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CLINICAL TOXICOLOGY > ENVENOMATION > Flashcards

ENVENOMATION Flashcards

1
Q

Snakebite envonoming is a …… disease

A

Neglected tropical disease

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2
Q

Snakebite envenomation is a ————- medical emergency

A

Life threatening

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3
Q

Which regions of the world experience snakebites the most

A

Tropical and Subtropical

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4
Q

Vast majority of deaths due to snakebites occur in ………

A

Sub Saharan Africa and south east Asia

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5
Q

Country with the highest snakebite mortality

A

India

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6
Q

Why do children suffer more severe effects from snakebites than adults

A

Due to their smaller body mass

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7
Q

Why do children suffer more severe effects from snakebites than adults

A

Due to their smaller body mass

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8
Q

Epidemiology of snakebites

A

Males are bitten more than females
Agricultural workers and children are most affected
Elderly are at a greater risk of mortality

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9
Q

Number of snake species considered venomous

A

600 out of the 3500 species

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10
Q

Classification of snakes to their suborder

A

Class Reptilian
Order Squamata
Suborder Serpentes

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11
Q

Venomous snakes are in ——- families

A

Five

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12
Q

Largest and second largest venomous snake families

A

Viperidae and Elapidae

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13
Q

Five families of venomous snakes

A

Colubridae
Atractaspididae
Elapidae
Viperdae- Viperinae
Crotalidae

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14
Q

Examples of Colubridae

A

Boomslang
Bird snake

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15
Q

Examples of atractaspididae

A

Burrowing asps

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16
Q

Examples of elapidae

A

Cobras, kraits, coral snakes , mambas, death adder, tiger snake, most Australian snakes

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17
Q

Examples of Hydrophiidae

A

Hydrophiidae are in the family Elapidae
Examples are Sea snakes and Sea kraits

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18
Q

Examples of Viperinae ( True/Pitless vipers)

A

Vipers
Adders
Asps

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19
Q

Examples of Crotalidae or pit vipers

A

Rattlesnakes
Bushmaster
Copperhead

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20
Q

Types of snake fangs

A

fangless (aglyphous),
rear-fanged (opisthoglyphous),
front fanged and fixed maxilla (proteroglyphous),
Front fanged and mobile maxilla (solenoglyphous)

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21
Q

Anatomical classifications of snakes based on fangs

A

Colubridae- Opisthoglyphous
Elapidae- Proteroglyphous
Viperidae- Solenoglyphous
Atractaspididae- All types of fangs

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22
Q

Which family of snakes contain species capable of spraying their venom

A

Elapidae

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23
Q

Two examples of cobras

A

Common cobra- Naja naja
King cobra- Ophiophagus hannah

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24
Q

Examples of kraits

A

Common krait: Bangarus caeruleus

Banded krait: Bangarus fasciatus

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25
Q

Most venomous snake based on the murine LD50

A

Western or Inland taipan from the family Elapidae

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26
Q

Examples of true cobras (Najas)

A

Common cobra - Naja naja
Black necked spitting cobra- Naja nigricollis
Egyptian cobra- Naja heje

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27
Q

Key identification feature of the common cobra

A

Well marked hood
Monocellate or Binocellate spectacle mark

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28
Q

Key identification feature of the common krait

A

Paired white bands

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29
Q

Two examples of mambas

A

Green mamba - Dendroaspis angusticeps
Black mamba - Dendroaspis polyplepis

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30
Q

Features of pit vipers

A

Pit between eye and nostril
Flat triangular shaped head
Vertical pupils
Curved fangs

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31
Q

Examples of true or pitless vipers

A

Russell’s Viper - Daboia russelii
African saw scaled viper or carpet viper - Echis ocellatus
African puff adder - Bitis arietans

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32
Q

Examples of pit vipers /Crotalidae

A

Rattlesnakes
Cottonmouth or Water moccasin
Copperhead
Bushmaster

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33
Q

Key identification feature of the Russell’s viper

A

Black edged almond or chain shaped marks on the back

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34
Q

Examples of rattlesnakes

A

Sidewinder
Diamondback

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35
Q

Key venomous snakes in Ghana

A

West African saw scaled / carpet viper - Echis ocellatus
Puff adders- Bitis arietans
Black necked spitting cobra- Naja nigricolis
Senegales cobra - Naja senegalensis
Western green mamba -Dendroaspis viridis

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36
Q

Identification features of venous and nonvenomous snakes

A

Venomous
Triangular head or arrowhead head
Elliptical pupil
Fangs
Single row of subcaudal anal plates

