SNAKE BITE

Anatomy:
1) Head:
a] Eyes: No eyelids, poor vosion.
Pupils - Vipers- vertical, Cobra Round
b] No ear
c] Mouth Distensible
d] Teeth multiple rows
e] Fangs
f] Tongue forked
2) Tail Flat in case of sea snakes.
3) Trunk slender or stout
Other important features-
1. Cold blooded
2. Nocturnal
3. Moulting
4. Some are oviparous (cobra, krait),
some are viviparous (vipers)
Biting Apparatus (Fangs):
-Only in venomous snakes.
- Upper jaw.
- Vipers hypodermic needle like like,
retractable, long
- Cobra short, fixed, groove on inner aspect.
- Dry bites
- Protection
- Bite mark
Classification of Snakes:
World Total no. of species 3500,
Venomous 350
India Total no. of species 300
- Venomous 70 (Land snakes 40, sea
snakes 30)
Common venomous snakes in India
1. Common krait
2. Common cobra
3. Saw scaled viper
4. Russels viper
Venomous snakes :
1. Colubridae
2. Atractispididae
3. Elapidae Cobra, krait
4. Viperidae Vipers
5. Hydrophidae Sea snakes.
Identification of venomous snake:
Importance
Features:
1. Cobra- Hood, spectacle mark
(confused with Rat snake)
2. Krait Dorsal midline scales are large,
diamond shaped. White bands on body.
(confused with wolf snake)
3. Russels viper Triangular head, inverted V
mark on head.
(confused with python)
4. Saw scaled viper small, serrated scales.
(confused with Common cat snake)
WHO classification of Indian
Venomous Snakes:
Class I : Commonly cause death
Cobra & Vipers
Class II : Not common, but can
cause death
Krait, King cobra
Class III : No serious effects
Cobra & Rat Snake
Krait & Wolf Snake
Russels Viper & Python
Saw scaled viper & Cat snake
The Big Four:

A] Elapids - Neurotoxic
1. Common Cobra Naja Naja
2. Common Krait Bungarus caeruleus

B] Viperids Vasculo- & haemotoxic

3. Saw Scaled Viper Echis carinatus
4. Russels Viper Vipera Russelli
A] Coomon Cobra:
Naja Naja
-Length -5-6 feet
-Hood
-Monocle or spectacle mark
-3rd supralabial scale is largest
-Less agressive
B] Common Krait
-Bungarus Caeruleus
-Common Name: Manyar
-Length 3-4 feet
-Colour Steel blue/Black with white bands
- Dorsal midline scales are largest,
hexagonal
- Habit to enter human dwellings.
C] Saw scaled Viper:
Echis carinatus
-Common name: Phoorase
-Length- 1.5-2 feet
-triangular head, serrated scales,
-Figure of 8
-hissing sound
- Very aggressive
D] Russels viper:
-Vipera russelli
-Common name Ghonas
-Length- 5-7 feet
-Head Triangular with V mark
-3 rows of chained dark spots over body
-Loud hissing.
-Very aggressive & most dangerous.
Snake Venom:
Venom: Must be injected.
Toxic saliva secreted by modified parotid
glands.
Most complex of all poisons.

Consists of:
A] Proteins Enzymes & non- enzymes
B] Non proteins Carbohydtrates & metals.

Most dangerous are polypeptides.

A] Elapids: Neurotoxic venom
Cobrotoxin & Bungarutoxin Prevent release of acetyl
choline at NM junction.

B] Viperids: Vasculotoxic & haemotoxic.

Russels viper Proteases Starts blood clotting
Saw scaled Viper ecarin activates prothrombin.

