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					HERPETOLOGIC ENVENOMATION
   UNITED STATES AND THE MIDDLE EAST


       Capt John Kitsteiner, MD
        Eglin AFB Family Medicine Residency
    Common Corn Snake                 Amelanistic Corn Snake             Green Tree Snake
      Elaphe guttata guttata            Elaphe guttata guttata          Dendrelaphis punctulata




    Honduran Milksnake                  Eastern Kingsnake                Scarlet Kingsnake
Lampropeltis triangulum hondurensis    Lampropeltis getula getula   Lampropeltis triangulum elapsoides




           Ball Python                  Green Watersnake                 Eastern Glass Lizard
            Python regius                 Nerodia floridana                Ophisaurus ventralis
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
CASE STUDY
        9 year old male was bit multiple times by “some baby snakes”.
        Told his parents after his arm started to “feel funny”.
        Parents brought him immediately to the ER.
        Attempts were made to identify the snakes.
        Likely juvenile Copperheads or Cottonmouths.
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
SNAKEBITE EPIDEMIOLOGY
herpetologic envenomations
SNAKEBITE EPIDEMIOLOGY
      Over 120 species of snakes in North America.
      Only 20 species are venomous.
      300 of over 2,700 species worldwide are venomous.


      About 45,000 snakebites occur annually in the U.S.
      About 8,000 of these bites are from venomous snakes (10-50% are dry bites).
      300,000 – 400,000 venomous snakebites occur yearly worldwide.


      About 12 fatalities yearly from snake envenomations in the U.S.
      30,000 – 110,000 deaths worldwide from envenomations.


      Mortality is 2.6% if envenomated in the U.S. without treatment.
      Mortality is 0.28% if antivenom is given.
herpetologic envenomations
SNAKEBITE EPIDEMIOLOGY
      Most snakebite victims are males (>70%).
      Most victims are between 10 and 27 years of age.

      Highest group for non-venomous: 10-14 year old males.
      Highest group for venomous bites: 19-27 year old males.

      98% of snakebites are on extremities (most on hands and arms).

      Most bites occur between April and September.

      >45% occur at victim’s home or yard.
      ~4% occur while victim was fishing or golfing.

      Alcohol intake is a factor in many envenomations.
herpetologic envenomations
SNAKEBITE EPIDEMIOLOGY
      IN THE MILITARY
      U.S.
         - 9 snakebites among 3,265 U.S. troops in Iraq and Afghanistan
         - Higher rates with trench and burn toileting facilities
         - Incidence peak in April-October
         - Hands most common site on soldiers (compared to legs of locals)


      Israel
         - 43.6 visits for snakebites per year per 100,000 Israeli troops


      British
         - E5 and E6 ranks had highest number of bites
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
VENOMS
      Produced in venom glands:
          Modified salivary glands
          Specialized Duvernoy's glands

      Snake venom consists of:
      Proteins                   Enzymes
           Alpha-neurotoxins           Phosphodiesterases
           Kappa-toxins                Phospholipases
           Beta-toxins                 Cholinesterases
           Dendrotoxins                Hyaluronidase
           Cardiotoxins                Oxidases
           Myotoxins                   Proteases
           Hemorragines                ATPases



      Most are classified as mainly:
          Hemotoxic
          Neurotoxic
herpetologic envenomations
VENOMS
      CLINICAL EFFECTS OF HEMOTOXIC SNAKEBITE ENVENOMATION
           Intense Pain at bite                      Rapid Pulse
           Spreading edema at bite                   Muscle Fasciculations
           Weakness                                  Parethesia (oral) / Funny Taste (metalic or minty)
           Numbness or Tingling                      Vomiting
           Ecchymosis                                Confusion

      Coagulopathy (In the U.S. most common with rattlesnake envenomation)
         Coagulopathy characterized by:
           - Defibrination
           - Thrombocytopenia
         May last for 1-2 weeks.
         May recur after antivenom is metabolized.

