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Bites and Stings. Dr Pavan .M MD(A &EM), VMKVMC. Epidemiology. 3 million bites and 1,50,000 deaths/year from venomous snake worldwide. Bites highest in temperate and tropical regions. 3000 species of snakes, out of them only 10-15% of snakes are venomous

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bites and stings

Bites and Stings

Dr Pavan .M

MD(A &EM), VMKVMC

epidemiology
Epidemiology

3 million bites and 1,50,000 deaths/year from venomous snake worldwide.

Bites highest in temperate and tropical regions.

3000 species of snakes, out of them only 10-15% of snakes are venomous

97% of all snake bites are on the extremities

common snakes india
Common Snakes - INDIA

Cobras(nagraj) –Naja naja,N.oxiana, N.kabuthia

Neurotoxicity usually

predominates.

slide5

Russell’s viper(kander)-Daboia russelii

Heat-sensing facial pits

(hence the name "pit vipers").

slide7

Features of poisonous & non-poisonous snakes

Non Poisonous Snakes

Head - RoundedFangs - Not presentPupils - RoundedAnal Plate - Double row Bite Mark - Row of small teeth.

Poisonous Snakes

Head – Triangle

Fangs – Present

Pupils - Elliptical pupil

Anal Plate - Single row

Bite Mark - Fang Mark

Approximately 2500 different species of snakes are known. Approximately

snake venom
Snake Venom

Snake venom is highly modified saliva

mechanism of toxicity
Mechanism of toxicity

Cytotoxic effects on tissues

Hemotoxic

Neurotoxic

Systemic effects.

Toxic dose. The potency of the venom and the amount of venom injected vary considerably.

20% of all strikes are "dry"

snake venom necrosis
Snake Venom, Necrosis

Proteolytic enzymeshave a trypsin-like activity.

Hyaluronidase splits acidic mucopolysaccharides and promotes the distribution of venom in the extracellular matrix of connective tissue.

Phospholipases A2-break down membrane phospholipids -causes cellular membrane damage

contd
Contd..

All these enzymes cause oedema, blister formation and local tissue necrosis

snake venom paralysis
Snake Venom ,Paralysis

Blocks the stimulus

transmission from

nerve cell to muscle

and cause paralysis

Does not penetrate

the blood-brain barrier

contd1
Contd..

Postsynaptic effects are reversible with antivenom and neostigmine.

Presynaptic nerve terminal, e.g. beta-bungarotoxin and here neostigmine will not be effective.

snake venom hemorrhages
Snake venom, Hemorrhages

Activate prothrombin (e.g. ecarin from Echis carinatus)

Effect on fibrinogen and convert it into fibrin -thrombin-like activity, such as crotalase (rattlesnake venom)

Activate factor 5, factor 10 , Protein C

Activate or inhibit platelet aggregation

Haemmorhagins- cause endothelial damage

clinical syndromic approach syndrome 1
Clinical syndromic approachSyndrome 1

Local envenoming

(swelling etc) with

bleeding/clotting

disturbances

VIPERIDAE

syndrome 2
Syndrome 2

Ptosis, external opthalmoplegia, facial paralysis etc and dark brown urine=Russell\'s viper, Sri Lanka and South India

syndrome 3
Syndrome 3

Local envenoming (swelling etc) with paralysis=Cobra or king cobra

syndrome 4
Syndrome 4

Paralysis with minimal or no local envenoming

Krait, Sea snake

syndrome 5
Syndrome 5

Paralysis with dark brown urine and renal failure: Russle viper

grade 0
Grade 0

No evidence of envenomation

Suspected snake bite

Fang mark may be present

Pain and 1 inch edema & erythema

No systemic signs- first 12 hours

No lab changes

grade 1
Grade 1

Minimal envenomation

Fang wound & moderate pain present

1-5 inches of edema or erythema

No systemic involvement in present after 12 hours

No lab changes

grade 2
Grade 2
  • Moderate envenomation
  • Severe pain
  • Edema spreading towards trunk
  • Petechiae and ecchymosis limited area
  • Nausea,vomiting,giddiness
  • Mild temperature
grade 3
Grade 3

Severe envenomation

Within 12 hours edema spreads to the extremities and part of trunk.

