snake bite,rabies,scorpion bite ppt – presented by prof.dr.r.r.deshpande on 10-10-14

10/10/2014 Prof.Dr.R.R.Deshpande 1

Snake bite,Rabies,Scorpion Bite

• Presented By –

• Prof.Dr.R.R.Deshpande (M.D in Ayurvdic

Medicine & M.D. in Ayurvedic Physiology)

• www.ayurvedicfriend.com

• Mobile – 922 68 10 630

• mailme.drrrdeshpande@rediffmail.com

Special Thanks for

Expertise suggestions

• Prof.Dr.Jayant Phadke – HOD ,Toxicology

Dept ,Ayurved college ,Nigdi ,Pune

• Dr.Sohiel Deshpande,MBBS

God of Health = God Dhanvantari

Snake Bite

• Toxic Snakes

• 1) Neuro Toxic – Nag ( Cobra) & Manyar

(common Krait)

• 2) Haemotoxic or Vasculotoxic – Ghonas (

Russels viper ) & Furse ( Saw scaled

Viper)

Cobra & common krait

Russels viper &

Saw scaled Viper

Difference of Poisonous

& Non Poisonous

Sr,No Poisonous Non Poisonous

1 Head Scales – Small Head Scales – Large

2 Body scales -- Large Body scales – small or moderate

3 Tail - Compressed Not so

4 Nocturnal Not so

5 Bite mark – 2 Fang marks No fang marks

Poisonous Snakes –Special

Anatomical featurs • 1) All poisonous snakes have broad

ventral plates on the belly that extend right

across.

• 2) All poisonous snakes have 2 fangs,

which really are 2 prominent teeth besides

many other small teeth.

Poisonous & Non Poisonous –

Head Scales

Poisonous & Non Poisonous -

Body Scales

After bite of Snake

• 1) A patient bitten by a poisonous snake

will always complain of pain over the bitten

• 2) Two fang marks are always seen. The

shape of an inverted U (∩).

After bite of Snake

• 3) Bite by poisonous snake should not be

considered as serious poisoning every

time, because the poison glands of the

snake at the time of the bite might have

been empty.

• Also even a thin layer of clothing usually

gives great protection.

After bite of Snake

• 4) Many times fright and panic leads to

fainting.

Watch Symptoms

• 1) Elapids Neurotoxic – Cobra or Krait

• Local – Mild Burning ,Triple Response i.e redness, swelling,inflammation

• Systemic – Vomiting, Giddiness, Ptosis ,Difficulty in speaking & swalowing, Staggering gait ,Difficult respiration, Difficulty in motor Activities like hand & leg movements, spreading paralysis ( ascending from lower limbs), convulsions ,death may results within minutes or several hours due to respiratory failure

Watch Symptoms

• 2) From Russell’s & saw scaled Vipers - Haemotoxic Symptoms – Local symptoms are more severe like Intense pain,swelling,Cellulitis,Ozzing of bloody serum & formation of blisters & necrosis

• Systemic – Vomiting, Unconsciousness, Intravascular haemolysis, Epistaxsis, Haematuria, Haemetemesis, Bleeding under skin like Petechiae, Bleeding from orifices ,Hypotension.Death result from cardiovascular shock or renal failure

2 types of Snake Poison

• 3 stages can be seen in Paralytic Type

• Stage 1 – Ptosis

• Stage 2 – Difficulty in Swallowing

• Stage 3 – Difficulty in Respiration ,

Paralysis

2 types of Snake Poison

• Haemolytic Type

• Local swelling around the bite appears

quickly

• Blood collected in bulb does not clot

Symptoms of Snake Bite

Snake Bite

Signs of Poisoning

• 2 puncture marks ,3/4th to 1 cm apart can

be of Poisonous snake bite

When person can die ?

• 1) After bite of Elapidae –20 min to 6 hrs

• 2) After bite of Viperine – 2 to 4 days

Snake Bite Management

• 1) Snake bites should be treated as

wounds. Antibiotics is given for secondary

infection and Inj. Tetanus toxoid.

• 2) If the patient is completely alright 6-8

hours after the bite, he is usually out of

danger.

• To Slow the absorption and spread of the

poison:

• 1) Patient is prevented from walking. Bitten limb

is immobilized, preferably in a splint.

