Grade 2

Moderate envenomation

Severe pain
Edema spreading towards trunk Petechiae and ecchymosis limited area Nausea,vomiting,giddiness Mild temperature

Grade 3
Severe envenomation Within 12 hours edema spreads to the extremities and part of trunk. Petechiae and ecchymosis may be generalized Tachycardia Hypotension Subnormal temperature

Grade 4
Envenomation very severe Sudden pain rapidly Progressive swelling which leads to ecchymosis all over trunk Bleb formation and necrosis

Grade 4 contd
Systemic manifestations within 15 min after the bite Weak pulse,N&V,vertigo Convulsions, coma

What investigation to do?

CBC RFT Coagulation studies Blood grouping & cross matching Sr.electrolytes Urinalysis

20 min whole blood clotting time

A few milliliters of fresh blood are placed in a new, plain glass receptacle (e.g., test tube) and left undisturbed for 20 min.

Contd
The tube is then tipped once to 45 to determine whether a clot has formed. If not, coagulopathy is diagnosed

Hess's test
Blow up a blood pressure cuff to 80 mm Hg and leave it on for 5 minutes. If a crop of purpuric spots appears below the cuff, the test is positive.

First Aid

Donts
No Tornique No Suction apparatus to be used(Sawyers) Do not run No role of Ice application

ASV
When to use ASV? How much to use? What if a reaction occurs? When to stop ASV?

When to use ASV

Hemostatic abnormalities(lab and clinical) Progressive local findings Neurotoxicity Systemic signs and symptoms Generalised rhabdomyolysis

Polyvalent antivenin

Manufactured by hyper immunizing horses against venoms of four standard snakes Cobra (naja naja) Krait (B.caerulus) Russels viper(V.russelli) Saw scaled viper(Echis carinatus)

Contd..

Lyophilised form: stored in a cool dark place & may last for 5 years Liquid form: has to be stored at 4c with much shorter life span
Each 1ml of reconstituted serum neutralise 0.6 mg of naja naja 0.45 mg of Bungarus caerulus 0.6 mg of V.russelli 0.45 mg of Echis carinatus

Guide for initial dose of antivenin Grade 0 1 Amount of Antivenin None None Route None None

2
3

5 vials
5-10 vials

IV 1:10 dilutions
IV 1:10 dilutions

10-20 vials

IV 1:10 dilutions

Dose in Paediatric
Same as adult as the amount of venom does not change-hence the dose of antivenom should be the same Only the dilution changes

Skin testing- Done if patient is stable and time available

0.02ml of 1:100 solution of serum is injected sc A positive reaction occurs within 5 to 30 mins. Appearance of wheal & surrounding erythema

What to do in case of anaphylactic reaction to ASV

Adrenaline 0.5 to 1ml IM If hypotension,severe bronchospasm or laryngeal edema give 0.5 ml of adrenaline diluted in 20 ml of isotonic saline over 20 mins iv.

contd..
A histamine anti H1 blocker-chlorpheniramine maleate-10 mg IV Pyrogenic reactions-antipyretics Late reactions-respond to CPM-2 mg, 6 hrly or oral prednisolone-5 mg 6 hrly

What if the patient needs ASV following reaction

Dose should be further diluted in isotonic saline and restarted as soon as possible. Concomitant IV infusion of epinephrine may be required to hold allergic sequelae at bay while further antivenom is administered

When to stop using ASV

Bleeding subsides Lab values returns to baseline Signs of neurotoxicity reverses Local effects halts progression

Supportive treatment
Anticholineesterase have variable but useful role Trial Atropine sulphate 0.6 mg Edrophonium chloride 10 mg IV (or) Neostigmine: 1.52.0 mg IM (children, 0.0250.08 mg/kg)

Contd..
If objective improvement is evident at 5 min continue neostigmine at a dose of 0.5 mg (children, 0.01 mg/kg) every 30 min as needed with atropine by continuous infusion of 0.6 mg over 8 h -children, 0.02 mg/kg over 8 h

Contd
Hypotension Administration of crystalloid (2040 mL/kg) Trial of 5% albumin (10 20mL/kg)