Petechiae and ecchymosis may be generalized

Tachycardia

Hypotension

Subnormal temperature

grade 4
Grade 4

Envenomation very severe

Sudden pain rapidly

Progressive swelling which leads to ecchymosis all over trunk

Bleb formation and necrosis

grade 4 contd
Grade 4 contd…

Systemic manifestations within 15 min after the bite

Weak pulse,N&V,vertigo

Convulsions, coma

what investigation to do
What investigation to do?

CBC

RFT

Coagulation studies

Blood grouping & cross matching

Sr.electrolytes

Urinalysis

20 min whole blood clotting time
20 min whole blood clotting time

A few milliliters of fresh blood are placed in a new, plain glass receptacle (e.g., test tube) and left undisturbed for 20 min.

contd2
Contd…

The tube is then tipped once to 45° to determine whether a clot has formed. If not, coagulopathy is diagnosed

hess s test
Hess\'s test

Blow up a blood pressure cuff to 80 mm Hg and leave it on for 5 minutes.

If a crop of purpuric spots appears below the cuff, the test is positive.

first aid
First Aid

First Aid

donts
Donts
  • No Tornique
  • No Suction apparatus to be used(Sawyers)
  • Do not run
  • No role of Ice application
slide34
ASV

When to use ASV?

How much to use?

What if a reaction occurs?

When to stop ASV?

when to use asv
When to use ASV

Hemostatic abnormalities(lab and clinical)

Progressive local findings

Neurotoxicity

Systemic signs and symptoms

Generalised rhabdomyolysis

polyvalent antivenin
Polyvalent antivenin

Manufactured by hyper immunizing horses against venoms of four standard snakes

Cobra (naja naja)

Krait (B.caerulus)

Russel’s viper(V.russelli)

Saw scaled viper(Echis carinatus)

contd3
Contd..

Lyophilised form: stored in a cool dark place & may last for 5 years

Liquid form: has to be stored at 4°c with much shorter life span

Each 1ml of reconstituted serum neutralise0.6 mg of naja naja0.45 mg of Bungarus caerulus0.6 mg of V.russelli0.45 mg of Echis carinatus

dose in paediatric
Dose in Paediatric
  • Same as adult as the amount of venom does not change-hence the dose of antivenom should be the same
  • Only the dilution changes
skin testing done if patient is stable and time available
Skin testing- Done if patient is stable and time available

0.02ml of 1:100 solution of serum is injected sc

A positive reaction occurs within 5 to 30 mins.

Appearance of wheal & surrounding erythema

what to do in case of anaphylactic reaction to asv
What to do in case of anaphylactic reaction to ASV

Adrenaline 0.5 to 1ml IM

If hypotension,severe bronchospasm or laryngeal edema give 0.5 ml of adrenaline diluted in 20 ml of isotonic saline over 20 mins iv.

contd4
contd..

A histamine anti H1 blocker-chlorpheniramine maleate-10 mg IV

Pyrogenic reactions-antipyretics

Late reactions-respond to CPM-2 mg, 6 hrly or oral prednisolone-5 mg 6 hrly

what if the patient needs asv following reaction
What if the patient needs ASV following reaction

Dose should be further diluted in isotonic saline and restarted as soon as possible.

Concomitant IV infusion of epinephrine may be required to hold allergic sequelae at bay while further antivenom is administered

when to stop using asv
When to stop using ASV

Bleeding subsides

Lab values returns to baseline

Signs of neurotoxicity reverses

Local effects halts progression

supportive treatment
Supportive treatment

Anticholineesterase have variable but useful role

Trial

Atropine sulphate 0.6 mg

Edrophonium chloride 10 mg IV (or) Neostigmine: 1.5–2.0 mg IM (children, 0.025–0.08 mg/kg)

contd5
Contd..

If objective improvement is evident at 5 min

continue neostigmine at a dose of 0.5 mg (children, 0.01 mg/kg) every 30 min as needed with

atropine by continuous infusion of 0.6 mg over 8 h -children, 0.02 mg/kg over 8 h

contd6
Contd

Hypotension

Administration of crystalloid (20–40 mL/kg)

Trial of 5% albumin (10– 20mL/kg)

CVP guided fluids

Inotropic support and invasive monitoring

contd7
Contd..

