2. Snake Bite Incidence Less than 50 % of snake bites are poisonous Less than 50 % of snake bites are poisonous Less than 20 % of bites by poisonous vipers result in envenomation. Less than 20 % of bites by poisonous vipers result in envenomation. Bites by Cobra may result in no envenomation Bites by Cobra may result in no envenomation

3. Types of Poisonous Snakes in Egypt Viperidae Cerastes cerastes Cerastes cerastes Echis carinatus Echis carinatus Echis coloratus Echis coloratus

4. Elapidae Naja haje (Egyptian Cobra) Naja haje (Egyptian Cobra) Naja nigricollis (Black Spitting Cobra) Naja nigricollis (Black Spitting Cobra)

5. Behavior and Senses Snakes strike from the coiled position. Strike speed is 2 meters/ sec. Snakes strike from the coiled position. Strike speed is 2 meters/ sec. Reflex bites may occur up to 1 hour after snake dies. Reflex bites may occur up to 1 hour after snake dies. Best sensory modalities are vibration and smell followed by thermal change. Snakes are deaf and have poor vision. Best sensory modalities are vibration and smell followed by thermal change. Snakes are deaf and have poor vision. Cobra live in a humid environment (around the Nile Valley) while vipers distribute in all the Egyptian desert Cobra live in a humid environment (around the Nile Valley) while vipers distribute in all the Egyptian desert

6. Venom is injected in the victim through 2 fangs situated in front of upper teeth.Venom gland is connected to the tips of fangs by narrow ducts carrying the venom Venom is injected in the victim through 2 fangs situated in front of upper teeth.Venom gland is connected to the tips of fangs by narrow ducts carrying the venom

7. Venom Composition and Effects 1- Hyaluronidase Facilitate the rapid spread Facilitate the rapid spread 2- Proteases Local tissue destruction Local tissue destruction Necrosis Necrosis Edema Edema 3- Phospholipases Disrupt neurotransmission Disrupt neurotransmission Hemolysis Hemolysis 4- Neurotoxins With phospholipases they produce respiratory paralysis With phospholipases they produce respiratory paralysis 5- Small peptides DIC DIC Platelet aggregation Platelet aggregation Thrombocytopenia Thrombocytopenia

8. 6- Thrombin like enzymes Formation of microthrombi Formation of microthrombi Fibrinogen depletion Fibrinogen depletion Fibrinolysis Fibrinolysis Formation of Fibrin Degradation Products )FDP( Formation of Fibrin Degradation Products )FDP( Anticoagulation Anticoagulation 7- Serotonin and bradykinin Hypotension Hypotension Capillary leak Capillary leak Non cardiogenic Pulmonary Edema )NCPE ( Non cardiogenic Pulmonary Edema )NCPE (

9. Manifestations I- Local manifestations Fang marks: one or two punctures at the site of the bite Fang marks: one or two punctures at the site of the bite Mild local pain Mild local pain Local edema occurs within 5 minutes and may progress to involve the whole limb within 1 hour Local edema occurs within 5 minutes and may progress to involve the whole limb within 1 hour Tender regional lymph nodes Tender regional lymph nodes In addition vipers produce the following: Echymosis Echymosis Vesicles and petechiae Vesicles and petechiae Skin necrosis and gangrene Skin necrosis and gangrene

12. Systemic Manifestations A- Elapidae )cobra( Gradual progressive muscle weakness up to paralysis of the whole body including respiratory muscles with cranial nerves palsy is the main and may be the only manifestation of Cobra envenomation. Gradual progressive muscle weakness up to paralysis of the whole body including respiratory muscles with cranial nerves palsy is the main and may be the only manifestation of Cobra envenomation. Paralysis may be preceded by fasciculations of face and neck muscles Paralysis may be preceded by fasciculations of face and neck muscles It starts 1-4 hours but may start as late as 12 hours It starts 1-4 hours but may start as late as 12 hours Consciousness and sensations are retained Consciousness and sensations are retained Local manifestations are milder than in viper bites Local manifestations are milder than in viper bites

13. B- Viperidae 1- General manifestations: Sweating, rigors, nausea, vomiting, metallic taste and hypertension (hypotension may occur late in complicated cases). Sweating, rigors, nausea, vomiting, metallic taste and hypertension (hypotension may occur late in complicated cases). 2- Non Cardiogenic Pulmonary Edema 3- Congestive heart failure 4- Renal failure

14. 5- Coagulopathy A- Localised Hypofibrinogenemia and thrombocytopenia may occur without significant coagulopathy. Hypofibrinogenemia and thrombocytopenia may occur without significant coagulopathy. Thrombocytopenia reaches maximum after 2-4 days and may last for 1 week. Thrombocytopenia reaches maximum after 2-4 days and may last for 1 week. Fibrinolysis may be absent (no Fibrin Degradation Products FDP). Fibrinolysis may be absent (no Fibrin Degradation Products FDP). Bleeding tendency is mild with anemia and hypotension. Bleeding tendency is mild with anemia and hypotension.

