Animal Envenomation:

Snakebite

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 Introduction
• Animal envenomation accounts for about a
tenth of all admissions to major referral
hospitals in Namibia
• Animals involved include
– snakebite (>80%)
– scorpion sting
– spiders and other insects

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Snakebite (DDT) 3
 Snakebite
• Over 2500 species of snakes world-wide
• Only <200 are recorded as being venomous
• Australia home to most venomous snake in
the world (name?)
• In Namibia there are about 76 species of
snakes from seven families
– only between 19 - 22 are thought to be
venomous
– venomous snakes belong to four families
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Snakebite (DDT) 5
 Venomous snake families
• The four families are:
– Elapids (Elapidae)
– Vipers (Viperidae)
– Colubrids (Colubridae)
– African Burrowing Asps (Actractaspididae)
• Bites from venomous colubrids and asps are
documented as being rare
• Most bites occur from vipers esp. puff adder
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 Factors associated with snakebite
• These vary from country to country
• Include;
– farming activities
– time and season
– occupational activities
– endemnicity/population
– types of snakes
– gender-related activities
– other
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Snakebite (DDT) 8
 Factors affecting severity of bite
• These are varied and include:
– Snake characterisics
– date of last bite or feeding
– size of snake
– age of snake (?)
– type of snake
– other
– Patient characteristics
– age, sex of victim
– bite site e.g., foot vs neck
– nutritional status of patient
– medical status of patient incl. Drugs
– other
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 Identification of PVS in Namibia
• The identification of the snake responsible for the
bite is usually difficult, unless a dead snake is
brought into hospital with its victim and can be
reliably identified.
• Descriptions of the snake and the circumstances of
the bite may suggest a species diagnosis, but this
is not often a satisfactory basis for specific
treatment.

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 Identification of PVS in Namibia
• Snake is probably not venomous if:
– has > 1 conspicuous line along its body
• Snake is probably venomous if :
– over 2 metres long
– has conspicuous rings or V-shapes on front half
of body/back/belly
• Snake almost always venomous if:
– fat-bodied, head like ace of spades, lies quietly
– has dark blotches or bars on upper neck
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 Identification of PVS in Namibia
• Almost certainly venomous if:
– > 1.2m & grey, green or greenish tree snake
• elapid or boomslang or vine snake
– spreads hood or flattens neck
• cobra or black mamba
– raises the forepart of its body when threatened
• cobra or mamba
• Venomous if:
– black & small with tiny eyes, short flat tail with
spike, no obvious neck (asp)
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 Snake Venoms
• These venoms are complex mixtures: proteins
and peptides, consisting of both enzymatic and
nonenzymatic compounds, make up over 90%
of the dry weight of the venom (Phui Yee et al.,
2004).
• Snake venoms also contain inorganic cations
such as sodium, calcium, potassium,
magnesium, and small amounts of zinc, iron,
cobalt, manganese, and nickel.

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 Snake venoms
• A simplistic approach would group toxin
components as neurotoxins, coagulants,
hemorrhagins, hemolytics, myotoxins,
cytotoxins, and nephrotoxins.

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 Snake venoms
• Neurotoxins produce neuromuscular
paralysis ranging from dizziness to ptosis;
to ophthalmoplegia, flaccid facial muscle
paralysis, and inability to swallow; to
paralysis of larger muscle groups; and
finally to paralysis of respiratory muscles
and death by asphyxiation.

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 Snake venoms
• Coagulants may have an initial procoagulant
action that uses up clotting factors, leading to bleeding.
• Coagulants may directly inhibit normal clotting at several
places in the clotting cascade or via inhibition of platelet
aggregation.
• In addition, some venom components may damage the
endothelial lining of blood vessels, leading to
haemorrhage.
• Bite victims may show bleeding from the nose or gums,
from the bite site, and in saliva, urine, and stools.

