SNAKE BITE

PRESENTER: PPW KONG IAN CHARLES

MENTOR : AMO LORIS

 CONTENT
1. Introduction
2. Snake of Medical Importance in Malaysia
3. Snake Venom
4. Clinical Assessment and Diagnosis
5. Monitoring : Serial Clinical Assessment
6. Treatment
7. Antivenom Therapy
8. Treatment of the Bitten Part
9. Appendix
 INTRODUCTION
• venomous snakes are predators, as human is not the usual prey,
most venomous bites in human are “ defensive “ bites with
small amount of venom injected, this explains the relatively low
mortality due to snake bite
• bites by venomous snakes can causes local and /or systemic
envenomation that can result in a life-threatening medical
emergency
• in land snakes bite, the greater the local tissue damage, the larger
the amount of venom introduced and vice versa
• in sea snakes bite, local tissue injury tends to be negligible and is
often missed or ignored, the systemic and neurological impact of
the venom on the other hand could be devastating
SNAKES OF MEDICAL IMPORTANCE
IN MALAYSIA
 CLASSIFICATION
1. Elapidae
• cobras : large snake, 6’-18’ long (adult), brown blackin
colour, erect forebody with spectacular outspread hood,
hissing, no Loreal pit, third upper labial scale enlarged
• coral snakes : small & slender, brightly coloured, no
Loreal pit, third upper labial scale enlarged
• kraits : body is triangular in cross section, vertebral
scales enlarged, no Loreal pit, third upper labial scale no
enlarged
2. Viperidae
• comprises two subfamilies : Viperinae and Crotalinae
• Vipers : Loreal pit present on the head between eye and
nostrils, head triangular in shape, distinct neck
3. Natricidae
• keelback snakes : do not cause significant harm to
human, one species of medically important identified in
Malaysia; the red-necked keelback (Rhabdophis
subminiatus) which potentailly cause significant
coagulation
4. Hydrophidae
• sea snakes : tail laterally flattened
 SNAKE VENOM
• Snake venoms are complex toxic secretions produced by highly
specialised venom glands, and are comprised of proteins and
peptides
• venom is therefore distinct from poison, and the pathology arises
from the introduction of such biological secretion into the body is
called envenoming, not poisoning.
• Clinically, the presentation of an envenomed patient is often
complex because of the pathophysiological responses to the
actions of different toxins in a venom. The toxic effects of snake
venom have often been conveniently classified as neurotoxic,
hemotoxic, cytotoxic, nephrotoxic, myotoxic, etc., based on
the predominant clinical effect of a venom.
 CLINICAL ASSESSMENT AND
DIAGNOSIS
1. History
• detailed history of the event surrounding envenomation is
important for an accurate diagnosis
• History regarding the snake’s behaviour and location will
give important clues in indentifying the possible snake
species.
2. Clinical Features

• signs and symptoms according to species responsible for

the bite, size, age and the amount of the venom injected
• if the species is unknown, patient should be observe
closely for at least 24 hours to allow recognition of the
emergening pattern of symptoms and laboratory tests
result
• together with history, may help in identification of the
snake responsible
(i) General
• nausea, vomitting, malaise, abdominal pain, weakness, drowsiness, prostration
(ii) Cardiovascular
• visual disturbances, dizziness, fainting or light-headedness, collapse, shock, hypotension,
cardiac arrhythmias and pulmonary oedema
(iii) Bleeding and clotting disorders
• prolonged bleeding from the bitten site, site of venepuncture, conjuctiva, oral cavity,
petechial rashes or bleeding from occult sites ( gastrointestinal, urinary and intracranial
bleeding)
(iv) Musculoskeletal and renal
• generalised severe myalgia, stiffness, tenderness, dark coloured urine and oliguria/anuria
(v) Neurological
• descending type of paralysis, early sign is ptosis,
• other signs are opthalmoplegia, paralysis of facial muscles and other muscles innervated by
cranial nerves
• may have a nasal voice, aphonia or dysphalgia, regurgitation through nose, difficulty in
sallowing secretions leading to respiratory and generalised flaccid paralysis
Examining for ptosis ( weakness of the upper eyelids)
i. Hold your finger or a pen in front of the patient.
ii. Instruct the patient to follow the movement with
his/ her eyes without moving the head.
iii. Slowly move your finger/pen upwards.
iv. If ptosis is present, the upper eyelids upward movement is reduced or absent.

