snake bite and scorpion bite discussed here

1. PAEDIATRIC INDIAN PROTOCOL
FOR SNAKE BITE
SIVA VYASAM

2. SUMMARY
• BACKGROUND
• FIRST AID
• DIAGNOSIS AND TREATMENT

3. • 236 Species in india
• FOUR important
• 1)Cobra (Naja naja),
• 2)Russell’s viper (Dabiola russelii),
• 3)Saw-scaled viper (Echis carinatus)
• 4)Common krait (Bungarus caeruleus)

4. DO NOT
• Do not apply a tourniquet.
• Do not wash the bite site with soap or any other
solution to remove the venom.
• Do not make cuts or incisions on or near the bitten
area.
• Do not use electrical shock.
• Do not freeze or apply extreme cold to the area of
bite.
• Do not apply any kind of potentially harmful herbal
or folk remedy.
• Do not attempt to suck out venom with your mouth.

5. FIRST AID
• The first aid recommended is based around the
• mnemonic:
• “Do it R.I.G.H.T.”
• It consists of:
• 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

6. DIAGNOSIS
• Identification of type of snake is important
• Haemostatic abnormalties-Viper bite
• Renal failure- Russel’s Viper,Hump Nosed pit
Viper
• Russels viper can also cause neurotoxic
symptoms sometimes(presynaptic)
• Delayed symptoms (>6hrs)–Krait and hump
nosed pit viper

7. 20WBCT
• Twenty-minute whole blood clotting test
(20WBCT) is considered as reliable test of
coagulation which can be carried out by
bedside.
• The test should be carried out every 30
minutes from admission for 3 hours and then
hourly after that.

8. INVESTIGATIONS
• Hb/platelet count/peripheral smear
• PT/ APTT
• FDP/D-Dimer
• Urine examination for proteinuria /RBC
/hemoglobinuria/Myoglobinuria
• Serum creatinine/Urea/Potassium
• Oxygen saturation/arterial blood gas (ABG)

9. TREATMENT PHASE
• PAIN CONTROL
• HANDLING TORNIQUETS
• ASV
• .i)Administration criteria
• .ii)Dosage and premeds
• .iii)Adverse reactions
• .iv)Repeat doses of ASV
• .V) Late arrivals

10. TREATMENT PHASE
• Pain can be relieved with oral paracetamol or
tramadol.
• Aspirin or nonsteroidal anti-inflammatory
drugs (NSAIDs) should not be administered.

11. • Handling tourniquets though not recommended,
Care must be taken while removing these as
sudden removal can lead to a massive surge of
venom, leading to paralysis, hypotension.
• Before removal of the tourniquet, check for the
presence of pulse distal to it.
• If it is absent or occluded the distal pulse, then
blood pressure cuff should be applied and
pressure should be slowly reduced.

12. ASV
• Anti-snake venom (ASV) is the mainstay of
treatment.
• In India, polyvalent ASV effective against all
the four common species and no monovalent
ASVs are available.

13. ASV
• ASV is produced both in liquid and lyophilized
forms.
• There is no evidence to suggest which form is
more effective.
• Liquid ASV requires a reliable cold chain and has
2-year shelf life.
• Lyophilized ASV, in powder form, has 5-year shelf
life and requires only to be kept cool.

14. Anti-snake Venom Administration
• Anti-snake venom should be administered only
1)Definite signs of envenomation like coagulopathy
or neurotoxicity.
2)Severe local symptoms which are defined as swelling
rapidly crossing a joint or involving half the bitten
limb, in the absence of a tourniquet
• Once the tourniquet has been removed for more than
one hour, if the swelling rapidly continues, this should
be viewed as venom generated and not due to the
continuing effect of the tourniquet

15. Prophylaxis for Anti-snake Venom
Reactions
• Two regimens are normally recommended, i.e.
hydrocortisone (10 mg/kg) + antihistamine
(0.2mg/kg)Intravenously
• ASV test dose is not recommended

16. ASV DOSE
Initial Dose
• Mild envenomation (systemic symptoms manifest
> 3 hours after bite) neurotoxic/hemotoxic 8–10 Vials
• Severe envenomation (systemic symptoms
manifest < 3 hours after bite) neurotoxic or hemotoxic
8 Vials
• Each vial is 10 ml of reconstituted ASV.
• Children should receive the same ASV dosage as adults.

