Envenoming: Consequences and Management

Abstract

Some snakes, lizards, arthropods and aquatic animals can inject venom into prey or enemies by biting or stinging. These accidents are preventable by wearing boots, using a light after dark and not sleeping unprotected on the ground. Treatment involves specific antivenom, supporting vital functions and surgically debriding necrotic wounds.

Snakebites: Local effects include swelling, blistering, necrosis and painful lymph node enlargement. Life‐threatening systemic effects are shock, bleeding, descending paralysis, generalised rhabdomyolysis, intravascular haemolysis and acute kidney injury.

Arthropods: Hypersensitisation to bee, wasp and ant venoms is a common cause of fatal anaphylaxis. Mass attacks can kill unsensitized people. Scorpion stings are intensely painful and may cause autonomic storm, leading to myocardial damage and pulmonary oedema particularly lethal in children. Some species cause neurotoxic effects. Loxosceles spiders cause local necrosis while Latrodectus bites cause painful muscle spasms.

Fish, cnidarian (jellyfish), coral, cone shell and sea urchin stings can be painful and dangerous.

Key Concepts

  • Animal venoms and venom apparatus have evolved to immobilise and digest their prey, and for defence.
  • Knowledge of the venomous fauna of a particular locality, use of protective footwear, a flash light after dark and avoidance of sleeping on open ground reduce the risk of envenoming.
  • Antivenom, purified immunoglobulin from animals that have been hyperimmunised with specific venoms, is the only antidote to envenoming.
  • Animal venoms may have tissue‐damaging local effects leading to permanent dysfunction and, by targeting physiological receptors, can cause haemostatic disturbances, shock, paralysis and autonomic nervous system overactivity.
  • Snakebite is a neglected occupational and environmental disease particularly affecting agricultural workers and their children in tropical developing countries. Community education is of paramount importance in reducing risky behaviour.
  • The greatest risk after neurotoxic snakebite is respiratory arrest. This may be delayed by first‐aid pressure immobilisation and treated by assisted ventilation.
  • Identification of the biting species, either directly if the causative animal, or a photographic image of it, is available, or by use of clinical syndrome‐based algorithms, is important for optimal management.
  • Bee, wasp and ant stings more often kill by anaphylaxis in hypersensitized people than by direct effects of their venoms.

Keywords: venoms; poisons; bites; stings; antivenom; treatment

Figure 1. Fangs of a South American pit viper (Jararacuçu from Brazil, Bothrops jararacussu) showing erected fangs, one emitting a drop of venom. Copyright © DA Warrell.
Figure 2. Severe local effects of envenoming. Swelling, bruising and blistering of the lower limb of a boy bitten by a Malayan pit viper (Calloselasma rhodostoma) 4 days earlier. Copyright © DA Warrell.
Figure 3. Spontaneous systemic bleeding of the gums and floor of the mouth in a patient bitten by a saw‐scaled viper in Nigeria (Echis ocellatus). Copyright © DA Warrell.
Figure 4. Neurotoxic envenoming in a woman bitten by a common krait (Bungarus caeruleus) in Sri Lanka. Note paralysis of the eyelids (ptosis). She is struggling to open her mouth and protrude her tongue. Copyright © DA Warrell.
Figure 5. Pressure‐pad plus immobilisation technique.
Figure 6. Transfer of a boy with advanced cobra‐bite paralysis to medical care by a village‐based volunteer motorcycle driver in Nepal. Copyright SK Sharma.
Figure 7. Swelling rapidly advancing up the arm in a man bitten by a saw‐scaled viper (Echis ocellatus) in Nigeria. Copyright © DA Warrell.
Figure 8. Dangerous Brazilian scorpion (Tityus obscurus). Note slender pincers (pedipalps) implying a potent venom (see text). Copyright © DA Warrell.
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References

Anker RL, Straffon WG, Loiselle DS and Anker KM (1983) Snakebite. Comparison of three methods designed to delay uptake of ‘mock venom’. Australian Family Physician 12 (5): 365–8.

Bogert CM (1943) Dentitional phenomena in cobras and other elapids, with notes on adaptive modification of fangs. Bulletin of the American Museum of Natural History 81: 285–360.

Carrijo‐Carvalho LC and Chudzinski‐Tavassi AM (2007) The venom of the Lonomia caterpillar: an overview. Toxicon 49 (6): 741–757.

Chappuis F, Sharma SK, Jha N, et al. (2007) Protection against snake bites by sleeping under a bed net in southeastern Nepal. American Journal of Tropical Medicine and Hygiene 77 (1): 197–199.

Chippaux JP (1998) Snake‐bites: appraisal of the global situation. Bulletin of World Health Organization 76 (5): 515–524.

de Silva HA, Pathmeswaran A, Ranasinha CD, et al. (2011) 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 Medicine 8 (5): e1000435.

