আলে�কলে�ন্ডারআলে�কলে�ন্ডার:: ' ' আমার মৃত্যু র পর আমার মৃত্যু র পর শুধু আমার চি�চিকৎসকরাই★ শুধু আমার চি�চিকৎসকরাই★ আমার কচি�ন বহন করলেবন। আমার কচি�ন বহন করলেবন। ★আমার কচি�ন যে� পথ চি�লে �ালেব যেসই ★আমার কচি�ন যে� পথ চি�লে �ালেব যেসই

পলেথ অচি�"ত যেসানা ও রুপা ছচি&লে থাকলেব। পলেথ অচি�"ত যেসানা ও রুপা ছচি&লে থাকলেব। ★ কচি�ন বহলেনর সম আমার �ইু হাত বাইলের ঝুচি�লে রাখলেব। ★ কচি�ন বহলেনর সম আমার �ইু হাত বাইলের ঝুচি�লে রাখলেব।

চি�চিকত্সক মৃত্যু র থাবা যেথলেক রক্ষা করলেত অক্ষম। চি�চিকত্সক মৃত্যু র থাবা যেথলেক রক্ষা করলেত অক্ষম। যেসানাযেসানা-- �ানার একটা �ানার একটা কণাওআমার সলে. �ালেব না। পৃচিথবীলেত খাচি� হালেত এলেসচিছআ� পৃচিথবী কণাওআমার সলে. �ালেব না। পৃচিথবীলেত খাচি� হালেত এলেসচিছ আ� পৃচিথবী যেথলেক খাচি� হালেতই �লে� �াচি0 যেথলেক খাচি� হালেতই �লে� �াচি0

Cobra

AnimalAnimal Bites Bites Dr M Nurul HuqDr M Nurul Huq

BMCBMC

Facts of Animal bitesFacts of Animal bites

Most imp. Most imp. animal-bites: animal-bites: dogs, snakes, cats, monkeysdogs, snakes, cats, monkeys Major PH problem. Significant c/of MMMajor PH problem. Significant c/of MM Fate: Fate: type and health of the animal, size and health of type and health of the animal, size and health of

victim, any toxin and carevictim, any toxin and care World:World: of 3000 spp. of of 3000 spp. of snakessnakes: : 20% are venomous20% are venomous Tens of millions of Tens of millions of dog bites/ydog bites/y; the highest in children; the highest in children Rabies can follow dog-, cat- and monkey bitesRabies can follow dog-, cat- and monkey bites

PH: public health. MM: mortality and morbidity. SB: snake bitesPH: public health. MM: mortality and morbidity. SB: snake bites

Snake Bite FactsSnake Bite Facts‘‘Neglected tropical disease’. Neglected tropical disease’. Disease of povertyDisease of poverty Single most important toxin injury, with substantial mortality in Single most important toxin injury, with substantial mortality in

Africa, Asia, AmericasAfrica, Asia, Americas 5 million SB/y. 5 million SB/y. 10% venomous. 10% venomous. Mostly in Africa, SEA Mostly in Africa, SEA Poorest Poorest rural rural people affected: people affected: resource-poor, traditional farming. resource-poor, traditional farming.

Farmers, women, children most frequently bittenFarmers, women, children most frequently bitten 50% venomous SB are envenomated50% venomous SB are envenomated 125k deaths/y; 2.7million permanently disabled 125k deaths/y; 2.7million permanently disabled and emotionally and emotionally

destroyeddestroyed Prompt Rx with ASV (if indicated) is essentialPrompt Rx with ASV (if indicated) is essential

SB: snake bite. ASV: anti snake venomSB: snake bite. ASV: anti snake venom

Regional estimates of SB envenomingsRegional estimates of SB envenomings

Venomous snakes occur throughout many regions and are a threat to Venomous snakes occur throughout many regions and are a threat to PH, most abundant in rural tropics. Out of >3000 spp, 600 are PH, most abundant in rural tropics. Out of >3000 spp, 600 are

venomous and >200 are medically importantvenomous and >200 are medically important

