Bites & Stings - Faculty of Tropical Medicine, Mahidol University

Bites & Stingsin

Thailand

Bites & StingsBites & Stingsin in

ThailandThailandSuchai Suteparuk, M.D.

Division of Toxicology

Chulalongkorn University

Suchai Suteparuk, M.D.Suchai Suteparuk, M.D.

Division of ToxicologyDivision of Toxicology

Chulalongkorn UniversityChulalongkorn University

Dept of Medicine, Chulalongkorn Uviv

Bites & Stings

AcknowledgementAcknowledgement

•• This presentation can be reproduced or This presentation can be reproduced or

distributed for academic purposes only.distributed for academic purposes only.


Bites & Stings

Bites & StingsBites & Stings

•• ReptilesReptiles

•• ArthropodsArthropods

•• Toxic marine Toxic marine creaturescreatures


Bites & Stings

SnakebitesSnakebites

•• WorldwideWorldwide

–– 2,500,000 snakebites causing about 125,000 2,500,000 snakebites causing about 125,000

deaths per yeardeaths per year

•• Thailand scenarioThailand scenario

–– most common with about 7,000 cases and 30 most common with about 7,000 cases and 30

deaths annuallydeaths annually

–– peak incidence during Aprilpeak incidence during April--November November


Bites & Stings

Snake venomsSnake venoms

•• NeurotoxinNeurotoxin

•• CardiotoxinCardiotoxin

•• CytolysinCytolysin

•• MyotoxinMyotoxin

•• ProcoagulantProcoagulant

•• AnticoagulantAnticoagulant

•• HemorrhaginHemorrhagin

•• Platelet Platelet

aggregator/inhibitoraggregator/inhibitor


Bites & Stings

Important Venomous Snakes Important Venomous Snakes in Thailandin Thailand

•• Neurotoxin producing snakesNeurotoxin producing snakes

–– Thai Cobra (Thai Cobra (Naja Naja kaouthiakaouthia),),

Siamese Spitting cobra (Siamese Spitting cobra (Naja Naja siamensissiamensis))

–– King cobra (King cobra (Ophiophagus Ophiophagus hannahhannah))

Cobra (showing hood)

Cobra (showing hoodmarks)

King cobra


Bites & Stings


•• Neurotoxin producing snakesNeurotoxin producing snakes–– Banded krait (Banded krait (Bungarus Bungarus fasciatusfasciatus))

• Central Thailand

–– Malayan krait (Malayan krait (Bungarus Bungarus candiduscandidus))

• Northeastern & Southern Thailand

–– RedRed--headed krait (headed krait (Bungarus Bungarus flavicepsflaviceps))

• Southern Thailand esp in forests

Banded krait

Malayan krait

Red-headed krait


Bites & Stings


•• Hematotoxin producing snakesHematotoxin producing snakes

Vipers (Viperinae)Vipers (Viperinae)

–– RussellRussell’’s viper (s viper (DaboiaDaboia russelli russelli siamensissiamensis))

• Central and Eastern Thailand


Bites & Stings


•• Hematotoxin producing snakesHematotoxin producing snakes

Pit vipers (Crotalinae)Pit vipers (Crotalinae)

–– Malayan pit viper (Malayan pit viper (Calloselasma Calloselasma rhodostomarhodostoma))

• Eastern & Southern Thailand

–– Green pit vipers (Green pit vipers (Trimeresurus spp.Trimeresurus spp.))

• Bangkok, Central & Eastern Thailand

Russell’s viper

Malayan pit viper

Green pit viper

Green pit viper

Green pit viper


Bites & Stings


•• MyotoxinMyotoxin

–– Sea snakes (Sea snakes (Hydrophinae Hydrophinae & & LaticudinaeLaticudinae))

Sea snake

Sea snake


Bites & Stings


•• RearRear--fanged snakesfanged snakes

–– Mangrove snake Mangrove snake

• Redness, swelling and tenderness

–– Keel back snakeKeel back snake

• Bleeding tendency, sometimes severe

Boiga dendrophila

Wiroj Suksamai (www.siamensis.org/board/8517.html)

