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Snakes
Introduction
There are approximately 3000 types of snakes that exist around the world, with an estimated 600 types that are venomous. Reports from databases of the World Health Organization estimate a range of 20 000–94 000 deaths occurring, annually, from snakebites. Snakes exist on every continent, with the exception of Antarctica.
Viperinae are the families and subfamilies of poisonous snakes (see Figure 3).
COLUBRIDAE https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/colubridae
ELAPIDAE https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/elapidae
HYDROPHIDAE
HYDROPHIINAE https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/hydrophiinae
VIPRIDAE https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/viperidae
Colubridae
The Colubridae family is the largest snake family. It contains approximately 2000 species. Many colubrids are technically considered venomous but very few are considered dangerous to humans. Human deaths have been attributed to the boomslang (Dispholidus typus), keel snake (Rhabdophis spp.), and twig snakes (Thelotornis spp.). Medically important colubrids possess rear fangs, which are not as developed as elapid or viper fangs. In order to inject significant amounts of venom they frequently have to ‘chew’ on their victims. The venom of colubrids has not been studied as extensively as elapids and vipers and relatively little is known about it. Surprisingly, some of the same toxins found in elapid venom have been isolated from certain colubrids. However, clinical experience with colubrid envenomation is more consistent with a hemotoxic venom, similar to vipers, which can cause significant coagulopathy. Like other snakebites, the care of colubrid envenomations begins with supportive care measures. Considering the reports of coagulopathy after envenomation from boomslang and keel snakes, laboratory parameters should be closely followed. Though antivenom therapy is again the definite treatment, few colubrid antivenoms are commercially produced. An equine-derived boomslang antivenom and goat-derived Rhabdophis tigrinus antivenom are available. There is currently no Thelotornis spp. antivenom in production.
Elapids
The family Elapidae includes cobras, mambas, and sea snakes (see Marine Envenomations). In North America, the family is represented by the coral snake Micrurus spp. (Color Plate 8-14). The venom of many members of the elapid family is predominantly neurotoxic. The bite of an elapid such as a coral snake can produce local pain (but usually not swelling), headache, nausea, paresthesias, cranial nerve involvement, altered mental status, and respiratory failure. As with pit viper bites, medical care should be sought immediately. Treatment involves administration of a Micrurus-specific antivenin as soon as possible. Some evidence suggests that pressure and immobilization of the wound area until antivenin can be administered is beneficial for the outcome of elapid bites. This treatment method is shown in Figure 8-33.
Coral snake bites also cause significant morbidity and mortality in cats and dogs. As with human beings, neurotoxic effects predominate and treatment is based on the use of antivenin.10
Hydrophiids = family HYDROPHIIDAE
The hydrophiids or sea snakes are widely distributed throughout equatorial and tropical regions of the Indian and Pacific oceans, from the coast of Africa to America. There is some evidence that they have navigated the Panama canal and are colonising the Caribbean (Warrell, personal communication). They are closely related to the Elapids, having a similar venom and fang apparatus. Medically important genera include Enhydrina, Hydrophis, Pelamis, and Laticauda.
Viperids = family VIPERIDAE
Viperids are amongst the best known and probably medically most important venomous snakes. They are divided into two subfamilies, Viperinae and Crotalinae. The latter encompasses all the pit vipers, so called because they have highly developed paired heat-sensing organs on the anterior part of the head in pits. These allow them to more effectively locate and strike warm blooded preys at night. All vipers have a very well-developed anteriorly placed proteroglyphous fang structure. The fangs are on a modified maxilla which is capable of considerable rotation, allowing the fang to be folded against the roof of the mouth when not in use. This has enabled development of larger fangs than in other venomous snakes of equivalent size and in some vipers fang length may exceed 2 cm.
The subfamily Viperinae is found in Africa, Asia and Europe. Medically important Genera include Vipera, Bitis, Echis, Cerastes, Causus.
The subfamily Crotalinae is found in Asia and the Americas. Medically important Genera include Crotalus, Trimeresurus, Agkistrodon, Sistrurus, Calloselasma, Bothrops, Bothriechis, Bothriopsis, Lachesis, Porthidium. There are no vipers naturally occurring in Australia or New Guinea.
Crotalids
Three genera of crotalids are Crotalus (Rattlesnake), Sistrurus (Massasauguas or pigmy rattlesnakes), and Agkistrodon (Copperhead and Cottonmouth). Crotalids (‘Pit Vipers’) have triangular heads, elliptical pupils, a single row of subcaudal scales behind the anal plate, and facial pits which serve as heat sensors. Crotalids have hinged front fangs ∼2 cm in length, which are curved and hollowed. Rattlesnakes usually have a rattle – keratin scales at the end of the tail that produce a rattling sound when rubbed together. Venom glands are located posterior to the eyes and connected to fangs by venom ducts. Identifiable characteristics of copperheads are the rust-colored heads, and a white buccal cavity is noteworthy of cottonmouths or ‘water moccasins’.
Envenomation from a crotalid bite leaves one or more puncture wounds with a potential for progressive edema and ecchymosis. Crotalid venom contains a mixture of proteins, lipids, and metals. The venom forms fibrin polymers, which are susceptible to normal fibrinolysis and phagocytosis. It is represented by falling fibrinogen levels. Copperhead venom has a weak effect on this series of events in coagulation, resulting in lower morbidity after envenomation.
Initial pain at the site of the bite may be followed with a ‘metallic sensation’ in the mouth. Victims may become weak, and experience nausea, diarrhea, diaphoresis, and chills. Edema may begin around the bite area or may be delayed. Observation of the site for edema is a clue as to whether or not a ‘dry bite’ has occurred; that is, that no venom was injected into the site. Envenomation is most serious if venom is injected directly into joints, muscles, or veins. Hemorrhagic blisters and tissue destruction are possible. Neurotoxicity from rattlesnakes (but generally not from cottonmouths or copperheads) may be manifested as fasciculations, which are fine continuous contractions. In some cases, systemic neurotoxicity may involve respiratory failure. In the most serious cases, massive envenomation may lead to serious bleeding, hypotension, shock, multiple organ failure, and a high incidence of mortality.
Despite popular belief, crotalid envenomation does not generally result in life-threatening symptoms. Maintaining a patent airway, intravenous access, clinical observation of edema and the bite area, adequate laboratory work, and the use of antivenin when necessary are the essentials of treatment in snakebite envenomation. Antivenin should only be used in moderate to severe envenomations, usually within 8 h postenvenomation. This is an equine-derived product and thus skin testing for sensitivity is usually performed after the decision that antivenin is necessary has been made. Serum sickness may occur from the antivenin. Hospital monitoring, wound care, and patient follow-up are important for the recovery of these patients.