Risk Factors of Snake BitesRisk Factors of Snake Bites

Africa and SEA: warm humid weatherAfrica and SEA: warm humid weather Farm workers, women, childrenFarm workers, women, children Mostly the poor, young, active personsMostly the poor, young, active persons Monsoon, floodMonsoon, flood Rural life, poor housing, lying on floor, darknessRural life, poor housing, lying on floor, darkness Lack of awareness, poor health careLack of awareness, poor health care Scarcity of ASV, resource-poor settingsScarcity of ASV, resource-poor settings Not seeking medical careNot seeking medical care

End the end of this session you will learnEnd the end of this session you will learn

3% of SB victims seek medical Rx3% of SB victims seek medical Rx 90% SB are nonvenomous90% SB are nonvenomous Cytotoxic venom has severe local reactionsCytotoxic venom has severe local reactions Ptosis, Ptosis, drowsiness,drowsiness, are an imp. s/of neurotoxinare an imp. s/of neurotoxin Bleeding Bleeding shock are imp. s/of hemotoxinshock are imp. s/of hemotoxin Tourniquet must be tight enough to block lymph flow and Tourniquet must be tight enough to block lymph flow and

loose enough to insert a fingerloose enough to insert a finger

Barbados threadsnake (Leptotyphlops carlae) is blind

Smallest known snake, found only in BarbadosSmallest known snake, found only in Barbados

Neglected Tr. DiseaseNeglected Tr. Disease IncidenceIncidence DeathsDeathsSnakebite envenomingSnakebite envenoming 5million5million 125k125kChaga’sChaga’s 217,000217,000 14k14k

CholeraCholera 178,000178,000 4k4k

DHFDHF 73,00073,000 19k19k

LeishmaniasisLeishmaniasis 1,691,0001,691,000 5151

J. EncephalitisJ. Encephalitis 44,00044,000 14k14k

SchistosomiasisSchistosomiasis 5,733,0005,733,000 15k15k

Y. Fever Y. Fever 2,1002,100 100100

SB does not have the epidemic potential of IDs. But death from it SB does not have the epidemic potential of IDs. But death from it doubles the NTD mortalitydoubles the NTD mortality

Peculiarities of Snakes Peculiarities of Snakes NocturnalNocturnal Shed skin periodicallyShed skin periodically No moveable eyelid, no ears! No moveable eyelid, no ears! Deaf to airborne soundsDeaf to airborne sounds Feel vibrations by skinFeel vibrations by skin 3 spp. can spit venom at enemy’s eyes up to 8 ft3 spp. can spit venom at enemy’s eyes up to 8 ft 1 tree-snake of SEA can 'fly‘ by flattening its body1 tree-snake of SEA can 'fly‘ by flattening its body

SEA: South East AsiaSEA: South East Asia

BANGLADESH SCENARIOBANGLADESH SCENARIO The single most toxin-injuryThe single most toxin-injury A big PH issue: big impact on health and economyA big PH issue: big impact on health and economy 700k SB/y700k SB/y: : 30% while walking at night, 25% in field, 15% in 30% while walking at night, 25% in field, 15% in

sleep. sleep. CFR 20%: CFR 20%: 6k death: 6k death: 22ndnd c/of unnatural death c/of unnatural death More in monsoons/flood (2More in monsoons/flood (2ndnd mortality after drowning) mortality after drowning) More in monsoons, after earthquakesMore in monsoons, after earthquakes 3% 3% seek medical care! seek medical care! CMCH: 30% envenomated SB (CFR 0.5%)CMCH: 30% envenomated SB (CFR 0.5%) 82 spp. snakes: 28 venomous (82 spp. snakes: 28 venomous (cobras, kraits, green pit cobras, kraits, green pit

vipers and sea snakes vipers and sea snakes Neurotoxic kraits and cobras main c/of deathNeurotoxic kraits and cobras main c/of deathPH: public health. CFR: case fatality ratePH: public health. CFR: case fatality rate

CMCH, ChittagongCMCH, Chittagong

623/100k/Y: 710,159 bites623/100k/Y: 710,159 bites

6,041 death/y6,041 death/y

Community Survey Community Survey 20102010

Problems with SB in BangladeshProblems with SB in Bangladesh

97% not seeking medical RX or are late in response97% not seeking medical RX or are late in response Lack of awareness, guidanceLack of awareness, guidance SuperstitionsSuperstitions Dangerous unhealthy practicesDangerous unhealthy practices Scarcity of ASVScarcity of ASV High costs, poor quality ASVHigh costs, poor quality ASV No political willNo political will

