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Snakes

Bite

SnakesSnakes

BiteBite

Snakes BiteSnakes Bite

Dr. Lili K. Djoewaeny SpB

SMF Bedah RSUD Cianjur


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In North America approximatelly 8000 person areIn North America approximatelly 8000 person are

bitten each year by poissonous snakesbitten each year by poissonous snakes

Over 98 percent of bite occuring on theOver 98 percent of bite occuring on the

extremitiesextremities

Rattle snakes are responsible for approximatellyRattle snakes are responsible for approximatelly

70 percent of deaths from snakes bites70 percent of deaths from snakes bites


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The venoms of poisonous snakes consist ofThe venoms of poisonous snakes consist of

enzymatic complex proteins that affect allenzymatic complex proteins that affect all

soft tissuesoft tissue

Venoms have been shown to haveVenoms have been shown to have

neurotxic, antifibrinolytic, hemolytic,neurotxic, antifibrinolytic, hemolytic,

thrombogenic, hemorrhagic, cytotoxic, andthrombogenic, hemorrhagic, cytotoxic, and

anticoagulant effectsanticoagulant effects


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Most of venoms contain hyaluronidase,Most of venoms contain hyaluronidase,which enhances the rapid spread of venomswhich enhances the rapid spread of venoms

by way of th superficial lymphaticby way of th superficial lymphatic

Variation of the venoms effectsVariation of the venoms effects

Neurotoxic such as muscle cramping,Neurotoxic such as muscle cramping,

fasciculation, weakness, and respiratoryfasciculation, weakness, and respiratoryparalysis or hemolytic characteristic mayparalysis or hemolytic characteristic may

predominate, depending on the snakepredominate, depending on the snake


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Fang marks produce characteristically bysnakes

Local signs and symptoms can includeswelling, tenderness, pain, and echymosisand may appear within minutes at the site

of venom injection

If no pain or edema is present within 30minutes after injury, the snake probablydidnot inject any venom


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Swelling may continue to increase for 24

hours

Hemorrhage vesiculation, bullae, andpetechiae may appear between 8 and 36hours, with thrombosis superficial vesselsand eventual sloughing of tissues


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Systemic symptom include such ashypotension, weakness, sweating and

chills, dizziness, nausea and vomiting,parestesias, and muscle fasciculating

Muscle fasciculation are most common

after a ratlesnake bite, often in the perioralregion and face muscle area, neck andback


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Some times the venomsproduce deleterious changes

in the blood cells, defect inblood coagulations, injuries into the intimal linings ofvessels, damage to the heartmuscles, alterations in

respiration, and to lesserextent, changes inneuromuscular conduction


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In severe poisoning: pulmonary

edema, hemorrhage into the lungs,kidney, heart, and peritoneum can

occurs

Hematemesis, melena, changes insalivation, and muscle fascuculation

may be seen


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Urinalysis may reveal hematuria,glycosuria, and proteinuria

Red blood cells and platelets are can

decrease, bleeding and clotting timeusually are prolonged

Total afibrinogrenemia are hallmark of

severe envenomation


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Management of Snake BitesManagement of Snake Bites

Application of tourniquet, incission, and

suction are appropriate if used within 1hour of the time of bite

The tourniquet should be applied toobstruct only venous and lymphatic flow

The tourniquet is not released once

applied and may be left in place during the30 minutes that suction is applied.


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The tourniquet may be removed afterdefinitive treatment has been instituted

and patient is not in shock

Incision and suction for 30 minutes may be

beneficial if accomplished within 30minutes after snakebite

The incision should be longitudinal notcruciate


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When two fang marks are seen, the depthof the venom injection is generally

considered to be one-third of the distancebetween the fang marks

Incision made proximal to the bite arecontraindicated

Most important treatment for snakebite isantivenin


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Because antivenin contains horse serum,

before its administration skin testing isrequired

Epinephrine 1/1000 in a syringe should beavaliable before antivenin is given

The indication of antivenin is governed by

the degree of envenomation (see table)


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Always presentPresentMay extend beyond

the involve

extremityinto the ipsilateral

trunk

Severe+IV

Very Severe

Envenomation

Petechie and

ecchymosis

Present> 12 inchSevere+III

Severe

Envenomation

Possible12 hours after

bite

6 12 inchSevere+II

Moderate

Envenomation

No12 hours after

bite

1 5 inchModerate

To

Severe

+I

Minimal

Envenomation

NoAt 12 hours< 1 inchMinimal+0

No

Envenomat

ion

systemicerythemaedemapainfang markgrade

Table of grading envenomatinTable of grading envenomatin


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Grade 0 I usually not required

Grade II may required 3 4 ampules

Grade III usually required 5 15 ampules

If systemic manisfetation are severe,antivenin should be given rapidly, byintravenous drip, in large dose

The injection antivenin locally around the

bite is not advised


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If antivenin is indicated, 3 to 5 ampules are

given by intravenous drip in 500 mLnormal saline solution or 5% glucosesolution

If severe systemic symptom are alreadypresent 6 to 8 ampules are given inaddition


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The dose of antivenin more easily titrated

with respond to treatment, based onimprovement sign and symptoms not onthe weight of the patient

Antivenin is administered until severe localor systemic symptoms improve


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If too much time has elapsed for excisionto be effective or the patient is allergic to

horse serum, a slow infusion 1 ampule ofantivenin in 250 mL of 5% glucose solutionmay given in 90 minutes period constant

monitoring of blood pressure andelectrocardiogram


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If an immediate reaction occurs, the

antivenin is stopped, and vasopressor andepinephrine may be required

Vitamin K also may also be required

Tetanus toxoid is administered

Antibiotic is recomended to preventsecondary infection


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