      Rhabdomyolysis (In the U.S. more likely with Canebrake / Mojave rattlesnakes)
         May lead to renal failure
         May lead to electrolyte abnormalities (hyper/hypokalemia, hypocalcemia)
herpetologic envenomations
VENOMS
      CLINICAL EFFECTS OF NEUROTOXIC SNAKEBITE ENVENOMATION

         Minimal Pain                         Impending Respiratory Failure
                                                Respiratory Distress
         Neurologic Dysfunction                 Pharyngeal Spasm
            Diaphoresis                         Hypersalivation
            Parasthesia (numb at bite site)     Cyanosis
            Altered Mental Status               Trismus
            Ptosis
            Diplopia                          Cardiovascular Collapse
            Dysphagia                           Hypotension
            Generalized Weakness                Tachycardia
            Muscle Fasciculations
            Hyporeflexia
            Paralysis


      NOTE:
      Systemic reactions are difficult to reverse once they develop,
      so early use of antivenom is strongly recommended
herpetologic envenomations
VENOMS
      SEVERITY OF CLINICAL EFFECTS
      Extremely variable. Depends on:
         Species of snake
         Size of snake
         Location of bite
         Volume of venom injected
         Age of victim
         Size of victim
         Health of victim
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
ENVENOMATION TREATMENT
             FACT OR FICTION?
               Tourniquets
               Wound Incisions (Cut and Suck)
               Negative Pressure Venom Extractors
               Ice
               Electric Shock
               Alcohol
               Stimulants
               Aspirin
               Wearing blue jeans reduces venom injection
               Lymphatic bands
herpetologic envenomations
ENVENOMATION TREATMENT
             PRE-HOSPITAL CARE
                ACLS (Oxygen, 2 large bore IVs, Fluids)
                Minimize Activity
                Remove tight clothing or jewelry
                Mark and time border of edema
                Maintain extremity in neutral position
                Do not capture or kill snake
                Do not handle snake if you do not heed above advice
                Take photo of snake
herpetologic envenomations
ENVENOMATION TREATMENT
             EMERGENCY DEPARTMENT CARE (Part I)
                Give fluid bolus (repeat as needed)
                Anaphylaxis protocol (treat as shock patient)
                Draw labs
                Contact Poison Control
                Give loading dose of antivenom if signs of envenomation
                    NOTE: ADULT DOSE = PEDIATRIC DOSE
herpetologic envenomations
ENVENOMATION TREATMENT
             EMERGENCY DEPARTMENT CARE (Part II)
                Envenomation Grading
                Wound care and analgesia
                Tetanus toxoid or tetanus immune globulin
                Observe asymptomatic patients 8-12 hrs before discharge
                (if the bite is from a neurotoxic snake, observe for 24 hrs)
herpetologic envenomations
ENVENOMATION TREATMENT
      INITIAL ENVENOMATION GRADING
herpetologic envenomations
ENVENOMATION TREATMENT
             LABORATORY STUDIES (All labs not needed with neurotoxins):
                 Initial and every 12 hrs         Additional Initial Labs
                     CBC with Differential            Blood Type and Match
                     Platelet Count                   Metabolic Panel
                     PT/INR                           LFTs
                     Fibrinogen (measured)            CPK
                     D-Dimer                          Phosphorus
                                                      Magnesium
                                                      UA