Rhabdophis subminiatus

Fang marks

Teeth marks


Bites & Stings

Neurotoxin: Systemic S & SNeurotoxin: Systemic S & S

•• Neuromuscular junction blockade Neuromuscular junction blockade

–– Muscle paralysis which started from the group of Muscle paralysis which started from the group of

small sized muscles, larger and then generalized small sized muscles, larger and then generalized

paralysisparalysis


Bites & Stings

Neurotoxin: Systemic S & SNeurotoxin: Systemic S & S

•• Neuromuscular junction blockade Neuromuscular junction blockade

–– ptosisptosis

–– droolingdrooling

–– dysphagiadysphagia ----> aspiration> aspiration

–– respiratory paralysisrespiratory paralysis

–– ggeneralized paralysiseneralized paralysis

Ptosis


Bites & Stings

HematotoxinHematotoxin: Systemic S & S: Systemic S & S

•• Vipers Vipers : : thromboplastinthromboplastin--like activity like activity stimulate common stimulate common hemostatichemostatic pathway pathway classical DICclassical DIC–– systemic bleedingsystemic bleeding

–– thrombocytopeniathrombocytopenia

–– acute renal failureacute renal failure


Bites & Stings

HematotoxinHematotoxin: Systemic S & S: Systemic S & S

•• Pit vipers Pit vipers : thrombin: thrombin--like activity like activity

stimulate fibrin formation stimulate fibrin formation fibrinogen fibrinogen

depletion depletion defibrinationdefibrination syndromesyndrome

–– systemic bleeding (not severe)systemic bleeding (not severe)

–– thrombocytopenia (direct effect)thrombocytopenia (direct effect)


Bites & Stings

Local Symptoms & SignsLocal Symptoms & Signs

•• very mild : very mild : BBanded kraitanded krait, M, Malayan alayan kkraitrait, non, non--envenomatedenvenomated bitesbites

•• mild : mild : early cobras, early King cobra, Rearly cobras, early King cobra, Russellussell’’s s viper (RV)viper (RV)

•• inflamed with necrosis : inflamed with necrosis : cobras, Kcobras, King cobraing cobra


Bites & Stings

Local Symptoms & SignsLocal Symptoms & Signs

•• edemaedema ::Green pit viper (GPV)Green pit viper (GPV)

•• blisters, blisters, ecchymosisecchymosis : : Malayan pit viper Malayan pit viper (MPV), (MPV), GPVGPV

•• Compartment syndrome : Compartment syndrome : MPVMPV

•• Digital ischemia : Digital ischemia : GPVGPV

Necrosis from cobra bite

Necrosis from cobra bite (late)

Edema from GPV

Hemorrhagic and multiple hemorrhagic

blebs from Malayan pit viper bite

Compartment syndrome

Digital ischemia


Bites & Stings

DiagnosisDiagnosis

•• Systemic S&SSystemic S&S

•• Local S&SLocal S&S

•• Snake morphology, habitatsSnake morphology, habitats


Bites & Stings

LaboratoryLaboratory

•• ImmunodiagnosisImmunodiagnosis & & SerodiagnosisSerodiagnosis are are

available but not ready for clinical practiceavailable but not ready for clinical practice


Bites & Stings

LaboratoryLaboratory

•• CBC, platelet count, VCT for CBC, platelet count, VCT for hematotoxinhematotoxin

•• renal function, muscle enzyme, serum renal function, muscle enzyme, serum

electrolytes for electrolytes for myotoxinmyotoxin


Bites & Stings

Severity AssessmentSeverity Assessment

•• Neurotoxin:Neurotoxin:

–– muscle powermuscle power

–– severity of respiratory failureseverity of respiratory failure


Bites & Stings

Severity AssessmentSeverity Assessment

Severity Ecchymosis Platelet VCT Systemicbleeding

Mild No Normal Normal No

Moderate Yes Decreased Prolonged No

Severe Yes Decreased > 30 min. Yes

• Hematotoxin


Bites & Stings

TreatmentTreatment

•• GeneralGeneral

•• Specific treatmentSpecific treatment

•• AntivenomAntivenom


Bites & Stings

General TreatmentGeneral Treatment

•• PrePre--hospitalhospital

–– transfer to medical personnel as soon as possible transfer to medical personnel as soon as possible

with or without snakeswith or without snakes

–– activity limitation & immobilizationactivity limitation & immobilization

–– clean the wound, clean the wound, do notdo not cut, suck, cauterize or cut, suck, cauterize or

apply local remedyapply local remedy

–– tourniquet only if can be done properly ????tourniquet only if can be done properly ????