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 Snake venoms
• Myotoxins can directly impact muscle
contraction, leading to paralysis or cause
rhabdomyolysis or the breakdown of
skeletal muscle.
• Myoglobinuria, or a dark brown urine, and
hyperkalemia may be noted

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 Snake venoms
• Cytotoxic agents have proteolytic or
necrotic properties leading to the
breakdown of tissue.
• Typical signs include massive swelling,
pain, discoloration, blistering, bruising, and
wound weeping.

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 Snake venoms
• Nephrotoxins can cause direct damage to
kidney structures leading to bleeding,
damage to several parts of the nephron,
tissue oxygen deprivation, and renal failure.

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 Snake venoms
• At least 26 different enzymes have been
isolated from snake venoms, which can be a
sequence of 150 to 1500 amino acids
(Menez, 2003).

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 Main clinical syndromes
• Five main clinical syndromes of snake
envenoming are recognised in southern Africa:
I. marked local pain and progressive swelling associated with
prominent cytotoxic skin changes with coagulable blood
II. progressive paralysis (neurotoxicity), with negligible or minor
local swelling
III. incoagulable blood, with negligible to mild local swelling
IV. moderate to marked local swelling, associated with neurotoxicity
V. mild to moderate swelling, with negligible or absent systemic
symptoms.

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 Marked local pain and progressive swelling associated
with prominent cytotoxic skin changes with coagulable
blood
• Snakes responsible for this syndrome include:
– The major adders, e.g. Bitis arietans (puff adder) and B. gabonica (gaboon
adder).
– Spitting cobras, e.g. Naja mossambica (Mozambique spitting cobra, M’fesi),
N. nigricollis (black-necked spitting cobra), [Link] (barred, zebra
spitting cobra) and N. nigricincta woodi (black spitting cobra).
– The rinkhals, Hemachatus haemachatus. Although mild neurotoxic effects
have been mentioned to occur in rinkhals bite, these have not been well
documented
• The toxins of cytotoxic snake venom are digestive hydrolases (proteolytic enzymes
and phospholipases) and polypeptides that destroy cell membranes, skeletal muscle
and other tissues.
• These effects increase the permeability of the vascular endothelium, which leads to
local swelling, blistering and oedema.
• Irreversible death of tissues may occur (necrosis/gangrene).
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 Vipers
• Have large hollow fangs in front of mouth
• Fangs are hinged - move forward in preparation
for a bite
• Have large heads - ace of spades normally

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Puff adder (Bitis arietans). A very large, heavy-bodied snake, maximum total length exceeding 190 cm. Its colour may vary
from brown, reddish to orange to very dark, with distinctive pale back edged U or V markings (chevron-like patterns) along the
dorsum becoming annular rings around the tail. The belly is pale. When threatened it inflates its body and hisses loudly. Bites
are common. (Photo: John Visser.)

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The large adders (vipers) have large, hinged, tubular fangs that can fold back into a
protected sheath against the roof of the mouth. When attacking, the fangs are forced
forward, enabling a deep penetrating injection of venom. (Photo: John Visser.)
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Mozambique spitting cobra (Naja mossambica). Average length 80 - 130 cm. Above it is
black grey to olive brown. Below it is pale or salmon pink, sometimes yellowish with
crossbars, half-bars and blotches on the throat and anterior third of the belly. Bites are
common. Spits and bites. (Photo: John Visser.)
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 Marked local pain and progressive swelling associated
with prominent cytotoxic skin changes with coagulable
blood

• Clinical features
– The local effects of bites by spitting cobras are essentially similar to those of
large adder bites.
– Swelling usually begins early, often within 10- 30 minutes. It may become
extensive, involving the entire limb and even adjacent areas of the trunk,
especially in children.
– Regional lymph nodes may become enlarged and painful within 30 - 60
minutes.
– The aggressive and progressive cytotoxic nature of envenoming is usually
evident within hours of the bite.
– Blisters and bullous skin lesions, fluid or blood filled, and ecchymoses often
develop, at first near the fang marks, but may later extend beyond the bite site
within 6 - 24 hours
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Snakebite (DDT) 29
 Marked local pain and progressive swelling associated
with prominent cytotoxic skin changes with coagulable
blood

