Snakebite

SNAKE
BITE
http://www.kgmu.org/download/virtualclass/Forensic_Medicine/FM-Snake_bite-16-12-14.ppt 09/08/18 12.06
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Classification of snakes
Poisonous snakes belong to three Families on the
basis of poison secreted :
• 1. Elapidae : Neurotoxic
• 2. Viperidae : Vasculotoxic
• 3. Hydrophidae : Myotoxic

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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

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

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Monocellate Cobra
Naja Naja
Kaouthia

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Common krait
Bungarus
Caeruleus
Neurotoxic

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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 Viper-
Crotalidae
b) Common Green
Pit Viper

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Saw scaled viper
(carpet viper)
Echis carinatus
Haematotoxic

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Russell’s viper
Daboia russelli
Haematotoxic

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

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DIFFERENCES BETWEEN COBRA
AND VIPER
TRAIT VIPER
S.
1COBRA Usually long and cylindrical Usually short and stout with narrow
neck
Body
2. Head Small ,seldom broader than body, Larger and broader than body ,usually
usually of same width as that of wider than the neck , covered with small
neck, covered with large scales scales
3.Maxillary They carry other teeth beside the They carry only the poison fangs
bones poison fangs
4. Eye It has round pupil It has vertical pupil
5. Fangs. Placed little anteriorly , grooved They are canalised ,long , movable and
short ,fine and fixed strong,
6. Eggs Oviparous Viviparou
7. Tail Round s Tapering
8.Veno Neurotoxic mainly Haemotoxic usually

m

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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

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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)

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

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Non Enzyme Peptides :
• α- bungarotoxin,β- bungarotoxin,Crotoxin,
Crotamine,Cardiotoxin.
Peptide- Pyroglutamyl peptide
Nucleoside-Adenine,Guanine,Inosine.
Lipid-Phospholipid,Cholestrol
Amine-Histamine,Serotonin,Spermin
Metal-Cu,Zn,Ni,Mg.

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Difference between poisonous
and non-poisonous snakes
Points Poisonous snakes Non Poisonous
1. Belly scales Large : They cover the entire breadth of Small : They never cover
belly
2. Head scales a)Usually small in vipers Are usually large with
b) May be large in pit vipers exceptions as outlined under
c)Cobras and Coral snakes where third poisonous snakes
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
3. Fangs Are hollow like hypodermic needle Short and solid
4. Tail Compressed Not markedly compressed
5. Habits Usually nocturnal Not so
6. Teeth bite marks Two fang marks with or without marks of Two fang marks with number
other teeth of small teeth marks

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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

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SIGNS AND
A. ElapiSdYBiMte:PTOMS
a). Local Features :
Fang marks
Burning pain
Swelling and discoloration
Serosanguinous discharge
Local symptoms are milder in comparison
to that in Viperine bite.

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Systemic features
• Preparalytic • Paralytic stage:
stage: • Ptosis.
• Vomiting • Ophthalmoplegia
• Headache Drowsiness
• Giddiness • Convulsion
• Weakness and
• Bulbar paralysis
lethargy
• Respiratory
failure
• death

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

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

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C. Hydrophid bite
• Local features: Systemic
Local swelling
Features :
Pain Myalgia
Muscle stiffness
Myoglobinuria
Renal failure

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Summary of Manifestations

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No Mild Moderate Severe
Envenomation Envenomation Envenomation Envenomati
o n
Fang marks +/- + + +
Local reaction:
Pain - Moderate Severe Severe
Local edema NO Minimum Moderate Severe

(0-15cm) (15-30cm) >30cm
Erythma NO + + +
Echymosis NO +/- + +
Symptoms No No Weaknes Hypotensio

s n
Sweating Paresthesia
Syncope Coma
Nausea Pulm. edema
Vomiting Resp.failure
Thrombo
cytopenia

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Factor affecting snake bite
factor effect toxicity
Body weight Bigger the size lesser toxicity
Aggravatin Predispose to harmful effect of snake venom

g factor
Part bitten Bite on face and trunk are most lethal
Exercise Poor outcome
Individua Sensitivity of individual to venom modified clinical

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

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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

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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

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• ECG-non specific changes like
bradycardia, AV-block.
• EEG-mainly in temporal lobe.60% in Grade-

I,31% Grade-II,4% Grade III

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Management
Management
Local
Specific
Supp
ortive

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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 non-venomous
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.