ASV: anti-snake venomASV: anti-snake venom

Monocellete cobra/ gokhra

SNAKES OF BANGLADESHSNAKES OF BANGLADESH

King cobra, King cobra, Raj gokhra, Raj gokhra, ShankhochurShankhochurSylhet, Ctg. Sylhet, Ctg. BarisalBarisal

Common krait, kal kewtey, Common krait, kal kewtey, Malcha alad Malcha alad Everywhere in Bangladesh.Everywhere in Bangladesh.

Banded krait. More in Chittagong rare

Black krait, recently found in Chittagong and other parts of the country

Russel viper in Rajshahi & Khulna, Ctg

Green snake, bash-bora, sabuj-bora in Green snake, bash-bora, sabuj-bora in Sylhet, Ctg, Barisal & KhulnaSylhet, Ctg, Barisal & Khulna

Hooknosed sea snake in sea and coastal saline Hooknosed sea snake in sea and coastal saline water of Bangladesh.water of Bangladesh.

Dog BitesDog Bites Tens of millions/y. Mostly childrenTens of millions/y. Mostly children L&MICs: 76–94% of animal bites. 60k death from rabiesL&MICs: 76–94% of animal bites. 60k death from rabies >50% of animal-related injuries in travellers>50% of animal-related injuries in travellers

Rx.: Rx.: depends on site of bite, health of victim and dog: depends on site of bite, health of victim and dog: irrigation and cleansing of the woundirrigation and cleansing of the wound primary closure if low-risk for inf.primary closure if low-risk for inf. ABT for high-risk wounds or in immune deficiencyABT for high-risk wounds or in immune deficiency rabies post-exposure Rx depending on the dog vaccinationrabies post-exposure Rx depending on the dog vaccination TT if not adequateTT if not adequate

Prevention of Dog BitesPrevention of Dog Bites

Communities – especially children – should be informed Communities – especially children – should be informed about the risks of dog bites and prevention techniques about the risks of dog bites and prevention techniques such as avoiding stray dogs and never leaving a child such as avoiding stray dogs and never leaving a child unattended around a dog unattended around a dog

Appropriate Rx of bites. Ensure rabies control for all dogs Appropriate Rx of bites. Ensure rabies control for all dogs by ARV, and develop data collection systems to further by ARV, and develop data collection systems to further document the burden of this problemdocument the burden of this problem

GSI: in Australia, led by snake experts dedicated to making access to GSI: in Australia, led by snake experts dedicated to making access to ASV in the poorest communities; works also for rehabilitation victimsASV in the poorest communities; works also for rehabilitation victims

Venomous snakesVenomous snakes90% are of 3 families90% are of 3 families

Elapidae (cobra, coral, krait, mamba)Elapidae (cobra, coral, krait, mamba) Viperidae (vipers)Viperidae (vipers) Hydrophidae (sea)Hydrophidae (sea)

Children have more reactions and death due to their Children have more reactions and death due to their small sizesmall size

PathogenesisPathogenesis

Venoms: Venoms: mix. of enzymes (mix. of enzymes (polypeptides, proteases, polypeptides, proteases, toxin: toxin: sp. specific)sp. specific)

Neurotoxin:Neurotoxin: paralysis paralysis (c(cobra, krait, and obra, krait, and sea)sea) Cytolytic:Cytolytic: necrosis necrosis (viper)(viper) Coagulopathin/hemorrhagin/hemotoxin:Coagulopathin/hemorrhagin/hemotoxin:

bleeding bleeding (vipers,(vipers, cobras, kraits, sea snakes) cobras, kraits, sea snakes) Myotoxins: Myotoxins: muscle breakdownmuscle breakdown

