Review article. Diagnosis and management of venomous snakebites in Southeast Asia

Rojnuckarin, Ponlapat; Suteparak, Suchai; Sibunruang, Suda

doi:10.5372/1905-7415.0606.125

Abstract

Background: Globally, snake envenoming is an important medical problem. Various species from different parts of the world require a variety of diagnostic and therapeutic strategies.

Objective: Review clinical manifestations, diagnosis, and management of venomous snakebites in Southeast Asia.

Method: Relevant information was extracted from publications in the PUBMED database (up to June 2012) and the World Health Organization (WHO) website. Expert opinions of the authors were added when clinical trial evidence was lacking.

Results: The clinical findings including local tissue damage, muscular weakness, coagulopathy, and renal injury were summarized. These data can be used to deduce the responsible snake species. The guide for the first aid, initial evaluation, follow-up observation, and antivenin administration was also suggested.

Conclusion: It is critical to transport snakebite victims to hospitals as soon as possible for basic and advance life supports. Appropriate usage of antivenin is life-saving. However, a mode to prevent debilitating tissue necrosis remains to be defined.

References

1. World Health Organization. Neglected tropical diseases; Snakebite [Internet]. 2009 [cited 2012 Apr 4]. Available from http://www.who.int/neglected_diseases/diseases/snakebites/en/
Search in Google Scholar Back to article
2. Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, Premaratna R, et al. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med. 2008; 5:e218.10.1371/journal.pmed.0050218
Open DOI Search in Google Scholar Back to article
3. Chanhome L, Cox MJ, Vasaruchapong T, Chaiyabutr N, Sitprija V. Characterization of venomous snakes of Thailand. Asian Biomed. 2011; 5:311-28.
Search in Google Scholar Back to article
4. Limthongkul S, Pochanugool C, Meemano K. Respiratory failure and its non-antivenin treatment in 37 adult neurotoxic snakes bite patients. In: Gophalakrishnakone P, Tan CK, editors. Progress in Venom and Toxic Research Singapore: National University of Singapore Press; 1987. p. 52-9.
Search in Google Scholar Back to article
5. Laothong C, Sitprija V. Decreased parasympathetic activities in Malayan krait (Bungarus candidus) envenoming. Toxicon. 2001; 39:1353-7.10.1016/S0041-0101(01)00087-3
Open DOI Search in Google Scholar Back to article
6. Leeprasert W, Kaojarern S. Specific antivenom for Bungarus candidus. J Med Assoc Thai. 2007; 90: 1467-76.
Search in Google Scholar Back to article
7. Warrell DA, Looareesuwan S, White NJ, Theakston RD, Warrell MJ, Kosakarn W, et al. Severe neurotoxic envenoming by the Malayan krait Bungarus candidus (Linnaeus): response to antivenom and anticholinesterase. Br Med J (Clin Res Ed). 1983; 286:678-80.10.1136/bmj.286.6366.678
Open DOI Search in Google Scholar Back to article
8. Warrell DA. Snake venoms in science and clinical medicine. 1. Russell’s viper: biology, venom and treatment of bites. Trans R Soc Trop Med Hyg. 1989; 83:732-40.10.1016/0035-9203(89)90311-8
Open DOI Search in Google Scholar Back to article
9. Rojnuckarin P. Snakebite-induced coagulopathy and bleeding disorders. In: Kini RM, Clemetson KJ, Markland FS, McLane MA, Morita T. Toxins and Hemostasis: From bench to bedside. Dordrecht: Springer. 2000, p. 699-710.10.1007/978-90-481-9295-3_39
Search in Google Scholar Back to article
10. Mitrakul C, Impun C. The hemorrhagic phenomena associated with green pit viper (Trimeresurus erythrurus and Trimeresurus popeorum) bites in children. A report of studies to elucidate their pathogenesis. Clin Pediatr (Phila). 1973; 12:215-8.10.1177/000992287301200409
Search in Google Scholar Back to article
11. Rojnuckarin P, Intragumtornchai T, Sattapiboon R, Muanpasitporn C, Pakmanee N, Khow O, et al. The effects of green pit viper (Trimeresurus albolabris and Trimeresurus macrops) venom on the fibrinolytic system in human. Toxicon. 1999; 37:743-55.10.1016/S0041-0101(98)00214-1