17. ASV DOSE
• ASV should be administered over one hour.
• There is no benefit in administering each dose
over longer periods and indeed lengthening
the period before the ASV is able to neutralise
the venom is counter intuitive.

18. Adverse reactions to anti-snake
venom
• At the first sign of any of the following:
• Urticaria, itching, fever, shaking chills, nausea,
vomiting, diarrhea, abdominal cramps,
tachycardia, hypotension, bronchospasm and
angio-oedema
1. ASV will be discontinued
2. 0.5 mg. of 1:1000 adrenaline should be
given IM
• The pediatric dose is 0.01 mg/kg body weight
of adrenaline IM.

19. Adverse reactions to anti-snake
venom
• If after 10 to 15 minutes the patient’s condition
has not improved or is worsening, a second dose
of 0.5 mg of adrenaline 1:1000 IM is given.
• This can be repeated for a third and final occasion
but in the vast majority of reactions, 2 doses of
adrenaline will be sufficient.

20. • Once the patient has recovered, the ASV can
be restarted slowly for 10-15 minutes, keeping
the patient under close observation.
• Evidence has shown that adrenaline reaches
necessary blood plasma levels in 8 minutes via
the IM route, but up to 34 minutes in the
subcutaneousroute.

21. Repeat doses of ASV
• In anti-hemostatic bites, once the initial dose
has been administered over one hour, no
further ASV is given for 6 hours.
• Twenty WBCT test /PT,APTT should be done
after 6 hours, will determine if additional ASV is
required.
• This reflects the period the liver requires to
restore clotting factors

22. Repeat doses of ASV
• If WBCT more than 20 minutes repeat dose of
5–10 vials of ASV(1/2‒1 full dose) should
continue 6 hourly till coagulation is restored or
species is identified against which polyvalent
ASV is ineffective.

23. NEOSTIGMINE TEST
• Neostigmine is an anticholinesterase, which is
particularly effective in postsynaptic neurotoxins
such as those of cobra and is not useful against
presynaptic neurotoxin i.e. common Krait and the
Russell’s viper.
• Neostigmine test should be performed by
administering 0.5–2 mg IV and if neurological
improvement occurs, it should be continued 1/2
hourly over next 8 hours.

24. Repeat doses of ASV
• The ASV regime for neurotoxic envenomation
is not clear.
• After 1–2 hours of initial dose and
neostigmine test, patient should be
reassessed and if symptoms have worsened or
have not improved,a second dose of ASV
should be given.
• This dose should be the same as the initial
dose,(10 vials )and then discontinued.

25. Repeat doses of ASV
• Once the patient develops respiratory failure,
has received 20 vials, ASV therapy should be
discontinued assuming that all the circulating
venom is neutralized and should have assisted
ventilation if required.

26. Victims Who Arrive Late
• Perform a 20WBCT to determine if any
coagulopathy is present. If it is present,
administer ASV, otherwise treat renal failure.
• In the case of neurotoxic envenoming ,it is
probably wise to administer 1 dose of 8–10 vials
of ASV to ensure that no unbound venom is
present.
• But mostly at this stage it is likely that most of
the venom is bound and respiratory support will
be required.

27. TAKE HOME MESSAGE
• Indications of ASV administration
• Time to repeat further doses
• Management of adverse reactions to ASV

28. SCORPION STING

29. INTRODUCTION
• Acute life threatening emergency
• Case fatality rates 3- 22%
• In India there are 86 species only 2 are
dangerous
1)Indian red scorpion( Mesobuthus Tamulus)
2)Palamneus swammer-dami

31. DISTRIBUTION
• Warm, dry regions
• Inhabit commonly the underground areas
(crevices,burrows,debris,paddy)
• Found outside too (Thanks to the transport
facilities)
• Retreat in crevices during day (Nocturnal )
• MOST STINGS ARE IN THE NIGHT