Bilateral ptosis: neurotoxin

Ophthalmoplegia: attempting to look to right

Snake Bites: EffectsSnake Bites: Effects Non-venomous

anxiety, grievance, depression, 2y infx.,

Venomous severe local swelling: cytolysis, skeletal muscle damage paralysis: resp. failure bleeding: fatal shock irreversible renal failure cardiac abnormalities

Local swelling, blistering with early necrosis: cobra (Naja kaouthia)

Necrosis: Malayan pit viper

Necrosis: spitting cobra (Naja siamensis)

Antivenoms (ASV): Made in horse, sheep

Most effective within 4h No value after 12h Serious SE like anaphylaxis (more in equine serum)

Management of Snake Bites in the SEA

CFCF

Envenomation or notEnvenomation or not Type of venomType of venom Amount of venom Amount of venom

When venom has not been injectedWhen venom has not been injected

People who are bitten/suspect bite/imagine bite, may have People who are bitten/suspect bite/imagine bite, may have striking SS!striking SS! tachypnea, paresthesias, stiffness/tetany, dizzinesstachypnea, paresthesias, stiffness/tetany, dizziness

some may faint with profound bradycardia. Others are some may faint with profound bradycardia. Others are v. agitated, irrational with misleading symptomsv. agitated, irrational with misleading symptoms

Another source of SS: Another source of SS: first aid/traditional Rx.first aid/traditional Rx.

Tourniquets:Tourniquets: pain, swellingpain, swelling Herbal remedies: Herbal remedies: vomitingvomiting Irritant plant juices into eyes: Irritant plant juices into eyes: red eyesred eyes Forcible blowing oils into RT: Forcible blowing oils into RT: aspiration, broncho-aspiration, broncho-

spasm, ruptured ED, pneumothoraxspasm, ruptured ED, pneumothorax Incisions, cautery, immersion in scalding liquid and Incisions, cautery, immersion in scalding liquid and

heating over a fire: heating over a fire: devastating devastating injuriesinjuries

Fang marks. Early bite painFang marks. Early bite pain local pain (burning, local pain (burning, bursting)bursting) red, hot, blistering, hge., bruising, swelling red, hot, blistering, hge., bruising, swelling gradually extending up, b, blistering, abscess, necrosisabscess, necrosis

Lymphangitis, tender LAP. Local infectionLymphangitis, tender LAP. Local infection Bites by kraits, sea snakes, Philippino cobras may be Bites by kraits, sea snakes, Philippino cobras may be

painless with little swelling. painless with little swelling. Someone asleep may not Someone asleep may not even wake up. even wake up. There may be no visible fang marksThere may be no visible fang marks

If envenomatedIf envenomated

Local (immediate) FeaturesLocal (immediate) Features

General (gradual) Features

Prostration, agitation, frustration, fear of death NVD, malaise AP, weakness, severe HA, “Heaviness” of eyelidsevere HA, “Heaviness” of eyelids Inappropriate dInappropriate drowsiness, blurred visionlurred vision Fainting, convulsions, dizziness, collapse (shock)Fainting, convulsions, dizziness, collapse (shock) Fever, excessive sweating, increased thirstFever, excessive sweating, increased thirst ARDS, etc.

Envenomation GradesEnvenomation Grades

Grade Grade 00:: no envenomationno envenomation ,, ,, 1:1: minimal: minimal: local swelling, pain. local swelling, pain. Static Static ,,,, 2:2: moderate: moderate: progressive swelling, pain, progressive swelling, pain,

bruises, bruises, mild system upset, mild system upset, lab featureslab features ,,,, 3:3: severe: severe: marked local and/or sys. marked local and/or sys.

features. features. Significant lab. findings Significant lab. findings

ChildrenChildren have rapid progress. 75% have Gr. 2have rapid progress. 75% have Gr. 2ndnd or 3 or 3rdrd

Fang marks of Russell’s viper

Local swelling, blistering  with bruising

Local hge. from fang marks: Malayan pit

viper

NeurotoxicNeurotoxic (Elapidae, Russell viper)(Elapidae, Russell viper)

ptosis: ptosis: “Heavy” eyelids“Heavy” eyelids (100%) (100%) ophthalmoplegia (94.2%), ophthalmoplegia (94.2%), Cr. nerve palsiesCr. nerve palsies broken neck sign (80%), broken neck sign (80%), flaccid paralysisflaccid paralysis dysphagia (77.1%)dysphagia (77.1%) dysphonia (68.5%), aphoniadysphonia (68.5%), aphonia drowsiness, paresthesia, abnormal taste, smelldrowsiness, paresthesia, abnormal taste, smell

