Snake Bite

SNAKE BITE
PREPARED BY
ABU GHARBIEH MAZEN, MD.
EMERGENCY DEPARTMENT
MAKASSED HOSPITAL
JERUSALEM
Types Of
Snakes
Poisonous Non-poisonous
Palestinian Echis
Viper Colorata
Palestinian
Viper
Echis
Colorata
Types Of
Snakes
Poisonous Non-poisonous
POISONOUS SNAKE TEETH MARKS
Fang marks from the bite are always there
Teeth marks are often absent
Upper jaw
Lower jaw
POISONOUS SNAKE VENOM APPATATUS
NON – POISONOUS SNAKE TEETH MARKS
Two rows of teeth marks at the upper jaw & one row at the lower jaw
May be painful but no local or systemic reactions
What to do?
1. Minor wound care
2. If in doubt, go to hospital
Upper jaw
Lower jaw
SNAKE BITE OVERVIEW
 Snakes are remarkable animals, successful on land, in the sea, in
forests, in grasslands, in lakes, and in deserts
 Despite their sinister reputation, snakes are almost always more

scared of you than you are of them
 Few snakes act aggressively toward a human without provocation
 Only about 400 of 3000 snake species worldwide inject venom

SNAKE BITE OVERVIEW
Snake bite is primarily a problem of the:
1. Poor rural population
2. Farming activities
3. People who have poor access to health services
4. People fail to reach hospitals in time

SNAKE BITE OVERVIEW
FEAR
SNAKE BITE OVERVIEW
How Do Snakes Catch

Their Preys
Injecting Constriction and Teeth catch and

Venom suffocation swallowing
SNAKE BITE OVERVIEW
 Snakes are most likely to bite when they feel
threatened, provoked, or have no means of escape
when cornered
 Snakes do not ordinarily prey on humans & most will

not attack humans
 Non-venomous snakes are usually not threat to

humans
Snake Venom
Snake venom is a combination of numerous substances with
varying effects. In simple terms, these proteins can be
:divided into 4 categories
1.Cytotoxins cause local tissue damage
2.Hemotoxins cause internal bleeding
3.Neurotoxins affect the nervous system
4.Cardiotoxins act directly on the heart

Snake Venom
Almost all snake venom contains

Hyaluronidase, an enzyme that ensure
rapid diffusion of the venom
When to Seek Medical Care
1. Any snakebite victim should go to a hospital emergency

department unless the snake is positively identified as
nonvenomous.
2. Remember, misidentification of the snake species could

be a fatal error.
3. Bites by nonvenomous species require good wound care.
4. Victims should receive a tetanus booster if they have not

had one within the last 5 years.
Age
1. 50% of patients were aged 18-28 years
2. 95% of bites were located on an extremity, 56% to the

hand
3. Seasonal occurrence of 90% from April to October
4. In the pediatric population, most snakebites occurred in

school-aged children and adolescents
Mortality/Morbidity
• Deaths secondary to snakebites are rare.
• With the proper use of antivenin, they are becoming rarer still.
• Local tissue destruction rarely contributes to long-term

morbidity.
• Occasionally, skin grafting is required to close a defect from
fasciotomy
• Wounds requiring fasciotomy to reduce compartment

pressures from muscle edema are infrequent.
• The average length of stay was 3.2 days. No deaths occurred
• Morbidity was limited to the local wounds.

1 AID
st DO NOT
Do it RIGHT
PANIC
R = Reassure the patient. 70% of all snake bites are from non –
venomous snakes. Only 50% are true bites
I = Immobilize in the same way as a fractured limb
G &H = Go to Hospital immediately, traditional remedies have

NO PROVEN benefits in treating snake bites
T = Tell the Doctor of any systemic symptoms that manifest on

the way to hospital
DID BITE OCCUR
WITH CERTAINTY
YES NO
Fangs marks -1 Fangs marks -1 No Fangs -1

:Symptoms -2 No symptoms -2 No Symptoms -2
within 20/min
TRUE DRY NO
BITE BITE BITE
General Symptoms Of Snake Bite
The most common symptoms of all snakebites are
Panic, fear and emotional instability, which

may cause symptoms such as:
1.Nausea & vomiting, diarrhea
2.Vasovagal attack, Vertigo
3.Fainting
4.Tachycardia, bradycardia, cold clammy skin

General Symptoms Of Snake Bite
Clinical / History
 History usually can be obtained from the patient.
 Most cases result from attempting to handle snakes
1.Obtain a description of the snake.
2.Most snakes remain within 20 feet after biting.
3.Assess the timing of events and onset of symptoms.
4.Early and intense pain implies significant envenomation.
5.Local swelling, pain, and paresthesias may be present.
6.Systemic symptoms if present.
7.Determine history of prior exposure to antivenin or snakebite.
8.Determine history of allergies.
9.Determine history of comorbid conditions and Medications history.