Oliguria & renal failure- fluids,diuretics, dopamine

no response-fluid restriction- Dialysis

Local infection- TT,antibiotics

Haemostatic disturbances-FFP,fresh whole blood,cryoprecipitates

cobra spit opthalmia
Cobra spit opthalmia

Topical antimicrobial

0.1% adrenaline relieves pain

No need for ASV

compartment syndrome
Compartment syndrome

If signs of compartment syndrome are present and compartment pressure > 30 mm Hg:

Elevate limb

Administer Mannitol 1-2 g/kg IV over 30 min

Simultaneously administer additional antivenom, 4-6 vials IV over 60 min

If elevated compartment pressure persists another 60 min, consider fasciotomy

bee sting
Bee Sting

Honey bee belong

Family- Hymenoptera

Sub Family-Apidae

Only the females have adapted a stinger from the ovipositor on the posterior aspect of the abdomen

venom
Venom

Histamine.

Melittina–membraneactive polypeptide that can cause degranulation of basophils and mast cells, constitutes more than 50 percent of the dry weight of bee venom

Venom commonly causes pain, slight erythema, edema, and pruritus at the sting site

presentations
Presentations

Local reaction

Toxic manifestation and anaphylaxis

Delayed reaction –Serum sickness

treatment
Treatment

Immediate removalis the important principle and the method of removal is irrelevant.

Sting site should be washed thoroughly with soap and water to minimize the possibility of infection.

contd8
Contd..
  • Intermittent ice packs at the site- diminish swelling and delay the absorption of venom while limiting edema.
  • Oral antihistamines and analgesics may limit discomfort and pruritus.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) can be effective in relieving pain
severe systemic reaction
Severe systemic reaction

Epinephrine 0.3 to 0.5 mg (0.3 to 0.5 mL of 1:1000 concentration) in adults and 0.01 mg/kg in children (never more than 0.3 mg).

Injected IM and the injection site massaged to hasten absorption

If hypotension,severe bronchospasm or laryngeal edema give 0.5 ml of adrenaline diluted in 20 ml of isotonic saline over 20 mins

Observation for 24 hours in ICU

contd9
Contd…

Parenteral antihistamines (diphenhydramine 25 to 50 mg IV, IM, or PO) and H2-receptor antagonists (ranitidine 50 mg IV)

Steroids (methylprednisolone 125 mg) -to limit ongoing urticaria and edema and may potentiate the effects of other measures.

Bronchospasm is treated with -agonist nebulization.

contd10
Contd..

Hypotension

-massive crystalloid infusion, and central venous pressure monitoring may be helpful in these patients.

-Persistent hypotension require dopamine.

-If dopamine isineffective, an intravenous infusion of epinephrine can beused

preventive care
Preventive Care

Every patient who has had a systemic reaction -insect sting kit containing premeasured epinephrine and be carefully instructed in its use.

Patient must inject the epinephrine at the first sign of a systemic reaction.

Medic alert tag

scorpion sting c exilicauda
Scorpion sting- C. exilicauda

Scorpions have a world-wide distribution.

Highly toxic species are found in the Middle East, India, North Africa, South America, Mexico, and the Caribbean island of Trinidad.

mechanism of action
Mechanism of action

Venom can open neuronal sodium channels and cause prolonged and excessive depolarization

symptoms and sign
Symptoms and sign

Somatic and autonomic nerves may be affected

Initial pain and paresthesia at the stung extremity that becomes generalised

Cranial nerve- abnormal roving eye movements, blurred vision, pharyngeal muscle incoordination and drooling and respiratory compromise

contd11
Contd…

Excessive motor activity

Nausea, vomiting, tachycardia, and severe agitation can also be present.

Cardiac dysfunction, pulmonary edema, pancreatitis, bleeding disorders, skin necrosis, and occasionally death can occur

treatment1
Treatment

Pain Management

Ice pack

Immobilization of limb

Local anaesthetics are better than opiates

Tetanus prophylaxis, wound care and antibiotics

Benzodizepines for motor activity.

contd12
Contd..

Stabilize Airway Breathing and Circulation

Hyperdynamic circulation

Always combination of alpha blocker with beta blocker to prevent unopposed alpha action causing tachycardia

Nitrates for Hypertension/MI

contd13
Contd..

Hypodynamic Circulation:

CVP guided fluids

Decrease preload with furosemide (not hypovolumic)

Reduction of afterload improves outcome-Prazosin, nitroprusside, hydralizine, ACE inhibitor

Dobutamine is the best inotrope, avoid Dopamine

Noradrenaline can be used

newer modality
Newer modality

Insulin has shown to improve cardiopulmonary status in case of scorpion envenomation

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