15. B- Disseminated Full blown consumption coagulopathy. Full blown consumption coagulopathy. It is a lethal picture that usually reaches hospital in very serious condition or commonly dies before reaching it. It is a lethal picture that usually reaches hospital in very serious condition or commonly dies before reaching it. Patient presents with petechiae, bleeding from all orifices and site of the bite. Patient presents with petechiae, bleeding from all orifices and site of the bite. Laboratory results show: Laboratory results show: Very high PTT, very low platelets and fibrinogen, high FDPs and anemia. Very high PTT, very low platelets and fibrinogen, high FDPs and anemia. It is usually complicated by multiple organ failure, ARDS, renal failure and shock It is usually complicated by multiple organ failure, ARDS, renal failure and shock

16. Treatment A- First aid measures Reassurance of the patient Reassurance of the patient Immobilization of the affected limb Immobilization of the affected limb Light tourniquet may be applied proximal to site of the bite Light tourniquet may be applied proximal to site of the bite

17. B- At hospital I- Stabilization of the patient II- Antidote : Polyvalent Antivenom It neutralizes the venom but don't reverse local injury It neutralizes the venom but don't reverse local injury It should be given within the first 4 hours to prevent local injury It should be given within the first 4 hours to prevent local injury Skin sensitivity test must be done before administration. Skin sensitivity test must be done before administration. Initial dose is 3 - 5 vials to be repeated according to the severity and the follow up of the patient. Initial dose is 3 - 5 vials to be repeated according to the severity and the follow up of the patient. It is given in normal saline up to 1: 1 dilution. It is given in normal saline up to 1: 1 dilution.

18. III- Supportive treatment IV Fluids for hypotension IV Fluids for hypotension Blood for bleeding and hemolysis Blood for bleeding and hemolysis Platelets concentrates Platelets concentrates Fresh frozen plasma to replenish coagulation factors Fresh frozen plasma to replenish coagulation factors Artificial ventilation for the paralytic syndrome of Cobra or the pulmonary edema of vipers Artificial ventilation for the paralytic syndrome of Cobra or the pulmonary edema of vipers Antibiotics and antitetanic serum Antibiotics and antitetanic serum Care of the wound Cleansing, debridement of necrosed tissues and fasciotomy if peripheral vascular impairment follow limb edema and compartment syndrome. Cleansing, debridement of necrosed tissues and fasciotomy if peripheral vascular impairment follow limb edema and compartment syndrome.

19. Scorpion Sting Scorpions are yellowish, brown or black in colour. Scorpions are yellowish, brown or black in colour. They live in desert, hide at day time under rocks and stones and emerge at night for hunting. They live in desert, hide at day time under rocks and stones and emerge at night for hunting. Scorpions are blind but possess sensitive thermoreceptors. Scorpions are blind but possess sensitive thermoreceptors. Accidents predominate in summer, rare in winter when scorpions are hibernating. Accidents predominate in summer, rare in winter when scorpions are hibernating.

20. Pathogenesis 1. Excessive catecholamine release 2. Acetyl choline release 3. Release of kinins and serotonin 4. Direct central toxic effect 5. Direct peripheral effect Myocarditis Myocarditis NCPE NCPE

21. Clinical Picture A- Factors affecting severity 1- Age Serious manifestations are seen in infants (younger age), Serious manifestations are seen in infants (younger age), 2- Site of sting Stings affecting central location (neck, back, face) are more dangerous Stings affecting central location (neck, back, face) are more dangerous 3- Number of stings Victims receiving more than one sting usually show more severe manifestations Victims receiving more than one sting usually show more severe manifestations B- Onset of manifestations Rapid Rapid Severe sting produces symptoms within half an hour. Severe sting produces symptoms within half an hour.

