1. Snake bites and insect stings Snake bites and insect stings

2. Outline Outline u Case presentation u Clinical manifestations of snake bites u Treatment

3. Case Report Case Report u 15 y male u Barefoot u Sudden onset of pain in Lt foot u Snake seen and killed

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

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

6. Poisonous Snakes in Israel u צפע א"י (Vipera palaestina) צפע חרמון (Vipera bornmuelleri) עכן קטן (Cerastes vipera) עכן גדול (Cerastes gasperetti) עכן מקורנן (Cerastes cerastes) שפיפון הנגב (Pseudocerastes fieldi) שרף עין-גדי (Atractaspis engaddensis) פתן שחור (Waltrinnesia aegyptia) אפעה מגוון (Echis coloratus)

7. צפע א"י u In Israel most cases are due to Vipera palaestina

11. צפע חרמון (Vipera bornmuelleri)

12. אפעה מגוון (Echis coloratus)

13. עכן מקורנן (Cerastes cerastes)

14. שפיפון הנגב (Pseudocerastes fieldi)

15. u Bites usually occur on the extremities, causing burning pain and swelling at the site within minutes. u As the venom spreads to the body through the lymphatics, there is advancing edema and echymosis with lymphadenopathy. Clinical Manifestations Clinical Manifestations

18. u Nausea and vomiting, diaphoresis, numbness or tingling around the mouth, scalp and digits and muscle fasciculations. u Generalized edema, shock, cardiac arrhythmias and death. u Clotting abnormalities are common in viper envenomations. Clinical Manifestations - Systemic Symptoms

19. u The patient should be placed at rest with local pressure and immobilization of the involved extremity. u A tourniquet should be placed proximal to the site of envenomation ???. TreatmentTreatment

20. u suction may remove some venom, in practice the procedure may aggravate bleeding, introduce infection and delay recovery. u Isotonic solutions are needed. TreatmentTreatment

21. u Fresh frozen plasma, cryoprecipitate, platelet infusions - if necessary. u Tetanus prophylaxis. u A broad-spectrum antibiotic. u Antivenin - depends on the severity or rapid progression of symptoms. u Antivenin is most effective within 4 hrs from the bite; questionable value if delayed more than 12 hr. TreatmentTreatment

22. AntiveninsAntivenins u Antivenins are animal-derived Immunoglobulins u Work by direct binding and neutralization of the antigens contained in the venom

23. u Concentrates of animal serum. u Immediate and delayed hypersensitivity reactions are common and may themselves be life threatening. AntiveninsAntivenins

24. EnvenomationReactionDosage NoneNo local or systemic reactionsNo antivenin MinimalLocal swelling but no systemic reactions 5 vials ModerateSwelling that progresses beyond the site of the bite together with a systemic reaction, laboratory changes, or both 10 vials SevereMarked local reaction, severe symptoms, and laboratory abnormalities10-15 vials EnvenomationReactionDosage NoneNo local or systemic reactionsNo antivenin MinimalLocal swelling but no systemic reactions 5 vials ModerateSwelling that progresses beyond the site of the bite together with a systemic reaction, laboratory changes, or both 10 vials SevereMarked local reaction, severe symptoms, and laboratory abnormalities10-15 vials System for Grading Envenomation

25. u Results from the deposition of antibody-antigen complexes on endothelial surfaces u Symptoms occur 7-21 days after administration of the antivenin and may last days or weeks Serum Sickness

26. u Fever, malaise, lymphadenopathy, rash, arthralgia. u Arthritis, nephritis, vasculitis and neuropathy. u Treatment - Antihistamines and corticosteroids. Serum Sickness Symptoms

27. טיפול בחדר מיון נהוג לתת – 1 אמפ' ב- 100 מ"ל סליין במשך חצי שעה. ולאחר מכן את שאר הטיפול ב- 500 מ"ל סליין למשך כשעתיים.

28. Summary u Always start with ABC u For snake bite treatment with antivenin is indicated in case of systemic toxicity or rapid progression of local signs