• 2) Strip of cloth or handkerchief or a rubber

tourniquet should applied a few cms. above the

bitten area. Be released every 15 minutes for a

period of one minute.

• 3) Tourniquet should not be too tight .It is just to

occlude venous & lymphatic return

• 4) Ice should be applied to and around the bitten

• 5) Immobilize the part .Because movements can

cause more absorption of poison

• 4) The wound and the incision can be

washed with very dilute solution of

potassium permanganate.

• When there are No signs of Poison –

• Tab Diazepam – 1 tab stat as a

Tranquilizer

• Tab Paracetamol – As Analgesic

Wait & Watch for min 6 hours

• Look following signs of Poisoning

• 1) Ptosis

• 2) Local swelling

• 3) Dysphagia

• 4) Difficulty in breathing

• In Paralytic Type –

• If Ptosis or Dysphagia develops ,take

immediate action

• If GP & do not have ASV – shift to

appropriate hospital

• Respiratory Paralysis is an Emergency

• Neutralize the poison by --

1)Injection of anti venom. Most effective if

administered within 1 to 4 hours of the

2) Old Thought -- Sensitivity tests must be

done. If the patient is not sensitive, 5cc. of

the serum should be injected locally

around the wound. Avoid local infiltration

into a finger or a toe

• ASV vial contains powder. Dissolve in 10 ml of sterile

water for injection.

• Give ½ cc IV as Test Dose .Watch for 2 min for Urticaria

• If no allergy ,inject Full dose

• New Thought in 2014 -- Sensitivity tests are no longer

recommended because they are unreliable and may

even lead to sensitisation of patient before the actual

therapeutic dose.

Snake Venom Antiserum

• Manufactured by Vins Bioproducts Limited

Survey no 117 Thimmapur (V)

509325,Kothur (Mandal) ,Mahaboobnagar

( Dist) ,Andhra Pradesh,India

• Each 1 ml of has capacity of specifically

neutralising the venom of following

species of Snake

• O.60 mg of dried Indian Cobra venom

• 0.45 mg of dried common Krait Venom

• 0.60 mg of dried Russell’s viper venom

• 0.45 mg of dried Saw scaled Viper

• Reconstituted antivenin is administered as

soon as possible ,if clear cut signs or

symptoms of envenomation are evident

• It can be administered in 2 ways

• 1) Intravenous injections – Reconstituted

antivenin is administered by slow

intravenous injection ( 1 to 2 ml per

minute)

• 2) Infusion – Reconstituted antivenin is

diluted in isotonic saline or glucose

solution ( 5 to 10 ml per kg body weight)

• At present there is no simple method to

measure the amount of circulating venom

in the body.

• So dose of Antivenin can not be accurately

recommended

• The dose also depends on the type of

snake bite & severity of envenomation

• Presentation – Snake venom antiserum IP

is supplied as freeze dried powder in glass

vials .Sterile water for Injection IP is

supplied in 10 ml vials

• The antivenin is also supplied as 10 ml

liquid in glass vials

• Disposal – Left over antivenin & used

empty vials should be discarded as

biomedical waste

• 2 vials are usually injected directly by IV

route slowly ( 1 to 2 ml per minute) &

taking care of sensitivity reaction

• 2 more vials are given after half an hour to

one hour ,if the symptoms of

envenomation persists.

• Further dose can be given with IV fluids,till

envenomation symptoms subside

• The patient should be closely monitored

for 2 hours

• Local administration of antivenin in or

around the bite site is ineffective ,painful &

may raise intra compartmental pressure

particularly in digits .So not recommended

• Antivenin Reactions – Anaphylaxis is life

threatening .

• Anaphylaxis can be rapid onset & can

deteriorate into a life threatening

emergency very quickly

• Patient should be monitored closely & at

the first sign of any of the following ,anti

venin should be discontinued

• Anaphylaxis –

• Indicating signs & symptoms – Urticaria,

Itching, fever, chills or rigors, vomiting,

diarrhoea, abdominal cramps,

Tachycardia, Hypotension,

Bronchospasm, angioedema.