                 If Respiratory Compromise: ABG

                 If age >50 or history of Heart Disease: ECG, Cardiac Enzymes
herpetologic envenomations
ENVENOMATION TREATMENT
            IN-PATIENT MANAGEMENT
              Admission Criteria
                    - Rattlesnake envenomation
                    - Mojave Rattlesnake bite
                    - Antivenom given (always for Eastern/Texas Coral Snake bite)
                    - All young children bitten by a venomous snake
                    - All patients bitten by exotic/unidentified venomous snake
              Envenomation Grading 30-60 min
              Administer antivenom if indicated / available
              Treat pt as you would a shock patient
                    - Telemetry
                    - Pulse Oximetry
                    - Intubation
                    - Dialysis
herpetologic envenomations
ENVENOMATION TREATMENT
      SURVEILLENCE ENVENOMATION GRADING
        to be done every 30-60 minutes:
herpetologic envenomations
ENVENOMATION TREATMENT
       ADMINISTERING ANTIVENOM: FabAV (Pit-Viper Envenomations)
       •   Initial dose of 4-6 vials in 250 mL of NS IV over 1 hour.
       •   Observe for 1 hour to achieve intial control
           (complete arrest of local manifestations, and return of coagulation tests and systemic
           signs to normal)
       •   If initial control is not achieved, give additional doses of 4-6 vials until initial
           control has been achieved.
       •   After initial control has been established, additional 2-vial doses of CroFab
           every 6 hours for up to 18 hours (3 doses) is recommended.
       •   Additional 2-vial doses may be administered as necessary, based on the
           patient’s clinical course.
herpetologic envenomations
ENVENOMATION TREATMENT
       ADMINISTERING ANTIVENOM: Antivenin Micrurus Fulvius (Coral Snake)
       •   Start an intravenous drip of 250 to 500 ml of NS
       •   If no hypersensitivity to horse serum, administer 3 to 5 vials IV
           (The first 1 or 2 ml should be injected over a 3- to 5-minute period with careful
           observation of the patient for evidence of allergic reaction)
       •   If no signs / symptoms of anaphylaxis, continue the infusion.
           (In small children, allow the first 100 ml to run in rapidly but then decrease to a rate not
           to exceed 4 ml per minute)
       •   Response to treatment may be rapid and dramatic.
       •   Observe the patient and administer additional Antivenin as required.
herpetologic envenomations
ENVENOMATION TREATMENT
       ADMINISTERING ANTIVENOM: Snakes in the Middle East
       •   Polyvalent Antivenoms only stocked at Level 3 Facilities
       •   The most effective treatment is a geographic and species-specific antivenom
            - Certain antivenom cannot be utilized for a number of reasons
       •   Antivenom is considered Investigational New Drug (IND)
herpetologic envenomations
ENVENOMATION TREATMENT
       ANTIVENOM COMPLICATIONS
       Acute Allergic Reaction (Anaphylaxis)
       •   Less common with ovine-based antivenoms
       •   Treat with systemic antihistamines and steroids
       •   Consider pre-treatment with IV diphenhydramine (1 mg/kg) and cimetidine (6 mg/kg)

       Serum Sickness
       •   Fever, urticaria, lyphadenopathy, and arthritis
       •   Occurs 3-21 days following antivenom
       •   Is very common with equine-derived antivenoms (up to 56%)
       •   Typically benign and treated with steroids and antihistamines
       •   Prevented with prednisone 40-60 mg daily for 5 days after antivenom

       Return of Venom Reaction
       •   Patients exhibit an initial response to antivenom, but it dissipates
       •   Delayed absorption of sequestered venom

       Failure to Respond
       •     Expired antivenom, too little antivenom, treatment given too late?
herpetologic envenomations
ENVENOMATION TREATMENT
       SURGICAL MANAGEMENT
          Fasciotomy is now rarely used.
          Only done in patients with signs / symptoms of compartment syndrome
               - pain on passive stretch
               - hypoesthesia
               - tenseness of compartment
               - weakness
               - Wick catheter intracompartment pressures exceeding 30 mm Hg
          Only to be done with above criteria and administration of 20 vials antivenom.
herpetologic envenomations
ENVENOMATION TREATMENT
       CONSULTATION
             Poison Control
              1-800-222-1222

              Miami-Dade Fire Rescue Antivenin Bank
              (formerly the Florida Antivenin Bank, Inc.)
              Assistance with most envenomations
              1-786-336-6600
              http://www.venomousreptiles.org/pages/antbnk

              American Zoo and Aquarium Association with U of Arizona
              Source of the Antivenom Index
              1-301-562-0777
              http://www.aza.org/

              Munich Antivenom Index (MAVIN)
              http://www.toxinfo.org/antivenoms/

              Cro-Fab Hotline
              Assistance with use of Cro-Fab
              1-87-SERPDRUG (1-877-377-3784)
herpetologic envenomations
ENVENOMATION TREATMENT
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
VENOMOUS SPECIES IN THE UNITED STATES
  CROTALIDAE (Pit Vipers)
     Crotalus and Sistrurus: RATTLESNAKES               Agkistrodon contortrix: COPPERHEADS
       Banded Rock                                           Broad-Banded
                                Prairie                      Northern
       Black-Tailed
                                Red Diamond                  Osage
       Canebrake
                                Ridge-Nosed                  Southern
       Diamondback (E & W)
                                Sidewinder                   Trans-Pecos
       Massasauga (E & W)
                                Speckled
       Mojave
                                Tiger
       Mottled Rock                                     Agkistrodon piscivorous: COTTONMOUTHS
                                Timber
       Pacific (N & S)                                       Eastern
                                Twin-Spotted
       Pigmy (SE & W)                                        Florida
                                                             Western