22. Manifestations I- General Agitation Agitation Fever Fever Sweating Sweating Dehydration Dehydration Conjunctival congestion Conjunctival congestion Peripheral cyanosis Peripheral cyanosis Cold extremities ( 2ry to peripheral vasospasm caused by catecholamines) Cold extremities ( 2ry to peripheral vasospasm caused by catecholamines) Priapism. Priapism. II- Local Severe local pain Severe local pain Tender regional lymph nodes Tender regional lymph nodes Numbness Numbness

23. III- Neurological Confusion and agitation Confusion and agitation Tremors, fasciculations and rigors Tremors, fasciculations and rigors Convulsions Convulsions Hypertensive encephalopathy Hypertensive encephalopathy Coma Coma Malignant hyperthermia (> 41 C) Malignant hyperthermia (> 41 C) Cranial nerve palsy: Cranial nerve palsy: 6th Nerve is usually affected 6th Nerve is usually affected Reversible Reversible Secondary to cerebral edema Secondary to cerebral edema IV- Cardiovascular Tachycardia Tachycardia Hypertension Hypertension Myocarditis Myocarditis Shock : usually follow severe myocarditis Shock : usually follow severe myocarditis Cardiac Arrest Cardiac Arrest

24. V- Respiratory Tachypnea Tachypnea Respiratory distress and respiratory failure Respiratory distress and respiratory failure Acute pulmonary edema: Acute pulmonary edema: VI- Gastrointestinal Severe vomiting and diarrhea Severe vomiting and diarrhea Gastric distension Gastric distension Acute erosive gastritis, hematemesis and melena Acute erosive gastritis, hematemesis and melena VII- Metabolic Metabolic acidosis Metabolic acidosis Hyperkalemia Hyperkalemia Stress hyperglycemia Stress hyperglycemia

25. Manifestations of Grave Prognosis 1. Acute pulmonary edema 2. Respiratory failure 3. Myocarditis 4. Metabolic acidosis 5. Malignant hyperthermia 6. Convulsions

26. Management A- First aid measures B- At hospital I- Stabilization of the patient

27. II- Antidote Best given in the first 4 h but can still be given as late as 24 hours Best given in the first 4 h but can still be given as late as 24 hoursIndications All children, and senile patients All children, and senile patients Adults presenting with any of the systemic manifestations Adults presenting with any of the systemic manifestations Patients with previous cardiovascular disease, hypertension or diabetes Patients with previous cardiovascular disease, hypertension or diabetesDoseAdult 3 - 5 amp slow IV or IM after negative skin sensitivity test to be repeated every 30 minutes if signs still progress or do not regress 3 - 5 amp slow IV or IM after negative skin sensitivity test to be repeated every 30 minutes if signs still progress or do not regressPediatric The same dose as adults (Dose is not related to body weight but to neutralizing power of the circulating venom) The same dose as adults (Dose is not related to body weight but to neutralizing power of the circulating venom)

28. III- Supportive treatment Pain NSAIDs NSAIDs Local anesthesia. Local anesthesia.CorticosteroidsIndications Stridor Stridor Myocarditis Myocarditis Non cardiogenic pulmonary edema Non cardiogenic pulmonary edema Cranial palsy (cerebral edema) Cranial palsy (cerebral edema) IV vasodilators To control hypertension To control hypertension Careful monitoring of the patient to avoid hypotension or shock that may occur with catecholamine depletion or after myocarditis. Careful monitoring of the patient to avoid hypotension or shock that may occur with catecholamine depletion or after myocarditis. They include Na nitroprusside, hydralazine or prazocin They include Na nitroprusside, hydralazine or prazocin

29. Mechanical ventilation Indications Respiratory failure Respiratory failure Non cardiogenic pulmonary edema in which PEEP mode is used. Non cardiogenic pulmonary edema in which PEEP mode is used. Dehydration, hypotension and shock IV fluids IV fluids Dobutamine if cardiogenic shock 2ry to myocarditis complicates the picture Dobutamine if cardiogenic shock 2ry to myocarditis complicates the picture Anticonvulsants e.g. diazepam Malignant hyperthermia Cooling measures and chlorpromazine Cooling measures and chlorpromazine

30. Spider Sting The most important is the black widow spider of mediterranean distribution. Manifestations Local pain Local pain Profuse sweating Profuse sweating Severe myalgia Severe myalgia Weakness and rhabdomyolysis. Weakness and rhabdomyolysis. Excess catecholamine release with hypertension, irritability, tachycardia and vomiting Excess catecholamine release with hypertension, irritability, tachycardia and vomitingTreatment Supportive Supportive