• Anaphylaxis – 0.5 mg of 1: 1000

Adrenaline IM

• Children – Adrenaline IM – 0.01 mg/kg

body weight

• Anaphylaxis – To provide longer term

protection against Anaphylactoid reaction

,100 mg of Hydrocortisone & 10 mg of H1

antihistamine ,IV

• Children – 0.2 mg/kg of Anti histamine IV

& 2 mg /kg of Hydrocortisone IV

• Anaphylaxis – If the condition is worsening

,a second dose of 0.5 mg of Adrenaline

1:1000 IM ,may be given

• Inj ASV 1 to 4 vials ,slow IV

• Then 1 vial ,every 15 to 30 min ,till the

signs start reversing

• Inj Atropine 2 amp IV ,to control excess

salivation

• Inj Neostigmine 4 amp IV

• Associated Treatment – Pain – Paracetamol

• Aspirin or other NSAIDS should not be given – can excerbate bleeding

• For severe pain – mild opiates – Tramodol 50 mg

• Neostigmine is Anti cholinesterase drug – prolongs the action of Acetylcholine – revert respiratory failure & Neurotoxic symptoms – 0.5 mg IM ,half hourly + 0.6 mg of Atropine IV ,over an 8 hour period by continuous infusion

• In Dysphagia – Continuous throat suction

• In Respiratory Paralysis – Endotracheal

Intubation, Artificial Respiration

• Total 10 to 15 vials of ASV may be

required in Respiratory Paralysis

• Haemolytic Type –

• Inj Decadron 2 cc IV stat

• Inj Avil 1 amp IV stat

• Inj ASV 2 to 6 vials IV slowly ( Old

Thought -- AST)

• Repeat Inj ASV ,if local swelling continues

to increase

• Repeat CT ,every 4 to 6 hours

• Haemolytic Type

• Inj ASV 1 vial ,if Local swelling continues to increase

• Locally -- around the site-

• Inj ASC -1 to 2 ml

• Elevation of Leg

• Application of Thrombophob ointment

• Megasulph compresses

• Haemolytic Type

• Local –

• If Oedema is very less then,

• Apply -- Elastrocrepe bandage

• After 6 hours ,remove the bandage + watch Skin

• If necessary -- Reapply

• Haemolytic Type

• When oedema becomes severe ,Skin

becomes bluish black ,Circulation of toes

is diminished ---

• Then to save the limb ,emergency

Faciotomy incisions must be taken

• Haemolytic Type

• In advanced cases ,we must look for

Haematuria, Bleeding from other sites like

nose, skin, check urine output.

• Haemolytic Type --

• In cases of bleeding –

• BT is given

• When possible – Platelet Transfusion is given

• Inj Fibrinogen 300 to 600 mg IV

• Inj Heparin –if DIC [ New Thought in 2014 -

Heparin is ineffective against venom induced

Thrombin and should never be used]

• Haemolytic Type

• When urine out put reduces –

• Inj Mannitol 300 ml IV

• Inj Lasix 2 amp IV stat & repeat sos

• Inj Decadron 2cc IV – 6 hrly

• In Renal failure ( Urea & Creatinine level

increases) – Peritoneal Dialysis is done

• After giving adrenaline 1:1000 solution I.M.

½ c.c. and antihistaminic, 30 c.c. of the

serum should be added to 300 c.c. or

normal saline and given as I.V. drip in 1 to

2 hours.

• [ New Thought in 2014 - Prophylactic

Adrenaline should not be given as a

routine]

• Old Thought -- Patients who are, sensitive,

desensitization should be done. Under the cover

of adrenaline, antihistaminic and steroids, small

doses are injected till 40 c.c. of serum I.M. are

given.

• New Thought in 2014 -- In sensitive patients

Adrenaline , Antihistaminics and steroids can be

given prophylactically but ASV is always given

IV only

• Symptomatic treatment:

• 1) Inj. Pethidine (not morphine) 50 mg.

I.M. or Inj. Largactil 25 mgm. I.M. is given

for pain.

• 2) Inj. Streptopenicillin

• 3) Inj. Tetanus Toxoid

• 4) I.V. steroid is given in massive doses

e.g. in serious patients, 300mgm. Efcorlin

I.V. to start and 200 mgm. as slow I.V. drip

later.