Harmless
Oval head or egg shaped head
Round pupil
Double row of subcaudal anal plates

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37
Q

Difference between poison and venom

A

Venom must be injected into the body by mechanical means however poisons must be ingested inhaled or absorbed

Venoms are generally nontoxic if swallowed

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38
Q

Functions of snake venom

A

Prey immobilization
Assist in or start the digestive process
Self defense

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39
Q

Causes of difference in snake venom composition

A

Geographical distribution
Seasons of the year
Age or ontogenic variation

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40
Q

Two main classes of snake venoms

A

Proteins and Peptides
Non enzyme and Enzymes

Non proteinaceous components

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41
Q

Effect of 3FTX neurotoxin

A

Selective inhibition of nAchR

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42
Q

Effect of 3FTX cardiotoxin

A

Membrane perturbation by electrostatic and hydrophobic interactions with the cell membranes

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43
Q

Effect of Disintegrin peptide components

A

Inhibit platelet aggregation
.

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44
Q

Effect of kurnitz type inhibitors

A

Inhibition of serine proteases (e.g., plasmin, kallikrein, trypsin).
Interferes with the blood coagulation cascade and fibrinolysis

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45
Q

Effect of natriuretic peptide components

A

Vasodilation
Hypotension
Increase NO production
Cardiprotective action

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46
Q

Effect of BPP( Bradykinin potentiating peptides) protein components

A

Inhibit the function of ACE and raise the level of bradykinin.
Hypotension

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47
Q

Effects of Crotamine peptide components

A

Interacts electrostatically with DNA.
Penetrates membranes via heparan sulphate proteoglycans binding.

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48
Q

Effects of safarotoxin

A

Vasoconstriction via endothelin receptors

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49
Q

Effect of waglerin

A

nAChR antagonist.

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50
Q

Effect of CRISPs

A

Inhibit high K induced contraction

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51
Q

Effects of PLA2

A

Hypotension
Vasorelaxation
Antiatgetogenic activity

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52
Q

Effects of 3FTXs

A

Hopotension
Vasorelaxation
Inhibition of platelet aggregation

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53
Q

Effect of fibrinolytic enzymes

A

Inhibit platelet aggregation
Fibrinolytic activity

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54
Q

Which snakes produce neurotoxic venoms

A

Elapidae- cobras, kraits, coral snake
Hydrophiidae
Small Bitis vipers
Russell’s viper

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55
Q

Which snakes produce cytotoxic venoms

A

Black necked spitting cobra
Bothrops asper
Saw scaled/ Carpet viper

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56
Q

Snakes that produce haemotoxic venoms

A

Viperidae, spitting cobra, certain Colubridae

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57
Q

Snakes that produce myotoxic venoms

A

Hydrophiidae

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58
Q

Snakes that can produce venoms with combined toxicities

A

Spitting cobra
Saw scaled or carpet viper

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59
Q

Signs of neurotoxic venoms

A

Descending muscular paralysis

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60
Q

Predominant neurotoxic toxins

A

PLA2
3FTX

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61
Q

Sign of cytotoxic venoms

A

Swelling at the bite site which can develop into blistering and bruising and hypovolaemic shock

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62
Q

Predominant cytotoxic toxins

A

Hydrolytic enzymes eg: Snake Venom Metalloproteinases (SVMPs)

PLA2s
Non enzymatic cytotoxic 3FTs

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63
Q

Signs of myotoxic envenoming

A

Negligible local swelling
Myalgia
Associated features of neurotoxic venoms and progressive descending paralysis
Rhabdonyolysis and renal failure

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64
Q

Examples of myotoxic toxins

A

Myotoxic single chain peptides (42-44amino acid residues)
Myotoxic PLA2s

65
Q

Signs of haemotoxic venoms

A

Cardiovascular effects- Hypotension leading to shock

Haemostatic effects- local and systemic hemorrhage

66
Q

What is VICC

A

Venom-induced consumption coagulopathy (VICC) is a disseminated intravascular coagulation(DIC)-likesyndrome, characterized by low or undetectable levels of fibrinogen, resulting in incoagulable blood

67
Q

Examples of haemotoxic venoms

A

Snake venom serine proteases
Snake venom metalloproteinases
Bradykinin potentiating peptides
C-type lectins
PLA2
Disintegrins
Factor Va toxin
Factor Xa toxin
Kurnitz type serine protease inhibitors

68
Q

Factors determining risk of the human envenomation by different snakes

A

Venom toxicity/potency
Size of snake
Effectives of the bite
Innate aggressiveness of snake
Likelihood of human contact