CVP guided fluids

Inotropic support and invasive monitoring

Contd..
Oliguria & renal failure- fluids,diuretics, dopamine
no response-fluid restriction- Dialysis Local infection- TT,antibiotics Haemostatic disturbances-FFP,fresh whole blood,cryoprecipitates

Cobra spit opthalmia

Topical antimicrobial 0.1% adrenaline relieves pain No need for ASV

Compartment syndrome
If signs of compartment syndrome are present and compartment pressure > 30 mm Hg: Elevate limb Administer Mannitol 1-2 g/kg IV over 30 min Simultaneously administer additional antivenom, 4-6 vials IV over 60 min If elevated compartment pressure persists another 60 min, consider fasciotomy

Bee Sting
Honey bee belong Family- Hymenoptera Sub Family-Apidae Only the females have adapted a stinger from the ovipositor on the posterior aspect of the abdomen

Venom
Histamine. Melittina membrane active polypeptide that can cause degranulation of basophils and mast cells, constitutes more than 50 percent of the dry weight of bee venom

Venom commonly causes pain, slight erythema, edema, and pruritus at the sting site

Presentations
Local reaction Toxic manifestation and anaphylaxis Delayed reaction Serum sickness

Treatment
Immediate removal is the important principle and the method of removal is irrelevant. Sting site should be washed thoroughly with soap and water to minimize the possibility of infection.

Contd..
Intermittent ice packs at the site- diminish swelling and delay the absorption of venom while limiting edema.

Oral antihistamines and analgesics may limit discomfort and pruritus.

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in relieving pain

Severe systemic reaction

Epinephrine 0.3 to 0.5 mg (0.3 to 0.5 mL of 1:1000 concentration) in adults and 0.01 mg/kg in children (never more than 0.3 mg). Injected IM and the injection site massaged to hasten absorption If hypotension,severe bronchospasm or laryngeal edema give 0.5 ml of adrenaline diluted in 20 ml of isotonic saline over 20 mins Observation for 24 hours in ICU

Contd
Parenteral antihistamines (diphenhydramine 25 to 50 mg IV, IM, or PO) and H2-receptor antagonists (ranitidine 50 mg IV) Steroids (methylprednisolone 125 mg) -to limit ongoing urticaria and edema and may potentiate the effects of other measures. Bronchospasm is treated with -agonist

nebulization.

Contd..
Hypotension -massive crystalloid infusion, and central venous pressure monitoring may be helpful in these patients. -Persistent hypotension require dopamine. -If dopamine is ineffective, an intravenous infusion of epinephrine can be used

Preventive Care
Every patient who has had a systemic reaction insect sting kit containing premeasured epinephrine and be carefully instructed in its use. Patient must inject the epinephrine at the first sign of a systemic reaction. Medic alert tag

Scorpion sting- C. exilicauda

Scorpions have a world-wide distribution. Highly toxic species are found in the Middle East, India, North Africa, South America, Mexico, and the Caribbean island of Trinidad.

Mechanism of action
Venom can open neuronal sodium channels and cause prolonged and excessive depolarization

Symptoms and sign

Somatic and autonomic nerves may be affected Initial pain and paresthesia at the stung extremity that becomes generalised Cranial nerve- abnormal roving eye movements, blurred vision, pharyngeal muscle incoordination and drooling and respiratory compromise

Contd
Excessive motor activity Nausea, vomiting, tachycardia, and severe agitation can also be present. Cardiac dysfunction, pulmonary edema, pancreatitis, bleeding disorders, skin necrosis, and occasionally death can occur

Treatment
Pain Management Ice pack Immobilization of limb Local anaesthetics are better than opiates

Tetanus prophylaxis, wound care and antibiotics Benzodizepines for motor activity.

Contd..
Stabilize Airway Breathing and Circulation Hyperdynamic circulation Always combination of alpha blocker with beta blocker to prevent unopposed alpha action causing tachycardia Nitrates for Hypertension/MI

Contd..
Hypodynamic Circulation: CVP guided fluids Decrease preload with furosemide (not hypovolumic) Reduction of afterload improves outcome-Prazosin, nitroprusside, hydralizine, ACE inhibitor Dobutamine is the best inotrope, avoid Dopamine Noradrenaline can be used

Newer modality
Insulin has shown to improve cardiopulmonary status in case of scorpion envenomation

THANK YOU