• Clinical features
– Gaboon adder bites may be accompanied by cardiovascular
abnormalities, including hypotension, cardiac dysrhythmias and
shock. Fortunately, these bites are rare.
– Neglected major adder bites may be complicated by
rhabdomyolysis, with release of muscle contents into the plasma
(myoglobinaemia), manifesting with myoglobinurea, which may
lead to compromised renal function

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 Marked local pain and progressive swelling associated
with prominent cytotoxic skin changes with coagulable
blood

• Management
– Antivenom is available for bites of the
abovementioned snakes (SAIMR Polyvalent
Snakebite Antiserum SAVP).

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 Vipers - Representative species
• Puff adder (Bitis arietans)
– most dangerous snake in Africa, stubborn
– distributed throughout Zimbabwe
• Gaboon adder (Bitis babonica)
– very large fangs (4 - 5 cm), also inject very
large volume of venom deep into tissue
– beautiful snake, rarely bites, very big (20 kgs!)
• Berg adder (Bitis atropos)
– weak neurotoxic venom
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 Progressive paralysis (neurotoxicity), with
negligible or minor local swelling
• Snakes responsible for this syndrome include:
– Neurotoxic cobras: Naja anchietae (Anchieta’s Egyptian cobra), N.
annulifera (banded or snouted cobra), N. melanoleuca (forest,
black and white-lipped cobra) and N. nivea (Cape cobra)
– Mambas: Dendroaspis polylepis (black mamba) and D. angusticeps
(common, eastern green, white mouthed mamba).

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 Elapids
• These are normally big snakes and include
all cobras, mambas, rinkhals
• all have large, hollow, non-hinged fangs
situated in front of the mouth

Fangs

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 Elapids - Clinical Presentation
• Produce large quantities of venom containing
potent neurotoxins
• Little or no local damage
• spitting cobras are an exception - extensive tissue damage
• venom in eyes leads to severe pain, ulceration of cornea
within 24 hrs and blindness
• Typical clinical presentation of bites:
• dizziness, sweating, muscular weakness and paralysis
• ptosis, respiratory distress, facial palsy
• death from respiratory distress
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Snakebite (DDT) 38
 Elapids - Representative species
• Cobras include
• Egyptian Cobra (Naja haje)
• Forest Cobra (Naja melanoleuca)
• Mozambique Spitting Cobra (Naja mossambica)
• Mambas include
• Black mamba (Dendroaspis polylepis)
• Green mamba (Dendroaspis angusticeps)
• Rinkhals (Hemachatus haemachatus)
• Shield nosed snake (Aspidelaps sculatus)
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 Colubrids
• Very large family of snakes
– most non-venomous snakes in this family
• Long thin snakes, back fanged
• Medically important ones have very toxic
venom - chew on victim

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 Colubrids- Clinical Presentation
• Bites from these snakes are very rare - ‘shy’
• venom contains haematoxin
– affects blood clotting
• snake bite victims ‘bleed’ to death
• latent period of 1 - 24 hours after bite
• bleeding from gums, GIT, urinary tract
• bleeding from old wounds, mucous membranes
• fang punctures narmally exude blood stained serum
• Progressive intravascular coagulopathy leads to
death Snakebite (DDT) 43
Colubrids - Representative species
• Two medically important colubrids
• Boomslang (Dispholidus typus)
• Savannah vine snake (Thelotornis capensis)
• both are tree snakes