  ELAPIDAE
     Micrurus spp: CORAL SNAKES
           Eastern (Northern or Harlequin or Florida)
           Texas
           West Mexican

     Micruroide spp: CORAL SNAKES
           Arizona
           Western
           Sonoran
herpetologic envenomations
VENOMOUS SPECIES IN THE UNITED STATES
  CROTALIDAE (Pit Vipers)
     Crotalus and Sistrurus: RATTLESNAKES   Agkistrodon contortrix: COPPERHEADS




                                            Agkistrodon piscivorous: COTTONMOUTHS




  ELAPIDAE
     Micrurus spp: CORAL SNAKES




     Micruroide spp: CORAL SNAKES
herpetologic envenomations
SPECIES PROFILES   COPPERHEAD Agkistrodon contortrix subspecies
herpetologic envenomations
SPECIES PROFILES     COPPERHEAD Agkistrodon contortrix subspecies


                  RANGE Nebraska east to Massachusetts and south to NE Mexico
            DESCRIPTION Length: 40-80 cm (1-2.5 ft)
                            Color: Pale brown / Tan / Reddish-brown; Alternating broad bands of light and dark
                            Juveniles with bright yellow / green tails; Two folding, upper fangs
                 HABITAT Varied; Wooded to desert scub and low coastal areas


               BEHAVIOR Mainly nocturnal and usually terrestrial; Will climb bushes


                  VENOM Mainly hemotoxic and rather mild
                 THREAT Many documented human envenomations with rare fatalities
                            Seldom injects large amounts of venom
                            Local pain and edema, ecchymosis and bullae
             TREATMENT Supportive
                            Antivenom available – FabAV may be used
herpetologic envenomations
SPECIES PROFILES   COTTONMOUTH Agkistrodon piscivorus
herpetologic envenomations
SPECIES PROFILES     COTTONMOUTH Agkistrodon piscivorus


                  RANGE Arkansas east to Virginia and south to Texas and NE Mexico
            DESCRIPTION Length: 80-180 cm (2-6 ft)
                            Color: Olive / Light-dark brown; Dark irregular cross bands; Mouth and throat white
                            Juveniles paler with bright yellow tails; Two folding, upper fangs
                 HABITAT Found mainly in or near water (swamps, streams, lakes)


               BEHAVIOR Mainly nocturnal and terrestrial / aquatic; Will usually attempt escape
                            If cornered will coil and gape the mouth wide
                            May become very aggressive


                  VENOM Mainly hemotoxic
                 THREAT Many documented human envenomations with some fatalities (20% with no antivenom)
                            Local pain and edema, ecchymosis and bullae
                            Can progress to coagulation dysfunction and shock
             TREATMENT Supportive
                            Antivenom available – FabAV
herpetologic envenomations
SPECIES PROFILES   RATTLESNAKES Crotalus and Sistrurus species
herpetologic envenomations
SPECIES PROFILES     RATTLESNAKES Crotalus and Sistrurus species


                  RANGE Most of the Unites States
            DESCRIPTION Length: 40-250 cm (1-8+ ft)
                            Color: Brown / Green / Red / Pink / Yellow; Darker dorsal pattern of diamonds or spots
                            Distinctive rattle at tip of tail (hollow scales); Two folding, upper fangs
                 HABITAT Wide range of habitats, Forests to deserts; Below sea level to 4,500 m (14,000+ ft)


               BEHAVIOR Mainly nocturnal and terrestrial; Ambush hunter
                            Vibrate tail rattle when alarmed


                  VENOM Mainly hemotoxic; Some with neurotoxic activity as well
                 THREAT Many human envenomations and deaths reported
                            Local pain and edema, ecchymosis and bullae
                            Nausea, vomiting, coagulation dysfunction, shock
             TREATMENT Supportive
                            Antivenom available – FabAV
herpetologic envenomations
SPECIES PROFILES   CORAL SNAKES Micrurus and Micruroides species
herpetologic envenomations
SPECIES PROFILES     CORAL SNAKES Micrurus and Micruroides species