Open DOI Search in Google Scholar Back to article
12. Mitrakul C. Effect of five Thai snake venoms on coagulation, fibrinolysis and platelet aggregation. Southeast Asian J Trop Med Public Health. 1979; 10: 266-75.
Search in Google Scholar Back to article
13. Warrell DA. Guidelines for the management of snakebite. New Delhi: WHO regional office for Southeast Asia; 2010.
Search in Google Scholar Back to article
14. Sano-Martins IS, Fan HW, Castro SC, Tomy SC, Franca FO, Jorge MT, et al. Reliability of the simple 20 minute whole blood clotting test (WBCT20) as an indicator of low plasma fibrinogen concentration in patients envenomed by Bothrops snakes. Butantan Institute Antivenom Study Group. Toxicon. 1994; 32: 1045-50.10.1016/0041-0101(94)90388-3
Search in Google Scholar Back to article
15. Pongpit J, Limpawittayakul P, Juntiang J, Akkawat B, Rojnuckarin P. The role of prothrombin time (PT) in evaluating green pit viper (Cryptelytrops sp) bitten patients. Trans R Soc Trop Med Hyg. 2012; 106:415-8.10.1016/j.trstmh.2012.04.00322627102
Open DOI Search in Google Scholar Back to article
16. Ho M, Warrell DA, Looareesuwan S, Phillips RE, Chanthavanich P, Karbwang J, et al. Clinical significance of venom antigen levels in patients envenomed by the Malayan pit viper (Calloselasma rhodostoma). Am J Trop Med Hyg. 1986; 35:579-87.10.4269/ajtmh.1986.35.5793706625
Search in Google Scholar Back to article
17. Ribeiro LA, Jorge MT, Lebrão ML Prognostic factors for local necrosis in Bothrops jararaca (Brazilian pit viper) bites. Trans R Soc Trop Med Hyg. 2002; 95: 630-410.1016/S0035-9203(01)90101-4
Open DOI Search in Google Scholar Back to article
18. Pugh RN, Theakston RD. Fatality following use of a tourniquet after viper bite envenoming. Ann Trop Med Parasitol. 1987; 81:77-8.10.1080/00034983.1987.11812097
Open DOI Search in Google Scholar Back to article
19. Sutherland SK, Coulter AR, Harris RD. Rationalisation of first-aid measures for elapid snakebite Lancet. 1979; 1:183-5.
Search in Google Scholar Back to article
20. Norris RL, Ngo J, Nolan K, Hooker G. Physicians and lay people are unable to apply pressure immobilization properly in a simulated snakebite scenario. Wilderness Environ Med. 2005; 16:16-21.10.1580/PR12-04.1
Open DOI Search in Google Scholar Back to article
21. Watt G, Padre L, Tuazon ML, Theakston RD, Laughlin LW. Tourniquet application after cobra bite: delay in the onset of neutotoxicity and dangers of sudden release. Am J Trop Med Hyg. 1998; 38:618-22.10.4269/ajtmh.1988.38.618
Search in Google Scholar Back to article
22. Suankratay C, Wilde H, Nunthapisud P, Khantipong M. Tetanus after white-lipped green pit viper (Trimeresurus albolabris) bite. Wilderness Environ Med. 2002; 13:256-61.10.1580/1080-6032(2002)013[0256:TAWLGP]2.0.CO;2
Open DOI Search in Google Scholar Back to article
23. Rojnuckarin P, Mahasandana S, Intragumtornchai T, Swasdikul D, Sutcharitchan P. Moderate to severe cases of green pit viper bites in Chulalongkorn hospital. J Hematol Transfus Med. 1996; 6:199-205.
Search in Google Scholar Back to article
24. Nuchprayoon I, Pongpan C, Sripaiboonkij N. The role of prednisolone in reducing limb oedema in children bitten by green pit vipers: a randomized, controlled trial. Ann Trop Med Parasitol. 2008; 102: 643-9.10.1179/136485908X311786
Open DOI Search in Google Scholar Back to article
25. Rojnuckarin P, Mahasandana S, Intragumtornchai T, Sutcharitchan P, Swasdikul D. Prognostic factors of green pit viper bites. Am J Trop Med Hyg. 1998; 58: 22-5.10.4269/ajtmh.1998.58.22
Search in Google Scholar Back to article
26. Rojnuckarin P, Banjongkit S, Chantawibun W, Akkawat B, Juntiang J, Noiphrom J. Pakmanee N, Intragumtornchai T. Green pit viper (Trimeresurus albolabris and T. macrops) venom antigenaemia and kinetics in humans. Trop Doct. 2007; 37:207-10.10.1258/004947507782332838