Page 31 of 54
First Aid
DOs-
Assurance of patient
Immobilisation
Application of
tourniquet????
DON’TS-
Incision
Suction
Application of Ice ,massage or any chemical
treatment

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Specific treatment
Anti snake
Indication for ASV
Venom
• Spontaneous systemic Bleeding
• WBCT > 20 min
• Thrombocytopenia (platelet < 1 lac)
• Shock, paralysis, ARF, Rhabdomyolysis,
Hyperkalemia.
• Local swelling involving > ½ of bitten
limb
• Rapid extension of swelling

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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.

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• 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.

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Disadvantage of ASV
• Pain at injection site
• Hematoma formation
• Increase intra compartmental pressure
ASV SENSTIVITY IS NOT

RECOMMONDED NOW A DAYS

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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,nephrits,myog
lobinuria.etc.

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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

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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
Predinisolone-
5mg/6h in adult
0.7 mg/kg/day in divided dose in children

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

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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
don’t cross blood brain barrier
• Care of bitten part-
Antibiotic prophylaxis & ATS injection

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Scorpions

Page 42 of 54
Scorpions
Introductio
• n than 1250 species of
There are more
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.

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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.

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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.

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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.

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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

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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

Page 48 of 54
Questions

Page 49 of 54
1. True about cobra poison
• Neurotoxic
• Myotoxic
• Cardiotoxic1
• Vasculotoxic

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2. Cholinesterase is present in
• Elapid
• Viper
• Sea snakes
• All

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3. Muscle paralysis is caused by
• Sea snakes
• Mamba
• Krait
• python

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4. True about poisonous snakes is
• Fangs present
• Belly scale are small
• Small head scales
• Grooved teeth

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5. Most characteristic feature of elapidae snake
envenomation
• Bleeding manifestation
• Neuro-paralytic symptoms
• Rhabdomyolysis
• Cardiotoxicity

Page 54 of 54

Snakebite

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SNAKE

http://www.kgmu.org/download/virtualclass/Forensic_Medicine/FM-Snake_bite-16-12-14.ppt 09/08/18 12.06

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• Well marked hood

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http://www.kgmu.org/download/virtualclass/Forensic_Medicine/FM-Snake_bite-16-12-14.ppt 09/08/18 12.06

All are poisonous.

They are myotoxic.

http://www.kgmu.org/download/virtualclass/Forensic_Medicine/FM-Snake_bite-16-12-14.ppt 09/08/18 12.06

8.Veno Neurotoxic mainly Haemotoxic usually

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Local edema NO Minimum Moderate Severe

Symptoms No No Weaknes Hypotensio

http://www.kgmu.org/download/virtualclass/Forensic_Medicine/FM-Snake_bite-16-12-14.ppt 09/08/18 12.06

Aggravatin Predispose to harmful effect of snake venom

Part bitten Bite on face and trunk are most lethal

Exercise Poor outcome

Individua Sensitivity of individual to venom modified clinical

http://www.kgmu.org/download/virtualclass/Forensic_Medicine/FM-Snake_bite-16-12-14.ppt 09/08/18 12.06

http://www.kgmu.org/download/virtualclass/Forensic_Medicine/FM-Snake_bite-16-12-14.ppt 09/08/18 12.06

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• EEG-mainly in temporal lobe.60% in Grade-

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

G.H. = Get to Hospital Immediately. Traditional remedies have NO

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

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• AVS dilute 5-10 ml/kg body weight of normal

• ASV should never given locally at site of snake

http://www.kgmu.org/download/virtualclass/Forensic_Medicine/FM-Snake_bite-16-12-14.ppt 09/08/18 12.06

ASV SENSTIVITY IS NOT

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Early anaphylactic reaction-

Late Serum Sickness

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