                  RANGE Arizona east to Florida and north to Arkansas and North Carolina
            DESCRIPTION Length: 60-120 cm (2-4 ft)
                            Color: Tricolored (black, yellow, red); Blunt head; Grooved, fixed front fangs
                 HABITAT Open uplands and moist environments to sandy, desert areas


               BEHAVIOR Mainly nocturnal and terrestrial; Often burrows in loose sandy or leaf litter
                            Usually not aggressive


                  VENOM Mainly neurotoxic; Has cardiotoxic and myonecrotic factors
                 THREAT Many human envenomations and deaths reported, but not common
                            Numbness to major neurologic disorders
                            Cranial nerve paralysis and respiratory failure
             TREATMENT Supportive
                            Antivenom available? – Antivenin Micrurus fulvius
                            No antivenom available for Micruroides
herpetologic envenomations
SPECIES PROFILES         CORAL SNAKES




   Red touches yellow…
   ONLY IF NORTH OF
   MEXICO CITY!
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
VENOMOUS SPECIES IN THE MIDDLE EAST
            Kurdistan Viper (Vipera raddei subspecies)
            Asian Pitvipers (Gloydius species)
            Desert Horned Viper (Cerastes cerastes subspecies)
            Montpellier snake (Malpolon monspessulanus subspecies)
            Persian Horned Viper / Field’s Sand Viper (Pseudocerastes persicus subspecies)
            McMahon’s desert viper (Eristocophis macmahoni)
            Cobras (Naja species)
            Lebetine Viper (Macrovipera lebetina subspecies)
            Common Krait (Bungarus caeruleus)
            Sea Snakes (Hydrophis species)
            Saw-Scaled Vipers ( Echis carinatus subspecies)
herpetologic envenomations
SPECIES PROFILES   KURDISTAN VIPER (Monti)Vipera raddei subspecies
herpetologic envenomations
SPECIES PROFILES     KURDISTAN VIPER (Monti)Vipera raddei subspecies


                  RANGE Eastern Turkey to Northern Iraq and Northwestern Iran
            DESCRIPTION Length: 60-90 cm (2-3 ft)
                            Color: Gray / Brown; Dorsal reddish-orange zig-zag pattern
                 HABITAT Rocky terrain with sparse vegetation; 1,200 - 3,000 m (4,000 - 10,000 ft)


               BEHAVIOR Relatively little is known; Mainly nocturnal or crepescular, terrestrial;
                            Tries to hide when alarmed
                            Hisses loudly and repeatedly when threatened


                  VENOM Likely hemotoxic
                 THREAT No reported human deaths
                            Local swelling and necrosis; Nausea and vomiting
                            Taccycardia and hypotension
             TREATMENT Supportive
                            No antivenom available
herpetologic envenomations
SPECIES PROFILES   ASIAN PITVIPERS Gloydius species
herpetologic envenomations
SPECIES PROFILES     ASIAN PITVIPERS Gloydius species


                  RANGE NE Middle East (Afghanistan, Iran) into Southern Russia to China, Korea, and Japan
            DESCRIPTION Length: 55-90 cm (1.5-3 ft)
                            Color: Pale gray / Brown / Reddish or yellow-brown; Irregular dark side markings
                            Typical “pit-viper” head
                 HABITAT Widely varied; Marshes / swamp to rocky hillsides; Sea level to over 4,200 m (13,000 ft)


               BEHAVIOR Nocturnal (except at higher elevations), terrestrial
                            Usually docile, inoffensive, and sluggish


                  VENOM Mainly hemotoxic with some neurotoxic facotrs
                 THREAT Many documented envenomations and deaths, but not for species in Middle East
                            Painful swelling at bite site; Systemic symptoms in 1-6 hrs
                            Diplopia, neck rigidity, and labored breathing
             TREATMENT Supportive
                            Antivenom available – India
herpetologic envenomations
SPECIES PROFILES   DESERT HORNED VIPER Cerastes cerastes subspecies
herpetologic envenomations
SPECIES PROFILES     DESERT HORNED VIPER Cerastes cerastes subspecies