Ducancel F (2005) Endothelin‐like peptides. Cellular and Molecular Life Sciences 62 (23): 2828–2839.

França FOS, Benvenuti LA, Fan HW, et al. (1994) Severe and fatal mass attacks by bees (Africanised honey bees – Apis mellifera scutellata) in Brazil: clinicopathological studies with measurement of serum venom concentrations and a review of the literature. Quarterly Journal of Medicine 87: 269–282.

Freire‐Maia L, Campos JA and Amaral CFS (1996) Treatment of scorpion envenoming in Brazil. In: Bon C and Goyffon M (eds) Envenomings and Their Treatments, pp. 301–310. Lyon: Fondation Marcel Mérieux.

Hartwick R, Callanan V and Williamson J (1980) Disarming the box‐jellyfish: nematocyst inhibition in Chironex fleckeri. Medical Journal of Australia 1 (1): 15–20.

Harvey AL and Robertson B (2004) Dendrotoxins: structure‐activity relationships and effects on potassium ion channels. Current Medicinal Chemistry 11 (23): 3065–3072.

Ho M, Warrell DA, Looareesuwan S, et al. (1986) Clinical significance of venom antigen levels in patients envenomed by the Malayan pit viper (Calloselasma rhodostoma). American Journal of Tropical Medicine and Hygiene 35 (3): 579–587.

Hunt KJ, Valentine MD, Sobotka AK, et al. (1978) A controlled trial of immunotherapy in insect hypersensitivity. New England Journal of Medicine 299 (4): 157–161.

Jorge MT, Malaque C, Ribeiro LA, et al. (2004) 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. Transactions of the Royal Society of Tropical Medicine and Hygiene 98 (9): 529–34.

Kasturiratne A, Wickremasinghe AR, de Silva N, et al. (2008) The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Medicine 5 (11): e218.

Kochva E (1987) The origin of snakes and evolution of the venom apparatus. Toxicon 25 (1): 65–106.

Lewin MR, Bickler P, Heier T, et al. (2013) Reversal of experimental paralysis in a human by intranasal neostigmine aerosol suggests a novel approach to the early treatment of neurotoxic envenomation. Clinical Case Reports 1 (1): 7–15.

Lewin MR, Samuel SP, Wexler DS, et al. (2014) Early treatment with intranasal neostigmine reduces mortality in a mouse model of Naja naja (Indian Cobra) envenomation. Journal of Tropical Medicine 2014: 131835.

Little M, Pereira P, Carrette T and Seymour J (2006) Jellyfish responsible for Irukandji syndrome. Quarterly Journal of Medicine 99 (6): 425–427.

Lu Q, Clemetson JM and Clemetson KJ (2005) Snake venoms and hemostasis. Journal of Thrombosis and Haemostasis 3 (8): 1791–1799.

Mackessy SP (ed.) (2010) Handbook of Venoms and Toxins of Reptiles. Boca Raton: CRC Press.

Ménez A (2003) The Subtle Beast. Snakes, from Myth to Medicine. London: Taylor & Francis.

Mohapatra B, Warrell DA, Suraweera W, et al. (2011) Snakebite mortality in India: a nationally representative mortality survey. PLoS Neglected Tropical Diseases 5 (4): e1018.

Montecucco C, Gutiérrez JM and Lomonte B (2008) Cellular pathology induced by snake venom phospholipase A2 myotoxins and neurotoxins: common aspects of their mechanisms of action. Cellular and Molecular Life Sciences 65 (18): 2897–2912.

Müller UR, Golden DB, Demarco PJ and Lockey RF (2004) Immunotherapy for hymenoptera venom and biting insect hypersensitivity. Clinical Allergy and Immunology 18: 541–559.

Warrell Myint‐Lwin DA, Phillips RE, et al. (1985) Bites by Russell's viper (Vipera russelli siamensis) in Burma: haemostatic, vascular and renal disturbances and response to treatment. Lancet ii: 1259–1264.

Nomura JT, Sato RL, Ahern RM, et al. (2002) A randomized paired comparison trial of cutaneous treatments for acute jellyfish (Carybdea alata) stings. American Journal of Emergency Medicine 20 (7): 624–626.

Rahman R, Faiz MA, Selim S, et al. (2010) Annual incidence of snake bite in rural Bangladesh. PLoS Neglected Tropical Diseases 4 (10): e860.

Rivière G, Choumet V, Audebert F, et al. (1997) Effect of antivenom on venom pharmacokinetics in experimentally envenomed rabbits: toward an optimization of antivenom therapy. Journal of Pharmacology and Experimental Therapeutics 281 (1): 1–8.