Physical Examination
Follow the established routine for a complete comprehensive examination.
 ABCDE
 Vital signs
Fang marks
Local tissue destruction
1. Pitting edema that generally develops over 6-12 hours but
may start within 5 minutes
2. Bullae
3. Blisters
4. Erythema or discoloration
5. Contusions
Systemic toxicity
1. Hypotension
2. Petechiae, epistaxis, hemoptysis
3. Paresthesias
4. Respiratory distress
Workup
Laboratory Studies
1. 20 min whole blood clotting test (WBCT20)
2. CBC
3. CK
4. PT, PTT and INR.
5. Fibrinogen and split products
6. Type and cross
7. Electrolytes, BUN, creatinine
8. Urinalysis for myoglobinuria
9. ABG’s, lactate
Imaging Studies
1. Baseline chest radiograph in patients with pulmonary edema
2. Plain radiograph to rule out retained fang(s)
Evenomation Grading
MILD MODERATE SEVERE
Stable V/S Stable V/S Unstable V/S
Localized pain Progressive pain, Massive edema &

edema & echymosis echymosis
Local edema Mild lab abnormality SOB & depressed resp
Echymosis Systemic symptoms: C V collapse
No lab abnormality fever, nausea,vomiting Seizure & coma

diarrhea, salivation Clinical coagulopathy
lethargy, weakness
No systemic symptoms CXR: >> pul edema
peripheral parasthesia
progression ECG: >> dysrhythmias
Abnormal Lab tests

hemolysis, anemia
coagulopathy.low
platelets, proteinurea
hematuria
GENERAL
MEAGURES
DO DON’T
• ABC, V/S, IV line • Run or walk (patient)

• O2 by face mask • Suction of wound
• Patient is assured and calmed • Incision of wound
• Put at rest, • Use tourniquet
• Immobilization of the Affected limb • Use ice
• Cardiac monitoring (if available) • Use alcohol
• Physical Exam: focus on CVS • Raise the site of the bite
pulmonary and CNS. above heart.
• Repeat evaluation q 15 min • Give the person anything by
• Remove constricting items on the mouth
victim
the affected limb should be used as little as possible to delay absorption of the venom
IMOBILIZATION OF LIMB
the affected limb should be used as little as
possible to delay absorption of the venom
SPECIFIC MEASURES
• Stabilization of patient & treatment
I of complications
• Desensitization:
adrenaline
steroids
antihistamines
glucagon
• Local wound care
• T – toxoid
• Antibiotics
• Anti venin
II Safe disposition
Drugs & Doses
Adrenaline Adult: 0.2-0.5 mL (0.2-0.5 mg) of 1:1000 solution IM;

repeat prn, depending on response
Pediatric: 0.01 mg/kg
Glucagon Adult: 1-5 mg IV bolus
Pediatric: <20 kg: 1 mg IV/IM/SC

>20 kg: 2 mg IV/IM/SC
Drugs & Doses/con’t
Diphenhydramine adult dose is 25-50 mg IM/IV every 4-6 hours

promethazine
Pediatric: 5 mg/kg/d IV/IM
H2 blockers Adult: 50 mg/dose IV/IM q6-8h

Ranitidine
Pediatric: <12 years: Not established
>12 years: 1.25-2.5 mg/kg/dose PO q12h
Steroids Hydrocortisone 200 mg IV stat
T toxoid Adult: 0.5 mL IM
Pediatric: 0.5 ml IM booster dose > 6 years of age

Anti biotics Adult: 1-2 g IV q12-24h

Rocephin
Pediatric: 75 mg/kg/d IV divided q12h
ANTI VENOM
 Anti venom is available only in hospitals
 Different types of snakes have different

anti venom
 Anti venom must be given within 4 hours

of the bite
ANTI VENIN
SKIN TEST
POSITIVE NEGATIVE
• Important warning. • Suggest but it doesn’t