                  RANGE Arid North Africa through the Arabian Peninsula and Iraq and into Iran
            DESCRIPTION Length: 30-90 cm (1-3 ft)
                           Color: Yellow / Brown / Gray with dark spots along the back; Spines above eyes
                 HABITAT Sandy terrain (dunes) to rocky outcroppings


               BEHAVIOR Mainly nocturnal and terrestrial; Can burrow into the sand in seconds
                           May sidewind; Ability to scale-rasp
                           Very common snake in Iraq; Not very aggressive


                  VENOM Primarily hemotoxic
                 THREAT Envenomation can cause deep local tissue damage and necrosis
                           Stomach pain, sweating, nausea, fever
                           No documented human fatalities
             TREATMENT Supportive
                           Antivenom available – Saudi Arabia, France
herpetologic envenomations
SPECIES PROFILES   MONTPELLIER SNAKE Malpolon monspessulanus subspecies
herpetologic envenomations
SPECIES PROFILES     MONTPELLIER SNAKE Malpolon monspessulanus subspecies


                  RANGE Southern Europe and Northern Africa east to Northern Iraq and Western Iran
            DESCRIPTION Length: 120-150 cm (4-5 ft)
                            Color: Blackish / Grayish / Brown / Olive; Indistinct pattern of brown side spots
                            Distinctive head; Large, fixed, upper rear fangs
                 HABITAT Dry, open, stony areas and semi-arid areas along coasts (Mediterranean, Black Seas)


               BEHAVIOR Mainly diurnal and terrestrial (will climb into bushes)
                            Aggressive and will bite repeatedly, especially when restrained


                  VENOM Moderately neurotoxic
                 THREAT Human envenomations are rare
                            Immediate pain, stiffness, swelling, and fever
                            Central nervous system depression and paresis
             TREATMENT Supportive, observe for 48 hours in severe cases
                            No specific antivenom available (ViperFav?)
herpetologic envenomations
SPECIES PROFILES   FIELD’S / PERSIAN VIPER Pseudocerastes persicus subspecies
herpetologic envenomations
SPECIES PROFILES     FIELD’S / PERSIAN VIPER Pseudocerastes persicus subspecies


                  RANGE NE Africa through Arabian Peninsula and Turkey, to Iraq, Iran, Afghanistan, and Pakistan
            DESCRIPTION Length: 50-90 cm (1.5-3 ft)
                            Color: Pale bluish gray / Khaki-brown; Darker, alternating cross bars; Often eye bands
                 HABITAT Brushy, sandy, or rocky areas; Often near or in rodent burrows; Up to 2,000 m (7,000 ft)


               BEHAVIOR Mainly nocturnal or crepescular, terrestrial; Tries to escape when alarmed
                            Hisses very loudly; Ability to scale-rasp
                            Can be very aggressive at night


                  VENOM Either primarily neurotoxic or hemotoxic, depends on subspecies
                 THREAT Depends on subspecies
                            P.p. fieldi: Minor numbness to full respiratory failure
                            P.p. persica: Minor pain and swelling to massive hemorrhage
             TREATMENT Supportive
                            Antivenom available for P. persicus – produced in France, Iran
herpetologic envenomations
SPECIES PROFILES   MCMAHON’S DESERT VIPER Eristicophis macmahoni
herpetologic envenomations
SPECIES PROFILES     MCMAHON’S DESERT VIPER Eristicophis macmahoni


                  RANGE Desert region of Balochistan of Iran, Afghanistan, and Pakistan
            DESCRIPTION Length: 60-80 cm (2-2.5 ft)
                            Color: Pale reddish / Brown / Khaki; Lateral dark spots; Large broad head
                 HABITAT Sand dunes below 1,200 m (3,900 ft)


               BEHAVIOR Nocturnal, terrestrial, semi-fossorial; Will bury itself in sand
                            Sidewinds when hurried; Alert, bad-tempered, strikes with great vigor
                            Hisses loudly, raises head and loop of body when agitated