Rodríguez de la Vega RC and Possani LD (2005) Overview of scorpion toxins specific for Na+ channels and related peptides: biodiversity, structure‐function relationships and evolution. Toxicon 46 (8): 831–844.

Russell FE and Bogert CM (1981) Gila monster: its biology, venom and bite – a review. Toxicon 19 (3): 341–359.

Seymour J, Carrette T, Cullen P, et al. (2002) The use of pressure immobilization bandages in the first aid management of cubozoan envenomings. Toxicon 40 (10): 1503–1505.

Sharma SK, Chappuis F, Jha N, et al. (2004) Impact of snake bites and determinants of fatal outcomes in southeastern Nepal. American Journal of Tropical Medicine and Hygiene 71 (2): 234–238.

Sharma SK, Bovier P, Jha N, et al. (2013) Effectiveness of rapid transport of victims and community health education on snake bite fatalities in rural Nepal. American Journal of Tropical Medicine and Hygiene 89 (1): 145–50.

Sutherland SK, Coulter AR and Harris RD (1979) Rationalisation of first‐aid measures for elapid snake bite. Lancet i: 183–186.

Swaroop S and Grab B (1954) Snakebite mortality in the world. Bulletin of World Health Organization 10 (1): 35–76.

Tun‐Pe, Aye‐Aye‐Myint, Khin‐Ei‐Han, Thi‐Ha and Tin‐Nu‐Swe (1995) Local compression pads as a first‐aid measure for victims of bites by Russell's viper (Daboia russelii siamensis) in Myanmar. Transactions of the Royal Society of Tropical Medicine and Hygiene 89 (3): 293–5.

Vonk FJ, Admiraal JF, Jackson K, et al. (2008) Evolutionary origin and development of snake fangs. Nature 454 (7204): 630–633.

Welfare P, Little M, Pereira P and Seymour J (2014) An in‐vitro examination of the effect of vinegar on discharged nematocysts of Chironex fleckeri. Diving and Hyperbaric Medicine 44 (1): 30–4.

World Health Organization (2010) WHO Guidelines for the Production, Control and Regulation of Snake Antivenom Immunoglobulins, Geneva, WHO also at http://www.who.int/bloodproducts/snake_antivenoms/snakeantivenomguide/en/

Warrell DA and Arnett C (1976) The importance of bites by the saw‐scaled or carpet viper (Echis carinatus). Epidemiological studies in Nigeria and a review of the world literature. Acta Tropica 33 (4): 307–341.

Williams SS, Wijesinghe CA, Jayamanne SF, et al. (2011) Delayed psychological morbidity associated with snakebite envenoming. PLoS Neglected Tropical Diseases 5 (8): e1255.

Wüster W and Thorpe RS (1992) Dentitional phenomena in cobras revisited: spitting and fang structure in the Asiatic species of Naja (Serpentes: Elapidae). Herpetologica 48 (4): 424–434.

Further Reading

Halstead BW (1988) Poisonous and Venomous Marine Animals of the World, 2nd edn. Princeton, NJ: Darwin Press.

Junghanss T and Bodio M (1995) Notfall – Handbuch Gifttiere. Diagnose – Therapie – Biologie. Stuttgart: George Thieme. https://www.vapaguide.info.

Meier J and White J (eds) (1995) Clinical Toxicology of Animal Venoms. Boca Raton, FL: CRC Press.

Sutherland SK and Tibballs J (2001) Australian Animal Toxins. The Creatures, Their Toxins and Care of the Poisoned Patient, 2nd edn. Melbourne: Oxford University Press.

Warrell DA (2010a) Snake bite. Lancet 375 (9708): 77–88.

Warrell DA (2010b) Guidelines for the Management of Snake‐bites. New Delhi: World Health Organization Regional Office for South‐East Asia. http://www.searo.who.int/entity/emergencies/documents/9789290223774/en/.

Warrell DA (2004) Epidemiology, clinical features and management of snake bites in Central and South America. In: Campbell J and Lamar Venomous WW (eds) Reptiles of the Western Hemisphere, vol. 2, pp. 709–761. Ithaca: Cornell University Press.

Warrell DA (2007) Bites by venomous snakes outside the Americas. In: Auerbach PS (ed.) Wilderness Medicine, pp. 1086–1123. St. Louis, MO: Mosby.

Williamson JA, Fenner PJ, Burnett JW and Rifkin JF (eds) (1996) Venemous and Poisonous Marine Animals: A Medical and Biological Handbook. Sydney, Australia: University of New South Wales Press.

World Health Organization (2010) Guidelines for the Prevention and Clinical Management of Snakebite in Africa. World Health Organization Regional Office for Africa: Brazzaville.

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Warrell, David A(Oct 2015) Envenoming: Consequences and Management. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net [doi: 10.1002/9780470015902.a0002188.pub3]