Open DOI Search in Google Scholar Back to article
27. Archundia IG, de Roodt AR, Ramos-Cerrillo B, Chippaux JP, Olguín-Pérez L, Alagón A, et al. Neutralization of Vipera and Macrovipera venoms by two experimental polyvalent antisera: a study of paraspecificity. Toxicon. 2011; 57:1049-56.10.1016/j.toxicon.2011.04.009
Open DOI Search in Google Scholar Back to article
28. Chotwiwatthanakun C, Pratanaphon R, Akesowan S, Sriprapat S, Ratanabanangkoon K. Production of potent polyvalent antivenom against three elapid venoms using a low dose, low volume, multi-site immunization protocol. Toxicon. 2001; 39:1487-94.10.1016/S0041-0101(01)00108-8
Open DOI Search in Google Scholar Back to article
29. Otero R, Gutiérrez JM, Rojas G, Núñez V, Díaz A, Miranda E, et al. A randomized blinded clinical trial of two antivenoms, prepared by caprylic acid or ammonium sulphate fractionation of IgG, in Bothrops and Porthidium snake bites in Colombia: correlation between safety and biochemical characteristics of antivenoms. Toxicon. 1999; 37:895-908.10.1016/S0041-0101(98)00220-7
Open DOI Search in Google Scholar Back to article
30. Otero-Patiño R, Cardoso JL, Higashi HG, Nunez V, Diaz A, Toro MF, et al. A randomized, blinded, comparative trial of one pepsin-digested and two whole IgG antivenoms for Bothrops snake bites in Uraba, Colombia. The Regional Group on Antivenom Therapy Research (REGATHER). Am J Trop Med Hyg. 1998; 58:183-9.10.4269/ajtmh.1998.58.183
Search in Google Scholar Back to article
31. Boyer LV, Seifert SA, Cain JS. Recurrence phenomena after immunoglobulin therapy for snake envenomations: Part 2. Guidelines for clinical management with crotaline Fab antivenom. Ann Emerg Med. 2001; 37:196-201.10.1067/mem.2001.113134
Open DOI Search in Google Scholar Back to article
32. Pochanugool C, Limthongkul S, Wilde H. Management of Thai cobra bites with a single bolus of antivenin. Wilderness Environ Med. 1997; 8:20-3.10.1580/1080-6032(1997)008[0020:MOTCBW]2.3.CO;2
Open DOI Search in Google Scholar Back to article
33. Mitrakul C, Impun C. The hemorrhagic phenomena associated with green pit viper (Trimeresurus erythrus and Trimeresurus popeorum) bites in children. A report of studies in elucidate their pathogenesis. Clin Pediatr. 1973; 12:215-8.10.1177/000992287301200409
Search in Google Scholar Back to article
34. Karnchanachetanee C, Hanvivatvong O, Mahasandana S Monospecific antivenin therapy in Russell´s viper bite. J Med Assoc Thai. 1994; 77:293-7.
Search in Google Scholar Back to article
35. Mitrakul C. Juzi U, Pongrujikorn W. Antivenom therapy in Russell’s viper bite. Am J Clin Pathol. 1991; 95:412-7.10.1093/ajcp/95.3.412
Open DOI Search in Google Scholar Back to article
36. Hung DZ, Yu YJ, Hsu CL, Lin TJ. Antivenom treatment and renal dysfunction in Russell’s viper snakebite in Taiwan: a case series. Trans R Soc Trop Med Hyg. 2006; 100:489-94.10.1016/j.trstmh.2005.07.020
Open DOI Search in Google Scholar Back to article
37. Rojnuckarin P, Chanthawibun W, Noiphrom J, Pakmanee N, Intragumtornchai T. A randomized, double blind, placebo-controlled trial of antivenom for local effects of green pit viper bites. Trans R Soc Trop Med Hyg. 2006; 100:879-84. 10.1016/j.trstmh.2005.10.006
Open DOI Search in Google Scholar Back to article
38. Chotenimitkhun R, RojnuckarinP. Systemic Antivenom and Skin Necrosis after Green Pit Viper Bites. Clin Toxicol. 2008; 46:122-5.10.1080/15563650701266826
Open DOI Search in Google Scholar Back to article
39. Gutiérrez JM, León G, Rojas G, Lomonte B, Rucavado A, Chaves F. Neutralization of local tissue damage induced by Bothrops asper (terciopelo) snake venom. Toxicon. 1998; 36:1529-38.10.1016/S0041-0101(98)00145-7
Open DOI Search in Google Scholar Back to article
40. Thiansookon A, Rojnuckarin P. Low Incidence of Early Reactions to Horse-derived F(ab’)2 Antivenom for Snakebites in Thailand. Acta Trop. 2008; 105:203-5.10.1016/j.actatropica.2007.09.00717996842
