Pathophysiology and

management of bite

Dr
Abdulsatar Kamil Faeq
Consultant Interventional cardiologist
MRCP(UK)-MRCP(LONDON)
 Overview of envenoming
• Envenoming is a process when a venomous
animal inject venom in to the body of the
pray, by bite or sting, inducing venom induced
disease (VID).
• This mostly occur accidentally or as defense
mechanism.
• Mainly seen in rural area.
• Snake bite is the most commonly presenting
cases.
 What is venom?
• Venom is a complex mixture of diverse
components (notably toxins), often with
several separate toxins that can cause adverse
effects in humans, and each is potentially
capable of multiple effects.
• Not necessary all bites associated with venom
injection there are also what is called dry
bites.
Effects of venom
 Venomous animals
• Snakes
• Scorpion
• Spiders.
• Bees
• Wasps
Local and systemic effects of venom
Assessment of patients with suspected envenoming
 First Aids management
• A proper first aid though not offered in most of instances is crucial in
determining the outcome.
A s most of venom especially large molecular one as in snake venoms
transported via lymphatics It is recommended that for most forms of
envenoming, the patient
should be kept still, the bitten limb immobilized with a splint and vital
systems supported, where required.
• A patent upper airway should be specifically ensured and respiratory
support
provided, if required.
• For some animals, notably snakes in certain regions, the use of a local
pressure pad bandage over the bite site or a pressure immobilization
bandage is recommended.
• Ineffective or dangerous first aid, such as suction devices, ‘cut and suck’,
local chemicals, snake stones (stones of some sort placed over the
snakebite) and tourniquets, should not be used. Tourniquets, in particular,
have the potential to cause catastrophic distal limb injuries in snakebite
when applied too narrowly or too tightly, or left on too long.
 Transportation
• Where possible, transport should be brought to the
patient.
• Its also vital to obtain medical assessment and
intervention at the earliest opportunity, however, so
any delay in transporting the patient to a medical
facility should be avoided.
• Severely envenomed patients may develop life-
threatening problems, such as shock or respiratory
failure, during transport, so ideally the transport
method used should allow for management of
these problems en route.
 Assessment and management of life-threatening problems
• Patients who are seriously envenomed must be identified early
so that appropriate management is not delayed.
• Critically ill patients must be resuscitated and this takes precedence
over administration of any antivenom
• . Clinicians should look for signs of:
• shock/hypotension
• airway and/or respiratory compromise (likely to be
secondary to flaccid paralysis)
• major bleeding, including internal bleeding (especially
intracranial)
• impending limb compromise from inappropriate first aid
• (e.g. a tourniquet) – though beware sudden envenoming on removal of a
tourniquet.
• In a patient with severe neurotoxic flaccid paralysis, who is
still able to maintain sufficient respiratory function for survival,
clinical assessment may suggest irretrievable brain injury (fixed dilated
pupils, absent reflexes, no withdrawal response to painful
stimuli, no movement of limbs, fixed forward gaze with gross
ptosis; when, in fact, the patient is conscious
 History taking for evidence of envenoming
• comprehensive assessment of a patient bitten/stung by a venomous animal requires a good
history, a careful targeted examination and, where appropriate,
‘laboratory’ testing (though the latter may just consist of simple
bedside tests performed by the doctor)
The following key questions should be asked:
• When was the patient exposed to the venomous
bite/sting?
• Was the organism causing it seen and what did it look like
(size, colour)?
• What were the circumstances (on land, in water etc.)?
• Was there more than one bite/sting?
• What first aid was used, when and for how long?
• What symptoms has the patient had (local and systemic)?
• Are there symptoms suggesting systemic envenoming
(paralysis, rhabdomyolysis, coagulopathy etc.)?
• Is there any significant past medical history and
medication use?
• Is there a past exposure to antivenom/venom and
allergies?
• As the time from envenoming and apperance of symptoms is varriable from few minutes to
24 hours so repeated assessment of the patient is necessary in the first 24 hours
 Lab investigations
• RFT
• SE
• CBC
• Full coagulation screen
• CPK
• PFT
• Oximetry and ABG
• ECG
• Echocardiography
 Treatment
• Treatment of life threatening complications
• 1- Shock treatment (IV fluid, vasopressors,
sometimes mechanical support).
• 2- Hypoxia and resp failure ( O2, and assisted
ventilation).
• 3- Bleeding and coagulopathy ( blood and
blood products).
• 4-Convulsions ( IV lorazepam).
Continue
 Continue
• Anticholinesterases are used as an adjunctive
treatment for post-synaptic paralysis.
• Prazosin (an α-adrenoceptor antagonist) is used in the
management of hypertension or pulmonary oedema in
scorpion sting cardiotoxicity,.
• Routine antibiotics not indicated.
• Tetanous toxoid to be given after correction of
coagulopathy.
• Fasciotomy to combat compartment syndrome and
wound debridement to remove necrotic tissues.
• Reconstruction and physiotherapy.
Dog bite