Bilateral ptosis: common krait

RhabdomyolysisRhabdomyolysis (sea snakes, Russell viper)(sea snakes, Russell viper)

Generalized painGeneralized pain Stiff and tender Stiff and tender musclesmuscles TrismusTrismus MyoglobinuriaMyoglobinuria HyperkalemiaHyperkalemia Cardiac arrestCardiac arrest ARFARF

Renal damageRenal damage (Viperidae, sea snakes)(Viperidae, sea snakes)

Loin painLoin pain Hematuria, hemoglobinuria, myoglobinuriaHematuria, hemoglobinuria, myoglobinuria Oliguria/anuria, ARFOliguria/anuria, ARF Uremia (acidotic breathing, hiccups, NV, pleuritic pain)Uremia (acidotic breathing, hiccups, NV, pleuritic pain)

Russell viper: She passes

dark brown urine 8h after SB

EndocrineEndocrine (pituitary/adrenal). (pituitary/adrenal). Russell viperRussell viper

CytotoxinCytotoxin Ac. phaseAc. phase: : adrenal crisis, shock, hypoglycemiaadrenal crisis, shock, hypoglycemia Late: Late: months to yearsmonths to years

weaknessweakness loss of 2y sexual hairloss of 2y sexual hair amenorrheaamenorrhea testicular atrophytesticular atrophy hypothyroidism etchypothyroidism etc

Panhypopituitarism: loss of secondary sexual hair and testicular

atrophy 3 y later

Cardiovascular/blood Toxicity Cardiovascular/blood Toxicity (Vipers)(Vipers)

Bleeding from fang marks, venepuncture sitesBleeding from fang marks, venepuncture sites Spontaneous bleeding Spontaneous bleeding

gums, nose, tears, hemoptysis, hematemesisgums, nose, tears, hemoptysis, hematemesis PR hge., malena, hematuria, PV hgePR hge., malena, hematuria, PV hge purpura, ecchymoses, eye chemosis, vpurpura, ecchymoses, eye chemosis, visual problems

Shock, collapse, arrhythmias, Shock, collapse, arrhythmias, IC Hge, pIC Hge, pulmonary edema

Gingival bleeding: viper

Subconjunctival hge.: Burmese Russell’s viper

Species of snake can beSpecies of snake can be

confirmed by seeing the dead snakeconfirmed by seeing the dead snake from pt.’s description or the circumstancesfrom pt.’s description or the circumstances from clinical effectsfrom clinical effects

This will choose ASV better, anticipate complications. If This will choose ASV better, anticipate complications. If unknown, pattern of SS and lab results may suggest unknown, pattern of SS and lab results may suggest

SyndromicSyndromic Approach for MxApproach for MxLimitations:Limitations: Considerable overlap of CF c/by venoms of different spp.Considerable overlap of CF c/by venoms of different spp. Effects of a particular venom is very wideEffects of a particular venom is very wide Some cobras cause severe local reactionsSome cobras cause severe local reactions Russell viper: paralysis mimics elapid neurotoxicityRussell viper: paralysis mimics elapid neurotoxicity Myalgia and dark urine mimic sea snake rhabdomyolysisMyalgia and dark urine mimic sea snake rhabdomyolysis

““Syndromic approach" Syndromic approach" may still be useful if the may still be useful if the snake is not identified and only monospecific AV snake is not identified and only monospecific AV

are availableare available

SYNDROME 1SYNDROME 1 Local features with Local features with swelling with bleeding/clotting

disturbances. No paralysis. All ll VipersVipers

SYNDROME 2 SYNDROME 2 (Russell viper)(Russell viper) Features of hge., shock or ARFFeatures of hge., shock or ARF Neurotoxicity and dark brown urineNeurotoxicity and dark brown urine Chemosis and ac. pituitary insufficiency,Chemosis and ac. pituitary insufficiency, ptosis, external

ophthalmoplegia, facial palsy, etc.