• 5) If B.P. is falling, Inj. Lomodex or glucose

saline with two ampoules of Noradrenaline

or 100 mgm. Inj. Mephentine is added to

the bottle

When Hospital Admission is

must in Snake Bite ? • Patients who start bleeding extensively or

• Develop blackish red urine or

• Extensive paralysis

• Assurance – Relieve fear & Anxiety

• Clean the bite area with soap & water

• Symptomatic & General Treatment --

• Wait & watch – First just give Inj TT+ IV DNS +

Antibiotics, Anti histaminics, Analgesics,

Steroids, Blood Transfusion, Artificial respiration,

Haemodyalysis etc .If absolute No symptoms

except fear & Patient is alright ,not necessary to

give ASV

Treatment of absorbed venom

• 1) In Elapids – Alternate 0.6 mg Inj.

Atropine & 0.5 mg Neostigmine

• In paralytic cases – Inj.Adrenaline – s/c &

Inj Calcium chloride – I/M

Treatment of absorbed venom

• 2) In Vipers –

• 30,000 to 40,000 Units Inj Heparin

• [Heparin not to be used]

• 300 to 600 gms – Inj Fibrinogen

• Also used are fresh whole blood, Platelets

or Fresh frozen plasma(FFP).

Anti Snake Venom

• 1) Powder form – ASV – By Serum

Institute of India ( SII) –This is PAVS =

Polyvalent Anti snake Venom Serum

.Price – Rs 400/- for Powder to form 10 ml

solution

• Also available Powder by Haffkine Bio

Pharma ,Mumbai .10 ml .Rs 400/-

Anti Snake Venom

• 2) Liquid Form – By Bharat

Company,Thane ,Mumbai.For IV – 10 ml

vial .Rs.400/-

How to Administer ASV ?

• 1) Old Thought -- Test Dose – 0.01 ml by

Insulin Syringe s/c --- New Thought --

Not Recommended as unreliable.

• If No Allergic reactions –

• 10 ml Liquid ASV in 500 ml DNS .Speed

30 drops per min

• Constant watch in the Improvement of

Symptoms or Toxic or Side effects of ASV

ASV & Blood Test

• 1) PT,BT,CT – For Viperidae ( Ghonas &

Phurse ) Haemotoxic

Blood Tests • 20 WBCT : 2ml fresh venous blood collected in Glass

bulb.Keep undisturbed for 20 minutes.Slightly tilt the bulb

and check for clotting.

Normally the blood should have clotted by the end of 20

minutes. Repeat test after 6 hours.

• BT/CT

• Platelet count : May be decreased in viper bite.

• PT : Normal is 12-14 seconds.

• TLC/DLC : May show neutrophil predominant

leucocytosis.

Snake Bite

• Tab Pinak – Herbal Tablet

• http://www.shreebharadiayurpharma.com/t

abpinak.html

• http://www.shreebharadiayurpharma.com/

studypinaksasun.html ( Study in Sassoon

Hosp,Pune)

Rabies or Hydrophobia

• Infectious disease – due to Neurotropic

filtrable virus ,transmitted by the bite or lick

of an infected dog

• Incubation period – 10 days to several

months

Rabies – Symptoms

• 1) Premonitory – Stage lasts for 2 days

.Pain & discomfort at the site of

bite.Irritable even to slight noise – cause

spasm of different muscles like muscles of

swallowing

• 2) Stage of Irritability – Spasm of

different muscles ,particularly deglutition

• Can not speak or drink

Rabies – Symptoms

• 2) Contd –

• Even sight of water may initiate spasm

• Muscles of Larynx etc undergo spasmodic

contraction.

• Respiration becomes difficult .RR – Increased

• Cyanosis, Hoarseness of voice, Jerks become

• Stage lasts for 3 days .Then Heart Failure

Rabies – Symptoms

• 3) Stage of Paralysis –

• Paralysis of different muscle groups like

respiration,Heart.

• Stage lasts for few hours & then Death

• Death is inevitable

• So take immediate injection after dog bite

Do not kill the Dog

• The dog in question should never be killed

• Rather it should be kept under observation for

10 days

• If Dog is normal & live after 5 days – Chances of

Rabies are almost zero & so no worry

• If dog behaves abnormal or dies in this period ,&

then if Negri bodies are found in the Brain in

postmartem –Then Diagnosis is confirmed of

Rabies

When full Immunization is must ?