                  VENOM Hemotoxic (strongly hemorrhagic); ? neurotoxic
                 THREAT Many documented envenomations and deaths
                            Local swelling; Abdominal pain and distention
                            Inability to swallow and open eyes
             TREATMENT Supportive
                            No antivenom available
herpetologic envenomations
SPECIES PROFILES   DESERT / CENTRAL ASIAN / ARABIAN COBRA Naja species
herpetologic envenomations
SPECIES PROFILES     DESERT / CENTRAL ASIAN / ARABIAN COBRA Naja species
             DESERT COBRA / DESERT BLACKSNAKE Walterinnesia aegyptia / morgani
                   RANGE NE Africa through Arabian Peninsula into Iraq, Kuwait, and Iran
             DESCRIPTION Length: 70-130 cm (2-4 ft); Color: Glossy black, may have brownish tinge
                BEHAVIOR Nocturnal; Very aggressive
                   VENOM Strongly neurotoxic
                   THREAT Many reported human deaths
              TREATMENT Supportive; Antivenom available – produced in Saudi Arabia

             CENTRAL ASIAN COBRA Naja oxiana
                   RANGE Northeast Iran through Afghanistan south to India and north to Kyrgyzstan
             DESCRIPTION Length: Up to 180 cm (6 ft); Color: Yellowish-gray with dark crossbands
                BEHAVIOR Diurnal; Not aggressive
                   VENOM Strongly neurotoxic  Death can occur in one hour
              TREATMENT Supportive; Antivenom available – produced in Iran
             EGYPTIAN / ARABIAN COBRA Naja haje (arabica)
                   RANGE Widespread in Africa and S Arabian Peninsula; Often seen in street markets
             DESCRIPTION Length: Up to 180 cm (6 ft); Color: Variable, but most have dark band on throat
                BEHAVIOR Nocturnal; Not aggressive
                   VENOM Strongly neurotoxic  Death can occur in five hours
              TREATMENT Supportive; Antivenom available – produced in Saudi Arabia, France
herpetologic envenomations
SPECIES PROFILES   LEBETINE VIPER Macrovipera lebetina subspecies
herpetologic envenomations
SPECIES PROFILES     LEBENTINE VIPER Macrovipera lebetina subspecies


                  RANGE Arid Mediterranean, Iraq, Iran, Afghanistan, through to Southern Russia and W. China
            DESCRIPTION Length: 70-180 cm (2-6 ft)
                           Color: Light gray / Khaki / Reddish-brown; Double row of alternating dorsal spots
                 HABITAT Widespread from marshes to dry ,rocky areas at elevations to 2,000 meters (7,000 ft)


               BEHAVIOR Mainly nocturnal or crepuscular and terrestrial; Slow-moving and seeming oblivious
                           Temperament unpredictable – can strike suddenly
                           Often found in areas of human inhabitation


                  VENOM Primarily hemotoxic
                 THREAT Numerous documented envenomations and fatalities yearly
                           (6.6% mortality rate)
                           Large fangs often leave bleeding puncture wounds
                           Causes immediate burning pain, swelling, and tissue damage
             TREATMENT Supportive
                           Antivenom available – produced in France, Croatia, Iran
herpetologic envenomations
SPECIES PROFILES   COMMON KRAIT Bungarus caeruleus
herpetologic envenomations
SPECIES PROFILES     COMMON KRAIT Bungarus caeruleus


                  RANGE Afghanistan and Pakistan through India to Sri Lanka and Bangledesh
            DESCRIPTION Length: 100-180 cm (3-6 ft)
                            Color: Blackish / Brownish / Blue-black; Smooth, shiny; ~40 thin white crossbars
                 HABITAT Mainly in open country and cultivated areas up to 1,700 m (5,500 ft)
                            Often found in termite mounds, rodent burrows, and roofs of buildings


               BEHAVIOR Strictly nocturnal; Mainly terrestrial
                            Daytime – docile and attempts to hide;
                            Nighttime – Very aggressive, quick; Often enters human dwellings


                  VENOM Potent neurotoxins
                 THREAT High mortality rate; Most victims bitten while asleep at night
                            Almost absent local symptoms; Severe systemic symptoms
             TREATMENT Supportive
                            Antivenom available – Produced in India, Pakistan
herpetologic envenomations
SPECIES PROFILES   SEA SNAKE Hydrophis species
herpetologic envenomations
SPECIES PROFILES     SEA SNAKES Hydrophis species


