2. Outline
• case
• identify venomous
snakes
• family of snakes
• pathological effects
of snake’s venom
• management
• anti venom
3. Case 1
56 y Indian female @ 3pm
Bitten by a black snake at 12.30pm while feeding
chicken at home.
Was sent to private clinic where she developed
cardiorespiratory arrest. Pt. was resuscitated and
sent to KKM Hospital
At the ED she was unresponsive, intubated and
manually ventilated PR 140, BP 100/87, pupils
3 mm and sluggish bilaterally.
Swelling and blue black discolouration over
dorsum of left hand. 2 bite marks seen.
4. Specific anti-venom for the Naja naja (Cobra)
was given.
ATT, Chlorphenaramine and hydrocortisone was given
before the anti-venom
Pt. was transferred to HKL where
she was ventilated in CCU.
In CCU she developed hypoxic fits.
Bullae formation over left hand which later turned
gangrenous
Pt. died form septicaemia.
5. Case 2
35y male Burmese.
Bitten by a black snake on the right foot while
feeding his rabbits at 12.30pm.
On arrival at the ED , he complained of pain
over his right foot.He was conscious, alert,
PR 70/min, BP 133/60, RR 20/min. There was bilateral
ptosis.
The dorsum of right foot - swelling and erythema
6. ATT, chlorphenaramine, hydrocortisone and
diclofenac was given
Polyvalent anti-venom was started in the ward
The ptosis immediately disappeared. He remained
stable in the ward.
The right foot became swollen with cellulitis, necrotic
area and desloughing was done.
Patient discharged well.
Follow up ortho clinic
7. Case 3
56 y female Iban at 11.10am referred
from Batu Arang clinic.
Bitten by a black snake with yellow dots at the
left hand at 8.30am in the flat.
At ED , complained of difficulty in breathing and
chest pain on and off.
Pt. was conscious and alert, PR 103/min, BP 149/100
RR 22/min, a single bite mark seen at base of left
thumb dorsally, minimal erythema and no swelling.
8. ATT given
Anti-venom was not given and patient was
closely
observed in the ward.
No further swelling of the left hand.
Pt. discharged well.
9. 5 Genera of Venomous Snakes In
Malaysia
• Pit Vipers
• Cobras
• Kraits
• Coral Snake
• Sea Snake
14. Some Facts on Snake Bites
• Even though not all snake bites are venomous,it is
best to consider all snakes are dangerous.
• A fang mark does not necessarily mean that venom
is injected.
• Most snake bite in defense which venom injected
usually minimal.
• If venom injected it is usually quite deep & it serves
no purpose to incise wound to remove venom.
• Very little venom reaches blood stream if firm
pressure is applied & limb is immobilized.
• Not to handle `dead snake’ as reflex envenomation
by a decapitated snake can occur several hours after
death
15. EPIDEMIOLOGY OF SNAKE BITE
75% of snake bites are reported form the northern
states namely Perlis, Kedah and Penang
60% are due to the Malayan Pit Viper (Reid et al. 1963)
Mortality rates 0.1% - 1.6%
The Malayan Pit Viper, Cobra and Kraits constitute
higher percentage around human habitat than other
poisonous snakes.
16.
17.
18. • In M’sia : >/= 18 species of venomous land snakes &
>/= 22 species of venomous sea snakes
• 5 subfamilies :
1. Crotalinae
2. Elapinae
3. Laticaudinae
4. Hydrophiini
5. Ephalophiini
(1) & (2) – land snakes ; (3) , (4) & (5) – sea snakes
19. LIST OF VENOMOUS SNAKES:
Family CROTALIDAE (Pit vipers)
Malayan pit viper (Agkistrodon rhodostoma)
(Ular Kapak Bodoh)
Sumatran pit viper (Trimeresurus sumatranus)
(Ular Kapak Sumatera)
Mangrove pit viper ( Trmeresurus purpureomaculatus)
( Ular Kapak Bakau)
24. VIPER BITES
1. Local symptoms are prominent
- severe persistent pain
- Intense swelling of the limb
- blisters
- slough and necrosis
2. General symptoms
- haemopthysis
- haemorrahge under the skin and mucous
membrane (discoid ecchymosis)
- epistaxis
- bleeding gums
- haematuria
- maleana
- oozing from bite
- +ve torniquet test
25. 3. Internal haemorrhage
- abdominal pain
- vomiting
- shock
4. Cardiotoxicity
5. Renal dysfunction
#coaguability last for 6-10 hours
@blood product will not correct it except anti-venom
44. SEA SNAKE BITES
1. History of painless bite occurring whilst swimming
or sorting of fish net
2. Half to one hour after bite:
- generalised muscle aches and pains
- stiffness
3. Myoglobinuria 3 - 6 hours after the bite
4. Hyperkalaemia and renal dysfunction
49. • Cobra
act at NMJ bind to post-synaptic Ach
receptor depolarizing neuromuscular
blockade paralysis
direct effect to heart arrythmias &
impaired contractility
enzymes proteinlysis & breakdown
connective tissue necrosis
50. TREATMENT OF SNAKE BITE
DO NOT apply an arterial tourniquet
DO NOT apply ice
DO NOT incise or suck the bitten area
DO NOT wash the bitten area
51. DO:
1. Do not panic and keep calm
2. Reassure the individual as complete recovery
is the rule
3. Lie the patient down to ensure minimal activity
4. Apply a broad pressure bandage over the bite
extend it as high as possible
52.