• Rabies is a Fatal disease

• So dog is unknown or street dog or difficult to keep watch or people killed the dog – Then Full Immunization for Rabies is must

• Do not avoid Treatment of Rabies ,because it is Fatal disease ( Death of Rabies patient is 100%)

• In Pune (MS)India ,these patients are isolated in Naidu Hospital

Catch Rabied Dog

Rabid Dog – Post mortem

Rabid Dog Bite prevention

Bite By Rabid Dog

Rabies Symptoms

Rabies Virus

Rabies – Local care

• Wash the wound repeatedly with soap & flowing

water for atleast 15 mins.

• Clean the wound with 70% alcohol or Iodine (

under LA)

• If CLW is small – Do not suture

• If CLW is large – Suture loosely with drain after

24 hours

• Bite wound should not be sutured during primary

treatment for the fear of introducing the virus into

deeper tissue.

Thanks for Rabies Vaccine

Rabies Management

• 1) Inj Rabipur = PCEC = Purified Chick

Embryo Cell Vaccine = Total 6 Injections

• 1 dose Vial of Powder = 1 ml = Rs.400/-

• Inj on Deltoid

• Days = 0 – 3 – 7 – 14 – 1 month & 3

months

Rabies – Passive Immunization

• If dog bites are multiple & deep

• If dog bites on face & neck

• Then ,

• Inj Berirab P ( Immunoglobulins) – 300 IU

in 1 ml amp --- 3 to 4 ml IM – Injected

away from the site of Inj Rabipur

• Sr.TIG 1 ml is applied locally to the wound

or infiltrated around it

Vaccine Site

Inj Rabipur

• Can be given Intradermal ,in low dose

• So more Economical

• Suggested by Dr.Anant Phadke ,Mumbai

Intradermal schedule.

• 8 site intradermal schedule.

• Sites : Deltoids, lateral thigh,

suprascapular area and lower quadrant of

abdomen.

• Dose : 0.1ml ID

8 site intradermal schedule

• Schedule :

Day 0 : 0.1ml ID on 8 sites

Day 7 : 0.1ml ID on 4 sites (Deltoid & thighs)

Day 28 : 0.1ml on 1 site (Deltoid)

Day 90 : 0.1ml on 1 site (Deltoid)

Rabies Management

• 2) Human Rabies Immuno Globulins

• 20 IU /KG body weight

• 60 kg person = 1200 IU

• Half Dose s/c ,around wound & half dose

• Price --- 3500/- for 1vial contains 150

IU/ml. (By Bharat serum/ Ranbaxy)Total

cost may go around 16 thousand Rs

Prevention is better than cure

• Persons exposed to Rabid animals –

Veterinary Doctors ,Workers in forestry or

in slaughter houses ,research workers

doing animal experiments ,rural postmen

• Prophylactic vaccine

• Inj Rabipur 1 ml on days as – 0,7,21,1

year ,then every 3 years

Rabies seen after bite of

Carnivorous Animals • Dog,Cat ,Wolf ,Jackel

Scropion Bite

• 2 Types of Scorpion

• 1) Black – 99% -- Pain is severe ,but not

fatal .To releive pain – Inj.Xylocaine 2 % -

around wound

• Another way – Keep KMno4 crystals on

the wound & sqeeze lemon on it

Red & Black Scorpion

Scorpion Bite

• 2 Types of Scorpion

• 2) Red Scorpion – found in Guhagar,Chiplun ,Kokan

area of Maharashtra state of India,Pondechari

• This bite can be Fatal

• Tab Prazosin ( Minipress) – Drug invented by

Dr.Bavaskar ( Actually this drug was previously used

only as Anti Hypertensive )

• Dose of Prazosin –1mg stat followed by 0.25 to 0.5mg

every 4 to 6 hours

Scorpion Bite

• Scorpion Venom – Neurotoxic &

Haematotoxic

• Since only a small quantity of the venom is

injected – mortality is very less

Symptoms of scorpion bite

• Local – more severe than snake bite –

pain,oedema & reddening

• Systemic –

Nausea,vomiting,restlessness,fever,convul

sions,coma,cyanosis

• The site of the bite is adentified as –

Pinpoint puncture spot ,local sweating &

oedema

Treatment of Scorpion bite

• 1) A tight ligature should be placed

proximal to the bite.