Examining for external opthalmoplegia

(weakness of extraocular eye muscles):
i. Hold your finger or a pen in front of the patient.
ii. Instruct the patient to follow the movement of
your finger/pen without moving their head.
iii. Observe eye movement.
iv. If external opthalmoplegia is present, the affected
eye(s) is unable to follow and move in certain
direction. The patient may also have diplopia.
3. Examination
4. Bite Site Examination
Local signs and symptoms inthe bitten part
• bruising, swelling, pain, bleeding, blistering or local necrosis may be seen
• draining lymph nodes may be painful and support a diagnosis of either
moderate to severe local or systemic envenoming

Examination of the bitten part

• bite mark, the number of punture wounds or lacerations, the width of the
punture wound, number of rows of teeth marks seen on the skin should be
documented
5. Investigation
Coagulation profile: APTT/PT and INR. Fibrinogen level and D-dimer can be
send if available. repeated 6 hourly for suspected pit viper cases
Full blood count : platelet count may be decreased in envenoming by vipers.
serial FBC will reveal a drop in hemoglobin if there is significant bleeding
Renal profile : serum creatinine is necessary to rule out renal failure. to detect
electrolyte imbalance in patients with repeated vomitting.
Creatine kinase : early detection of rhabdomyolysis
Urinalysis : assess for myoglobinuria, hematuria, and proteinuria
Liver function test : mild hepatic dysfunction is reflected in slight increases in
serum enzymes after severe local muscle damage
ECG : detect arrhythmia in envenoming Naja species bite
ABG : monitor and assess respiratory function. detect metabolic acidosis in
renal failure. arterial puncture is contraindicated in patients with suspected
coagulopahty ( viperdae)
6. Determining the most likely type of snake/venom
involved
7. Diagnosis : based on history, clinical
features and investigation results obtained
8. Disposition
Indication for observation and admssion
• snakebite with local and/or systemic envenomation
• venomous snake bite
• unidentified snakebite
• unidentified animal bite

Following non-venomous snakebite, patients can be safely discharged if

• snake can be positively identified as non-venomous species by a trained
expert
• clinical condition of patients correlates with expected effect of bite from the
identified snake species
• bite did not cause any significant tissue injury such as lacerations or
persistent bleeding that may need futher treatment
 MONITORING
• serial assessment should be performed for the first 48
hours of presentation and charted into snakebite chart
• useful to objectively monitor the progression of
envenomation before and after antivenom therapy
1. Neurotoxic envenoming effect
• paradoxical respiration
• ptosis
• fixed dilated pupils, absence of light reflex
• extrnal ophthalmoplegia
• paralysis of neck flexor muscles (broken neck sign)
• difficulty in swallowing (bulbar paralysis)
• cranial nerve palsy
• regurgitation
• aphonia
2. Haematoxic envenoming effect
• evidence of bleeding (skin,mucous
membrance,conjunctiva,gums,nose)
• coagulopathy-reducing platelet count, prolonged PT
( Prothrombin Time ), aPTT ( Activated Partial
Thromboplastin Time ) & INR
3. Rhabdomyolysis
• generalised muscle pain and tenderness
• myoglobinuria
• markedly elevated creatinine kinase level
• acute renal failure
• hyperkalaemia
4. Monitoring local envenoming (local
tissue injury/dremonecrosis)
• rate of proximal progression (RPP)
• pain score progression (PSP)
• lymph nodes draining the bitten site(for enlargement and
tenderness)
• progression of local tissue injury such as early necrosis,
blisters, bullae, redness or bruising-consider taking serial
pictures of the bitten area
5. Laboratory investigation
• important laboratory parameters to be serially monitored
- full blood count
- creatinine kinase
- coagulation profile ( PT, aPTT & INR ) for viper bite and
unidentified snake bite
 TREATMENT
1. Triage - patients with possible systemic and local envenomation
to critical/red zone, asymptomatic patients can be managed in semi
critical/yellow zone

2. rapid clinical assessment - the goal of primary assessment is to

identify any life threatening conditions
A - airway patency
B - breathing effort (poor respiratory effort/bradypnoea)
C - circulation (look for evidence of shock and bleeding)
D - disability of nervous system (conscious level,muscle weakness)
E - exposure and enviromental control
3. Resuscitation

