SNAKE

BITE

Classification of snakes
Poisonous snakes belong to three Families
on the basis of poison secreted :
1. Elapidae : Neurotoxic

2. Viperidae : Vasculotoxic
3. Hydrophidae : Myotoxic

1. ELAPIDAE
examples
A) Common Cobra / Nag or Kalsap or Naja naja
B) King Cobra Raj Nag or Naja hanna or Naja
bangarus
C) Krait : Subgrouped into :
a). Common krait or Bangarus caeruleus
b). Banded krait or Bangarus fasciatus
c). Coral snake
d). Tiger snake
e). Mambas
f). Death adder

Common Cobra / Nag or

Kalsap or Naja naja
Seen through out
India, Burma,
Srilanka
Well marked hood
Single
(monocellate) or
double spectacle
mark

Monocellate Cobra
Naja Naja Kaouthia

1. Common krait
Bungarus
Caeruleus

Neurotoxic

2. VIPERIDAE
They are grouped into:
A). Pitless Vipers : They are
a). Russel s Viper
b). Saw-scaled Viper
B). Pit Vipers : They are
a). Pit ViperCrotalidae
b). Common Green
Pit Viper

1. Saw scaled
viper (carpet
viper)

Echis
carinatus
Haematotoxic

1. Russells viper

Daboia
russelli
Haematotoxic

3. HYDROPHIDAE
20 types of sea snakes found in India.
All are poisonous.
They are myotoxic.

DIFFERENCES BETWEEN
COBRA AND VIPER
TRAIT COBRA
S

VIPER

1. Body

Usually long and cylindrical

Usually short and stout with

narrow neck

2. Head

Small ,seldom broader than Larger and broader than body

body, usually of same
,usually wider than the neck ,
width as that of neck,
covered with small scales
covered with large scales

3.Maxillary
bones

They carry other teeth

beside the poison fangs

They carry only the poison fangs

4. Eye

It has round pupil

It has vertical pupil

5. Fangs.

Placed little anteriorly ,

grooved short ,fine and
fixed

They are canalised ,long , movable

and strong,

6. Eggs

Oviparous

Viviparous

7. Tail

Round

Tapering

Snake Bite and Snake

Venom
When a snake bites, it may excrete venom
but this is dependent on the type of snake
venomous or non venomous.
Snake Venom is a Toxin (Hematotoxin,
Neurotoxin, or Cytotoxin)
It is a varied form of saliva and excreted
through a modified parotid salivary gland
Located on each side of the skull, behind the eye
Produced through a pumping mechanism from a
sac that stores the venom, proceeds through a
channel, down a tubular fang, hollow in the
center to project the venom

SNAKE VENOM
Snake venoms are
A combination of proteins and enzymes
90% protein by dry weight & most of these are
enzymes
Have 25 different enzymes found in various
venoms and 10 of these occur frequently in
most venoms
Synergistic in effects: different venoms contain
different combinations of enzymes causing a
more potent effect than any of the individual
effects (very similar to drug synergism)

Composition of snake
venom
Enzymes phospholipase A2( Lecithinase), 5nucleotidase,collaginase,L-aminoacid
oxidase, protinases, hyaluronidase,
Ach, Phospholipase-b (ellipdae)
Endopeptidases, kininogenase,
factor-X, prothrombin activating
enzyme (viper)

Non Enzyme Peptides :

- bungarotoxin,bungarotoxin,Crotoxin,
Crotamine,Cardiotoxin.
Peptide- Pyroglutamyl peptide
Nucleoside-Adenine,Guanine,Inosine.
Lipid-Phospholipid,Cholestrol
Amine-Histamine,Serotonin,Spermin
Metal-Cu,Zn,Ni,Mg.

Difference between
poisonous and nonpoisonous snakes
Poisonous
snakes

Non
Poisonous

1. Belly scales

Large : They cover the entire

breadth of belly

Small : They never cover

2. Head scales

a) Usually small in vipers

b) May be large in pit vipers
c) Cobras and Coral snakes
where third labial touches the
eye and nasal shields
d) Kraits ,where there is no pit
and the third labial does not
touch the nose and eye

Are usually large with

exceptions as outlined
under poisonous snakes

3. Fangs

Are hollow like hypodermic

needle

Short and solid

4. Tail

Compressed

Not markedly
compressed

Points

Mechanism of Toxicity of
Venom
The most common types of enzymes
are proteolytic, phospholipases and
hyaluronidases
Proteolytic Enzymes: digestive properties
Phospholipases: degrade lipids
Hyaluronidases: facilitates venom spread

through out the body

SIGNS AND
SYMPTOMS

A. Elapid Bite:

a). Local Features :

Fang marks
Burning pain
Swelling and discoloration
Serosanguinous discharge
Local symptoms are milder in
comparison to that in Viperine bite.