• 2) Ice should be applied around

• 3) Severe pain often responds to local

injection of emetine hydrochloride 30

mgm. given through the puncture made by

the sting, if this is visible.

Treatment for Scorpion bite

• If severe pain & sweating –

• Inj Fortwin or Inj Pethidine 10 mg IM or IV

• Inj Local Xylocaine 2 % -- Infiltrate around

the site of bite

• Tab Prazopress 1 mg stat or Tab Ciplar 40

mg stat ( Inchildren Tab Prazopress 1 mg

one forth to one half tab)

• Systemic Involvement –

• Profuse sweating

• Ice cold extrmities

• Priapism

• Hypersalivation

• Vomiting

• Hypertension

• Tachycardia

• Pulmonary oedema

• Note – BP ,RR –every 10 min

• Tab Prazopress 1 mg stat .Then ½ tab

after 4 hrs .Then ½ tab ,every 6 hours – till

systemic symptoms & signs disappear

• If pain is severe -- Inj Fortwin 1cc IM or IV

• If profuse sweating & dehydration – Inj

Ringer lactate IV

• If BP > 150 / 100 – Cap Depin 5 mg

sublingual .Can be repeated sos ,after ½

to 1 hour

• In Tachycardia .PR >110 /min

• Inj.Calmpose 2 cc IM or slow IV

• In Pulmonary oedema (

Breathlessness,Fine Basal Crepitions )

• Propped up position

• Oxygen

• Inj Lasix 2 to 4 amp IV stat

• Inj Efcorlin 100 mg IV stat

• Inj Aminophylline 10 ml + 25 % glucose 10

ml slow IV

• Life Threatening condition – severe

Dyspnoea ,frothing through mouth

• Sodium Nitroprusside drip – till pulmonary

oedema is controlled

• Inj Pruside 50 mg in 5 ml – added to 500

ml 5 % dextrose – 15 drops/min – can be

increased upto 40 drops / min

• 4) Alternatively, local injection of

Novocaine and adrenaline around the

puncture can be tried.

• 5) Application of tamarind juice locally may

also relieve the pain.

Scorpion Bite

• There is no specific Antidote for scorpion

poison

• Invention – by Dr.Bavaskar

,Mahad,Raigad,MS

• Prazocin – Total protection against cardiac

toxicity of Scorpion bite

• Wash wound with KMno4 water

• Immobilization

• Local infiltration of Anaesthetic

• Inj. Calcium Gluconate IV – to control

swelling

• Inj Atropine to avoid pulmonary oedema

• Inj Glucose, Saline & hydrocortisone

Scropion Bite • Scropion Venom Antiserum – Haffkine Bio

pharmaceuticals cop Ltd,Mumbai .Dose is 1 vial

reconstituted in 10 ml of Inj for water .If symptoms

persist administer another vial after 1 hour

• Dose --- • 5–25 mL of antivenom diluted in two to three volumes of

isotonic saline to be given intravenously over an hour. If

there is no significant improvement, further doses of

antivenom can be given (total dose of antivenom

required is 30–100 mL in severe envenomation).

Rat Bite

• Inj TT

• If Rat bite fever – Inj Penicilline G

• Dose --

• 3-5 million units IV 6 hourly.

• Even in Rat bite ,better give Inj Rabipur (

Anti Rabies Injection also)

Rat Bite

Rat Bite Fever

• Infection caused by Spirillum Minus

• Charaterised by Relapsing Fever ,arthritis

& Skin eruptions

• More common in infants

• Incubation period – 1 to 6 weeks

Rat Bite Fever

• Clinical Features –

• Local – Site becomes swollen ,purplish in

colour,Lymphadenitis,draining the part

• General – Fever with chill & rigor ,remains

for 2 to 4 days

• Then afebrile for 2 to 4 days .This cycle

goes on

• Headache,photophobia,nausea

Rat Bite Fever

• Clinical Features –

• General –-

• Arthritis of 1 or more joints

• Skin rashes of reddish or purplish patches

often confluent & found in extremities

,asymmetrically

• Course for – 4 to 8 weeks

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