32. SCORPION STING
• Scorpions stings primarily due to accidental
contact.
• They use their stings only when roughly
handed or trodded on.
• Sting ( Ejaculation) can be controlled
a)Partial
b)Total
c)Non existent

33. SCORPION VENOM
• Species specific
• Prevenom
• Short neurotoxic proteins, free aminoacids,
serotonin, hyaluronidase, various enzymes
that act on trypsinogen
• Enters circulation rapidly
• Tissue distribution half life 5-6 min
• Peak tissue conc in 37 mins
• Excretion half life 30 min
• INDUCES COMPLICATIONS IN ALL ORGANS

34. PATHO-PHYSIOLOGY
1 ) Ion channels
2) Alpha receptors
ION CHANNELS
• Toxin opens up the sodium channel at presynaptic nerve terminals
• Inhibits calcium dependant potassium channels = initiation of
AUTONOMIC STORM
• Transient parasympathetic (vomiting, profuse sweating, ropy
salivation bradycardia, ventricular pre mature contraction,priapism
in male,hypotension) and prolonged sympathetic (cold extremities,
hypertension, tachycardia, pulmonary edema and shock)
stimulation

35. Effect on Alpha receptors
• HTN
• Tachycardia
• Myocardial dysfunction
• Pulm edema
• Cool extremities

36. Effect of venom on Myocardium
• Myocardial injury
• Clinical symptoms and signs are minimal or absent
• Conduction distribution,arrythmia, myocarditis and
MI
• ECG criteria for myocarditis: ST segment and T wave
inversion in several leads
• Arrythmia- Ectopic beats, prolonged QT, sinus
bradycardia ( Transient 3-4 days)

37. Effect on Hemopoietic system & Lungs
• Hemopoeitic system: DIC
• Lungs: Abundant microthrombi → Acute lung
injury → Increased alveolocapillary membrane
permeability

38. Effect on brain
• Direct effect on neurons → Seizures
• 8% Cerebrovascular involvement
• 4 % haemorrhagic stroke ( High BP due to
sympathetic stimulation, rupture of unprotected
perforating arteries)
• 8% Thrombotic stroke ( Cerebral infarction due to
DIC)
• Hemiplegia, coma, encephalopathy, tonic
posturing,irritability, excessive sleepiness .

39. Effect of venom on skin
• Indian red scorpion – local inflammation is
unusual
• Iran yellow scorpion – erythema, edema,
lymphangitis and necrosis
• Polypeptide variations

40. Effect on kidneys & Pancreas
• Severe hemolysis and secondary renal failure
• Acute pancreatitis secondary to
intrapancreatic conversion of trypsinogen to
trypsin

41. SIRS
• Cumulative action of neurotoxin R complex leading
to activation of different ion channels → release of
various transmitters, kinins, ecosanoids, cytokines,
platelet activating factor, permeability increasing
factor, and nitric oxide.
• Cytokines leads to release of i-NOS,e-NOS→ Direct
tissue injury

43. Clinical features
• Time lapse between the sting and admission is a key factor.
• Dose weight relationship
• Complications were less if presented within 4 hours of sting
• Complex interaction between sympathetic and
parasympathetic stimulation → TRANSIENT CHOLINERGIC
AND PROLONGED SYMPATHETIC STIMULATION

44. Clinical features
• Pain ( Tap test)
• Autonomic storm( Vomiting, salivation, sweating, priapism &
bradycardia) EARLY DIAGNOSTIC SIGNS
• Tachycardia
• Ashen pallor of skin
• Hypertension( 4-8 hrs due to catecholamine outpour)
• Hypotension & ↓HR ( 1-2 hrs due to cholinergic stimulation)
• ↓ BP,↑ HR (4-48 hr) SEVERE LV DYSFUNCTION
• Fluid loss
• Pulmonary edema
• Encephalopathy and convulsions

45. Blood pressure
• Initial hypotension( Excessive fluid loss and is
transient hypotension)1-2hrs
• Subsequent hypertension( liberation of endogenous
catecholamines into the circulation)4-8hrs
• Hypotension ( depletion of catecholamines
secondary to prolonged hypertensive crises)48-72hrs

46. GRADING
• Grade 1: severe excruciating local pain at the sting site
radiating along with corresponding dermatomes, mild
local oedema with seating at the sting site, without
systemic involvement.
• Grade 2: signs and symptoms of autonomic storm
characterized by acetyl choline excess or
parasympathetic stimulation and sympathetic
stimulation

47. GRADING
• Grade 3: cold extremities, tachycardia,
hypotension or hypertension with pulmonary
edema (Respiratory rate > 24 perminute, basal
rales or crackles in lungs).
• Grade 4: tachycardia, hypotension with or
without pulmonary edema with warm
extremities (warm shock).

