Snakebites worldwide: Clinical manifestations and diagnosis
- Julian White, AM, MB, BS, MD, FACTM
Julian White, AM, MB, BS, MD, FACTM
- The University of Adelaide
- Allen C Cheng, MB, BS, FRACP
Allen C Cheng, MB, BS, FRACP
- Infectious Diseases Physician
- Menzies School of Health Research
- Section Editors
- Daniel F Danzl, MD
Daniel F Danzl, MD
- Section Editor — Environmental Emergencies
- Professor of Emergency Medicine
- University of Louisville School of Medicine
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Snakebites account for significant morbidity and mortality worldwide, especially in South and Southeast Asia, sub-Saharan Africa, and Latin America . Venomous snakes are widely distributed around the world and clinical effects from envenomation can overlap to a great degree even among different classes of snakes. This topic will discuss the clinical manifestations and diagnosis of snakebite worldwide.
The principles of management of snakebites within the United States are discussed separately. (See "Evaluation and Management of Crotalinae (rattlesnake, water moccasin [cottonmouth], or copperhead) bites in the United States" and "Evaluation and management of coral snakebites".)
Although common names are used to describe snakes throughout this topic, the genus and species that correlate with the common names can be found in the following tables for Africa (table 1), Asia (table 2), Central and South America (table 3), Australia and the Pacific Islands (table 4), Europe (table 5), and the Middle East (table 6) and at the following website: WHO snake and antivenom database.
Up to 5 million venomous snakebites occur worldwide each year and result in at least 100,000 to 125,000 annual deaths and 400,000 amputations [1-4]. Because most venomous snakebites occur in developing countries with poorly developed health reporting systems and because many deaths occur before medical care can be provided, these numbers likely reflect underestimates . Regions with the highest incidence of venomous snakebites and snakebite deaths include Southeast and South Asia (eg, India, Pakistan, Sri Lanka, and Bangladesh), sub-Saharan Africa, and Latin America (figure 1) [1,2,6,7]. In an effort to draw attention to the problem of venomous snakebites worldwide and to spur strategies that improve outcomes, the World Health Organization has designated snakebite as a neglected tropical disease [8,9]. The best strategy to increase the production of existing antivenoms is under debate .
Snakebites disproportionately affect poorer populations in rural areas. Two common patterns are described [1,7,10]:
- Chippaux JP. Snake-bites: appraisal of the global situation. Bull World Health Organ 1998; 76:515.
- Kasturiratne A, Wickremasinghe AR, de Silva N, 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.
- WHO tackles snake bites to spur production of antivenoms. WHO. Essential medicine and health products. http://www.who.int/medicines/news/antivenoms_spur_production/en/ (Accessed on September 14, 2016).
- Arnold C. Vipers, mambas and taipans: the escalating health crisis over snakebites. Nature 2016; 537:26.
- Warrell DA. Snake bite. Lancet 2010; 375:77.
- Mohapatra B, Warrell DA, Suraweera W, et al. Snakebite mortality in India: a nationally representative mortality survey. PLoS Negl Trop Dis 2011; 5:e1018.
- Vaiyapuri S, Vaiyapuri R, Ashokan R, et al. Snakebite and its socio-economic impact on the rural population of Tamil Nadu, India. PLoS One 2013; 8:e80090.
- Snakebite. Neglected tropical diseases. World Health Organization. http://www.who.int/neglected_diseases/diseases/snakebites/en/ (Accessed on March 25, 2013).
- Bhaumik S. Snakebite: a forgotten problem. BMJ 2013; 346:f628.
- Alirol E, Sharma SK, Bawaskar HS, et al. Snake bite in South Asia: a review. PLoS Negl Trop Dis 2010; 4:e603.
- White J. Overview of venomous snakes of the world. In: Medical Toxicology, 3rd edition, Dart RC. (Ed), Lippincott, Williams, & Wilkins, Philadelphia 2004. p.1543.
- Warrell DA. Envenoming and injuries by venomous and nonvenomous reptiles worldwide. In: Wilderness Medicine, 6th Edition, Auerbach PS. (Ed), Elsevier Mosby, Philadelphia 2012. p.1040.