SYNDROME 3SYNDROME 3 Local envenoming (swelling etc) with paralysis: Local envenoming (swelling etc) with paralysis: Cobra/ Cobra/

King CobraKing Cobra

SYNDROME 4: neurotoxin Features of paralysis with minimal/no local reaction

Bitten on land while sleeping: outside Philippines: krait; in Philippines: cobra

Bitten in the sea (sea snake) Paralysis with minimal or no local envenoming

Summary of ManifestationsSummary of ManifestationsLOCALLOCAL NEURONEURO BLEEDBLEED MISC.MISC.

COBRACOBRA ++ ++++ NilNil Shock +/-Shock +/-

KRAITKRAIT NilNil ++ NilNil Pupils –dilated, Pupils –dilated, fixedfixed

VIPERVIPER ++++++ + / -+ / - ++++ Renal failure, ShockRenal failure, Shock

Management Management Identify the sp. (killed/description) Mostly nonvenomous; if venomous: First aid: First aid:

block lymphatics by tourniquet, immobilization Tourniquet: loose enough to insert a finger Avoid ice pack, excision, suction

Transport to hospital/poison centre

Rapid clinical assessment, species Dx., resuscitation

Investigations:

DOs IN SNAKE BITE DOs IN SNAKE BITE Consolation. Remove tight outfitting & ornamentsConsolation. Remove tight outfitting & ornaments Crepe bandage/Crepe bandage/ tourniquet above wound above wound Rush to Hospital. Look for SS on the way Rush to Hospital. Look for SS on the way

DON’TsDON’Ts Don’t get panicked. Don’t waste time. No superstitionDon’t get panicked. Don’t waste time. No superstition ,, apply ice; make any incision or amputation,, apply ice; make any incision or amputation ,, allow victim any work,, allow victim any work ,, suck the wound. Don’t use electrical therapy,, suck the wound. Don’t use electrical therapy If killed, identify snake. A dead snake’s jaw can bite due to If killed, identify snake. A dead snake’s jaw can bite due to

reflex. Bites by small snakes should not be ignoredreflex. Bites by small snakes should not be ignored

LabLab

Blood: CBC, grouping, cross matching. BT, CTBlood: CBC, grouping, cross matching. BT, CT PT, APTT, fibrinogen, FDP, BUN, CreatininePT, APTT, fibrinogen, FDP, BUN, Creatinine CPK, LDHCPK, LDH Urinanalysis, myoglobinuriaUrinanalysis, myoglobinuria Toxin detection at bite site, serum, urineToxin detection at bite site, serum, urine Repeat at intervalsRepeat at intervals

RxRx Immediate: Immediate: completely immobilizecompletely immobilize bitten part, wound bitten part, wound

cleansing, breathing, circulation, TT, prompt transfercleansing, breathing, circulation, TT, prompt transfer Assess for type of venom if anyAssess for type of venom if any ASV: ASV: Polyvalent: highly effective and specific; Polyvalent: highly effective and specific; 25-100ml

(55ml). Mostly single dose, more for krait, more for krait Prepn. for SErepn. for SE Observe response to ASV:

decision for further dose(s) Supportive Rx. Rehabilitation Rx of chr. complications

DD venomous/non- bite: DD venomous/non- bite: cl. criteria, 20 min blood cl. criteria, 20 min blood clot test, seeing snake if available and venom detection in clot test, seeing snake if available and venom detection in bite site, serum, urine (n.a. here)bite site, serum, urine (n.a. here)

If neurotoxic: neostigmine-atropine may be the only If neurotoxic: neostigmine-atropine may be the only supportive if ASV is n.a.supportive if ASV is n.a.