Bites & Stings


•• InIn--hospitalhospital

–– ABCABC’’s & emergency problems treatments & emergency problems treatment

–– reassurereassure

–– rest the bitten parts and raise if swollenrest the bitten parts and raise if swollen

–– adequate hydrationadequate hydration

–– flow sheetflow sheet


Bites & Stings


•• InIn--hospitalhospital

–– analgesics: analgesics: no sedationno sedation in cases of neurotoxin, in cases of neurotoxin,

and and no aspirinno aspirin in cases of in cases of hematotoxinhematotoxin

–– appropriate (broad spectrum) antibiotics for appropriate (broad spectrum) antibiotics for

evident local or systemic infectionevident local or systemic infection

–– tetanus prophylaxis (if not contraindicated) tetanus prophylaxis (if not contraindicated)


Bites & Stings

AntivenomAntivenom

•• For indicated cases onlyFor indicated cases only

•• No need for skin test (no data to confirm its No need for skin test (no data to confirm its

necessity)necessity)

•• MonovalentMonovalent for Cobras, King cobras, BK, for Cobras, King cobras, BK,

MK, RV, MPV, GPVMK, RV, MPV, GPV


Bites & Stings

AntivenomAntivenom

•• Polyvalent available for Polyvalent available for

–– Neurotoxin: Cobra, King cobra & BKNeurotoxin: Cobra, King cobra & BK

–– HematotoxinHematotoxin: RV, MPV, GPV: RV, MPV, GPV


Bites & Stings

ArthropodsArthropods

•• Hymenoptera (Bees and wasps)Hymenoptera (Bees and wasps)

–– localized and extended edema from stingslocalized and extended edema from stings

–– anaphylaxis from bee stingsanaphylaxis from bee stings

–– angioedemaangioedema from multiple bee stingsfrom multiple bee stings


Bites & Stings


•• WaspsWasps

–– multiple wasp stings can cause hemolytic anemia, multiple wasp stings can cause hemolytic anemia,

thrombocytopenia, DIC, acute renal failure, thrombocytopenia, DIC, acute renal failure,

rhabdomyolysis and nonrhabdomyolysis and non--cardiogeniccardiogenic pulmonary pulmonary

edemaedema

Bees

Wasp

Bee sting lesion

Wasp sting lesions


Bites & Stings


•• Hymenoptera Treatment Hymenoptera Treatment –– Supportive careSupportive care

• analgesics

• antihistamines

–– In severe casesIn severe cases

• treat hypersensitivity

• vasopressor if needed

• steroid (controversy)


Bites & Stings


•• Scorpions, spiders, centipedes and Scorpions, spiders, centipedes and

millipedesmillipedes

–– localized and extended edemalocalized and extended edema

–– painpain

–– systemic effects are rare for species found in systemic effects are rare for species found in

ThailandThailand

Scorpion

Centipede

Spider


Bites & Stings

Toxic marine lifeToxic marine life

•• Thailand scenarioThailand scenario

–– seasonal, sporadic, small outbreaksseasonal, sporadic, small outbreaks


Bites & Stings


Bites & Stings

TetrodotoxinTetrodotoxin

•• Puffer fish (Puffer fish (LagocephalusLagocephalus spp.spp.))

•• Asiatic horseshoe crab (Asiatic horseshoe crab (CarcinoscorpiusCarcinoscorpius

rotundicaudarotundicauda))


Bites & Stings


•• BlueBlue--ringed octopus (ringed octopus (HapalochlaenaHapalochlaena sppspp))

–– bitebite

–– very low incidencevery low incidence


Bites & Stings


•• Neuromuscular junction blockadeNeuromuscular junction blockade

•• generalized paralysis generalized paralysis respiratory failurerespiratory failure

Conus spp

Thank You for your attention

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Bites & Stings - Faculty of Tropical Medicine, Mahidol University