- Ranawaka UK, Lalloo DG, de Silva HJ. Neurotoxicity in snakebite--the limits of our knowledge. PLoS Negl Trop Dis 2013; 7:e2302.
- Sells PG. Animal experimentation in snake venom research and in vitro alternatives. Toxicon 2003; 42:115.
- Gnanathasan A, Rodrigo C. Pulmonary effects and complications of snakebites. Chest 2014; 146:1403.
- Mosquera A, Idrovo LA, Tafur A, Del Brutto OH. Stroke following Bothrops spp. snakebite. Neurology 2003; 60:1577.
- Sutherland SK. Deaths from snake bite in Australia, 1981-1991. Med J Aust 1992; 157:740.
- Otero R, Gutiérrez J, Beatriz Mesa M, et al. Complications of Bothrops, Porthidium, and Bothriechis snakebites in Colombia. A clinical and epidemiological study of 39 cases attended in a university hospital. Toxicon 2002; 40:1107.
- Sano-Martins IS, Fan HW, Castro SC, 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.
- Isbister GK, Maduwage K, Shahmy S, et al. Diagnostic 20-min whole blood clotting test in Russell's viper envenoming delays antivenom administration. QJM 2013; 106:925.
- O'Rourke KM, Correlje E, Martin CL, et al. Point-of-care derived INR does not reliably detect significant coagulopathy following Australian snakebite. Thromb Res 2013; 132:610.
- Hudson BJ. Positive response to edrophonium in death adder (Acanthophis antarcticus) envenomation. Aust N Z J Med 1988; 18:792.
- Watt G, Theakston RD, Hayes CG, et al. Positive response to edrophonium in patients with neurotoxic envenoming by cobras (Naja naja philippinensis). A placebo-controlled study. N Engl J Med 1986; 315:1444.
- Bucaretchi F, Hyslop S, Vieira RJ, et al. Bites by coral snakes (Micrurus spp.) in Campinas, State of São Paulo, Southeastern Brazil. Rev Inst Med Trop Sao Paulo 2006; 48:141.
- Lee SW, Jung IC, Yoon YH, et al. Anticholinesterase therapy for patients with ophthalmoplegia following snake bites: report of two cases. J Korean Med Sci 2004; 19:631.
- Gold BS. Neostigmine for the treatment of neurotoxicity following envenomation by the Asiatic cobra. Ann Emerg Med 1996; 28:87.
- Bomb BS, Roy S, Kumawat DC, Bharjatya M. Do we need anti snake venom (ASV) for management of elapid ophitoxaemia. J Assoc Physicians India 1996; 44:31.
- Vital Brazil O, Vieira RJ. Neostigmine in the treatment of snake accidents caused by Micrurus frontalis: report of two cases (1). Rev Inst Med Trop Sao Paulo 1996; 38:61.
- Watt G, Meade BD, Theakston RD, et al. Comparison of Tensilon and antivenom for the treatment of cobra-bite paralysis. Trans R Soc Trop Med Hyg 1989; 83:570.
- Warrell DA, Looareesuwan S, White NJ, 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.
- Punde DP. Management of snake-bite in rural Maharashtra: a 10-year experience. Natl Med J India 2005; 18:71.
- Snake venom detection. CSL Antivenom Handbook, 2nd edition, 2001. http://www.toxinology.com/generic_static_files/cslavh_svdk.html (Accessed on June 05, 2013).
- Cheng AC, Currie BJ. Venomous snakebites worldwide with a focus on the Australia-Pacific region: current management and controversies. J Intensive Care Med 2004; 19:259.
- GEOGRAPHICAL DISTRIBUTION AND CHARACTERISTICS
- VENOM PROPERTIES
- Composition and sites of action
- CLINICAL MANIFESTATIONS
- Physical examination
- - Wound site
- - Systemic findings
- Tissue and muscle toxicity
- Ancillary studies
- - Coagulopathy
- - Rhabdomyolysis
- - Neurotoxicity
- Tensilon test
- - Shock
- - Venom identification
- DIFFERENTIAL DIAGNOSIS
- ADDITIONAL RESOURCES