Snake Envenomation management

1. Case based discussion -Snake
Envenomation
Dr. Zaheen Zehra
Dept of Paediatrics.

2. • 7 yr old boy brought with alleged h/o unknown
bite on 11/03/17 at 10:30 am at home.
• Site of bite- dorsum of left foot
• C/o Excrutiating pain and swelling on the left leg.
• After 1 hr child sustained localised swelling,H/o
progression of swelling upwards till left knee
associated with pain.
• No h/o bleeding from the site, LOC, Seizures, Ptosis
• No respiratory distress

3. • Past History:
No significant past history
• Family History: Nil significant
• Antenatal and perinatal history: Nil significant
• Immunisation History: Upto date
• Growth and development: Normal

4. Treatment History:
• Child was immediately taken to Kallukurichi
GH, diagnosed as snake bite with cellulitis of
left leg.
• Treated with IV fluids, Inj.Tramadol, Inj.Rantac,
Inj.Taxim, Inj.Metrogyl, ASV.
• Dose of ASV not mentioned. Not given
premedications
• Referred that day for ASV allergy.

5. ON EXAMINATION
Initial assessment: Stable
Primary assessment : Normal - (Urgent)
Active,febrile
GCS-15/15
Vitals:
Temperature-100 F
PR-130/min
RR-24/min
CFT-<3 sec
BP-130/90mmHg
Breath holding time – adequate
No bleeding sites

6. SYSTEMIC EXAMINATION:
• Respiratory System:
B/L AE equal, NVBS Heard.
• CNS:Sensorium-normal;No ptosis
• CVS:
S1,S2 heard; Tachycardia present
• P/A:
Soft, non tender, no organomegaly, no renal angle
tenderness

7. LOCAL EXAMINATION:
• Warmth,swelling and tenderness till distal one
third of the lower limb(Below knee)
• Fang mark on the dorsum of the left foot
• Blebs and discolouration present
• Peripheral pulses felt, no evidence of
compartment syndrome
• Left inguinal lymphadenopathy present- Tender+

9. • Provisional diagnosis of Left leg cellulitis-
secondary to ?snake bite envenomation was
made and child was shifted to PICU
• Whole blood clotting time done- less than 20mins
• CBC showed TLC 12,000 with plt of 2.18lakhs
• RFT was normal
• Child empirically started on iv ceftriaxone and
metronidazole
• Monitored for urine output, increase in
swelling,compartment syndrome.

10. • On day 3 of hospitalization - pus c/s was sent
from the bleb.
• Pediatric surgery opinion taken on day 3 of
hospitalization- Opined as Necrotizing fascitis
of leg.(Evolving)
• Iv antibiotics was changed to ampiclox and
amikacin and metronidazole was continued.
• Wound debridement with fasciotomy was
done on day 5 of hospitalisation. Tissue
culture was sent.

11. • Pus c/s (aerobic & tissue culture showed
evidence of klebsiella pneumoniae sensitive to
the ciprofloxacin, ceftriaxone, amikacin,
magnex, meropenem
• Anaerobic culture : sterile

12. • Taken over by paediatric surgery. Daily wound
dressing done.
• Planned to do skin grafting after 2 weeks.

13. Snake Envenomation
• Highest Mortality in the world.
• Deaths of 30,000 per annum. (WHO 2009)
• 236 species of snakes in India
• 15 varieties are poisonous.
• Cobra, Russell's viper, saw- scaled,vipers and
krait are the most common.

14. Cobra
Naga Pambu or Nalla
pambu
நாகப் பாம்பு/நல்ல பாம்பு
Naja naja

15. Common Krait
Bungarus caeruleus
Kattu viriyan/ Thani
Paambu
கட்டு விரியன்

16. Saw scaled snake
Echis carinatus.
Surutai pambu

17. Russell’s Viper
Daboia russelii
கண்ணாடி விரியன்
Kannaadi Viriyan

18. Common Name
of
the snake
Nature of
Toxin
Local symptoms and
signs at bite
Systemic Signs and
Symptoms
Russell's Viper Haemotoxic
Neurotoxic
1.Pain at bite site
2.Ecchymoses and
3.swelling
4.Blister formation
5.Necrosis of the limb
1.Rise in CT/BT
2. Bleeding from
various sites.
3. AKI
Saw Scaled Viper Haemotoxic 1.Local pain
2.Ecchymoses
3.swelling
4.Bleeding from the
site
5.Rapid discolouration
1.Rise in CT/BT.
2.Bleeding from
various sites.

19. Common Name of
the snake
Nature of
Toxin
Local symptoms
and signs at bite
Systemic Signs and
Symptoms
Cobra Neurotoxic
(post synaptic)
1.Local pain.
2.Swelling.
3.Ecchymoses
4.Local necrosis
1.Sluggish pupillary
Response.
2.Diplopia, Ptosis,
Dilated pupils,
arrhythmia.
3.Difficulty in breathing,
Hypotension.
4.Unconscious state.

20. Common Name of
the snake
Nature of
Toxin
Local symptoms
and signs at bite
Systemic Signs and
Symptoms
Common Krait Neurotoxic
(pre-synaptic)
1.Small puncture
marks.
2.Minimal or
absent
Iocal symptoms
3.GI
Manifestations.
1.Sluggish pupillary
response, ptosis,
Diplopia, Dilated Pupils.
2.Difficulty in
swallowing due to
Glossopharyngeal
dysfunction.
3. Difficulty in
Respiration.
4. Arrhythmia,
hypotension, Ioss of
conciousness, coma,
respiratory arrest, and
sudden cardiac arrest.