Systemic features
Preparalytic
stage:

Paralytic
stage:

Ptosis.
Ophthalmoplegia
Drowsiness
Convulsion
Bulbar paralysis
Respiratory failure
death

Vomiting
Headache
Giddiness
Weakness and
lethargy

 B. Viperid bite :
Local features : Rapid swelling at bite
site
Discoloration
Blister formation
Bleeding from bite
site
Pain

 Systemic features:
.Generalized bleeding : Epistaxis
,hemoptysis , hemetemesis ,bleeding
gums ,hematuria , malena ,
hemaorrhagic areas over skin and
mucosa
.Shock
.Renal failure

C. Hydrophid bite
Local
features:
Local swelling
Pain

Systemic
Features :
Myalgia
Muscle stiffness
Myoglobinuria
Renal failure

Summary of Manifestations

No
Envenomati
on

Mild
Envenomati
on

Moderate
Envenomatio
n

Severe
Envenoma
tion

Fang marks

+/-

Local
reaction:
Pain

Moderate

Severe

Severe

NO
NO

Minimum
(0-15cm)
+

Moderate
(15-30cm)
+

Severe
>30cm
+

NO

+/-

No

No

Weakness
Sweating
Syncope
Nausea
Vomiting
Thrombocytope
nia

Hypotensio
n
Paresthesia
Coma
Pulm.
edema
Resp.failure

Local
edema
Erythma
Echymosis
Symptoms

Factor affecting snake

bite toxicity
factor
effect
Body weight

Bigger the size lesser toxicity

Aggravating
factor

Predispose to harmful effect of snake venom

Part bitten

Bite on face and trunk are most lethal

Exercise

Poor outcome

Individual
sensitivity

Sensitivity of individual to venom modified clinical outcome

Bite
Type of bite(business or defence),Bite number ,depth,
characteristic duration of when snake clinges to body,bite through
clothes,ammount of venom,condition of fangs,different
species & their lethal dose

Prognosis assesment
Time of bite
Activity at the time of bite
First aid action taken since the
bite
Clinical examination
20 mn whole Blood Clotting Test

Lab investigations
20 WBCT-Test positive for viperine bite
ELISA Test
Non Specific- Hemogram, S.Creatinine,
S.Amylase, CPK, Creatine Phosphokinase,
PT, FDP & Fibrinogen level in viper bite
interfer with clotting mechanism.
ABG, Electrolyte-for systemic manifestion.
Urine Examination for Proteinuria ,
Myoglobinuria

 ECG-non specific changes like

bradycardia, AV-block.
EEG-mainly in temporal lobe.60% in
Grade-I,31% Grade-II,4% Grade III

Management
Management

Local
Specific
Supportive

Management
The first aid being currently recommended is based around
the mnemonic: Do it R.I.G.H.T.
R =Reassure the patient. 70% of all snakebites are from nonvenomous species. Only 50% of bites by venomous species
actually envenomate the patient.

I = Immobilise in the same way as a fractured limb. Use

bandages or cloth to hold the splints, not to block the blood

supply or apply pressure. Do not apply any compression in
the form of tight ligatures, they can be dangerous!

G.H. = Get to Hospital Immediately. Traditional remedies

have NO PROVEN benefit in treating snakebite.

T = Tell the doctor of any systemic symptoms such as ptosis

that manifest on the way to hospital.

First Aid
DOsAssurance of patient
Immobilisation
Application of tourniquet????
DONTSIncision
Suction
Application of Ice ,massage or any
chemical treatment

Specific treatment
Anti snake Venom
Indication for ASV
Spontaneous systemic Bleeding
WBCT > 20 min
Thrombocytopenia (platelet < 1 lac)
Shock, paralysis, ARF, Rhabdomyolysis,
Hyperkalemia.
Local swelling involving > of bitten
limb
Rapid extension of swelling

Anti venom Therapy

Ideally administer with in 4 hr but
effective if given with in 24 hrs
In mild cases-5 vial (50 ml)
In moderate cases-5 to 10 vial
In severe cases-10 to 20 vial
Additional infusion containing 5 to 10 vial
are infused until progression of swelling
ceased and systemic symptoms are
disappeared.