Hyluronidase Spread of venom

Hydrolases Necrosis
Histamine Pain

Russels viper is most toxic, but yield per bite is more in

case of cobra.
Snake Bite Epidemiology:
India
200000 bites per year; at least
15000 deaths per year.
Symptomology:
A] Non venomous snake:
Psychological shock

B] Venomous snake bite:

a) Without envenomation:
20-50% of cases are without
toxicity
With Envenomation:
A] Elapid bite Neurotoxicity

B] Viperid bite Vasculo & haemotoxicity

C] Hydrophid bite - Myotoxicity

Elapid Bite:
A] Local Effects:
- Fang Mark
- Pain & swelling is very less.
B] Systemic:
Preparalytic stage:
1. Vomiting
2. Ptosis
3. Blurred vision
4. Hyperacusis
5. Paraesthesiae around mouth
6. Headache, myalgia
7. Vertigo
8. Hypersalivation
Paralytic Stage:
Progressive paralysis, ultimately causing respiratory paralysis.
Viperid Bite:
Local:
-Progressive swelling with severe pain.
-Persistent bleeding & bruising
- Necrosis
Systemic:
Bleeding everywhere.

Viperid envenomation defibrination

incoagulable blood
Hydrophid Bite:
Local:
- No pain, minimal local effects.
Systemic:
Myalgia with stiffness & tenderness of muscles
due to rhabdomyolysis.
Myoglobinaemia & myoglobinuria occur.

Damaged muscles release of potassium

cardiac arrest.
Diagnosis of Snake bite:
1. Fang Marks
2. Identification of snake
3. Lab investigations.

Confirmation of venom is by
immunological methods like ELISA.
20 WBCT:
Very useful bed side test in case of
viper bite to check coaguability of
bood.
Treatment:
FIRST AID:
1. Reaasurance
2. Immobilization
General Sutherland wrap
Local Compression pads (Monash)
3. Drugs: Avoid NSAIDs, IM or SC injections
DONT
1. Alcohol
2. Torniquet
3. Incision & Suction
4. Cryotherapy
5. Electric shocks
Hospital Management:
A] Antivenom:
Never use as a routine.
Indications: (Reids criteria)
1. Prolonged hypotension
2. Persistent shock
3. Pronounced leukocytosis
4. Acidosis
5. ECG changes (bradycardia with ST elevation or
depression, T inversion, QT prolongation)
6. Extensive swelling
7. Hemolysis
8. Pregnant women, small children
How antivenom is prepared?
Immunization of horses with snake venom

Form: lyophylised

Route: Preferably IV

Procedure:
1. Sensitivity test
2. Desensitization

Timing: Never too late

Dose: No fixed dose. Can start with IV 2ml/minute. 7-10

vials given. Wait for 3-5 hours repeat tests.
Complications:
1. Anaphylactic reaction
2. Pyrogenic reaction
3. Late serum sickness

Contraindications: No absolute
contraindications.
Other Management:
1. Clean bite site.
2. Dont rupture blisters.
3. Antibiotics
4. Intracompartmental syndrome-
fasciotomy
5. Coagulation disorders
6. Hypotensive shock
7. Renal failure Diuretics
8. Neurotoxicity: Neostigmine & atropine.
Medico-legal Importance:
 Scorpion:
Scientific Name: Mesobethus Tumulus
Position in classification: Animal Irritant.
Identification:
Cephalothorax (fused head & chest), an
abdomen, & six segmented tail which
terminates in a bulbous enlargement called
telson.
- Length 3.
Red Scorpion
 Venom:
Complex, varies with species.
- Phospholipase- A causes GI &
pulmonary hemorrhages & DIC.
 Mode of Action:

Affect sodium channels Prolongation of

action potential & spontaneous
depolarization of nerves of both adrenergic
& parasympathetic nervous systems
Adrenergic & cholinergic symptoms.

Hyperkalemia, hyperglycemia, increased

secretion of renin & aldosterone.
 Clinical Features:
Local Local pain, swelling, redness &
regional lymhadenopathy.
Systemic S/o autonomic stimulation,
pulmonary oedema.
 Fatal Dose:
Uncertain
Fatal Period:
2-3 hours.
 Treatment:
A) First Aid:
1. Immobilisation
2. Torniquet
3. Negative- pressure suction.
B) Hospital:
1. Hemodynamic monitoring
2. Ventillation
3. Prazocin Hydrochloride -500gm every 4-6 hrs.
4. Antivenom
 PM appearance:
Widespread haemorrhages.
 Medico legal Aspects:
Accidental.