Snake bites and insect stingsSnake bites and insect stings

OutlineOutline

Case presentation Clinical manifestations of snake bites Treatment

Case ReportCase Report

15 y male Barefoot Sudden onset of pain in Lt foot Snake seen and killed

Alert, in pain Swollen leg BP 140/85 P 110

There are approximately 300,000 There are approximately 300,000 poisonous snakebites in the world each poisonous snakebites in the world each year. Approximately 10% of these year. Approximately 10% of these bites results in death; most of these due bites results in death; most of these due to cobra bites in southeast Asia. to cobra bites in southeast Asia.

EpidemiologyEpidemiology

Poisonous Snakes in IsraelPoisonous Snakes in Israel " י א (Vipera palaestina) צפע

חרמון (Vipera bornmuelleri) צפעקטן (Cerastes vipera) עכןגדול (Cerastes gasperetti) עכן

מקורנן (Cerastes cerastes) עכןהנגב (Pseudocerastes fieldi) שפיפון

- גדי עין (Atractaspis engaddensis) שרףשחור (Waltrinnesia aegyptia) פתן

מגוון (Echis coloratus) אפעה

צפע א"יצפע א"י

In Israel most cases are due to Vipera palaestina

חרמון חרמון צפע Vipera Vipera)) צפעbornmuelleri)bornmuelleri)

מגוון מגוון אפעה ((Echis coloratusEchis coloratus)) אפעה

מקורנן מקורנן עכן (Cerastes cerastes(Cerastes cerastes)) עכן

הנגב (Pseudocerastes fieldi) שפיפון

Bites usually occur on the extremities, causing Bites usually occur on the extremities, causing burning pain and swelling at the site within minutes. burning pain and swelling at the site within minutes.

As the venom spreads to the body through the As the venom spreads to the body through the lymphatics, there is advancing edema and lymphatics, there is advancing edema and

echymosis withechymosis with lymphadenopathy. lymphadenopathy.

Clinical ManifestationsClinical Manifestations

Nausea and vomiting, diaphoresis, numbness or Nausea and vomiting, diaphoresis, numbness or tingling around the mouth, scalp and digits and tingling around the mouth, scalp and digits and muscle fasciculations.muscle fasciculations.

Generalized edema, shock, cardiac arrhythmias and Generalized edema, shock, cardiac arrhythmias and death. death.

Clotting abnormalities are common in viper Clotting abnormalities are common in viper envenomations.envenomations.

Clinical Manifestations - Clinical Manifestations - Systemic SymptomsSystemic Symptoms

The patient should be placed at rest with The patient should be placed at rest with local pressure and immobilization of the local pressure and immobilization of the involved extremity. involved extremity.

A tourniquet should be placed proximal A tourniquet should be placed proximal to the site of envenomation ???. to the site of envenomation ???.

TreatmentTreatment

suction may remove some venom, in practice the procedure may aggravate bleeding, introduce infection and delay recovery.

Isotonic solutions are neededIsotonic solutions are needed..

TreatmentTreatment

Fresh frozen plasma, cryoprecipitate, platelet Fresh frozen plasma, cryoprecipitate, platelet infusions - if necessary.infusions - if necessary.

Tetanus prophylaxis.Tetanus prophylaxis. A broad-spectrum antibiotic.A broad-spectrum antibiotic. Antivenin - depends on the severity or rapid Antivenin - depends on the severity or rapid

progression of symptoms. progression of symptoms. Antivenin is most effective within 4 hrs from the bite; Antivenin is most effective within 4 hrs from the bite;

questionable value if delayed more than 12 hr.questionable value if delayed more than 12 hr.

TreatmentTreatment

AntiveninsAntivenins

Antivenins are animal-derived Immunoglobulins Antivenins are animal-derived Immunoglobulins Work by direct binding and neutralization of the Work by direct binding and neutralization of the

antigens contained in the venom antigens contained in the venom

Concentrates of animal serum.Concentrates of animal serum. Immediate and delayed hypersensitivity Immediate and delayed hypersensitivity

reactions are common and may reactions are common and may themselves be life threatening.themselves be life threatening.

AntiveninsAntivenins

EnvenomationEnvenomation ReactionReaction DosageDosage

NoneNone No local or systemic reactionsNo local or systemic reactions No antiveninNo antivenin

MinimalMinimal Local swelling but no systemic reactions 5 vialsLocal swelling but no systemic reactions 5 vials

ModerateModerate Swelling that progresses beyond the siteSwelling that progresses beyond the site

of the bite together with a systemic reaction,of the bite together with a systemic reaction,

laboratory changes, or both 10 vialslaboratory changes, or both 10 vials

SevereSevere Marked local reaction, severe symptoms,Marked local reaction, severe symptoms,

and laboratory abnormalitiesand laboratory abnormalities 10-15 vials10-15 vials

System for Grading System for Grading EnvenomationEnvenomation

Results from the deposition of antibody-Results from the deposition of antibody-antigen complexes on endothelial antigen complexes on endothelial surfacessurfaces

Symptoms occur 7-21 days after Symptoms occur 7-21 days after administration of the antivenin and may administration of the antivenin and may last days or weekslast days or weeks

Serum SicknessSerum Sickness

Fever, malaise, lymphadenopathy, Fever, malaise, lymphadenopathy, rash, arthralgia. rash, arthralgia.

Arthritis, nephritis, vasculitis and Arthritis, nephritis, vasculitis and neuropathy. neuropathy.

Treatment - Antihistamines and Treatment - Antihistamines and corticosteroids. corticosteroids.

Serum Sickness SymptomsSerum Sickness Symptoms

טיפול בחדר מיוןטיפול בחדר מיון

– נהוג לתת . מ"ל סליין במשך חצי שעה100אמפ' ב- 1

מ"ל סליין למשך 500ולאחר מכן את שאר הטיפול ב- .כשעתיים

SummarySummary

Always start with ABC For snake bite treatment with antivenin is

indicated in case of systemic toxicity or rapid progression of local signs