 ASV can be administer slow i.v. injection

or infusion @ rate of 2ml/min
AVS dilute 5-10 ml/kg body weight of
normal saline or 5% dextrose and
infused over 1 hr
ASV should never given locally at site of
snake bite.

Disadvantage of ASV
Pain at injection site
Hematoma formation
Increase intra compartmental
pressure
ASV SENSTIVITY IS NOT
RECOMMONDED NOW A DAYS

Adverse reaction of ASV

Seen in 20 % patient
Early anaphylactic reaction Seen with in 10 min to 3 hrs
Urticaria, diarrhoea, tachycardia, fever,
hypotension, etc.
Late Serum Sickness
1-12 days
Fever,nausea,vomiting,diarhoea,artheritis,ne
phrits,myoglobinuria.etc.

Treatment Of Early ASV

reaction
Adrenaline -1:1000 i.m.
0.5 mg in adult
0.01 mg/kg in children
can be repeated every 5 min if
necessary
H1 antihistaminic-i.v. 1 mg of CPM
I.V. Hydrocortisone

Treatment Of Late ASV

reaction
5 days course of oral anti histaminic CPM
2mg/6hour-adult
0.25 mg/kg/day in divided dose
Patient who fail to response with in
24 hr Predinisolone5mg/6h in adult
0.7 mg/kg/day in divided dose in
children

Supportive therapy
For Coagulopathy - if not reverse
after ASV therapy
Fresh frozen plasma
Cryoprecipitate (fibrinogen,
Factor VIII),
Fresh whole blood,
Platelet concentrate.

For Bulbar Paralysis & Resp. Failure ASV alone not sufficient
Tracheotomy, Endotrachial intubation,&
mechanical ventilation
Inj. of neostigmine-50 to 100
microgram/kg/4hrs as a continuous infusion
Glycopyrrolate-0.25 mg can be given
before neostigmine in place of atropine
dont cross blood brain barrier
Care of bitten partAntibiotic prophylaxis & ATS injection

Scorpions

Scorpions
Introduction
There are more than 1250 species of
scorpions.
About 100 species are found in India
Eight legged arthropods, have a
hollow sting in the last joint of their
tail
Venom is clear, colourless
toxalbumen,and can be classified as
either neurotoxic or haemolytic.

Introduction
Toxicity is more than snake but only
small quantity is injected.
Venom is potent autonomic
stimulator resulting in the release of
massive amount of catecholamine
from adrenals.
The mortality, except in children is
negligible.

Signs And Symptoms

In case of haemolytic venom reaction is mainly local and
simulates the viper snake bite,
but the scorpion sting will have only
one hole in the centre of reddened
area.
The extremity will have pain and
oedema.

Signs And Symptoms

In case of neurotoxic venom symptoms produced are similar to cobra bite.
There are usually no mark reaction in local area.
Nausea,vomiting,extreme restlessness,fever,
paralysis,cardiac arrythmia,convulsions,coma
and cyanosis,respiratory depression,and death
may occur with in hours from pulmonary
oedema and cardiac failure.
Diagnosis is confirmed by ELISA testing.

Treatment
Immobilise the limb and apply a
torniquet above the location of sting
Pack sting in ice, and incise and use
suction, and wash with week solution of
ammonia, borax or potassium
permanganate
A local anaesthetic (2% novocaine or
5% cocaine) is injected at site of pain

Treatment
A specific antivenin is available foe
most species
Calcium gluconate i.v. to control local
swelling.
Barbiturate to reduce convulsions.
Morphine is contraindicated
Atropine is valuable to prevent
pulmonary oedema

Questions

1. True about cobra poison

Neurotoxic
Myotoxic
Cardiotoxic1
Vasculotoxic

2. Cholinesterase is present
in
Elapid
Viper
Sea snakes
All

3. Muscle paralysis is caused

by
Sea snakes
Mamba
Krait
python

4. True about poisonous

snakes is
Fangs present
Belly scale are small
Small head scales
Grooved teeth

5. Most characteristic feature of

elapidae snake envenomation
Bleeding manifestation
Neuro-paralytic symptoms
Rhabdomyolysis
Cardiotoxicity