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 Asps
• All are burrowers, most are harmless
• Are back fanged - partially hinged with
unusual toxic venoms: cardiotoxins, also
cytoxic
• Bibron’s burrowing asp (Actractaspis
bibronii)
• medium-sized, slow moving, moderately
thick snake - widespread
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 Asp - Clinical Presentation
• Bites normally in snake-handlers
• stabs victim - normally with one fang
• Symptoms include
• immediate (intense) pain
• local swelling
• joint stiffness
• occasionally blistering and necrosis at bite site
• regional lymphadenopathy
• no neurological symptoms have been reported, but
may be minor haematological symptoms
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 Snakebite Treatment
• The treatment of bites by venomous snakes is now so highly
specialised that almost every envenomation requires specific
recommendations.
• Three general principles for every bite should be kept in mind:
– snake venom poisoning is a medical emergency requiring immediate
attention and the exercise of considerable judgment.
– the venom is a complex mixture of substances, of which the proteins
contribute the major deleterious properties, and the only adequate antidote is
the use of specific or polyspecific antivenom; and
– not every bite by a venomous snake ends in an envenomation. Venom may
not be injected.

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 First aid therapy
– While instituting first aid procedures, organise transport to
get the patient to a medical facility as soon as possible.
– Alert the medical facility or doctor ahead of arrival.
– Reassure the victim, who may be terrified.
– Remove constricting clothing, rings, bracelets, bands,
shoes, etc. from the bitten limb/area.
– Immobilise the whole patient.

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 First aid therapy
• Avoid the many harmful and time-wasting traditional first-
aid treatments such as cauterisation, local incision or
excision, tattooing, immediate prophylactic amputation of
the bitten digit, suction by mouth or vacuum pumps or
‘venom-ex’ apparatuses, instillation of chemical
compounds such as potassium permanganate, application
of petrol, ice packs, ‘snake stones’ and electric shocks.
• The above measures are contraindicated as they are
potentially harmful and none has any proven benefit

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 First aid therapy
• In suspected neurotoxic cobra or mamba bite, especially if
the patient is far from medical help, apply a tight crepe
bandage over and proximal to the bite site.
– The patient should be assessed regularly (e.g. every 10 - 15
minutes) for the development of complications of neurotoxicity.
• This procedure may reduce rapid distribution of the
venom.
• Cardiopulmonary resuscitation (CPR) may be needed. This
includes clearance of the airway, oxygen administration by
face mask or nasal catheters, and establishment of
intravenous access.
• Avoid crepe or other bandaging in all cytotoxic bites.
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 First aid therapy
• If the patient is unresponsive and no respiratory movement
is detectable, start CPR.
• In case of respiratory distress/failure:
– clear the airway, lift the chin, give oxygen by face mask or nasal
catheters with or without assisted ventilation and consider the need
for endotracheal intubation.
• Shocked, hypotensive patients should be given intravenous
fluids.
• Pressor agents, such as dopamine or phenylephrine may
need to be administered.

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 First aid therapy
• Give analgesia by mouth if required: paracetamol
(acetaminophen) or paracetamol/codeine combinations are
preferred.
• Aspirin and other non-steroidal anti-inflammatory agents
should be avoided in patients with haemostatic disorders.
• When using parenteral opioids in neurotoxic snake bite,
respiratory function should be monitored closely.

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 Antivenom
• Antivenom consists of venom-specific antisera or antibodies
concentrated from immune serum to the venom.
• Antisera contain neutralizing antibodies: one antigen (monospecific)
or several antigens (polyspecific).
• Monovalent antivenoms have a high neutralization capacity, which
is desirable against the venom of a specific animal.
• Polyvalent antisera are typically used to cover several venoms, such
as snakes from a geographic region.
• Polyvalent preparations usually required higher doses or volumes
than monovalent antivenoms.

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 Antivenoms
• All antivenom products may produce hypersensitivity
reactions.
• Type I (immediate) hypersensitivity reactions are caused
by antigen cross-linking of endogenous IgE bound to mast
cells and basophils.
• Type III hypersensitivity (serum sickness) may develop
several days after antivenom administration.
• In these cases, antigen–antibody complexes are deposited
in different areas of the body, often producing
inflammatory responses in the skin, joints, kidneys, and
other tissues.
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 Antivenom treatment
• Two snakebite antivenoms are available:
– Polyvalent antivenom (SAIMR Polyvalent Snakebite Antiserum
SAVP) is supplied in 10 ml ampoules.
– Venoms of the following snakes are used as antigens in the preparation of
the polyvalent antivenom: puff adder, gaboon adder, rinkhals, green
mamba, Jameson’s mamba, black mamba, Cape cobra, forest cobra,
snouted cobra and Mozambique spitting cobra. Polyvalent antivenom is
ineffective AND SHOULD NOT BE USED in treatment of bites caused
by the berg adder, other dwarf adders, night adders, the burrowing asp and
back-fanged snakes (boomslang and vine snake).

