Management of
Snake Bite
Sarfaraz Ahmed Khatri
Resident PGY V
Objectives
By the end of this lecture, participants should be able to
▪ Identify, potential life / limb threatening cases of snake
bite
▪ Provide initial supportive treatment
▪ Snake Anti-venom Administration.
Global Burden
Global Burden
Global Mortality
Situation in Pakistan
▪ Non-existent or poor data Base
▪ Lack of infrastructure on Vaccine development
▪ Lack of Local education on types of snakes in
the region
▪ Most of the doctors trained in cities with little to
none experience in dealing with snake bites
▪ Medical Education is based on western books
with lack of understanding of local context
▪ Estimates are up to 20,000 snakebite deaths per anum.
▪ Health Department morbidity and mortality figures from
Tharparkar District (Pop. 0.9Million), with the most
significant snakebite problem, in 2003 were
24.41, per 100,000.
▪ In Pakistan local criteria for ASV administration are:
▪ 1. Incoagulable blood determined by the 20WBCT.
▪ 2. Visible neurological signs such as ptosis or
ophthalmoplegia or other evidence of descending
paralysis.
▪ 3. Clear evidence of current systemic bleeding e.g.
haemoptysis, bleeding from wounds or orifices.
20 Minute Whole Blood Clotting Test
(20WBCT).
C • A few mls of fresh venous blood
oll • In a NEW, CLEAN, DRY, GLASS test tube
ec
t
W • Leave undisturbed for 20 minutes.
ai
t
• Gently tilted to 45 degrees and examine blood
Te
st
R If it has remained liquid, No Clot Victim requires ASV
es If blood has clotted ASV is necessary at this stage
ul
t
Snakes found in vicinity of Rekodiq
Non venomous, found in Mashki Cha, Hummai, and Reko
diq.
▪ The Schokari sand racer (Psammophis schokari)
▪ Other species of Psammophis snake
Venoumous Snakes.
▪ Persian horned Viper (hematotoxic)
▪ McMahan’s Viper (hematotoxic)
Psammophis schokari “Schokari sand
racer”
Non life-threatening to humans.
Localized pain, swelling, and
redness at the site of the bite.
Severe allergic reactions or
infections can occur in some
cases.
Eristicophis macmahonii
“McMahon's viper, Asian sand viper, leaf-
nosed viper
▪ Hemotoxic.
▪ Venom Similar to that of
“Echis” species. *
United States Navy (1991). Poisonous Snakes of the World. New York: United States Government/Dover Publications Inc. 203 pp. ISBN 0-486-26629-X.
Pseudocerastes persicus
“Persian horned viper, false horned
viper”.
▪ Hemotoxic.
▪ No specific Anti-venom
available
▪ Polyvalent anti-venom provides
some protection. *
D, Ludwig D, Nilson G. 2003. True Vipers: Natural History and Toxinology of Old World Vipers. Malabar, Florida: Krieger Publishing Company. 359 pp. ISBN 0-894
Local Envenomation in Snake Bites
Local Pain:
▪ Increase in pain at the bite site.
▪ Krait bites are typically painless initially.
Local Swelling:
▪ Swelling at the bite site spreading proximally.
▪ Swelling is tender and painful.
Lymphatic Involvement:
▪ Tender and painful swelling of regional lymph nodes draining the bite
site.
Other Signs
▪ Fang marks.
▪ Persistent local bleeding and bruising.
▪ Lymphangitis (inflammation of lymphatic vessels).
▪ Inflammation characterized by swelling, redness, and heat.
▪ Blistering, (Blebs/Bullae/Vesicles.
▪ Risk of infection.
▪ Abscess formation.
▪ Potential for necrosis (tissue death)
Bleeding and Clotting Disorders
▪ Local Traumatic Bleeding:
▪ Bleeding from recent and partly-healed wounds.
▪ Bleeding at venepuncture sites.
▪ Spontaneous Systemic Bleeding:
▪ Gums bleeding.
▪ Epistaxis (nosebleeds).
▪ Haematemesis (vomiting blood).
▪ Meningism (symptoms suggesting meningitis) from
subarachnoid hemorrhage.
▪ Cerebral hemorrhage/thrombosis leading to lateralizing
signs and/or coma.
Systemic Involvement
▪ Respiratory System Involvement:
▪ Haemoptysis (coughing up blood).
▪ Gastrointestinal Bleeding:
▪ Haematemesis (vomiting blood).
▪ Rectal bleeding or melaena (dark, tarry stools).
▪ Genitourinary Manifestations:
▪ Haematuria (blood in urine).
▪ Vaginal bleeding.
▪ Ocular Symptoms:
▪ Subconjunctival haemorrhages (eye bleeding).
Cutaneous Manifestations:
▪ Skin petechiae (small red or purple spots).
▪ Purpura (larger purple patches).
▪ Discoid haemorrhages.
▪ Ecchymoses (bruises).
Neurological and Muscular
Complications
Neurological Symptoms (Elapidae, Viperidae):
▪ Bilateral Ptosis: Drooping of both eyelids.
▪ External Ophthalmoplegia: Paralysis of eye muscles
▪ Descending Paralysis: Progressing to generalized flaccid
paralysis.
Generalized Rhabdomyolysis:
▪ Muscle Involvement: Stiff, tender, and painful muscles.
▪ Trismus: Inability to open the mouth fully.
▪ Dark Brown Urine: Resulting from breakdown of muscle
tissue.
Acute Kidney Injury (AKI):
▪ Loin (Lower Back) Pain: Associated with kidney involvement.
▪ Haematuria: Blood in the urine.
▪ Haemoglobinuria: Presence of hemoglobin in the urine.