                  RANGE Persian Gulf coasts along Indian Ocean coasts of Iran past India to South Pacific
            DESCRIPTION Length: 70-270 cm (2-8.5 ft)
                           Small heads with short fixed upper fangs
                           Color: White / Yellow / Olive-Gray; Lighter sides with dark encircling crossbands
                 HABITAT Mainly near the bottom of near-shore marine waters
                           Will occasionally swim up fresh water rivers; Sometimes on land near water


               BEHAVIOR Diurnal and nocturnal; Usually stays in the water – awkward on land
                           Usually very docile unless threatened


                  VENOM Most have very potent neurotoxins and myotoxins
                 THREAT 17% of envenomations are fatal
                           Fishermen and divers are most frequently bitten
             TREATMENT Supportive
                           Antivenom available – CSL Sea Snake Antivenom (Australia)
herpetologic envenomations
SPECIES PROFILES   SAW-SCALED VIPER Echis carinatus subspecies
herpetologic envenomations
SPECIES PROFILES     SAW-SCALED VIPER Echis carinatus subspecies


                  RANGE Arid Africa through Arabian Peninsula, Iraq, Iran, Afghanistan into India and Bangladesh
            DESCRIPTION Length: 20-80 cm (0.5-2.5 ft)
                           Color: Gray-greenish / Yellow-reddish brown; White zig-zag cross bars with dark edges
                 HABITAT Widespread in open, dry, and semi-arid areas, valleys, savannahs, and forest edges


               BEHAVIOR Mainly nocturnal in hot weather; Diurnal in cool weather
                           Mainly terrestrial, often fossorial, often climbs to 2 m (6.5 ft)
                           Figure 8 when alarmed; Ability to scale-rasp
                           Very nervous and strikes with little provocation


                  VENOM Primarily hemotoxic
                 THREAT Large fangs compared to body size
                           Causes burning pain, swelling, and enlarged lymph nodes
                           One of the most deadly snakes in the world (36% mortality rate)
             TREATMENT Supportive
                           Antivenom available – produced in many countries
herpetologic envenomations
VENOMOUS SPECIES IN THE MIDDLE EAST
herpetologic envenomations
OVERVIEW
            Case study
            Epidemiology in the United States and in the Military
            Venoms
            Envenomation Treatment
            Venomous Species in the United States
            Venomous Species in the Middle East
herpetologic envenomations
CASE STUDY
        9 year old male was bit multiple times by “some baby snakes”.
        Likely juvenile Copperheads or Cottonmouths.
        Patient had initial increase in swelling with moderate pain.
        Patient received 10 vials of Crofab (4 + 2 + 2 + 2).
        Patient improved after initial dose and remained stable throughout
        hospitalization.
        Discharged the following day after ~30 hrs in hospital.
        No issues as an outpatient
herpetologic envenomations
REFERENCES
 Envenomations: an overview of clinical toxinology for the primary care physician.
 American Family Physician. 2009 Oct 15;80(8):793-802.

Venomous Snakebites in the United States: Management Review and Update
American Family Physician. 2002 Apr 1;65(7):1367-74. 7

Self-reported incidence of snake, spider, and scorpion encounters among deployed U.S. military in Iraq and Afghanistan.
Military Medicine. 2007 Oct;172(10):1099-102.

Bites of Venomous Snakes
New England Journal of Medicine. 2002 Aug 1;347(5):347-56.

Snakebite Injuries Treated in U.S. Emergency Departments, 2001-2004
Wilderness & Environmental Medicine. 2007 Winter;18(4):281-7.

Wilderness Medicine. 5th edition. Paul Auerbach.

Venomous Snakes of Iraq and Kuwait. Presentation given by Tom Harkins, Entomolical Sciences Program
U.S. Army Center for Health Promotion and Preventive Medicine

The Armed Forces Pest Management Board (AFPMB) Website
http://www.afpmb.org/

J. Craig Venter Institute Reptiles Database Website
http://jcvi.org/reptiles/
QUESTIONSSSSSSSS?
Capt John Kitsteiner, MD
Eglin AFB Family Medicine Residency

				
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