• to optimise airway patency, perform “head tilt chin lift” manouver with adequate suctioning. depending
patient’s conscious state, position patients in left lateral supine or propped up position to ensure airway
is maintained
• administer oxygen with appropriate-delivery-device as indicated
• consider inserting oropharyngeal airway to aid airway patency. do not attempt if gag reflex is present
• neurotoxic enevnoming can lead to paralysis of respiratory muscles and cause respiratory failure.
positive pressure ventilation via bag valve mask may required and must followed by airway insertion
• profound hypotension and shock can be due to direct cardiovascular effects of venom or secondary
effects such as hypovolaemia, release of inflammatory vasoactive mediators and haemorrhagic shock.
in skeletal muscle breakdown (rhbdomyolysis), hyperkalemia can lead to cardiac arrest
• CPR should be initiated if cardiac arrest. 2 large bore intravenous cannulas inserted with appropriate
fluid resuscitation. look for source of external bleeding and apply method of bleeding control
• crdiac monitor attached to look for arrhythmias and management according to advance life support
management
• close serial monitoring of BP,PR,RR,SpO2, pain score every 5-15 min. temperature monitoring can
done 4hourly. use snakebite chart. monitor urine output hourly
4. General management
• immobilize the bitten limb and examine the bite site for swelling, bleeding and neurovascular
compromise
• positon the affected limb in neutral position or same level with heart
• prophylactic hydrocortisone and antihistamine administer only if has signs of allergic reaction
or anaphylaxis
• IM injections should be avoided in pit-viper snakebite due to risk of haematoma formation as
potential risk of coagulation. oral or IV route preferred
• Anti tetanus toxin should be administered as indicated. ( please refer to MOH guidelines for
vaccination)
• perform eye irrigation with copious amounts of NS (5-10 litres) if there is venom in eye. (refer
to management of venom opthalmia)
• if patients in severe pain, envenomation has occured. can given analgesic but avoid use
NSAIDS in pit-viper bite. serial assessment of pain score are important
• administer antivenom if indicated
• bleeding cause by hematoxic snakebite may be life threatening. blood products should be
administered until the appropriate is available
5. Supportive treatment
(i) steroid and antihistamines - should not be administered without clear indications, sedative effects of
antihistamnines can make neurological assessment inaccurate or misleading
(ii) analgesia - PCM can be administered 4-6hourly for mild pain, aspirin or non steroidal anti-inflamatory
should be avoided in patients who risk to developing coagulopathy, IV opioids (fentanyl) should
administered for moderateto severe pain
(iii) antivenom - administer if indicated
(iv) antibiotics - considered with local tissue necrosis/dermonecrosis or extensive tissue injury/damage
(v) tranexamic acid and Vitamin K - not effective in envenomation induced coagulopathy

6. Venom ophthalmia
• acute reaction of ocularr surface tissue to venom sprayed into eyes
• signs and symptoms - severe stinging pain and diminution of vision, excessive watering in eyes, severe
blepharospasm and corneal erosions
• immediately irrigate the affected eye using NS
• fluorescein stain used to exclude corneal abrasions
• topical analgesics like tetracaine drop or adrenaline 0.5% ( ophthalmic solution ) used to provide pain
relief
• topical cycloplegic drops like atropine or scopalamine to prevent ciliary spasm and discomfort
ANTIVENOM AVAILABLE IN MALAYSIA
 Observation of the response to antivenom
1. General - patient feel better, nausea, headache and
generalised aches and pain may disappear quiackly
2. Spontanous systemic bleeding - stop within 15-30min
3. Blood coagulability - restored in 3-9hrs
4. In shocked patients - BP may increase within first 30-
60min and arrhythmis ( sinus bradycardia ) may resolve
 TREATMENT OF THE BITTEN PART
• local effects of envenomination often incorrectly and prematurely assigned to compartment syndrome
• compartment syndrome diffeers in 2 ways - (i) causes superficial edema and increased subcutaneous
tissue pressure (ii) when venom injected into muscle compartment, myonecrosis related to the action of
venom
• clinical signs and symptoms of compartment syndrome
(i)pain out of proportion to injury
(ii)increased compartment pressure
(iii) paralysis
(iv)pulselessness or weak pulse
• managed with antibiotics,antivenom and debridement
• debridement of necrotics tissue be done when there is clear dermacation to reduce extent of
debridement
APPENDIX
 REFERENCES

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