▪ Myoglobinuria: Presence of myoglobin in the urine.
▪ Oliguria/Anuria: Reduced or absence of urine output.
▪ Uraemia: Symptoms include acidotic breathing, hiccups,
nausea, pleuritic chest pain, and encephalopathy.
Management of
Snake Bite
Dos and Don’ts
Management of Snake Bite – Dos
▪ ABC ▪ Blood product as needed
▪ Close monitoring (vitals, ▪ Oxygen
cardiac rhythms,
saturation,derail hx) ▪ Antibiotic
▪ Local examination (swelling, ▪ Tetanus immunization
it's extent, limb ▪ Wound care
circumference every 15
minutes) ▪ Lung function monitoring
▪ Large bore IV cannula
▪ Fluid resuscitation (RL, NS)
or dopamine infusion
Envenomation Grading.
▪ Grade-0
▪ fang marks but no local or systemic reaction
▪ Grade -1
▪ minimal local swelling, no systemic reaction
▪ Grade -2
▪ swelling beyond the bite site, systemic reaction and lab
changes
▪ Grade -3
▪ marked local and systemic reaction with gross lab changes
Snake Anti-venom
Two types of Antivenom
▪ Locally produced – non
lyophilized.
▪ Imported from India –
lyophilized.
Snake Anti Venom Sera
Polyvalent Snake Antivenom Sera.
Effective against.
▪ Russel’s Viper
▪ Black Cobra
▪ Saw Scaled Viper (Echis Carinatus)
▪ Common Krait.
Indications for Antivenom Treatment
▪ Systemic Envenoming:
▪ Haemostatic Abnormalities:
▪ Spontaneous systemic bleeding.
▪ Coagulopathy, indicated by a positive non-clotting 20WBCT,
INR >1.2, or prothrombin time >4-5 seconds longer than
control.
▪ Thrombocytopenia.
▪ Neurotoxicity:
▪ Bilateral ptosis, external ophthalmoplegia, paralysis, etc.
▪ Cardiovascular Abnormalities:
▪ Hypotension, shock, cardiac arrhythmia, abnormal ECG.
Indications for Antivenom Treatment
▪ Acute Kidney Injury:
▪ Oliguria/anuria, rising blood creatinine/urea.
▪ Haemoglobin/Myoglobinuria:
▪ Dark brown/black urine, positive urine dipsticks, other
evidence of intravascular haemolysis/generalized
rhabdomyolysis.
Indications for Antivenom Treatment
▪ Local Envenoming:
▪ Signs for Antivenom Treatment:
▪ Local swelling involving more than half of the bitten limb (in
the absence of a tourniquet) within 48 hours of the bite.
▪ Swelling after bites on digits.
▪ Rapid extension of swelling beyond the wrist/ankle within a
few hours of bites on the hand/foot.
▪ Enlarged tender lymph node draining the bitten limb
Anti-Snake Venom Serum
Administration Protocol
▪ Initial Dose:
▪ Administer 10-30 ml of the serum intravenously very slowly.
▪ Subsequent Doses:
▪ Second dose may be repeated two hours after the first or
earlier based on the patient's condition and symptom
severity.
▪ Further doses can be repeated at six-hour intervals until
symptoms completely disappear.
▪ Local Administration (Viper's Bite):
▪ One-third of the first dose of anti-snake venom serum can
be administered locally to prevent gangrene development,
especially in Viper's bites.
Anti-Snake Venom Serum
Administration Protocol
▪ Dilution with Isotonic Solution:
▪ Antiserum can be diluted with isotonic solution (quantity
determined at the rate of 5ml/Kg body weight).
▪ Emergency Preparedness:
▪ Adrenaline (1 ml:1000 Sol, Subcutaneously) or another
antihistamine should be readily available to address any
potential allergenic reaction to the serum.
Anti-Snake Venom Serum
Administration Protocol
▪ Components of Supportive Treatment:
▪ Antibiotics: To prevent or treat secondary infections.
▪ Antipyretics: For fever management.
▪ Anti-emetics: To alleviate nausea and vomiting.
▪ Antihistamines: For managing allergic reactions.
▪ Anti-Tetanus Serum: To prevent tetanus infection.
▪ Other Supportive Therapies: As recommended by physicians
based on the patient's condition.
Monitoring and Assessment Protocols
▪ Vital Signs Monitoring:
▪ Pulse, Blood Pressure, and Respiratory Rate: Monitored on a
half-hourly basis.
▪ Early detection of changes in vital signs is critical for timely
intervention.
▪ Clinical Assessments:
▪ Body Temperature: Regular monitoring for fever or
hypothermia.
▪ Urine Output Analysis: Regular analysis to assess renal
function.
▪ Limb Diameter: Measurement of the bitten limb's diameter
for signs of swelling.
▪ Proximal Spread Estimation: Monitoring the extent of
swelling beyond the bite site.
Monitoring and Assessment Protocols
▪ Neurological Assessment:
▪ Level of Consciousness and Reflexes: Regular evaluation to detect
neurotoxic effects.
▪ Early identification of neurological symptoms, such as altered
consciousness or paralysis.
▪ Laboratory Investigations:
▪ Blood Complete Picture (CP): Assessing overall blood cell count.
▪ Clotting Time and Prothrombin Time: Evaluating coagulation
status.
▪ Haemoglobin Level: Monitoring for anemia.
▪ Serum Bilirubin, Urea, and Electrolytes: Assessing renal and
metabolic functions.
▪ Liver Function Tests (LFT): Evaluating hepatic function.
▪ Blood Cross-Matching: If required for potential transfusions.
Limb Immobilization.
Thank you
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