Snakes Bite

Dr. Lili K. Djoewaeny SpB SMF Bedah RSUD Cianjur

Snakes Bite

In North America approximatelly 8000 person are bitten each year by poissonous snakes Over 98 percent of bite occuring on the extremities Rattle snakes are responsible for approximatelly 70 percent of deaths from snakes bites

The venoms of poisonous snakes consist of enzymatic complex proteins that affect all soft tissue

Venoms have been shown to have neurotxic, antifibrinolytic, hemolytic, thrombogenic, hemorrhagic, cytotoxic, and anticoagulant effects

Most of venoms contain hyaluronidase, which enhances the rapid spread of venoms by way of th superficial lymphatic Variation of the venoms effects Neurotoxic such as muscle cramping, fasciculation, weakness, and respiratory paralysis or hemolytic characteristic may predominate, depending on the snake

 Fang marks produce characteristically by snakes Local signs and symptoms can include swelling, tenderness, pain, and echymosis and may appear within minutes at the site of venom injection If no pain or edema is present within 30 minutes after injury, the snake probably didnot inject any venom

 Swelling may continue to increase for 24 hours

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

 Systemic symptom include such as hypotension, weakness, sweating and chills, dizziness, nausea and vomiting, parestesias, and muscle fasciculating

Muscle fasciculation are most common after a ratlesnake bite, often in the perioral region and face muscle area, neck and back

 Some times the venoms produce deleterious changes in the blood cells, defect in blood coagulations, injuries in to the intimal linings of vessels, damage to the heart muscles, alterations in respiration, and to lesser extent, changes in neuromuscular conduction

 In severe poisoning: pulmonary edema, hemorrhage into the lungs, kidney, heart, and peritoneum can occurs

Hematemesis, melena, changes in salivation, and muscle fascuculation may be seen

 Urinalysis may reveal hematuria, glycosuria, and proteinuria Red blood cells and platelets are can decrease, bleeding and clotting time usually are prolonged Total afibrinogrenemia are hallmark of severe envenomation

Management of Snake Bites

Application of tourniquet, incission, and suction are appropriate if used within 1 hour of the time of bite The tourniquet should be applied to obstruct only venous and lymphatic flow The tourniquet is not released once applied and may be left in place during the 30 minutes that suction is applied.

 The tourniquet may be removed after definitive treatment has been instituted and patient is not in shock Incision and suction for 30 minutes may be beneficial if accomplished within 30 minutes after snakebite The incision should be longitudinal not cruciate

 When two fang marks are seen, the depth of the venom injection is generally considered to be one-third of the distance between the fang marks Incision made proximal to the bite are contraindicated Most important treatment for snakebite is antivenin

 Because antivenin contains horse serum, before its administration skin testing is required Epinephrine 1/1000 in a syringe should be avaliable before antivenin is given The indication of antivenin is governed by the degree of envenomation (see table)

Table of grading envenomatin

grade 0 No Envenomat ion I Minimal Envenomation II Moderate Envenomation III Severe Envenomation IV Very Severe Envenomation fang mark
+

pain Minimal

edema < 1 inch

erythema At 12 hours

systemic No

Moderate To Severe Severe

1 5 inch

12 hours after bite 12 hours after bite Present

No

6 12 inch

Possible

Severe

> 12 inch

Petechie and ecchymosis Always present

Severe

May extend beyond the involve extremity into the ipsilateral trunk

Present

 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, by intravenous drip, in large dose The injection antivenin locally around the bite is not advised

 If antivenin is indicated, 3 to 5 ampules are given by intravenous drip in 500 mL normal saline solution or 5% glucose solution

If severe systemic symptom are already present 6 to 8 ampules are given in addition

 The dose of antivenin more easily titrated with respond to treatment, based on improvement sign and symptoms not on the weight of the patient

Antivenin is administered until severe local or systemic symptoms improve

 If too much time has elapsed for excision to be effective or the patient is allergic to horse serum, a slow infusion 1 ampule of antivenin in 250 mL of 5% glucose solution may given in 90 minutes period constant monitoring of blood pressure and electrocardiogram

 If an immediate reaction occurs, the antivenin is stopped, and vasopressor and epinephrine may be required Vitamin K also may also be required Tetanus toxoid is administered Antibiotic is recomended to prevent secondary infection