Open DOI Search in Google Scholar Back to article
41. Isbister GK, Brown SG, MacDonald E, White J, Currie BJ; Australian Snakebite Project Investigators. Current use of Australian snake antivenoms and frequency of immediate-type hypersensitivity reactions and anaphylaxis. Med J Aust. 2008; 188:473-6.10.5694/j.1326-5377.2008.tb01721.x18429716
Search in Google Scholar Back to article
42. Malasit P, Warrell DA, Chanthavanich P, Viravan C, Mongkolsapaya J, Singhthong B, et al. Prediction, prevention, and mechanism of early (anaphylactic) antivenom reactions in victims of snake bites. BMJ. 1986; 292:17-20.10.1136/bmj.292.6512.1713389723080048
Open DOI Search in Google Scholar Back to article
43. Otero R, León G, Gutiérrez JM, Rojas G, Toro MF, Barona J, et al. Efficacy and safety of two whole IgG polyvalent antivenoms, refined by caprylic acid fractionation with or without beta-propiolactone, in the treatment of Bothrops asper bites in Colombia. Trans R Soc Trop Med Hyg. 2006; 100:1173-82.10.1016/j.trstmh.2006.01.00616698053
Open DOI Search in Google Scholar Back to article
44. Premawardhena AP, de Silva CE, Fonseka MM, Gunatilake SB, de Silva HJ. Low dose subcutaneous adrenaline to prevent acute adverse reactions to antivenom serum in people bitten by snakes: randomised, placebo controlled trial. BMJ. 1999; 17: 1041-3.10.1136/bmj.318.7190.10412783510205101
Open DOI Search in Google Scholar Back to article
45. de Silva HA, Pathmeswaran A, Ranasinha CD, Jayamanne S, Samarakoon SB, Hittharage A, et al. Low-dose adrenaline, promethazine, and hydrocortisone in the prevention of acute adverse reactions to antivenom following snakebite: a randomised, double-blind, placebo-controlled trial. PLoS Med. 2011; 8:e1000435.10.1371/journal.pmed.1000435309184921572992
Open DOI Search in Google Scholar Back to article
46. Gawarammana IB, Kularatne SA, Dissanayake WP, Kumarasiri RP, Senanayake N, Ariyasena H. Parallel infusion of hydrocortisone +/- chlorpheniramine bolus injection to prevent acute adverse reactions to antivenom for snakebites. Med J Aust. 2004; 180:20-3.10.5694/j.1326-5377.2004.tb05768.x14709123
Search in Google Scholar Back to article
47. Fan HW, Marcopito LF, Cardoso JL, França FO, Malaque CM, Ferrari RA, et al. Sequential randomised and double blind trial of promethazine prophylaxis against early anaphylactic reactions to antivenom for bothrops snake bites. BMJ. 1999; 29:1451-2.10.1136/bmj.318.7196.14512788710346769
Open DOI Search in Google Scholar Back to article
48. Isbister GK, Shahmy S, Mohamed F, Abeysinghe C, Karunathilake H, Ariaratnam A. A randomised controlled trial of two infusion rates to decrease reactions to antivenom. PLoS One. 2012; 7:e38739.10.1371/journal.pone.0038739337770222719932
Search in Google Scholar Back to article
49. Gold BS, Dart RC, Barish RA. Bites of venomous snakes. N Engl J Med. 2002; 347:347-56.10.1056/NEJMra01347712151473
Open DOI Search in Google Scholar Back to article
50. Jorge MT, Malaque C, Ribeiro LA, Fan HW, Cardoso JL, Nishioka SA, et al. Failure of chloramphenicol prophylaxis to reduce the frequency of abscess formation as a complication of envenoming by Bothrops snakes in Brazil: a double-blind randomized controlled trial. Trans R Soc Trop Med Hyg. 2004; 98:529-34.10.1016/j.trstmh.2003.12.00915251401
Open DOI Search in Google Scholar Back to article
51. Pongprasit P, Mitrakul C, Nopadon N. Histopathology and microbiological study of cobra bite wounds. J Med Assoc Thai. 1988; 71:475-80.
Search in Google Scholar Back to article
52. Theakston RD, Phillips RE, Looareesuwan S, Echeverria P, Makin T, Warrell DA Bacteriological studies of the venom and mouth cavities of wild Malayan pit vipers (Calloselasma rhodostoma) in Southern Thailand. Trans R Soc Trop Med Hyg. 2002; 84:875-9.
Search in Google Scholar Back to article

Review article. Diagnosis and management of venomous snakebites in Southeast Asia

Abstract

Paradigm

My account