Despite ASV some neurotoxic victims develop resp. failure Despite ASV some neurotoxic victims develop resp. failure needing ventilationneeding ventilation

FU: FU: vitals, capillary refill, measure circumference of bitten vitals, capillary refill, measure circumference of bitten limb, demarcate ecchymoses and swellinglimb, demarcate ecchymoses and swelling

n.a.: not availablen.a.: not available

Problems with ASVProblems with ASV

first developed in the 1890 s′first developed in the 1890 s′ V. expensive, high dosage, shortage of supplyV. expensive, high dosage, shortage of supply May be of poor quality (unscrupulous manufacturer)May be of poor quality (unscrupulous manufacturer) Severe SESevere SE Polyvalent are often usedPolyvalent are often used Local cytolysis is not well-coveredLocal cytolysis is not well-covered

ASV SE: Early/delayed (88.5%)

Mild to severe Early: pyrogenic (chills, shivering, HA, F =88%),

anaphylaxis:

Delayed: serum sickness (F, rash, LAP, arthralgia)

AnaphylaxisAnaphylaxis

66%. Within 10-50 min, not later than 1 hr: urticaria (80%); 66%. Within 10-50 min, not later than 1 hr: urticaria (80%); NV and wheezing (40%); angioedema (10%), cough, HA, F, NV and wheezing (40%); angioedema (10%), cough, HA, F, tachycardiatachycardia

Rx with adrenaline, hydrocortisone, AH and ranitidineRx with adrenaline, hydrocortisone, AH and ranitidine The average recovery time was 4.5hThe average recovery time was 4.5h

Death from SBDeath from SB

Respiratory paralysisRespiratory paralysis Hemorrhagic shockHemorrhagic shock Local or systemic toxicityLocal or systemic toxicity NeurotoxicityNeurotoxicity Renal failureRenal failure

Tissue loss, débridement, dTissue loss, débridement, disfigurement, amputation isfigurement, amputation Chr. ulceration, infectionChr. ulceration, infection Osteomyelitis/arthritisOsteomyelitis/arthritis CRFCRF Panhypopituitarism or D insipidusPanhypopituitarism or D insipidus Chr. neurological deficit Chr. neurological deficit Malignant changeMalignant change

Long Term ComplicationsLong Term Complications

Chr. handicap from necrotic envenoming

Sq. cell Ca at the site of a chr. skin ulcer with osteomyelitis 8y after SB

Chr. handicap from necrotic envenoming

Hemorrhagic infarct of ant. pituitary (Sheehan-

like syn.): Burmese Russell’s viper 

Prevention of SBPrevention of SB

Raise public awareness, political willRaise public awareness, political will Avoid tall grassy areasAvoid tall grassy areas Wear protective shoes and dressWear protective shoes and dress Good housing. Keep storage areas clear of rodents. Store food Good housing. Keep storage areas clear of rodents. Store food

in rodent-proof containersin rodent-proof containers Raise beds and tuck mosquito nets securelyRaise beds and tuck mosquito nets securely No rubbish, woodpiles, low bush around houseNo rubbish, woodpiles, low bush around house Train HC providers, use ASV properlyTrain HC providers, use ASV properly ResearchResearch

WHOWHOis working to address animal bitesis working to address animal bitesFor SB: WHO helps dev. and distribution of AVFor SB: WHO helps dev. and distribution of AVFor rabies, WHO advocates greater access to PEP, education For rabies, WHO advocates greater access to PEP, education in Px and control, mass vax. of dogsin Px and control, mass vax. of dogs

For all animal-bites, WHOFor all animal-bites, WHO prioritizes data collection of burden and riskprioritizes data collection of burden and risk strengthens emergency responsestrengthens emergency response promotes research initiatives that focus on effective Px promotes research initiatives that focus on effective Px

and populations most affectedand populations most affected

Coral snake (Elapidae)

Blue Krait , SEA. 50% bites are fatal even with AV Rx

Cobras

Copperhead

Cottonmouth

Bushmaster

Boomslang

MCQMCQ

Most snake bites are non venomousMost snake bites are non venomous Antivenom is useful up to 24h of biteAntivenom is useful up to 24h of bite Absence of fang marks indicates no envenomationAbsence of fang marks indicates no envenomation Some snake venoms cause rhabdomyolysisSome snake venoms cause rhabdomyolysis Early hyperventilation indicates envenomationEarly hyperventilation indicates envenomation Renal damage is a recognised complicationRenal damage is a recognised complication Polyvalent ASV is commonly usedPolyvalent ASV is commonly used

Next Lecure:

Poisoning

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