21. “Do it R.I.G.H.T”
• R: Reassure the patient.
• I: Immobilise in the same way as a fractured
limb.
• G.H: Get to Hospital Immediately.
• T: Tell the doctor of any systemic symptoms
such as ptosis that manifest on the way to
hospital.

22. Methods to be Discarded
• Tourniquets
• Cutting and Suction
• Washing the Wound
• Pressure Immobilisation Method (PIM)
• Freeze or apply extreme cold to the area of
the bite.
• Attempt to suck venom out with mouth

23. Approach
• Initial Assessment and history.
• Symptoms:
Feature Cobras Kraits Russell's
Viper
Saw ScaIed
Viper
Local Pain/ Tissue Damage yes No Yes Yes
Ptosis/ Neurological Signs Yes Yes Yes No
Haemostatic
abnormalities
No No Yes Yes
Renal Complications No No Yes No
Response to Neostigmine Yes No No No
Response to ASV Yes Yes Yes Yes

24. • Hump nose viper
• Common in kerala
• Hemotoxic and nephrotoxic
• AVAILABLE ASV IS NOT EFFECTIVE

25. Investigations
• 20 minutes whole blood clotting test
• Haemoglobin/ Pcv/ Platelet count/ PT/ APTT/
FDP/ D-Dimer
• A Peripheral Smear
• Urine for for Proteinuria/ RBC/
haemoglobinuria/ myoglobinuria
• Sr.creatinine/urea/Potassium

26. TREATMENT
• Managing pain:
This can be treated with painkillers such as
Paracetamol.
• Handling Tourniquets:
Before removal of the touniquet, check for the
presence of pulse distal to the tourniquet.

27. Anti Snake Venom (ASV)
• INDICATION:
Evidence of systemic envenomation
Evidence of coagulopathy: Primarily detected by
2OWBCT or visible spontaneous systemic
bleeding etc.
Evidence of neurotoxicity: Ptosis, external
ophthalmoplegia, muscle paralysis,inability to
lift the head etc
Severe Local envenomation

28. • Premedication :
Hydrocortisone 2-5 mg/Kg
Chlorpheniramine 0.1-0.3 mg/kg
Ranitidine 2 mg /kg
Dosage: 10 vials
Russell's viper injects 63mg (Range 5mg - 147
mg; SD 7 mg) of venom- each vial contains
6mg of ASV

29. • Route of administration- Intravenous infusion
10 vials of ASV is diluted in 10-20ml/kg of
isotonic saline and given over one hour
• Child is monitored closely for ASV related
reactions.
Locally instilling ASV on bite site to be avoided

30. ASV Reactions
In cases of anaphyllaxis
• Discontinue ASV infusion
• 0.01mg/kg adrenaline 1 :1000 given IM
• Second or third dose may be repeated if
symptoms not reversed
• If anaphyllactic shock – start adrenaline
infusion
• Once recovered, ASV can be restarted slowly

31. Recovery Signs
• Spontaneous systemic bleeding such as gum
bleeding usually stops within 15 – 30 minutes.
• Blood coagulability is usually restored in 6 hours.
Principal test is 2OWBCT.
• Post synaptic neurotoxic envenoming such as in
Cobra bites, may begin to improve as early as 30
minutes after antivenom, but can take several
hours.
• Active haemolysis and rhabdomyolysis may
cease within a few hours and the urine returns to
its normal colour.
• In patients with Shock, blood pressure may
increase after 30 minutes

32. When and how much repeat dose
• Hemotoxic snake bite:
Maximum 25 vials
After 6 hours
• Neurotoxic snake bite:
Maximum 20 vials
After 1-2 hours

33. • Why ASV not effective after delayed
presentation or persistent local swelling?
ASV acts in the circulation to prevent binding
of unbound venom

34. Complications
• Hypotension
• Persistent or severe bleeding
• Renal Failure:
• Cardiac Complications

35. Surgical Complications
• Ulcer following snakebite
• Necrosis of the skin and underlying tissues
• Gangrene of the toes and fingers
• Debridement of necrotic tissues
• Compartment syndrome.

36. Role of Antibiotics
• Most common organism causing local reactions or infection
- Staph. Aureus
- E. Coli
- Different choices being mentioned
 Combination of ampiclox and cefotaxime
 Ciprofloxacin
 Metronidazole to cover anaerobes
Reference:
1.Dhanya Sasidharan Palappallil et al., Antibiotic Usage After Snake Bite
Journal of Clinical and Diagnostic Research. 2015 Aug, Vol-9(8)
Kerala Based Study.
2. Wound infections secondary to snakebite
Atul Garg, S. Sujatha, Jaya Garg, N. Srinivas Acharya, Subhash Chandra Parija
Department of Microbiology, Jawaharlal Institute of Postgraduate Medical
Education and Research (JIPMER), Pondicherry

42. How do we decide on Antibiotics??
• Invariably skin gets necrosed after initial few
days of snake bite due to proteolytic
properties of venom.
• If no features of septicemia or if local skin
appears relatively healthy amoxyclav or
ceftriaxone or ciprofloxacin is enough.
• If skin shows necrotising features or child is
very toxic then Cloxacillin (or piptaz )+
amikacin + metronidazole can be added.

43. • THANK YOU