53. 5. Apply a splint to immobilise the limb
6. Ask for help and transport the patient to hospital
as soon as possible
7. If the snake has been killed, bring it to the hospital
for identification
54. TREATMENT OF SNAKE BITES IN HOSPITAL
1. A B C D E
2. Take a detailed history from patient
- Identify location of snake bite
- Ask for detail description of the snake
if the snake is not caught
- Establish time interval between incident
and medical treatment
- Examine the site of snake bite and note
characteristics of the fang marks
- signs and symptoms of snake bit
poisoning
55.
56. 3. IM ATT
4. Evaluation of the severity of envenomation
57. Grades of envenomation
MINIMAL:
no pain to moderate
pain,
erythema,
oedema 2.5-15cm,
no systemic symptoms
MODERATE
severe pain
tenderness
oedema 25-40cm
spreading erythema
petechiae
vomiting
fever
weakness
58. SEVERE
widespread pain
oedema 40-50cm
ecchymosis
systemic sign
VERY SEVERE
rapid swelling
ecchymosis
CNS symp
visual disturbance
shock
convulsion
59. Guide for dosage of antivenin
grade of envenomation dosage
minimal not indicated
moderate 20-40ml (2-4 vials)
severe 50-90ml (5-9 vials)
very severe 100-150 ml (10-15vials)
60. Anti-Venom in HKL
• Specific:
1. Pit Viper
2. Cobra (Equinae,
Naja-naja, Karaothia)
3. Sea-snake
4. King Cobra
• Polyvalent :
• Standard Cobra (Naja-
naja)
• Standard Krait
(Bunganus Caeruleus)
• Russel’s Viper
• Saw-Scale Viper
(Echis Carinatus)
61.
62. How snake anti-venom made?
• the venom is "milked"
from the snake
• it's diluted and injected
into a horse or goat.
• the animal builds up
immunity to the venom,
the dosage is increased,
and the animal creates
blood rich in antibodies.
• antibodies collect in the
serum
63. Administration of antivenom
• specific antivenom for the particular species
of snake is prefered.
• Dilute 1-2 vials of antivenom in 200mls NS,
run a drip slowly at 5 drops per minute for
first 20 minutes. If no allergic reaction run
the rest fast within 1 H.
64. Reaction!!!?? What to do??
• skin test has no predictive value.
• if reaction occur, stop infusion immediately.
• administer H1,H2 blockers, aderenaline &
fluids.
• dilute antivenom further & administer at
lower rate
• re-assess at 6,12 & 18 H KIV repeat
antivenom
66. 6. Supportive treatment
- analgesia for pain
- Observe patient closely
- maintain adequate hydration
- surgical debridement of necrotic bite site
- antibiotics
- Renal dialysis
- ? Blood and blood products
67. WHAT TO DO IF YOU SEE A SNAKE:
1. Do not be afraid.
2. Allow the snake to go away or move away
from the snake.
3. Do not kill the snake unnecessarily.
4. Snakes do not attack man, They only bite
only when attacked or agitated.
68. HOW TO AVOID SNAKE BITE:
1. When walking in the jungle
- wear tall boots
- be alert
- do not put your hands in holes or put
your foot in pits
- do not overturn stones or logs.
2. Most snakes are active nocturnally, take extra care
when walking at night.
70. First Aid
• Do not torniqueyt
• Compression bandage with splint
• ATT
• Clean wound
• Analgesia
• Mark the fang & measure
• Whole blood clotting test Whole Blood Clotting
Test 20 mins leaved undisturbed-
hypofibrogenemia
