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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
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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.
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
Bites & StingsBites & Stings
•• ReptilesReptiles
•• ArthropodsArthropods
•• Toxic marine Toxic marine creaturescreatures
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Dept of Medicine, Chulalongkorn Uviv
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
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
Snake venomsSnake venoms
•• NeurotoxinNeurotoxin
•• CardiotoxinCardiotoxin
•• CytolysinCytolysin
•• MyotoxinMyotoxin
•• ProcoagulantProcoagulant
•• AnticoagulantAnticoagulant
•• HemorrhaginHemorrhagin
•• Platelet Platelet
aggregator/inhibitoraggregator/inhibitor
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Dept of Medicine, Chulalongkorn Uviv
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))
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Cobra (showing hood)
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Cobra (showing hoodmarks)
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
Important Venomous Snakes Important Venomous Snakes in Thailandin Thailand
•• 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
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
Important Venomous Snakes Important Venomous Snakes in Thailandin Thailand
•• Hematotoxin producing snakesHematotoxin producing snakes
Vipers (Viperinae)Vipers (Viperinae)
–– RussellRussell’’s viper (s viper (DaboiaDaboia russelli russelli siamensissiamensis))
• Central and Eastern Thailand
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
Important Venomous Snakes Important Venomous Snakes in Thailandin Thailand
•• 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
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Malayan pit viper
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
Important Venomous Snakes Important Venomous Snakes in Thailandin Thailand
•• MyotoxinMyotoxin
–– Sea snakes (Sea snakes (Hydrophinae Hydrophinae & & LaticudinaeLaticudinae))
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
Important Venomous Snakes Important Venomous Snakes in Thailandin Thailand
•• RearRear--fanged snakesfanged snakes
–– Mangrove snake Mangrove snake
• Redness, swelling and tenderness
–– Keel back snakeKeel back snake
• Bleeding tendency, sometimes severe
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Boiga dendrophila
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Wiroj Suksamai (www.siamensis.org/board/8517.html)
Rhabdophis subminiatus
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Fang marks
Teeth marks
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Dept of Medicine, Chulalongkorn Uviv
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
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Dept of Medicine, Chulalongkorn Uviv
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
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Dept of Medicine, Chulalongkorn Uviv
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
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Dept of Medicine, Chulalongkorn Uviv
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)
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Dept of Medicine, Chulalongkorn Uviv
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
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Dept of Medicine, Chulalongkorn Uviv
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
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Necrosis from cobra bite
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Necrosis from cobra bite (late)
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Hemorrhagic and multiple hemorrhagic
blebs from Malayan pit viper bite
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Compartment syndrome
Digital ischemia
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
DiagnosisDiagnosis
•• Systemic S&SSystemic S&S
•• Local S&SLocal S&S
•• Snake morphology, habitatsSnake morphology, habitats
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
LaboratoryLaboratory
•• ImmunodiagnosisImmunodiagnosis & & SerodiagnosisSerodiagnosis are are
available but not ready for clinical practiceavailable but not ready for clinical practice
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Dept of Medicine, Chulalongkorn Uviv
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
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
Severity AssessmentSeverity Assessment
•• Neurotoxin:Neurotoxin:
–– muscle powermuscle power
–– severity of respiratory failureseverity of respiratory failure
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Dept of Medicine, Chulalongkorn Uviv
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
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
TreatmentTreatment
•• GeneralGeneral
•• Specific treatmentSpecific treatment
•• AntivenomAntivenom
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Dept of Medicine, Chulalongkorn Uviv
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 ????
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
General TreatmentGeneral Treatment
•• 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
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
General TreatmentGeneral Treatment
•• 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)
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Dept of Medicine, Chulalongkorn Uviv
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
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Dept of Medicine, Chulalongkorn Uviv
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
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Dept of Medicine, Chulalongkorn Uviv
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
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
ArthropodsArthropods
•• 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
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Wasp sting lesions
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
ArthropodsArthropods
•• Hymenoptera Treatment Hymenoptera Treatment –– Supportive careSupportive care
• analgesics
• antihistamines
–– In severe casesIn severe cases
• treat hypersensitivity
• vasopressor if needed
• steroid (controversy)
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
ArthropodsArthropods
•• 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
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
Toxic marine lifeToxic marine life
•• Thailand scenarioThailand scenario
–– seasonal, sporadic, small outbreaksseasonal, sporadic, small outbreaks
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
TetrodotoxinTetrodotoxin
•• Puffer fish (Puffer fish (LagocephalusLagocephalus spp.spp.))
•• Asiatic horseshoe crab (Asiatic horseshoe crab (CarcinoscorpiusCarcinoscorpius
rotundicaudarotundicauda))
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
TetrodotoxinTetrodotoxin
•• BlueBlue--ringed octopus (ringed octopus (HapalochlaenaHapalochlaena sppspp))
–– bitebite
–– very low incidencevery low incidence
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Dept of Medicine, Chulalongkorn Uviv
Bites & Stings
TetrodotoxinTetrodotoxin
•• Neuromuscular junction blockadeNeuromuscular junction blockade
•• generalized paralysis generalized paralysis respiratory failurerespiratory failure
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Thank You for your attention