69
Q

Clinical features of snake bites

A

Increasing Local pain at site
Local swelling that extends oroximall
Tender painful enlargement of regional lumpen nodes

70
Q

Examples of snakes with painless bites

A

Kraits
Sea snakes

71
Q

Local signs and symptoms at the site of a snake bite

A

Fung marks *
Local pain
Local bleeding *
Brushing
Lymphangitis *
Lymph node enlargement
Inflammation
Blistering *
Local infection
Abscess formation
Necrosis

72
Q

Systemic signs of snake bites

A

Malaise
Nausea
Vomiting
Abdominal pain
Weakness
Drowsiness
Prostration

73
Q

Cardiovascular signs of snake bites

A

Hypotension
Shock , Blurred vision , Syncope, Dizziness, Collapse

Pulmonary edema
Cardiac arrhythmias
Cardiac arrest

74
Q

Bleeding and clotting disorders associated with snake bites

A

Bleeding from recent wounds and partly healed wounds
Spontaneous systemic bleeding

75
Q

Signs of spontaneous systemic bleeding in snakebites

A

Bleeding from gums
Epixtasis
Haemoptysis
Haematemesis
Rectal bleeding
Meleana
Haematuria
Vaginal bleeding
Bleeding into skin and mucosal
Intracranial hemorrhage
Antepartum haemorrhage

76
Q

Examples of skin bleeding

A

Purpura
Petechiae
Ecchymoses

77
Q

Signs of neurological snake venoms

A

Drowsiness
Paraesthesiae
Abnormalities of taste and smell
Heavy eyelids
Progressive descending paralysis

78
Q

Which venoms cause broken neck sign and respiratory or flaccid paralysis

A

Neurotoxic venoms

79
Q

Signs of skeletal muscle breakdown in snake envenoming

A

Généralised pain
Stiffness and tenderness of muscles
Lock jaw or trismus
Myoglobinuria
Hyperkalemia
Cardiac arrest

80
Q

Which snakes produce venoms that cause skeletal muscle breakdown

A

Sea snakes
Russell’s viper

81
Q

Signs or renal failure in snake envenoming

A

Loi or lower back pain
Haematuria
Haemoglobinuria
Myoglobinuria
Oliguria/Anuria
Uraemia signs and symptoms

82
Q

Examples of snakes that release venoms that cause renal failure

A

Viperidae
Sea snakes

83
Q

Signs and symptoms of uraemia

A

Acidotic breathing
Hiccups
Nausea
Pleuritic chest pain

84
Q

Four initial questions in assessing snake bites

A

Which part of body was bitten
When were you bitten
Where is the snake that but you or what did it look like
How are you feeling now

85
Q

Parameters to be examined

A

Tooth marks
Local signs
Bleeding
Shock
Neurotoxicity or paralysis

86
Q

Earliest signs of snake envenoming

A

Local swelling , enlargement and tenderness of regional lymph nodes

87
Q

First site of spontaneous systemic bleeding in snake envenoming

A

Gums (Gingival sulci)

88
Q

Snake responsible for most deaths in northern Ghana

A

Echis ocellatus

89
Q

Earliest symptoms of neurotoxity or paralysis in snake envenoming

A

Blurred vision
Heaviness of the eyelids
Apparent drowsiness
Contracted frontalis muscle

90
Q

Haematological investigations in snake envenoming

A

FBC
Neutrophil leukocytosis
Thrombocytopenia

20WBCT

PT as INT or activated Partial Thromboplastin Test (aPTT)

91
Q

Which snakes cause thrombocytopenia

A

Vipers
Colubrids

92
Q

How is 20WBCT performed

A

Leave 2-5 ml of blood in dried test tube
Failure to clot after 20 minutes implies incoagulable blood

93
Q

Biochemistry investigations in snake envenoming

A

BUE and Creatinine - renal dysfunction and acid base imbalance
LFT- increased bile
Serum electrolytes : CK, AST - muscle damage

94
Q

Other investigations

A

Urine examination
Arterial oxygen saturation
ECG
Chest radiography

95
Q

Duration to death for snake bites

A

Hours for Elapidae bites
Days for Viper bites

96
Q

Contraindicated potentially harmful treatments in snake envenoming

A

Torniquet
Wash, rub, massage, tamper with bite wound
Suction of bite site
Incision of bite site
Cryotherapy
Electric shock
Excision of bite site
Cauterization
Instillation of chemicals like KMnO4