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 Antivenom treatment
• Boomslang antivenom (SAIMR Boomslang Snakebite
Antiserum SAVP) is supplied in 10 ml ampoules. It is
effective against the venom of boomslang, but not against
the venom of the vine snake (bird of twig snake).

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 Antivenom treatment
• Antivenom neutralises a fixed amount of venom.
• Since snakes inject the same amount of venom into adults
and children, the same dose/volume of antivenom must be
administered to children as in adults.
• Antivenom is not always necessary: some patients are
bitten by nonvenomous snakes and 10 - 50% of those
bitten by venomous snakes are not envenomed (so-called
‘dry bites’).

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 Antivenom treatment
• Indications for antivenom treatment after bites:
– neurotoxicity
– abnormal blood clotting parameters, incoagulable blood and/or
spontaneous systemic bleeding
– rapidly progressive and/or extensive swelling involving more than
half the bitten limb within a few hours after the bite
– cardiovascular abnormalities such as hypotension, shock and
cardiac arrhythmias.

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 Antivenom treatment
• Precautions
– Skin testing for sensitivity is not recommended, since it is unreliable and only
delays urgent administration of antivenom.
– There is no absolute contraindication to antivenom treatment when a patient has
life-threatening systemic envenoming.
– However, patients with an atopic history and those with a history of previous
reactions to equine antisera have an increased risk of severe antivenom reactions.
– In these cases, pretreatment with subcutaneous adrenaline, 0.25 ml of a 1:1 000
(250 µg) solution in adults is justified to prevent or diminish the reaction

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 Ancillary treatment
• The risk of local infections greatly increases if the wound has
been incised with an unsterile instrument or tampered with in
some other way.
• The wound should be cleaned with an antiseptic.
• Blisters and tense bullae should be aspirated only if rupture
seems imminent.
• Snake-bitten limbs should be nursed in the most comfortable
position but should not be elevated excessively if there is tense
swelling or suspicion of incipient intracompartmental syndrome,
as this increases the risk of ischaemia.
• Debrided tissue, serosanguinous discharge and pus should be
cultured and the patient treated with appropriate antimicrobials.
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 In a nutshell
• Five main clinical syndromes of snake envenoming are recognised in
southern Africa:
– marked local pain and progressive swelling associated with prominent cytotoxic
skin changes with coagulable blood
– progressive neurotoxicity (paralysis), with negligible or minor local swelling
– incoagulable blood, with negligible to mild local swelling
– moderate to marked local swelling associated with neurotoxicity
– mild to moderate swelling with negligible or absent systemic symptoms.

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 In a nutshell
• Neurotoxic snakes can cause life-threatening paralysis and death within 1 - 8 hours.
Respiratory failure is usually the primary cause of death.
• Polyvalent antivenom is available for the management of mamba, neurotoxic cobra,
spitting cobra and major adder bites.
• Monovalent antivenom is used in the management of boomslang bite.
• Since snakes inject the same amount of venom into adults and children, the same
dose/volume of antivenom must be administered to children as in adults.
• The administration of polyvalent antivenom in the acute phase of neurotoxic snake
envenoming will usually not prevent progression of neurotoxic effects, most notably
respiratory paralysis, and consequently, the patient will not survive without life support.
• Respiratory support is the only life-saving treatment modality in neurotoxic snake
envenoming.
• Administration of antivenom may be associated with acute life-threatening anaphylactoid
reactions
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May God Bless You All!!!

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