• It doesn’t absolutely preclude guarantee that antivenin
its administration. reaction will not develop.
1. Ranitidine or Cimetidine.
2. Diphenhydrate.
3. Adrenaline.
ANTIVENIN
ANTIVENIN
ANTIVENIN
DOSE
MILD
1 – 5 VIALS
MODERATE
6 – 10 VIALS
SEVERE
11 – 20 VIALS
MODE OF ADMINISTRATION
Each vial: diluted in 10ml w/vial
SLOW IV INFUSION
:OBSREVE
• ALLERGY
• HYPOTENSION
IF NON
Infusion rate is increased so that

Antivenin is completed in 1 h
FACTORS AFFECTING THE
SEVERITY OF SNAKE BITE
Age , size, and health of the patient.
Location of bite.
The size & type of the snake.
Presence of various bacteria, particularly
clostridia
Exercise and exertion.
First aid measures performed.
Time of definitive therapy.
Type of therapy.
COMPLICATIONS
Local wound complications may include infection and skin loss.

Ischemia >> gangrene >> amputation.
Dysrythmias.
Pulmonary edema.
Neurotoxicity with myokymia of the respiratory muscles may lead to
respiratory failure and mechanical ventilation
DIC.
Seizures.
Coma.
Compartment syndrome is the most frequent complication of pit viper
snakebite.
Death is rare.
Antivenin-associated complications include immediate (anaphylaxis, type I)
and delayed (serum sickness, type III) hypersensitivity reactions.

Snake Bite

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SNAKE BITE

Fang marks from the bite are always there

Teeth marks are often absent

May be painful but no local or systemic reactions

 Despite their sinister reputation, snakes are almost always more

 Few snakes act aggressively toward a human without provocation

 Only about 400 of 3000 snake species worldwide inject venom

3. People who have poor access to health services

4. People fail to reach hospitals in time

How Do Snakes Catch

Injecting Constriction and Teeth catch and

 Snakes do not ordinarily prey on humans & most will

 Non-venomous snakes are usually not threat to

1.Cytotoxins cause local tissue damage

2.Hemotoxins cause internal bleeding

3.Neurotoxins affect the nervous system

4.Cardiotoxins act directly on the heart

Almost all snake venom contains

1. Any snakebite victim should go to a hospital emergency

2. Remember, misidentification of the snake species could

3. Bites by nonvenomous species require good wound care.

4. Victims should receive a tetanus booster if they have not

1. 50% of patients were aged 18-28 years

2. 95% of bites were located on an extremity, 56% to the

3. Seasonal occurrence of 90% from April to October

4. In the pediatric population, most snakebites occurred in

• Local tissue destruction rarely contributes to long-term

• Wounds requiring fasciotomy to reduce compartment

• The average length of stay was 3.2 days. No deaths occurred

• Morbidity was limited to the local wounds.

I = Immobilize in the same way as a fractured limb

G &H = Go to Hospital immediately, traditional remedies have

T = Tell the Doctor of any systemic symptoms that manifest on

Fangs marks -1 Fangs marks -1 No Fangs -1

Panic, fear and emotional instability, which

1.Nausea & vomiting, diarrhea

2.Vasovagal attack, Vertigo

4.Tachycardia, bradycardia, cold clammy skin

1.Obtain a description of the snake.

2.Most snakes remain within 20 feet after biting.

3.Assess the timing of events and onset of symptoms.

4.Early and intense pain implies significant envenomation.

5.Local swelling, pain, and paresthesias may be present.

6.Systemic symptoms if present.

7.Determine history of prior exposure to antivenin or snakebite.

8.Determine history of allergies.

9.Determine history of comorbid conditions and Medications history.

Localized pain Progressive pain, Massive edema &

Local edema Mild lab abnormality SOB & depressed resp

Echymosis Systemic symptoms: C V collapse

No lab abnormality fever, nausea,vomiting Seizure & coma

Abnormal Lab tests

• ABC, V/S, IV line • Run or walk (patient)

• Stabilization of patient & treatment

Adrenaline Adult: 0.2-0.5 mL (0.2-0.5 mg) of 1:1000 solution IM;

Pediatric: 0.01 mg/kg

Glucagon Adult: 1-5 mg IV bolus

Pediatric: <20 kg: 1 mg IV/IM/SC

Diphenhydramine adult dose is 25-50 mg IM/IV every 4-6 hours