97
Q

Thé Do it RIGHT mnemonic of snake envenoming first aid

A

R- Reassure patient
I- Immobilize
GH- Get to Hospital
T - Tell

98
Q

Early Treatment of local pain

A

Oral paracetamol
Opiates for sever pain

99
Q

Why are NSAIDS avoided in snake envenoming

A

Avoid NSAIDS due to risk of gastric bleeding in pts with incoagulable blood

100
Q

Early treatment of vomiting

A

Lay patient in recovery position( on left side), head down to avoid aspiration

IM Chlorpromazine 25-50mg in adults, 1mg/kg in children
OR
IM Prochlorperazine 12.5mg in adults

101
Q

What drug is used for mild sedation in snake envenoming

A

Diazepam oral 5-10mg stat

102
Q

Treatment of pain in snake envenoming

A

Paracetamol oral
Morphine IV/IM/SC

103
Q

Dose for polyvalent anti-snake serum

A

50-100ml (5-10ampoules)
by IV drip in 0.9%N/S or 5%Dextrose over 2-4 hours

104
Q

Treatment for hypovolaemic shock in snake envenoming

A

Crystalloids
Colloids
Blood

105
Q

Treatments for defects of hémostasis in snake envenoming

A

Clotting factors
Fresh frozen plasma
Platelets

106
Q

Treatments for respiratory distress in snake envenoming

A

Oxygen
Intubate
Ventilate

107
Q

Indication for antivenin in snake envenoming

A

Presence of symptoms and signs of systemic or severe local manifestations of envenomation

108
Q

Complications of antivenin use

A

Anaphylaxis
Pyrogenic reactions
Later immune complex disease ( Serum sickness)

109
Q

Storage of liquid antivenin

A

Stored at 2-8 degrees Celsius and not frozen

110
Q

Animals used in producing antivenins

A

Horses
Donkeys
Sheep

111
Q

Which has a longer shelf life, lyophiliséd or liquid antivenin

A

Lyophilised has a longer shelf life but is more expensive

112
Q

Types of antivenom

A

Monovalent or Monospecific
Polyvalent or Polyspecific

113
Q

Disadvantages of polyvalent antivenin

A

Larger doses required
Higher risk of adverse reactions
Increased cost of treatment

114
Q

Advantages of polyvalent antivenom

A

Neutralisons antibodies agains a wider pool of antigens
No need to identity snake that has bitten the patient

115
Q

Disadvantage of monospecific antivenom

A

Limited cross efficacy, often restricted to snake genus

116
Q

Why do children and adults require same dose of antivenom

A

Antivenom neutralizes a fixed amount of venom

117
Q

Patients with increase risk of severe actions to antivenom

A

Atopic history ( severe asthma, hay fever etc)
History of reactions to equine antisera(anti-tetanus serum)

118
Q

Pretreatment for diminishing reaction to antivenom

A

Subcutaneous adrenaline and IV antihistamine and hydrocortisone

119
Q

Why are tests with diluted antivenom not predictive of anaphylaxis or late serum sickness reactions

A

Large majority of antivenom reactions are not IgE based Type 1 hypersensitivity reactions but rather due to direct complement activation by aggregates of IgG or its fragments

120
Q

Antivenom is best given IV, why is IM not ideal

A

Absorption is very slow

121
Q

How is antivenom given

A

IV injection at a rate of about 5ml/min
Or
Diluted in isotonic fluid and infused over 30-60min

122
Q

Response to antivenom treatment on the various systemic and local effects of snake envenoming

A

Neurotoxic signs - change slowly after several hours

Cytotoxic - limit further damage but not reverse damage

Cardiovascular effects - respond within 10-20min

Spontaneous bleeding - stops within 15-30 min

Blood coagulability - restored within 6 hours

123
Q

If blood is still incoagulable 6hours after the first dose of antivenom, what should be done

A

Repeat dose and so on every 6h until blood coaguability is restored

124
Q

Which brand of antivenom is a solution

A

ASNA Antivenom C and
ASNA Antivenom D

125
Q

Symptoms of early antivenom reactions

A

Cough
Tachycardia
Itching
Urticaria
Fever
Nausea
Vomiting
Headache

126
Q

Symptoms of systemic anaphylaxis

A

Hypotension
Bronchospasm
Angioedema

127
Q

Treatment of early antivenom reactions

A

Adrenaline 0.5-1ml for adults, 0.01mg/kg for children

Followed by IV H1 antagonist

128
Q

Dose for IV H1 antagonists in treating early antivenom reaction

A

Chlorphenamine - 10mg for adults. 0.2mg/kg for children

Promethazine - 25mg IM in adults

129
Q

Signs of pyrogenic reactions to snake antivenom

A

Chill
Cutaneous vasoconstriction
Gooseflesh and shivering
Myalgia
Headache
Tachycardia
Fever
Intense vasodilation and hypotension
Febrile convulsions in children