49. Investigations
• Electrolytes ( Dehydration from vomiting, hypersalivation,
sweating and diaphoresis)
• Chest X ray: Pulm edema/ARDS
• ECG: Peaked T waves in V2-6,ST segment elevation in lead
I,aVL,Increased QR interval,LVH ( Low voltage complexes
throughout and left anterior hemiblock indicate poor
prognosis)
• ECG changes consistent with MI in 56.5%
• IL-6 levels

50. Treatment- Unhelpful
• Lytic cocktail
• Morphine
• Steroids
• Atropine
• Nifedepine
• ACE inhibitors

51. Prazosin
TIME LAPSE BETWEEN STING AND
ADMINISTRATION OF PRAZOSIN DETERMINES
OUTCOME

52. Prazosin
• Competetive postsynaptic ά 1, adrenoreceptor
antagonist
• Cellular & pharmacologic antidote to actions of
scorpion venom and is CARDIOPROTECTIVE
• How does it work ?
Suppresses sympathetic outflow & activates venom
inhibited potassium channels

54. Prazosin
What does it do?
a)Decreases preload, afterload and BP without
increasing the HR
b)Inhibits further myocardial injury(Inhibits
phosphodiesterase enzyme,inhibits formation
of ionositol triphosphate,cGMP)
c)Reverses the metabolic and hormonal effect

55. • 1 mg tablet
• Dose: 30 mcg/kg/dose
• Sustained release tabs are not recommended
• Oral/NG
• First dose phenomenon
• Monitor: BP,RR,PR Q 30min X 3 hrs, Q1h X 6hrs, Q4h till
improvement
• Can be repeated Q3h and later Q6h till extremeties, are
warm, dry and peripheral veins are visible easily
Prazosin

56. Antivenom
• Within 30 mins of sting can neutralise
• Antivenins against toxins of Indian scorpion is
not available
• Species specific
• Not much data
• Children reach late

57. Pulmonary edema
• Dobutamine ( 5-15 mcg/kg/min)-Adequate
cardiac output + Sodium nitroprusside (0.3-5
mcg/kg/min)- vasodilatation
• Shock- treated with prazocin + SNP= Prazosin
had good outcome (lesser mortality)

58. Pain and fluid management
• NSAIDS,Local anaesthetic, ice packs
• IV fluids
• CVP monitoring is essential in pulmonary
edema

60. PREVENTION
• False ceiling under loose tiles of roof and bamboo cot with
scrupulous use of mosquito net protect from scorpion
sting.
• In endemic areas of venomous sting clothing, beddings, shoes,
package should be vigorously shaken out and checked for scorpion
without blindly putting hands.
• Sandal did not prevent sting.
• Pesticides like organophosphates, pyrethrins and chlorinated
hydrocarbons are known to kill scorpions.
• At the timing of opening of he school the tables and rooms (roof,
walls and floor) should be thoroughly cleaned and washed.

61. TAKE HOME MESSAGE
• Scorpion venom is a potent sympathetic stimulator
• Cardiac manifestations are common in Indian red scorpion
envenomation
• Alpha receptors stimulation plays a major role in evolution of
myocardial dysfunction and acute pulmonary edema in victims of
scorpion sting
• Prazosin–an alpha adrenoreceptor antagonist–is antidote to
venom action
• Time lapse between the sting and administration of Prazosin for
autonomic storm determines the outcome.

62. • Ind jl pediatrics vol 73,2006
• Ind pediatrics vol 40,2003
• Ind pediatrics vol 37,2000
• IP,Vol 40,2003; BHJ,Vol 68,1992
• IP Vol 44,2007