130
Q

Treatment for pyrogenic reactions to snake antiserum

A

Reduce temperature by fanning, tepid spongin and antipyretics
IV adrenaline for severe cases with hypotension

131
Q

Symptoms of late reactions ( serum sickness) to snake antivenom

A

Itching
Urticaria
Lymphadenopathy
Arthralgia
Periarticular swellings
Proteinuria
Neurological symptoms

132
Q

Treatment of serum sickness

A

Antihistamine Chlorphenamine 2mg/6h adult 0.25mg/kg/day in divided doses for children: 5 days

Prednisolone for severe cases and failure of antihistamines within 24 hours

133
Q

Timelines for the different reactions to snake antivenom

A

Early and anaphylactic reactions - 3-60min
Pyrogenic reactions - 1-2 hours
Late reactions or serum sickness- 5-24 hours, averagely 7 hours

134
Q

Antibiotic prophylaxis in local envenoming

A

Amoxicillin/ Clavulanate

135
Q

Treatment of coagulopathy if not reversed by ASV therapy

A

Fresh frozen plasma
Cryoprecipitate ( Fibrinogen, Factor VIII)
Fresh whole blood
Platelet concentrate

136
Q

Treatment of bulbar paralysis and respiratory failure in snake envenoming

A

Tracheotomy
Endotracheal intubation
Mechanical ventilation

IV Neostigmine 50-100mcg/kg/4hours infusion
Glycopyrrolate 0.25mg before neostigmine in place of atropine

137
Q

Which snakes cause snake venom ophthalmia

A

Spitting elapid species

138
Q

Taxonomy of order Hymenoptera

A

Phylum Arthropoda
Class Insecta
Order Hymenoptera

139
Q

The three families under Hymenoptera

A

Vespidae ( True Wasps)
Apidea (bees)
Formicidae(Wasps)

140
Q

Subfamily and family of genus solenopsis (fire ants)

A

Subfamily - Myrmicinae
Family- Formicidae

141
Q

Examples of insects in subfamily aspinae

A

Honeybees
Bumblebees

142
Q

Genus of honeybees

A

Genus apis

143
Q

Insects under subfamily Vespinae

A

Hornet
Yellowjackets

144
Q

Which insects causes most all allergic reactions

A

Vespids

145
Q

Difference between apids and vespids in relation to stinging

A

Female apids sting once
Vespids sting multiple times, both males and females

146
Q

Composition of Vespids venoms

A

Proteins
PLA
Hyaluronidase
Acid Phosphatase
Antigen 5

Peptides
Mast cell degranulating peptide
Kinins

147
Q

Components of Formicids venoms

A

Proteins
PLA
Hyaluronidase
Unidentified third protein

Alkaloids
Piperidiones

148
Q

Components of Aphid venom

A

Proteins
PLA
Hyaluronidase
Acid Phosphatase

Peptides
Melittin
Apamin
Mast cell degranulating peptide

149
Q

Effects of melittin

A

Pain
Destruction of tissues
Basophils and mast cell degranulation

150
Q

Which insect mostly causes local infections from its stings

A

Yellow jacket

151
Q

Management of airway in anaphylactic reactions due to Hymenoptera

A

High flow oxygen

152
Q

Treatment of hypotension in anaphylactic reactions due to Hymenoptera

A

Lactated ringers

153
Q

Treatment of severe shock in anaphylactic reactions due to Hymenoptera

A

SC epinephrine 0.01mg/kg (0.3mg in adults
IV epinephrine 0.1mg

154
Q

Antihistamines used in anaphylactic reactions due to Hymenoptera

A

IV diphenhydramine 1mg/kg (50mg in adults )
IV cimetidine 300mg in adults
IV steroids (100-250’mg hydrocortisone or methyl prednisolone)

155
Q

Treatment of wheezing in anaphylactic reactions due to Hymenoptera

A

Orciprenaline 0.3cc or
Salbutamol 2.5cc in 3cc NS

156
Q

Management of hypotension despite IV fluids in anaphylactic reactions due to Hymenoptera

A

IV dopamine or Epinephrine drip

157
Q

If sting site of insect is red and swollen but mainly pruritic

A

Treat with oral antihistamines

158
Q

If sting site is red and swollen but mainly painful

A

Treat with oral antibiotic

159
Q

If sting site is red and swollen and pruritic and painful

A

Treat with oral antibiotic and antihistamines

CLINICAL TOXICOLOGY (14 decks)

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